GOVERNING BODY MEETING. 6 September am to 12.30pm. The Snow Room, West Offices, Station Rise, York YO1 6GA

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1 GOVERNING BODY MEETING 6 September am to 12.30pm The Snow Room, West Offices, Station Rise, York YO1 6GA Prior to the commencement of the meeting a period of up to 20 minutes, starting at 9.30am, will be set aside for questions or comments from members of the public who have registered in advance their wish to participate. The agenda and associated papers will be available at: AGENDA STANDING ITEMS 9.50am 1. Verbal Apologies for absence To Note All 2. Verbal Declaration of Members Interests in the Business of the Meeting To Note All 3. Pages 5 to 21 Minutes of the meeting held on 5 July 2018 To Approve All 4. Verbal Matters arising from the minutes All 5. Pages 23 to 33 Accountable Officer s Report To Receive Phil Mettam Accountable Officer 6. Pages 35 to 42 Risk Update Report To Receive Phil Mettam Accountable Officer

2 FINANCE AND PERFORMANCE 10.30am 7. Pages 43 to 59 Financial Performance Report 2018/19 Month 4 To Receive Simon Bell, Chief Finance Officer 8. Pages 61 to 100 Integrated Performance Report Month 3 The annexes are published as separate documents To Receive Caroline Alexander, Assistant Director of Delivery and Performance ASSURANCE 11.30am 9. Pages 101 to 130 Quality and Patient Experience Report To Receive Michelle Carrington, Executive Director of Quality and Nursing / Chief Nurse 10. Pages 131 to 219 Emergency Preparedness, Resilience and Response NHS Vale of York CCG Arrangements To Approve Phil Mettam Accountable Officer 11. Pages 221 to Pages 287 to 291 NHS Vale of York CCG Constitution Remuneration Committee Terms of Reference To Approve To Approve Phil Mettam, Accountable Officer Keith Ramsay, Remuneration Committee Chair RECEIVED ITEMS 12.15pm The minutes of each Committee are published as separate documents 13. Page Page Page 297 Chair s Report: Audit Committee 25 July 2018 Chair s Report: Executive Committee 20 June, 4 and 18 July and 1 August 2018 Chair s Report: Finance and Performance Committee 3 and 26 July 2018

3 16. Page Page Pages 303 to Pages 311 to 312 Chair s Report: Primary Care Commissioning Committee 26 July 2018 Chair s Report: Quality and Patient Experience Committee 9 August 2018 Medicines Commissioning Committee 13 June and 11 July 2018 Chair s Report: Joint Acute Commissioning Committee 25 July 2018 NEXT MEETING 20. Verbal 9.30am on 1 November 2018 at West Offices, Station Rise, York YO1 6GA To Note All CLOSE 12.30pm EXCLUSION OF PRESS AND PUBLIC In accordance with Paragraph 8 of Schedule 2 of the Health and Social Care Act 2012 it is considered that it would not be in the public interest to permit press and public to attend this part of the meeting due to the nature of the business to be transacted as it contains commercially sensitive information which, if disclosed, may prejudice the commercial sustainability of a body. A glossary of commonly used terms is available at

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5 Minutes of the Meeting of the NHS Vale of York Clinical Commissioning Group Governing Body on 5 July 2018 at West Offices, York Item 3 Present Dr Nigel Wells (NW) Michael Ash-McMahon (MA-M) David Booker (DB) Michelle Carrington (MC) Dr Andrew Field (AF) Phil Goatley (PG) Dr Arasu Kuppuswamy (AK) Denise Nightingale (DN) Dr Kevin Smith (KS) Dr Ruth Walker (RW) Clinical Chair Acting Chief Finance Officer Lay Member and Finance and Performance Committee Chair Executive Director of Quality and Nursing/Chief Nurse Central Locality GP Representative Lay Member and Audit Committee Chair Consultant Psychiatrist, South West Yorkshire Partnership NHS Foundation Trust Secondary Care Doctor Member Executive Director of Transformation, Complex Care and Mental Health Executive Director of Primary Care and Population Health South Locality GP Representative In Attendance (Non Voting) Caroline Alexander (CA) - item 10 Assistant Director of Delivery and Performance Abigail Combes (AC) Head of Legal and Governance Michèle Saidman (MS) Executive Assistant Sharon Stoltz (SS) Director of Public Health, City of York Council Apologies Dr Aaron Brown (AB) Dr Helena Ebbs (HE) Phil Mettam (PM) Keith Ramsay (KR) Local Medical Committee Liaison Officer, Selby and York North Locality GP Representative Accountable Officer Lay Member and Chair of Primary Care Commissioning Committee, Quality and Patient Experience Committee and Remuneration Committee There were three members of the public and a member of Healthwatch York present. There were no questions from members of the public. Unconfirmed Minutes Page 5 of 312

6 NW noted the meeting was taking place on the occasion of NHS70 and highlighted national and local celebratory events taking place, including in the foyer at West Offices during the afternoon. NW welcomed PG to his first meeting since his recent appointment as Audit Committee Chair. STANDING ITEMS 1. Apologies As noted above. AGENDA 2. Declaration of Members Interests in Relation to the Business of the Meeting There were no declarations of interest in the business of the meeting. All declarations were as per the Register of Interests. 3. Minutes of the Meeting held on 3 May 2018 The minutes of the meeting held on 3 May were agreed. The Governing Body: Approved the minutes of the meeting held on 3 May Matters Arising from the Minutes Safeguarding Children Annual Report : MC reported that, following the review of capacity, a Senior Quality Lead for Children had been appointed. With regard to succession planning a business case was being presented for consideration at the Executive Committee. Accountable Officer Report Rollout of free wi-fi capability to GP Practices: MA- M reported that the infrastructure work had been completed but there were delays due to issues with the sub-contractor employed to progress the rollout. Consequently wi-fi was not yet in place in any Practices. A pan Yorkshire and Humber approach was now being adopted and a timetable was awaited from a new sub-contractor who had been appointed. Risk Update Report Communication between GPs and the Local Authorities regarding services and referrals: DN reported on discussion with Katherine Davies, Clinical Director - Children and Young People s Services at Tees, Esk and Wear Valleys NHS Foundation Trust, and at their Contract Management Board noting that she had passed on the names of the GP Locality Representatives. MA-M had confirmed that the CCG s contribution towards City of York Council School Wellbeing Service would continue and a joint commissioning meeting had been established to develop a whole pathway Unconfirmed Minutes Page 6 of 312

7 approach to meet the needs of the 30% of children who may not require Child and Adolescent Mental Health Services. Three way discussion City of York Council, the CCG and Education was taking place regarding support for the most challenged children. SS emphasised the need for prevention and early intervention advising that work had begun to review the Healthy Child Service specification with a view to developing a whole pathway approach; GP engagement would be welcomed. A project plan was being developed with the aim of implementing the new specification from 2018/19 following stakeholder engagement. In response to NW seeking clarification about the funding MA-M explained that City of York Council had sought confirmation about the CCG s ongoing contribution to the Healthy Child Service. This had now been included within the baseline of the CCG s Financial Recovery Plan and remained unchanged. SS noted that this had been welcomed particularly as the Healthy Child Service staff had been on fixed term contracts. DN advised that this action should be considered as completed as any risks relating to these services would be on the Risk Register and therefore reported to Governing Body. A number of matters were noted as agenda items or completed. The Governing Body: Noted the updates and associated actions. 5. Accountable Officer s Report KS, on the 70 th anniversary of the NHS, reflected on fulfilment of the Beveridge Report and the development of the NHS where clinicians now viewed the whole person rather than focusing on health alone. The celebrations should include recognition that investment in the NHS was for the benefit of all and as such any investment should be made to ensure its use was maximised. KS also highlighted that the NHS provided support in many ways with stories to be celebrated. KS presented the report which provided an update on turnaround, legal Directions and the CCG s financial position; joint commissioning and the York Health and Care Place Based Improvement Board renamed the York Health and Care Place Based Partnership; Better Care Fund; Council of Representatives meeting; new mental health facilities in Haxby Road, York; the CCG Annual Review meeting; Emergency Preparedness, Resilience and Response; and national issues. Two annexes respectively comprised Next steps on aligning the work of NHS England and NHS Improvement and the CCG s Patient and Public Participation Annual Report 2017/18. KS highlighted agreement of the Aligned Incentives Contract arrangement between NHS Vale of York CCG, NHS Scarborough and Ryedale CCG, NHS East Riding of Yorkshire CCG and York Teaching Hospital NHS Foundation Trust commending the partnership working that had resulted in this achievement. This new approach was a key enabler in meeting the financial challenge across the system. Unconfirmed Minutes Page 7 of 312

8 KS referred to the York Health and Care Place Based Partnership noting that discussions were taking place with North Yorkshire County Council with a view to establishing similar arrangements for the North and South Localities. KS also noted that he was in discussion with SS regarding developing joint working with North Yorkshire County Council and East Riding of Yorkshire Council. With regard to the Council of Representatives KS explained that discussions were now focusing more on localities and there was the potential for full meetings to become less frequent with the time being utilised in the localities. Practices were working collaboratively on a number of areas including the Out of Hospital Strategy in terms of services relating both to physical and mental health. KS reported that NHS England had recognised the CCG s progress in 2017/18 at the Annual Review meeting on 23 April. The Annual Improvement and Assessment Performance rating - Outstanding; Good; Requires Improvement or Inadequate - was expected to be announced in July. KS noted that if the CCG moved from Inadequate to Requires Improvement this would support exit from legal Directions. Post meeting note: The CCG was rated as Requires Improvement for 2017/18. KS commended the Patient and Public Participation Annual Report for 2017/18. He noted that although engagement was increasingly becoming business as usual further work was required in this regard. KS highlighted that relationships across the CCG with Local Authorities and provider partner organisations had greatly improved over the past four to six months. He commended the progress on partnership working. In response to NW enquiring about the NHS England announcement of an additional 10m funding in 2018/19 to support the retention of GPs and specifically to facilitate the establishment of local schemes and initiatives that enable local GPs to stay in the workforce, KS advised that the CCG had not been successful in accessing this funding source. He noted however that the CCG did have access to the GP Retention Scheme which had been discussed at the Primary Care Commissioning Committee. MA-M reported that 7m of the 10m had been awarded to regional GP retention schemes and the remaining 3m to the seven intensive support sites. There was potential for the CCG to benefit from a proportion of the former. Discussion ensued of the need for Practices to consider the composition of their workforces and use of technology to alleviate capacity pressures caused by high demand. Wider consideration was also required of longer term strategy including the localities working with the respective Local Authorities. In this regard RW noted that the North and South Localities were considerably smaller than the Central Locality expressing concern that GP engagement in developments was variable. KS advised that the CCG would facilitate such as joint commissioning arrangements but highlighted that bespoke work was needed to bring all partners together in the localities. Unconfirmed Minutes Page 8 of 312

9 NW noted that fewer than five whole time equivalent GPs would be completing the GP Training Scheme this year and for the first time recruitment would not be full. A strategy was required to encourage trainees to join General Practice. KS highlighted that the approach of place should inform a recruitment strategy. MC added that the workforce required the full spectrum of professionals, not only GPs. MA-M provided further information about the Aligned Incentives Contract. He welcomed and commended its achievement noting that this would not alone deliver the cost savings programme but should incentivise and enable delivery of the joint cost reduction programme. MA-M emphasised that the focus would be on clinically led services and ensuring best use of the hospital. The Aligned Incentives Contract had been agreed within the parameters previously reported to the Governing Body. Discussions were progressing at an operational level with York Teaching Hospital NHS Foundation Trust and additional opportunities were also being developed. MA-M noted that the full benefit of the system transformation would take between six and 18 months. MA-M reported that the final draft Financial Recovery Plan, submitted to NHS England within the required timescale of 29 June, had been updated to reflect agreement of the Aligned Incentives Contract. The draft Plan had received positive feedback both from NHS England and from the Finance and Performance Committee where it had been presented earlier in the week. Formal evaluation by NHS England was taking place the following day, 6 July. MA-M referred to the information regarding the Independent Auditors Report for the 2017/18 financial accounts noting the Qualified Opinion on Regularity was due to expenditure above the CCG s allocation. MA-M added his appreciation to that of the auditors for the work of the finance team involved in the annual accounts process. The Governing Body: Received the Accountable Officer s Report. 6. Risk Update Report AC referred to the report which detailed current events and risks escalated to Governing Body by its committees of the Governing Body for consideration regarding effectiveness of risk management approach. She noted that all risks had been reviewed by the relevant lead officer week commencing 25 June 2018 advising that there were no risks of which the Governing Body was not already aware. MC advised that the outcome of the review of services at The Retreat, which would significantly reduce the inpatient bed base, was expected later in the month or in August. DN referred to the risks relating to mental health services for children and young people noting that, although these were still red, there had been progress as a Unconfirmed Minutes Page 9 of 312

10 result of joint work between the CCG and Tees, Esk and Wear Valleys NHS Foundation Trust to fully understand the issues and areas of highest risk. The CCG had planned further investment in these services in quarter 3 but this had been brought forward and a further 120k per annum investment was being made available much sooner in quarter 1. It had also been agreed with Tees, Esk and Wear Valleys NHS Foundation Trust that, where possible, any savings they achieved would be reinvested in mental health services. In line with this approach they had identified savings of 50k therefore since the last Governing Body meeting a further 175k had been invested in children s mental health services. DN advised that there were additional pathways under Child and Adolescent Mental Health Service where there was risk due to high numbers of children waiting, such as Community Eating Disorder Services and services relating to emotional health and wellbeing where the risk included self harm. Clarification was being sought in order to improve these areas of performance. DN added that discussion at the recent Tees, Esk and Wear Valleys NHS Foundation Trust Contract Management Board had included the CCG s appreciation of their identification from a different department of the additional savings for investment in these services; she would also reflect the Governing Body s appreciation in this regard. MA-M reported that the Finance and Performance Committee on 3 July had recognised these risks in mental health services and agreed to prioritise any available funds for areas of highest clinical risk. He noted that work was now taking place with Tees, Esk and Wear Valleys NHS Foundation Trust to agree trajectories for key measures and commended this aligned incentive approach. DB additionally reported on discussion at the Lay Members Summit, also on 3 July, when a Consultant Paediatrician from York Teaching Hospital NHS Foundation Trust had presented information including the fact that there were c2,000 referrals to children s mental health services in York per year. Whilst recognising the CCG had a number of priorities the Finance and Performance Committee had agreed the principle be adopted that any available funds should be considered for utilisation to support Child and Adolescent Mental Health Services as a priority. KS referred to the fact that mental health services were a priority in the CCG s Commissioning Intentions for 2018/19. He highlighted the return that would emanate from investment in these services to address the risk and noted that the effects of such investment would benefit other parts of the system. In response to RW enquiring about monitoring of performance in adult mental health services and expressing concern that referrals for Personality Disorder were currently closed DN explained that there were a number of ways that monitoring was undertaken but agreed that all aspects were not covered. Areas of performance monitoring included Liaison Psychiatry, Early Intervention in Psychosis and Improving Access to Psychological Therapies; the quality visits as reported in agenda item 14 also fulfilled this function. DN requested that RW provide information about her concerns regarding Personality Disorder referrals so that she could seek explanation. Unconfirmed Minutes Page 10 of 312

11 Discussion ensued in the context of the aligned incentives approach and the system change needed to enable these challenged services to improve to a level where they met all performance indicators. DN highlighted the need to both address the backlog and invest in prevention and KS emphasised the return on investment in children s services noting the need for resilience training in schools and reiterating the importance of prevention. RW noted the potential for a pilot to support 18 to 25 year olds with low level mental health needs. With regard to a prevention strategy SS, whilst recognising the funding issues, emphasised that the challenge was across the system and therefore required a whole system response. She highlighted the role of Health and Wellbeing Boards in this regard. The Governing Body: 1. Received the Risk Update Report. 2. Noted that RW would provide DN with information regarding concerns about Personality Disorder referrals. STRATEGIC 7. Healthier You: NHS Diabetes Prevention Programme KS referred to the Healthier You: NHS Diabetes Prevention Programme, a joint commitment from NHS England, Public Health England and Diabetes UK, to deliver at scale, evidence based behavioural interventions for individuals identified as being at high risk of developing Type 2 diabetes. KS described windows of opportunity at the onset of Type 2 diabetes through identifying people at risk from testing insulin levels. If these people were offered support, such as weight management and smoking cessation, their need for treatment could be reduced and further conditions prevented. KS explained that health checks were the most likely opportunity for such risks to be identified noting that the CCG was working with the City Practices in this regard. He also highlighted that health checks were funded. SS reported that the City of York Council health checks programme had ceased c18 months previously as part of savings required. However, she had now made a commitment to the CCG that they would resume and was working both on a restructure of Public Health to identify additional funding and with Practices to ensure availability of wellbeing services to address lifestyle issues. KS added that investment in primary intervention was required as well as in lifestyle services. With regard to changing behaviour KS explained that the evidence base was that community and group approaches were effective primary pre-diabetic, secondary prevention was for people with diabetes and the interim was intervention such as offering stop smoking literature or encouraging flu vaccination when pregnant. There was a need for engagement between primary and secondary prevention but for all support to be offered. Unconfirmed Minutes Page 11 of 312

12 AF highlighted that there was inequity across the CCG as health checks were available in North Yorkshire County Practices but not in City of York. He also noted that there was variance in reporting by Practices, for example with regard to blood pressure checks. SS explained that she was in discussion with the Local Medical Committee who were committed to working with Public Health to develop a model for health checks in the City and noted that work was also taking place in City of York Council on an in-house element. SS emphasised that this need to be progressed quickly but noted however that the timing was at the start of a new five year cycle. In response to NW enquiring where assurance would be sought regarding this issue, KS advised that the Finance and Performance Committee would receive the data. KS also highlighted that these concerns should be raised at the City of York Health and Wellbeing Board. SS supported this approach and in response to DN noting that the absence of health checks in City Practices should be recorded on the CCG s risk register advised that, although this was a system wide issue, it was on the Public Health risk register. Further discussion ensued in the context of historic City of York Council budgetary pressures, seeking opportunities to learn from other areas and emphasis on the need for a system solution. SS agreed to request a report on health checks and associated concerns be added to the Health and Wellbeing Board Forward Plan. The Governing Body: 1. Received the Healthier You: NHS Diabetes Prevention Programme report. 2. Noted that SS would request that health checks and associated issues be added to the Health and Wellbeing Board Forward Plan. FINANCE AND PERFORMANCE 8. Financial Performance Report 2018/19 Month 2 In presenting this item MA-M referred to the earlier discussion about the Aligned Incentives Contract noting that this was an area of improved performance and that a joint cost reduction programme would be presented at the System Transformation Board on 16 July. He also reported that the CCG s overall position was 300k better than the planned 3.5m deficit as at the end of May. With regard to areas of deterioration in performance MA-M explained there was 61k pressure relating to prior year adjustments from outstanding areas to be finalised for 2017/18. These related to acute providers with whom it had not been possible to agree a year end position and NHS Property Services, the latter being the most notable and with material value, although the CCG had been prudent in its accounting for this in 2017/18. MA-M highlighted that the 61k was a considerable improvement on the c 1.0m brought forward the previous year. Unconfirmed Minutes Page 12 of 312

13 MA-M referred to the ongoing work to validate continuing healthcare data transferred from the former Partnership Commissioning Unit and explained that there was a significant gap between the QA database for packages and forecasting expenditure compared to invoices processed and paid. It was anticipated that this would have a significant adverse impact across the North Yorkshire CCGs who had agreed in principle that this would be managed collectively should any CCG be materially adversely impacted by this work. In response to clarification sought by members MA-M explained historic and current factors relating to NHS Property Services. He assured them that, following unsuccessful efforts to resolve the position, a prudent assessment had been included in the financial plan in this regard. The Governing Body: Received the month 2 Financial Performance Report 9. Financial Control, Planning and Governance Assessment MA-M reported that on 30 May 2018 NHS England had written to all CCGs to request submission at the end of June of an update to the previously reported Financial Control Environment Assessment template that CCGs were first asked to populate in The purpose of the new Financial Control, Planning and Governance assessment template was to provide early warning signs of CCGs in financial distress and to provide assurance about adequately-designed and effective financial controls and governance processes in place to manage risk. The self-assessment was designed to consider the overall control environment and covered financial control, planning and governance. It had been submitted following discussion at the CCG s Executive Committee and sign off by PM and was now presented in accordance with the requirement for it to go to the next available Governing Board meeting in public. MA-M highlighted a number of areas of exception on the self-assessment noting that this was a view at a point in time. The Governing Body: Received and noted the CCG s self-assessed CCG Financial Control Planning and Governance Self-Assessment with specific awareness of the exceptional items. CA joined the meeting 10. Integrated Performance Report 2018/19 Month 1 NW introduced CA whose role now encompassed responsibility for overall assurance of the CCG to NHS England, oversight of delivery of performance recovery, as well as the new system delivery role as Transformation Lead for planned care under the Aligned Incentives Contract. CA further clarified her role supported having oversight of financial recovery alongside performance recovery, and that assurance and escalation as required to Governing Body was made through the Finance and Performance Committee. Unconfirmed Minutes Page 13 of 312

14 CA referred to the Integrated Performance Report for Month 1 which comprised key performance headlines, performance summary against all constitutional targets, and programme overviews relating to planned care, unplanned care, mental health, learning disability and complex care, primary care performance and included annexes providing core supporting performance information. CA highlighted the continuing improvement in A and E four hour performance advising that the 90.1% unvalidated data for May against the 95% target may mean that as a system the trajectory was being met for the month; however the full quarter performance would still need to be assessed in relation to access to the York Teaching Hospital NHS Foundation Trust Provider Sustainability Fund. CA noted that a refreshed system winter resilience plan for 2018/19 would be presented at the A and E Delivery Board on 19 July CA reported in respect of cancer two week waits, where performance against the 93% target had continued to improve, that work was taking place with providers to mitigate the impact from increasing colorectal and dermatology referrals. Dementia diagnosis had improved and the CCG was continuing to provide support, including case finding. With regard to areas of deterioration in diagnostics performance CA reported that the ongoing issues in a number of different diagnostics continued to impact the six week wait 99% target and highlighted the impact of a surge in referrals for colorectal, which had also been experienced nationally. CA noted the significant radiology capacity gaps locally and across the Sustainability and Transformation Partnership and the need to progress the investment proposals for MRI and CT additional capacity which was dependent on Humber, Coast and Vale Sustainability and Transformation Partnership transformational funding. CA also noted that a business case was being developed for a scanner at York Teaching Hospital NHS Foundation Trust. CA referred to the significant decrease in performance in April 2018 for cancer 62 day treatment noting that flash reports had been produced on the key Cancer Alliance workstreams supporting delivery of this target, including for Vague Symptoms, Colorectal and Lung. CA reported on discussion at the Finance and Performance Committee regarding cancer 62 day performance noting that failure to meet this target was resulting in access to only 75% of the available Sustainability and Transformation Partnership funding. CA also referred to the NHS Improvement health economics team recommendations around priorities for delivering 62 day performance and the focus on reducing the current two week wait within the 62 day pathway to seven days and also targeting reducing Did Not Attends. CA explained that a local CCG Cancer Board had been established comprising clinical leads across NHS Scarborough and Ryedale and NHS Vale of York CCGs. There would be more granular monitoring and reporting around local and Cancer Alliance recovery plans which were driving cancer performance targets. CA also noted that Dr Dan Cottingham, the CCG s Cancer Lead, was now working two days a week. Unconfirmed Minutes Page 14 of 312

15 Discussion ensued regarding inappropriate urgent referrals conversion rates and the need for diagnostic capacity that provided assurance in delivery of the required performance. CA responded that there should be greater transparency around the root cause issues and performance under the Aligned Incentives Contract and noted she had requested baseline information of pressures on the waiting lists by specialty. Consideration would then be given by all system partners to how to jointly address the waiting lists; the information would also inform commissioning decisions. In response to AF enquiring about the role and support of established clinical networks KS advised that these networks were variable but were being utilised where possible. He referred to the need for quick wins such as in rheumatology and the diabetes programme to prove a principle and progress through shared learning. CA added the focus and emphasis required for transformation needed all available resources, noting that specialties with potential had already been prioritised and advising that a Clinical Reference Group had been established for system recovery under the Aligned Incentives Contract. NW added that his role should include meeting with specialties to progress areas of work. KS highlighted that capacity for undertaking the reviews required for system transformation was a challenge and that clinical capacity was the most stretched part of the system. However, clinical engagement was key to the prioritisation and joint working under the Aligned Incentives Contract and must be maximised for the system transformation work. MC referred to the level of detail provided in the Integrated Performance Report and sought members views as to whether this could be reduced in the context of the reset Governing Body. CA explained that formal assurance reporting would continue and under the Aligned Incentives Contract there would be one set of joint partners data including performance information and additional new metrics. She noted that some of the information in the report was duplication of information published on the York Teaching Hospital NHS Foundation Trust website and that links to this and other reports could be provided electronically to fulfil governance requirements with assurance provided through the CCG s committee structure. DB noted that the detailed reporting also served to provide assurance to such as NHS England but recognised the tension between this and the volume of information. He supported the proposal for consideration in this regard. PG highlighted that the information should be such that it enabled the Governing Body to fulfil its role and to demonstrate in public the sustainability and competence of commissioned services. He also noted that once the CCG had come out of Special Measures there would be a greater degree of self determination. MC proposed that discussion should take place at the Finance and Performance Committee regarding information to be provided to inform clinical discussion at the Governing Body with further information available separately should members wish to access it. Unconfirmed Minutes Page 15 of 312

16 The Governing Body: 1. Received the Integrated Performance Report as at month Agreed that future reports be more succinct and guided by the areas highlighted by the Finance and Performance Committee. ASSURANCE /18 Annual Report and Annual Accounts MA-M referred to the 2017/18 Annual Report and Accounts which had been approved by the Audit Committee on 23 May 2018 as per the delegated authority from the Governing Body. The Governing Body: Ratified the 2017/18 Annual Report and Annual Accounts. 12. Governing Body Committees AC referred to the report on the Governing Body Committee Review which included terms of reference for the Audit Committee, Finance and Performance Committee, Quality and Patient Experience Committee, Executive Committee, Primary Care Commissioning Committee and Remuneration Committee noting that all except the latter, which were currently under review, had been approved by the appropriate Committees. AC highlighted the recommendation relating to inclusion of a form of words clarifying delegation to each of the Committees to ensure appropriate information was received. Discussion ensued about the Committee minutes under the Received Items section of the agenda which were presented for governance purposes. It was agreed that each Committee Chair should provide a succinct report highlighting areas of note for the Governing Body and that the minutes be available electronically but separate from the meeting papers. The Governing Body: 1. Supported the recommendations detailed in the report which primarily related to clear delegation to each of the Committees of the Governing Body. 2. Approved the terms of reference as approved by each of the Committees with the exception of those for the Remuneration Committee which were currently under review. 3. Requested a report to the September 2018 meeting of the governance structure for managing the Aligned Incentives Contract. 4. Agreed that the minutes of the Governing Body Committees be available separate from the meeting papers but a succinct summary of business be provided to the Governing Body by the Committee Chairs. Unconfirmed Minutes Page 16 of 312

17 13. Quality Assurance Framework MC advised that the Quality Assurance Framework, which described the CCG s approach to quality of commissioned services, had been approved at the Quality and Patient Experience Committee on 14 June. In commending the Framework to members MC noted that it had been circulated to stakeholders and that a user friendly version was being developed for publication on the CCG website. The Governing Body: Received the Quality Assurance Framework. 14. Quality and Patient Experience Report MC presented the report which provided an overview of the quality of services across the CCG s main providers and an update on the quality improvement work of the CCG s Quality Team relating to quality improvements affecting the wider health and care economy. Key pieces of improvement work included: Special School Nursing Review as part of review of the 0 19 pathway, Care Home Strategy development, maternity services transformation and workforce transformation. MC noted that the Quality and Patient Experience Committee on 14 June had discussed specific quality risks, particularly with regard to mental health services; approved the Quality Assurance Strategy, presented at the previous agenda item; renewed its terms of reference; emphasised that primary care engagement was essential cross all commissioners and providers; and noted the Care Home React to Red update requesting a further update at the next meeting. MC explained that soft intelligence meetings were being established to inform prioritisation of work with primary care. She also noted that learning would be shared with Practices from Care Quality Commissioning events and discussion would take place with Practices to provide support as appropriate. MC referred to the earlier discussion about workforce highlighting that the CCG was working with Practice Nurses on how best to support The General Practice Nursing 10 Point Plan. She reported that the CCG had appointed a Practice Nurse for one day a week to provide support to Practices. MC referred to the CCG s clinical quality visits to Tees, Esk and Wear Valleys NHS Foundation Trust commending all aspects of services visited. MC highlighted the ongoing work relating to learning disabilities services, including standardising and encouraging coding on the GP register across primary care; development with City of York Council of a Learning Disabilities Strategy; and liaison by NHS England staff with Practices to ascertain intentions about signing up to the Annual Health Check Designated Enhanced Service. In response to RW enquiring about educational events relating to learning disabilities, MC would also look into this. Unconfirmed Minutes Page 17 of 312

18 With regard to Safeguarding Children MC explained that the CCG, with the Police and Local Authorities, shared the associated legal duties. She noted that the CCG was a member of three Safeguarding Children Boards (City of York, North Yorkshire and East Riding of Yorkshire). MC highlighted that new partnership arrangements for the City of York Safeguarding Children Board were well advanced and application had been made for financial support to become one of 17 early adopters. MC also noted that discussion was taking place regarding new duties on CCGs and Local Authorities to review child deaths advising that the established process worked well. The Governing Body: 1. Received the Quality and Patient Experience Report. 2. Noted that MC would look into availability of educational events relating to learning disabilities. RECEIVED ITEMS The Governing Body noted the following items as received: 15. Audit Committee Minutes of 26 April and 23 May Executive Committee Minutes of 4 and 18 April, 2 and 16 May and 6 June Finance and Performance Committee Minutes of 26 April and 24 May Primary Care Commissioning Committee Minutes of 22 May Quality and Patient Experience Committee Minutes of 14 June Medicines Commissioning Committee recommendations of 11 April and 9 May Next Meeting The Governing Body: Noted that the next meeting would be held at 9.30am on 6 September 2018 at West Offices, Station Rise, York YO1 6GA. Close of Meeting and Exclusion of Press and Public In accordance with Paragraph 8 of Schedule 2 of the Health and Social Care Act 2012 it was considered that it would not be in the public interest to permit press and public to attend this part of the meeting due to the nature of the business to be transacted as it contains commercially sensitive information which, if disclosed, may prejudice the commercial sustainability of a body. Unconfirmed Minutes Page 18 of 312

19 Follow Up Actions The actions required as detailed above in these minutes are attached at Appendix A. A glossary of commonly used terms is available at: Unconfirmed Minutes Page 19 of 312

20 NHS VALE OF YORK CLINICAL COMMISSIONING GROUP Appendix A ACTION FROM THE GOVERNING BODY MEETING ON 5 JULY 2018 AND CARRIED FORWARD FROM PREVIOUS MEETINGS Meeting Date Item Description Director/Person Responsible Action completed due to be completed (as applicable) 8 March July 2018 Safeguarding Children Annual Report Business case for succession planning to be presented to Executive Committee MC Ongoing 4 January April July 2018 Accountable Officer Report Confirmation to be provided as to whether the end of December 2017 target date for the rollout of free wi-fi capability to GP Practices had been achieved Delayed new projected completion date TP MA-M 31 March May 2018 Ongoing Unconfirmed Minutes Page 20 of 312

21 Meeting Date Item Description Director/Person Responsible Action completed due to be completed (as applicable) 5 July 2018 Risk Update Report RW to provide information regarding concerns about Personality Disorder referrals RW/DN 5 July 2018 Healthier You: NHS Diabetes Prevention Programme 5 July 2018 Quality and Patient Experience Report City of York Council Health and Wellbeing Board to be asked to add a report on health checks and associated concerns to the Forward Plan MC to look into availability of educational events relating to learning disabilities SS MC Unconfirmed Minutes Page 21 of 312

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23 Item Number: 5 Name of Presenter: Phil Mettam Meeting of the Governing Body Date of meeting: 6 September 2018 Report Title Accountable Officer s Report Purpose of Report To Receive Reason for Report To provide an update on a number of projects, initiatives and meetings which have taken place since the last Governing Body meeting and an overview of relevant national issues. Strategic Priority Links Strengthening Primary Care Reducing Demand on System Fully Integrated OOH Care Sustainable acute hospital- single acute contract Transformed MH-LD- Complex Care System transformations Financial Sustainability Local Authority Area CCG Footprint City of York Council Impacts- Key Risks Financial Legal Primary Care Equalities East Riding of Yorkshire Council North Yorkshire County Council Covalent Risk Reference and Covalent Description Emerging Risks (not yet on Covalent) Recommendations The Governing Body is also asked to note the report. Responsible Executive Director and Title Phil Mettam Accountable Officer Report Author and Title Sharron Hegarty Head of Communications and Media Relations Annex 1 - General Practice Pay Awards letter from NHS England Annex Annex 3 Annex Page 23 of 312

24 GOVERNING BODY MEETING: 6 SEPTEMBER 2018 Accountable Officer s Report 1. Turnaround, financial position and system recovery 1.1 The CCG s financial plan submitted to NHS England on 31 May 2018 included an in-year deficit of 14.0m. This has reduced by 1.40m due to receipt of the Q1 instalment of the Commissioner Sustainability Fund and now stands at a forecast 12.6m deficit. 1.2 The CCG s financial position at month 4 is a deficit of 3.3million and is in line with the planned deficit anticipated at this point in the year. 1.3 The Aligned Incentive Contract (AIC) is now in operation and is having early positive impacts in changing the nature of the conversation between providers and commissioners and allowing more focus on the reorganisation of patient services and improving the efficiency and effectiveness of health and care services across the system. The contract is expected to operate for the duration of The exact operation of the AIC and its impact on organisational financial assumptions is being worked through. 1.4 The CCG s long term financial recovery plan has now been approved by NHS England following submission in June The CCG has received notification of the Government s decision regarding General Practice Pay Awards. The letter (see annex 1) provides details on pay scales for salaried GPs and information about the GP trainer grant, GP appraiser fees, and clinical educators pay for GP educators. It also discussed the delivery of an equitable and consistent approach to uplifting PMS and APMS contracts. 2. CCG annual assessment 2.1 The CCG s official performance rating has been confirmed as Requires Improvement. 2.2 The evidence-based annual assessment is conducted by local NHS England teams and moderated regionally and nationally. The assessment, an improvement on the rating for focused on six main components: Cancer, Mental Health, Dementia, Clinical measures, Finance (sustainability) and the Quality of Leadership. 2.3 The rating is based on improved performance delivery and demonstrates significant improvement in clinical performance indicators. NHS England highlighted the work to date to stabilise the local system s financial position in and the role of the strong, clinically-led Executive team that is now in place and delivering this improvement. Page 24 of 312

25 3. Improved access to primary care services 3.1 Following the CCG s contract awards, to Nimbuscare Ltd and the Modality Partnership, people living in the Vale of York s central and north localities will soon have the opportunity to visit, or talk to a healthcare professional in the evenings, at weekends and on bank holidays from October During the Big Conversations Roadshow series in 2017, the CCG asked the Vale of York community to share what was important to them about local healthcare services. Providing better access to primary care services was identified as one of the main themes. 4. Humber, Coast and Vale Health and Care Partnership 4.1 To support transformation programmes, a number of strategic boards have been established across the Humber, Coast and Vale (HCV) Health and Care Partnership working on key resourcing issues for workforce, capital and estates, finance and digital technology The Humber, Coast and Vale area will have access to up to 9.977m of national investment over the next three years to drive its digital strategy forward. To enable the draw down this funding, HCV partners will be working together, with North Region NHS England Digital, to agree local investment priorities. National investment will need to be matched locally, either financially or in-kind, for example resources such as staffing. Partners will be prioritising a schedule of investment programmes with oversight and management through the Strategic Digital Board. The board will also oversee the development of a Digital Strategy for the Partnership The Humber, Coast and Vale Executive Group has agreed draft workforce objectives and priority areas. The group s shared ambition for workforce will be delivered through a number of key objectives and priority areas as part of a Partnership-wide workforce plan. These are: - Developing the current workforce - Increasing future supply - Developing the workplace - Building workforce infrastructure and investment decision making Across the wider Humber, Coast and Vale geography, collaborative efforts are also focused upon work in six key clinical priority areas: - Mental health - Cancer - Elective (planned) care - Urgent and emergency care - Maternity services - Primary care Page 25 of 312

26 4.2 The Humber, Coast and Vale Health and Care Partnership s Annual Report that has been produced and is now published on its website. 5. Engaging the Vale of York community 5.1 End of life care, also known as palliative care, may not be an easy topic to think or talk about. That is why the CCG is working with its partners to create an end of life care strategy that aims to improve and further develop end of life care and support services. To ensure the needs and views of the Vale of York community are reflected, local people are being encouraged to share their experiences. The information collected will be used to shape the strategy and create a Citizens Charter. 5.2 The CCG is also working with North Yorkshire CCGs to gather feedback on services for adults with autism and attention deficit hyperactivity disorder (ADHD). The North Yorkshire Autism and ADHD Assessment Service, is currently provided at the Tuke Centre York. Patients are referred to the Tuke Centre by their GP or other health professional for assessment and diagnoses. Over the last few months the CCG has already met with Vale of York service users, their family members, carers and staff to ask for their views on the current services and if there were ways that they could be improved for them. To gather even more insight and opinions the CCG has produced a survey that is available online and in hard copy formats. 5.3 Involving people in their care and treatment means supporting people to manage their own health and wellbeing on a daily basis. It is about supporting them to become involved, as much as they want or are able to, and focusing on what matters to the individual within the context of their lives, not simply addressing a list of conditions or symptoms to be treated. The recent guidance will support the CCG to fulfil its legal duties to involve people in their health and care, so that people experience better quality care and improved health and wellbeing, and the system makes more efficient use of resources. For the CCG it means commissioning services that routinely provide individuals with the information, care and support to determine and achieve the outcomes that matter to them. (See Annex 2 for the link to more information). 5.4 The CCG has adopted new bite-size guides for good patient and public participation. The guides aim to support the planning and delivery of good patient and public participation and will help the CCG to put public, patient and carer voices at the centre of our healthcare services, from planning to delivery. (See Annex 3 for the link to more information). 5.5 The preventable, unfair and unjust differences in health status between groups, populations or individuals that arise from the unequal distribution of social, environmental and economic conditions. The CCG is using NHS Page 26 of 312

27 England s new Equality and Health Inequalities Hub which brings together equality and health inequalities resources and provides useful links and information for the sharing of good practice. (See Annex 4 for the link to more information). 6. Better Care Fund update 6.1 In line with national requirements the quarter 1 return for the York area was submitted in July Following a review of the revised Operating Guidelines, it is not necessary to submit a refreshed planning template for York. However, a number of amendments to the Section 75 Agreement will be made to reflect recent changes such as governance arrangements to fully describe the role of the newly formed Place Based Improvement Partnership and the York Health and Wellbeing Board as part of the Better Care Fund work The legal agreement also needs to include recent the commitment to invest part of the Improved Better Care Fund (ibcf) contingency in schemes which further promote prevention, early intervention and system integration. These are the expansion of Local Area Co-ordination, infrastructure support for the independent sector, infrastructure support for information sharing and business intelligence across BCF and a proposal to conduct a Capacity and Demand exercise across the wider health and care system to enhance planning capabilities for which is the expected period of the next BCF planning framework The Department of Health and Social Care has advised local authorities and health organisations of their ambitions for Revised Targets for Delayed Transfers of Care (DTOC) during The government has moved away from the approach whereby the target set was 3.5% of all beds being occupied by a patient experiencing a DTOC. The ambitions are to be measured against a baseline covering the period from October to December Using the national calculations the number of adults in York is 171,639 based upon the 2017 population estimate. 6.2 The BCF plan in North Yorkshire covers a two year period up to The majority of schemes are those that have been rolled forward from the plan. An agreement has been reached upon the allocation of the Disabled Facilities Grant The escalation process has been exited following the submission of DTOC targets. Submissions for BCF and ibcf updates for quarter 4 in have been submitted to NHS England and the Department for Communities and Local Government (DCLG) along with the newly combined BCF & ibcf updates for quarter 1 in The Section 75 agreement for the BCF pooled budget has been signed. Page 27 of 312

28 6.2.3 The performance against national metrics varies across areas of North Yorkshire. 7. Annual General Meeting 7.1 The Governing Body is holding its fifth Annual General Meeting in September at the Priory Street Centre, York YO1 6ET on Thursday 20 September 2018 from 2pm. 7.2 The meeting will discuss the Annual Report and Accounts for and offers an opportunity for those attending to talk to Governing Body members. 7.3 Questions can be submitted up to seven days in advance of the meeting by to or in writing to NHS Vale of York CCG, West Offices, Station Rise, York YO1 6GA 8. Chief Finance Officer appointment 8.1 I am pleased to officially welcome Simon Bell, the CCG s new Chief Finance Officer. Simon joins the CCG from NHS Kernow CCG in Cornwall, where he served as Chief Finance Officer for three years. Previously he was Chief Finance Officer at South Devon and Torbay CCG and has worked for the NHS for more than 20 years across a number of provider and commissioning organisations. 9. Emergency Preparedness, Resilience and Response Assurance 9.1 The CCG has completed the annual Emergency Preparedness, Resilience and Response (EPRR) self-assessment and assurance process and has received notification that is has retained a Substantial compliance level for The CCG s EPRR Lead took an active role in the York Teaching Hospital NHS Foundation Trust s (YTHFT) LIVEX event at the Army Medical Training Centre at Strensall in July LIVEX tested YTHFT s Incident Response Plan and provided Emergency Department staff with experience of dealing with a mass casualty event. It also enabled YTHFT to meet NHS England's EPRR standards that requires Category 1 responders to practice Incident Response Plans at least once every three years. 9.3 I am pleased to advise that Simon Bell, Chief Finance Officer, will join the Director On-Call rota in September National issues 10.1 Europe s largest survey of healthcare patients has been published and shows that more than eight out of 10 have a good experience of their GP practice. Almost 760,000 took part in the GP Patient Survey, sent to a sample of patients from practices across England. The survey has been redesigned to Page 28 of 312

29 reflect changes to primary care services, set out in the General Practice Forward View, providing more useful data to assess progress NHS Improvement has published the first patient-level information and costing system (PLICS) public view tool. This allows anyone to review high-level information about activity and costs of acute NHS services. This data can be used for a range of analyses to support the wider work of the costing transformation programme. The tool, developed in collaboration with NHS Digital, is based on PLICS collection and linked Hospital Episode Statistics data. A management information report has also been published, which is available on NHS Digital s website A new guide has been created to help Patient and Participation Group (PPG) members support their GP practices in encouraging patients to sign up for GP Online Services. The guide - Patient Participation Groups: What you need to know about GP Online Services gives ideas and tips that PPG members can use to support their GP practices, as well as resources, to help promote the use of GP Online Services. It also provides more information on how practices can register patients to use online services and help relieve some of the pressure on staff A new flu guide has been launched by NHS England Primary Care Digital Transformation to support GP practice staff in encouraging their patients to register and book their flu clinic online this autumn and winter. The guide- Flu Season: Making the most of online appointments includes information on how flu clinics can be used to register patients for online as well as providing information and links to further resources on the wider benefits of GP Online Services for both patients and practices National dementia diagnosis rates (DDR) for June 2018 have now been published and can be found on the NHS Digital website. Commissioners are asked to cascade this information to member practices and to continue working with practices reporting low diagnosis rates. The dementia CCG Improvement and Assessment Framework (IAF) support offer can be found on the NHS England website. Practices with a DDR of 66.7% are encouraged to continue to improve the care of people with dementia and their families. CCGs are being asked to check their DDR and act to maintain or improve their rate to support NHS England s business plan priority, to maintain a minimum of two thirds diagnosis rates for people with dementia NHS England has published its Annual Report and Accounts for , detailing the work of the organisation over the last year and outlining some of its most significant achievements and challenges The NHS Grant Agreement (July 2018 edition) has been updated and republished on the NHS Grant Agreement web page. A CCG can use a grant to provide financial support to a voluntary organisation which provides or Page 29 of 312

30 arranges for the provision of services which are similar to those in respect of which the CCG has statutory functions. The NHS Grant Agreement has now been republished to bring it in line with the General Data Protection Regulation The Government s response to Transforming Children and Young People s Mental Health details how its proposals will be developed and tested. For year one, eligible CCGs are being invited to bid with partners to become trailblazers, implementing and testing new school and college-based Mental Health Support Teams, and in some trailblazers, pilot four-week waiting times. The new resources are additional to existing services, including those commissioned by partners, and intended to build on the children and young people s mental health programme to improve outcomes in community and inpatient settings The experience of cancer patients in England remains generally positive, according to responses from more than 69,000 people participating in this year s National Cancer Patient Experience Survey. Assessing their overall care from 0 (very poor) to 10 (very good), respondents gave an average rating of 8.80, up from Most topics showed improvement except one. 60% of respondents thought GPs and nurses at their general practice definitely did everything they could to support them during cancer treatment, down from 62% last year and 63% the year before. The full report can be found on the National Cancer Patient Experience Survey website. Local level data will be published next month NHS England has requested CCG Clinical Leaders, Accountable Officers, and Heads of Medicines Management-Optimisation to keep informed and updated on national preparations for the entry to market this October of adalimumab biosimilars, via the regular briefings to Regional Medicines Optimisation Committees. An adalimumab biosimilar toolkit for commissioners and providers has also recently been made available, and is intended to support conversations among local hospital and pharmacy teams to plan and prioritise appropriate action NHS England has published an updated version of the Eye Health Policy Book. This document underpins the provision of NHS England s commissioning responsibilities in respect of the High Street NHS Sight Test Musculoskeletal conditions are the single biggest cause of disability in the UK, accounting for 30% of GP consultations in England. The Musculoskeletal core capabilities framework for first point of contact practitioners, published in partnership by NHS England, Skills for Health, Public Health England, Health Education England and the Arthritis and Musculoskeletal Alliance, aims to ensure the range of healthcare professionals who work with patients with MSK problems can play a full role in helping to manage problems appropriately at the first point of contact, and help to relieve pressures on Page 30 of 312

31 primary and secondary care. The framework offers commissioners, employers, regulators and practitioners clear definitions against which to assure and improve NHS England has launched a 12 week consultation on the contracting arrangements for Integrated Care Providers (ICPs). The consultation provides more detail about how the proposed ICP Contract would underpin integration between services, how it differs from existing NHS contracts, how ICPs fit into the broader commissioning system, and which organisations could hold the ICP Contract. The previous iteration of this draft contract was referred to as the draft Accountable Care Organisation (ACO) Contract. The consultation runs until 26 October Around one fifth of hospital beds are occupied by patients who have been in hospital for three weeks or more. The national ambition is to reduce the number of long-stay patients by 25% - freeing up at least 4,000 beds compared to The latest update released on 9 August 2018; offers a view by CCG, allowing commissioners to review their relevant data and support their providers in achieving the agreed ambition The National Collaborating Centre for Mental Health (NCCMH) has published The Dementia Care Pathway Full implementation guidance. This is one of a suite of mental health care pathways developed on behalf of NHS England to support the delivery of the ambitions of The Five Year Forward View for Mental Health and the Next Steps on the NHS Five Year Forward View. The guidance outlines the associated benchmarks to support improvements in the delivery and quality of care and support, for people living with dementia and their families and carers. It builds on NHS England s Implementation guide and resource pack for dementia care Quick guides to help support children and young people with special educational needs and disabilities (SEND) have been published to assist health commissioners and providers with joint commissioning of services and provide guidance on developing processes to ensure that children and young people with SEND are fully supported in the best ways possible. 11. Recommendation 11.1 The Governing Body is asked to note the report. Page 31 of 312

32 OFFICIAL Gateway Ref Sent via Directors of Commissioning Regional heads of Primary Care Heads of Primary Care CCG Clinical Leads Accountable Officers Primary Care Contracts NHS England Skipton House London Road SE1 6LH 26 July 2018 Dear colleagues Re: General Practice Pay Awards 2018/19 I wrote to you on 20 March 2018 to summarise the outcome of the 2018/19 General Medical Services contract negotiations. A copy of that letter can be found on the NHS England website: In that letter, I noted that, although a 1% pay uplift had been implemented from 1 April 2018, a further contract uplift may be made following the Government s response to any recommendations by the Doctors & Dentists Review Body (DDRB). The Government has now taken decisions on GP pay for 2018/19 and this was announced in a Written Ministerial Statement to Parliament which can be found at the following link: The Pay Award The Government has decided to award GPs and practice staff 2% pay uplift in 2018/19, which is to be backdated to 1 April High quality care for all, now and for future generations Page 32 of 312

33 OFFICIAL Given a 1% pay uplift has already been implemented, it now means a further 1% uplift needs to be implemented and backdated to April to deliver a total of 2%. As a result, the GMS Global Sum per weighted patient figure will increase by 1.2% to (as the baseline on which the pay uplift is calculated includes other costs, such as QOF and enhanced services) as set out in the table below. From 1 April 2019, there will also be the potential for up to an additional 1% to be added to the 2018/19 baseline on top of the 2% already paid, which is conditional on the ongoing contract negotiations. Additional increase Detail Current Revised % Global Sum price per weighted patient % As the National Health Asset & Infrastructure System (NHAIS) has already calculated global sum payments for quarter 2 of 2018/19, the change will be implemented from the start of quarter 3 i.e. from October For GMS contracts this will be affected by NHAIS and there is no action for local commissioners. PMS and APMS contracts To deliver an equitable and consistent approach to uplifting PMS and APMS contracts commissioners should uplift those local contracts by 1.04 per weighted patient backdated to 1 April Salaried GPs The Government has also decided that from 1 October 2018 the recommended minimum and maximum pay scales for salaried GPs will be uplifted by 2%. GP trainer grant, GP appraiser fees, clinical educators pay for GP educators From 1 October 2018, the GP trainer grant and GP appraiser fees will be increased by 3% as will clinical educators pay for GP educators. Please ensure that this letter is distributed to all relevant people within your teams. Yours sincerely Ed Waller Director New Business Models and Primary Care Contracts Groups High quality care for all, now and for future generations Page 33 of 312

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35 Item Number : 6 Name of Presenter : Phil Mettam Meeting of the Governing Body Date of meeting: 6 September 2018 Risk Update Report Purpose of Report To Receive Reason for Report To provide assurance that risks are strategically managed, monitored and mitigated. This report provides present details of current events and risks escalated to Governing Body by the sub-committees of the Governing Body for consideration regarding effectiveness of risk management approach. All events have been reviewed by the relevant lead since the last Governing Body. Strategic Priority Links Strengthening Primary Care Reducing Demand on System Fully Integrated OOH Care Sustainable acute hospital/ single acute contract Local Authority Area CCG Footprint City of York Council Impacts/ Key Risks Financial Legal Primary Care Equalities Transformed MH/LD/ Complex Care System transformations Financial Sustainability East Riding of Yorkshire Council North Yorkshire County Council Covalent Risk Reference and Covalent Description All corporate risks escalated to the Governing Body. Emerging Risks (not yet on Covalent) There is one emerging risk / event this month, PC.01, which has been deemed significant. This involves the Docman 7 system. Page 35 of 312

36 Recommendations The Governing Body is requested to: review risks arising and to consider risk appetite for events and high scoring risks. Responsible Executive Director and Title Phil Mettam Accountable Officer Report Author and Title Rachael Simmons Corporate Services Manager Page 36 of 312

37 GOVERNING BODY : 6 SEPTEMBER 2018 Risk Update Report A different way of recording risks / events has been trialed without the use of Pentana (Covalent). Risk / event owners and leads have also been asked to identify both the impact and the likelihood of each risk / event. This new process is proving successful. All events have been reviewed since the last Governing Body. The following event rating has increased : Reference Description QN.02 Potential risk to quality of care and patient safety at Unity Practice Rating increased from 16 to 20 The following event been added to the risk register : Reference Description PC.01 A problem with the Docman 7 system has resulted in results and correspondence from secondary care going to an unknown folder in a number of practices and therefore not being accessed Likelihood 5; impact 3 RAG 15 The rating for the following events have remained the same : Reference RAG Key Points ES.17 Failure to deliver 1% surplus in-year Likelihood 4x Impact 4 RAG 16 JC.26a CAMHS long waiting lists JC.26b children autism assessments JC.26c Children and young people s eating disorders Likelihood 4 x Impact 4 RAG 16 Likelihood 4 x Impact 3 RAG 12 Likelihood 4 x Impact 4 RAG 16 Categorised as an event rather than a risk as the 1% in-year surplus will not be delivered. Waiting lists remain very high reflecting high levels of referral into service despite the schools projects and the crisis team, all of which have reduced demand for support. Waiting lists remain long and 238 currently waiting for assessment. TEWV is investing an additional 50k recurrently in the service. The CCG has committed non-recurrent funding of 120k in the current year to fund additional assessments. Additional funding from the CCG has enabled recruitment of 0.6WTE clinical psychologist. Page 37 of 312

38 JC.30 Dementia - Failure to achieve 67% coding target in general practice. Likelihood 4 x Impact 4 RAG 12 Diagnosis decreased slightly in June to 60.6% from 60.7%. There are no risks or events this month identified as being within the CCG s risk appetite, thus requiring archiving. Page 38 of 312

39 CORPORATE NEW EVENT MANAGED BY GOVERNING BODY Risk Title & Ref Description Impact on Care, Potential for Harm Mitigating Actions Latest Note Operational Lead Lead Director L hood Impact Current Risk Rating Movement this Month Last Reviewed PC.01 Docman 7 system A problem with the Docman 7 system has resulted in results and correspondence from secondary care going to a unknown folder in a number of practices and therefore not being accessed Significant CAS alert raised by NHS England and an SI declared with NHS England to lead. All practices with version 7 aware. Practices now all aware of location correspondence going to Practices to record effect and impact and send to CCG to amalgamate and escalate to NHS England Shaun Macey Executive Director of Primary Care and Population Health NEW 17 August 2018 Page 39 of 312

40 CORPORATE ON-GOING EVENTS MANAGED BY GOVERNING BODY Risk Ref & Title ES.17 There is a potential risk that the CCG will fail to deliver a 1% surplus in-year. JC.26a CAMHS: long waiting lists for assessment and treatment that significantly extend beyond national constitutional standards JC.26b Children s Autism Assessments: long waiting lists and noncompliance with NICE guidance for diagnostic process Description The scale of the financial challenge for the organisation is such that the CCG will not deliver a 1% surplus in-year or cumulatively in the short term and will likely require a number of years to reach this point. Long waiting lists may adversely affect response to treatment and outcomes. CYP and families experience longer periods of stress and anxiety waiting for appointments and treatment. Poorer or reduced outcomes may have effects on longer term emotional and mental health. There is potential detriment to reputation, and effects on partnerships, e.g. local authority. For the 5-18 pathway there is a long waiting list. For both the 0-5 and 5-18 pathways, the diagnostic process does not comply with NICE guidance. Children and families can wait for long periods for assessment and diagnosis, with consequent strain and anxiety, and do not receive support from other agencies pending diagnosis. There are Impact on Care, Potential for Harm Mitigating Actions Latest Note Operational Lead Failure to retain a surplus of 1% will not have an overall impact on patient care. Delays in assessment and diagnosis leading to delays in treatment and support options. Poor patient experience. AIC including joint cost reduction programme. Joint System Transformation Board. Service Development Improvement Plan in place. Delays in assessment Finalising action plan to and diagnosis mean address issues around waiting families wait longer for lists and diagnostic process specialist support in school and other settings. The CCG has submitted a 2018/19 plan that delivers the required in-year control total deficit of 14m against which it will be measured and for which it would then be able to access Commissioner Sustainability Funding of 14m, a technical adjustment that would mean an inyear break-even position. Therefore the CCG will not deliver a 1% surplus in-year and local modelling of the Medium Term Financial Strategy does not anticipate this being delivered until around 2020/21. Waiting lists remain very high reflecting high levels of referral into service despite the schools projects and the crisis team, all of which have reduced demand for support. The CCG is investing 1210k recurrently into CAMHS services; TEWV will use this for additional support to the emotional and eating disorders pathways. TEWV is investing 50k recurring into autism assessment. Staff are being appointed and expected to be in post for October The impact is expected to be reduction in waiting lists; the capacity and demand analysis will quantify the effect. Waiting lists remain long and 238 currently waiting for assessment. TEWV is investing an additional 50k recurrently in the service. The CCG has committed nonrecurrent funding of 120k in the current year to fund additional assessments. The capacity and demand gap analysis is being costed and will facilitate discussions during Q2/Q3 around future investment models. TEWV Michael Ash-McMahon Susan De Val; Paul Howatson Susan De Val; Paul Howatson Lead Director Chief Finance Officer Executive Director of Transformation, Complex Care and Mental Health Executive Director of Transformation, Complex Care and Mental Health L hood Impact Current Risk Rating Movement this Month Last Reviewed 13 August August August 2018 Page 40 of 312

41 Risk Ref & Title JC.26c Children and young people eating disorders. Noncompliance with national access and waiting time standards JC.30 Dementia - Failure to achieve 67% coding target in general practice. QN.02 Potential risk to quality of care and patient Description concerns around the pathway for formal diagnosis because of limited input across professional input into assessment. Higher than anticipated referral rates into the NYY eating disorder service in York means TEWV does not meet access and waiting time standards. These patients are usually very ill and require intensive long term care and support. Although patients are seen outside the national waiting time standard, they generally do not wait long periods, but the high volume means patients are in treatment for longer than national standards recommend, and outcomes may be poorer and take longer to be apparent. Non delivery of mandatory NHS England targets Lack of sufficient providers in some areas resulting in delayed transfers of care or limited choice available to patients meeting new standards Unity Practice in NHS Vale of York CCG area has been assessed as Inadequate by Impact on Care, Potential for Harm Mitigating Actions Latest Note Operational Lead Delays in assessment and diagnosis: high referral rate leads to longer periods in treatment with potential for poorer outcomes. Further pressure from NHS England to rectify this. Service users may not be appropriately flagged and therefore ongoing referrals from primary care will not have the relevant information to make reasonable adjustments for their carers support. Quality of patient care and patient safety may be compromised Finalising an action plan to set out how TEWV will deliver to national standards. CCG/PCU leads have devised a comprehensive action plan. CCG to provide focussed support targeting the larger practices with the lowest coding rates. All practices will be encouraged to re-run the toolkit and review all records identified. Controls include: Programme meeting and TEWV CMB Unity engaging with M.Carrington, K.Smith and H.Marsh on a weekly basis. is also examining the pathway around integration of autism and ADHD referrals to reduce waiting times. SDIP now agreed following workshop in June Performance remains well below national trajectories, although TEWV s internal recording framework and continued staff training and improved performance against targets and has enabled focus to be placed on other aspects of service delivery. The SDIP covers quality auditing, service user engagement and future service model to facilitate discussions around funding post The additional funding from the CCG has enabled recruitment of 0.6WTE clinical psychologist into the service. TEWV, through New Models of care for Crisis Response, is planning how to expand into CEDs to support CYP to remain at home rather than inpatient admissions. The issue remains a standing exception at CMB, and QPEC and F&P are sighted. Diagnosis decreased slightly in June to 60.6% from 60.7%. 25 patients were added to the registers. The estimated prevalence increased to 4,441 from 4,430 which reduces the impact of the additional diagnoses. Movement from 4,410 to 4,430 which reduced the impact of this increase. Targeted support to GP practices continues and negotiations are underway to secure a technical and data quality resource in primary care to assist with identification and coding. Following a comprehensive inspection by CQC on the practice was rated as Susan De Val; Paul Howatson Sheila Fletcher Sarah Goode Lead Director Executive Director of Transformation, Complex Care and Mental Health Executive Director of Transformation, Complex Care and Mental Health Executive Director of Quality and L hood Impact Current Risk Rating Movement this Month Last Reviewed 09 August July July 2018 Page 41 of 312

42 Risk Ref & Title Description Impact on Care, Potential for Harm Mitigating Actions Latest Note Operational Lead Lead Director L hood Impact Current Risk Rating Movement this Month Last Reviewed safety at Unity Practice the CQC in all but one domain and placed in special measures. There is a risk that their closed list may not reopen in time for 5000 new York University students who will need to register at the practice. There is a risk the practice may not meet the required improvements when fully reinspected in around six months time leading to potential for the CQC to close the service. An RCGP GP, PM and nurse support Unity on a weekly basis. C.Lythgoe ½ day per week nurse manager supportaction plan written. Lou Johnson attending the Yorkshire and the Humber Leadership Academy Practice Managers Programme 2018/19. Jorvik Gillygate Practice supporting new patients. Weekly submission of required CQC action plans inadequate overall. The practice have closed their patient list. CQC will review on 10/09/18. Nursing Page 42 of 312

43 Item Number: 7 Name of Presenter: Simon Bell Meeting of the Governing Body Date of meeting: 6 September 2018 Financial Performance Report Month 4 Purpose of Report For Information Reason for Report To brief members on the financial performance of the CCG and achievement of key financial duties for 2018/19 as at the end of July To provide details and assurance around the actions being taken. Strategic Priority Links Strengthening Primary Care Reducing Demand on System Fully Integrated OOH Care Sustainable acute hospital/ single acute contract Transformed MH/LD/ Complex Care System transformations Financial Sustainability Local Authority Area CCG Footprint City of York Council Impacts/ Key Risks Financial Legal Primary Care Equalities East Riding of Yorkshire Council North Yorkshire County Council Covalent Risk Reference and Covalent Description F17.1- ORG Failure to deliver 1% surplus F17.2 ORG Failure to deliver planned financial position F17.3 ORG Failure to maintain expenditure within allocation Emerging Risks (not yet on Covalent) Page 43 of 312

44 Recommendations The Governing Body is asked to note the financial performance to date and the associated actions. Responsible Executive Director and Title Simon Bell, Chief Finance Officer Report Author and Title Natalie Fletcher, Head of Finance Page 44 of 312

45 Finance and Contracting Performance Report Executive Summary April 2018 to July 2018 Month /19 Page 45 of 312

46 Financial Performance Headlines IMPROVEMENTS IN PERFORMANCE Issue Improvement Action Required Commissioner Sustainability Funding (CSF) The CCG has received the first instalment of it s Commissioner Sustainability Funding. The Q1 payment received is 1.4m which is 10% of the 14.0m CSF available in 2018/19. The CCG s planned deficit has been adjusted to 12.6m to take account of this. Closely monitor financial performance throughout Q2, identifying mitigating actions where required, to ensure receipt of CSF payment at the end of the quarter. 3.5m of CSF is available in Q2. Page 46 of 312

47 Financial Performance Headlines DETERIORATION IN PERFORMANCE Issue Deterioration Action Required Year to date performance of AIC contract Mental Health Out of Contract Placements The AIC contract with YTHFT is again reported as if the risk share has been invoked within the contract position. There are on-going challenges around quantifying and reporting QIPP delivery and at the time of reporting the actual cost reduction by all schemes could not be evidenced. Across the AIC contract, this equates to a YTD overspend of 2.31m with no corresponding off-set from repatriation plans. This has been fully mitigated at Month 4 by reprofiling the CCG s contingency so that a higher amount is available at the beginning of the year. The CCG will not be able to continue to do this in Month 5 unless other mitigations are identified. A reported overspend of 365k at Month 3 has now increased to 532k for Month 4. The reported forecast overspend in this area is 1.3m. Confirm the cost reduction impact of QIPP schemes and review areas that are creating financial or activity pressure on YTHFT, to determine whether risk share contract value continues to be the most realistic year to date position. Rapid review of Trust opportunity to release costs over the remainder of the year and live within the 340m AIC envelope. Identify further mitigations within the CCG s financial position. The overspend in this area is being reviewed as part of the data cleansing work covering Complex Care, to establish to what extent this is due to growth in patient numbers and to increased cost of placements. Page 47 of 312

48 Financial Performance Headlines ISSUES FOR DISCUSSION AND EMERGING ISSUES 1. Continuing Healthcare Work is continuing to validate the data transferred from the PCU. This includes both the data cleanse process to identify the responsible commissioner and legacy issues with the PCU, both of which are likely to have a financial impact, although the value of this needs to be finalised, expected by September An assessment of the outcome of this and the timing of any impact can then be made. An estimate of 1m has been made at this stage and reported to NHS England as a risk to the CCG s financial position. The CCG does have an agreement in principle with the other North Yorkshire CCGs to manage this collectively should any individual CCG be materially adversely impacted by this work. However, the CCG is not anticipating any impact of the legacy issues in 2018/ NHS Property Services Work is continuing to agree a year end deal for 2017/18. The 2017/18 year end position included a prudent assessment of this as far as possible. 3. Aligned Incentive Contract (AIC) As part of the Month 4 reporting the AIC partner organisations triangulated the year-to-date financial positions. As at Month 4 there is a 2.7m alignment gap between commissioners and provider. 2.4m is a profiling issue ( 1.3m baseline and 1.1m QIPP) with a further 0.3m for other adjustments, although this is actually two separate issues 1.4m for YTHFT assumption around payment for urgent care and pass through costs and 1.1m from commissioners enacting the risk share. Although the corresponding forecast has not yet been fully assessed it is clear if current trends continue there is a significant financial risk within the system and if unmitigated will play out somewhere. Page 48 of 312

49 Financial Performance Summary Summary of Key Finance Statutory Duties Year to Date Forecast Outturn Indicator Target m Actual m Variance m RAG rating Target m Actual m Variance m RAG rating In-year running costs expenditure does not exceed running costs allocation In-year total expenditure does not exceed total allocation (Programme and Running costs) G (12.6) R Better Payment Practice Code (Value) 95.00% 99.05% 4.05% G 95.00% >95% 0.00% G Better Payment Practice Code (Number) 95.00% 96.93% 1.93% G 95.00% >95% 0.00% G CCG cash drawdown does not exceed maximum cash drawdown (0.8) R In-year total expenditure does not exceed total allocation outturn expenditure is forecast to be 12.6m higher than the CCG s in-year allocation. The CCG s financial plan submitted to NHS England on 31 st May 2018 included an in-year deficit of 14.0m. This has reduced by 1.40m due to receipt of the Q1 instalment of the Commissioner Sustainability Fund. The CCG s in-year deficit is expected to be offset by receipt of the remaining 12.6m of the 14.0m total CSF, resulting in an in-year break even position. Maximum cash drawdown the target is calculated by NHS England and includes an arbitrary value for depreciation, 670k, that nominally reduces the MCD. This happens every year at this time and will be corrected later in the year on the basis of returns submitted by the CCG. Page 49 of 312

50 Financial Performance Summary Summary of Key Financial Measures Year to Date Forecast Outturn Indicator Target m Actual m Variance m RAG rating Target m Actual m Variance m RAG rating Running costs spend within plan (0.1) A G Programme spend within plan G G Actual position is within plan (in-year) (3.3) (3.3) 0.0 G (12.6) (12.6) 0.0 G Actual position is within plan (cumulative) (56.4) (56.4) 0.0 G Risk adjusted deficit (12.6) (12.6) 0.0 G Cash balance at month end is within 1.25% of monthly drawdown ( k) G QIPP delivery (1.8) R (0.6) R QIPP Summary QIPP Summary m QIPP Target 14.5 Delivered at Month QIPP Remaining 12.9 Page 50 of 312

51 NHS Vale of York Clinical Commissioning Group Financial Performance Report NHS Vale of York Clinical Commissioning Group Financial Performance Report Detailed Narrative Report produced: August 2018 Financial Period: April 2018 to July 2018 (Month 4) 1. Overall reported financial position The Year to Date (YTD) reported deficit at Month 4 is 3.3m, and forecast deficit for 2018/19 is 12.6m. This position continues to be in line with the CCG s financial plan. However, the Month 4 YTD and forecast deficit represent an improvement on the Month 3 position, due to receipt of the quarter 1 Commissioner Sustainability Funding (CSF). This movement is detailed in the table below. CCG planned surplus / (deficit) Year to Date Forecast Outturn M3 M4 M3 M4 ( 3.50m) ( 4.67m) ( 14.00m) ( 14.00m) CSF received 0.00m 1.40m 0.00m 1.40m Planned surplus/(deficit) net of receipt of CSF Reported surplus/(deficit) ( 3.50m) ( 3.27m) ( 14.00m) ( 12.60m) ( 3.50m) ( 3.27m) ( 14.00m) ( 12.60m) As per submitted financial plan Q1 payment received, 10% of total value as per national quarterly profile 2. Year to Date Supporting Narrative The reported YTD deficit is in line with plan, however within this position were several variances from plan which are explained in further detail in the table below. QIPP delivery of 1.6m has been reported to NHS England, against a plan of 3.5m. This is largely due to reporting challenges around schemes linked to the Aligned Incentive Contract with York Teaching Hospital NHS Foundation Trust (YTHFT) and is described in detail in Section 8. Reported year to date financial position variance analysis Description Value Commentary / Actions York Teaching Hospital NHS Foundation Trust (YTHFT) ( 2.32m) The reported position is as if the risk share has been invoked within the contract position. The CCG s QIPP schemes were initially planned on a PBR basis and have now been reviewed to determine what the actual cost reduction would be for each scheme. Delivery of schemes and the associated financial impact on the AIC could not be evidenced at the time of reporting to NHS England, and the reported position therefore assumes that the AIC risk share has been invoked in full, although it is anticipated this will be recovered Financial Period: April 2018 to July 2018 Page 51 of 312

52 NHS Vale of York Clinical Commissioning Group Financial Performance Report over the remainder of the year in line with the contract agreement. Contingency 2.04m The 0.5% contingency provided for in plan has been re-profiled, so that a higher amount is available to support the pressures in the YTD position with no corresponding off-set from repatriation plans. Mental Health Out of Contract Placements ( 0.53m) The overspend in this area is being reviewed as part of the data cleansing work covering Complex Care to establish to what extent this is due to growth in patient numbers and to increased cost of placements. This is partly off-set by the current underspend on SRBI, 0.18m, although this is low volume high cost care and subject to fluctuation. Continuing Care ( 0.37m) The reported year to date position is based on information from the QA system this is currently subject to a data cleanse exercise to ensure that the reported position becomes an accurate assessment of CHC spend. The CHC plan includes 0.52m of YTD QIPP. For QIPP reporting purposes, this is assumed to be delivering at the planned level but a more robust assessment of QIPP delivery is being developed alongside the data cleansing. Other Primary Care 0.36m The primary care 3 per head provided in plan was 0.36m for April to July and spend in this period has been minimal. However, the forecast outturn accounts for spend of the full 1.08m funding within the financial year. Primary Care Prescribing ( 0.30m) Primary Care prescribing spend was high in May, however only April and May data is available therefore it is too early in the financial year to determine whether this represents a trend of increased expenditure or is a one off. CHC Clinical Team 0.29m The forecast underspend is based on the YTD expenditure levels and reflects the lower level of spend compared to the budget set to fund the former Partnership Commissioning Unit. QIPP adjustment 0.29m The CCG identified QIPP schemes totalling 0.86m more than required to deliver the financial plan. Identified schemes were applied to the relevant expenditure lines in full, which therefore created an additional QIPP contingency of 0.86m. The 0.29m YTD element of this therefore partly offsets slippage on delivery of QIPP schemes. Other variances Total impact on YTD position 0.54m 0.00m 3. Forecast Outturn Supporting Narrative The forecast outturn of 12.6m deficit is in line with plan, however within this position there are several variances which are explained in further detail in the following table. Financial Period: April 2018 to July 2018 Page 52 of 312

53 NHS Vale of York Clinical Commissioning Group Financial Performance Report Forecast in-year financial position variance analysis Description Value Commentary / Actions York Teaching Hospital NHS Foundation Trust (YTHFT) ( 6.07m) The forecast position reflects the contract value under the AIC. Reserves 3.13m This forecast includes an assumed cost reduction of 2.91m through optimising use of acute elective capacity across the Vale of York area. This has been forecast through reserves as it is currently not known where the cost reduction will be realised. Contingency 1.38m 1.38m of the CCG s contingency has been identified to offset the additional cost of the AIC contract value over the value in the financial plan. 0.94m of the contingency ( 2.32m in total) is therefore available to mitigate any further pressures on the CCG s forecast outturn. Mental Health Out of Contract Placements ( 1.32m) The forecast overspend in this area is based on YTD expenditure patterns. As this expenditure is reviewed and the data cleansing work progresses, this forecast will be refined. Other acute services 1.00m The forecast underspend across various acute contracts is based on extrapolation of year to date SLAM data, using the CCG s standard forecasting methodology. QIPP adjustment 0.86m The CCG identified QIPP schemes totalling 0.86m more than required to deliver the financial plan. Identified schemes were applied to the relevant expenditure lines in full, which therefore created an additional QIPP contingency of 0.86m. CHC Clinical Team 0.77m The forecast underspend is based on the YTD expenditure levels and reflects the lower level of spend compared to the budget set to fund the former Partnership Commissioning Unit. Other variances Total impact on forecast position ( 0.25m) 0.00m Financial Period: April 2018 to July 2018 Page 53 of 312

54 NHS Vale of York Clinical Commissioning Group Financial Performance Report 4. Gap and key delivery challenges In the Month 4 non-isfe submission, the CCG reported risks totalling 2.97m which are offset in full as follows: Pressures Description Expected Value Commentary Continuing Healthcare 1.00m Work is continuing to validate the data transferred from the PCU. This includes both the data cleanse process to identify the responsible commissioner and legacy issues with the PCU, both of which are likely to have a financial impact, although the value of this needs to be finalised, expected by September An assessment of the outcome of this and the timing of any impact can then be made. An estimate of 1m has been made at this stage and reported to NHS England as a risk to the CCG s financial position. The CCG does have an agreement in principle with the other North Yorkshire CCGs to manage this collectively should any individual CCG be materially adversely impacted by this work. However, the CCG is not anticipating any impact of the legacy issues in 2018/19. QIPP under-delivery 1.97m In-year QIPP risk around delivery of out of hospital and Continuing Healthcare schemes. Total 2.97m Proposals and contingencies Description Expected Value Commentary Acute SLAs 2.04m Further work to optimise use of elective capacity across the Vale of York area Contingency 0.93m The balance of the 0.5% contingency provided for in plan that is available to mitigate any further financial pressures. Total 2.97m 5. Allocations Additional allocations have been received in Month 4, as follows: Description Recurrent / Category Value Non-recurrent Total allocation at Month m Quarter 1 CSF payment Non-recurrent Programme 1.40m Medicines Optimisation in Care Non-recurrent Programme 0.20m Homes programme funding Q1&2 Other allocation adjustments Non-recurrent Programme 0.03m Total allocation at Month m The CCG has this month received notification of the Agenda for Change pay award allocation it will receive for running costs, 59k, compared to the assessed 101k cost, a 42k pressure. Financial Period: April 2018 to July 2018 Page 54 of 312

55 NHS Vale of York Clinical Commissioning Group Financial Performance Report 6. Underlying position Description Planned in-year deficit Adjust for non-recurrent items in plan - Commissioner Sustainability Funding Q1 Primary Care 3 per head Repayment of system support Additional Winter Capacity Other non-recurrent items in plan Adjust for other non-recurrent items Non recurrent contingency available to mitigate in year pressures Prior Year Pressures Underlying financial position Value ( 12.60m) ( 1.40m) 1.08m 0.33m 0.23m 0.01m 0.94m 0.08m ( 11.33m) 7. Balance sheet / other financial considerations There are no material concerns with the CCG s balance sheet as at 31 st July One of the CCG s statutory requirements is that the cash drawdown in year must not exceed the Maximum Cash Drawdown as determined by NHS England. This is currently showing as red on the RAG rating however this is due to the NHS England calculation which includes an arbitrary value for depreciation and will be corrected later in the year. The CCG achieved the Better Payment Practice Code in terms of both the volume and value of invoices being paid above the 95% target in Month 4. Financial Period: April 2018 to July 2018 Page 55 of 312

56 NHS Vale of York Clinical Commissioning Group Financial Performance Report 8. QIPP programme Year to Date Forecast Outturn Area Ref Scheme Plan Actual Variance Plan Actual Variance 2018/01 Trauma and Orthopaedics (469) 2,250 1,125 (1,125) 2018/02 Optimising Health Thresholds ,000 1, /03 General Surgery / Gastroenterology (111) 1, (500) 2018/04 Biosimilar high cost drugs gain share (211) (316) 2018/05 Microsuction (ENT) (125) Planned Care 2018/06 Cardiology 44 0 (44) (200) 2018/07 Ophthalmology 38 0 (38) (169) 2018/08 Back Pain PLCV 38 0 (38) (169) 2018/09 Neurology 33 0 (33) (150) 2018/10 PLCVs 31 0 (31) (141) 2018/11 General Medicine (78) Out of Hospital Prescribing Primary Care Complex Care Running Costs 2018/17 Reduce ED Attendances 50 0 (50) (76) 2018/20 Non Elective Admissions Management (390) 1, (584) 2018/21 Delayed Transfers of Care (DToC) Reduction (205) (307) 2018/22 Community Beds Productivity Programme (350) 2018/23 Patient Transport project - reprocurement (13) /24 Community Podiatry 9 5 (3) (10) 2018/40 Minor Ailments Prescribing /41 Prescribing Schemes ,500 1, /42 Continence and Stoma Care /31 GPIT - NYNET /32 Other Primary Care Indicative Budgets 14 0 (14) (63) 2018/50 Complex Care - CHC and FNC benchmarking ,500 2,500 (0) 2018/51 Recommission MH out of contract expenditure (104) (42) 2018/60 Commissioning support (embed) contract savings /61 Vacancy Control (80) Optimising elective capacity ,909 2,909 Adjustment for identified schemes above in-year QIPP requirement (286) (859) ,166 1,640 (1,526) 14,524 13,909 (615) Financial Period: April 2018 to July 2018 Page 56 of 312

57 NHS Vale of York Clinical Commissioning Group Financial Performance Report Appendix 1 Finance dashboard YTD Position YTD Previous Month YTD Movement Forecast Outturn (FOT) FOT Previous Month FOT Movement Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual Variance Commissioned Services Acute Services York Teaching Hospital NHS FT 64,987 67,307 (2,320) 49,072 50,549 (1,477) 15,915 16,758 (843) 191, ,682 (6,073) 191, ,643 (6,033) 0 39 (39) Yorkshire Ambulance Service NHS Trust 4,370 4, ,278 3, ,093 1, ,110 13, ,110 13, (0) 0 Leeds Teaching Hospitals NHS Trust 2,841 2, ,104 1, (60) 8,604 8, ,604 7,565 1, (451) Hull and East Yorkshire Hospitals NHS Trust 1,084 1, (3) 3,173 2, ,173 2, (45) Harrogate and District NHS FT ,283 2, ,283 2, (24) Mid Yorkshire Hospitals NHS Trust (1) ,365 2, ,365 2,380 (15) 0 (158) 158 South Tees NHS FT (24) (11) (14) 1,358 1,435 (77) 1,358 1,432 (74) 0 3 (3) North Lincolnshire & Goole Hospitals NHS Trust (3) (36) 36 Sheffield Teaching Hospitals NHS FT (1) (1) Non-Contracted Activity 1,438 1,492 (54) 1, (153) 4,313 4,346 (34) 4,282 4, (133) Other Acute Commissioning (1) 1,028 1, ,028 1, (1) 1 Ramsay 1,687 1, ,133 1, (9) 5,939 5, ,939 5, (86) Nuffield Health 1,049 1,085 (36) (5) (31) 3,159 3, ,159 3,181 (22) 0 (25) 25 Other Private Providers (61) (34) (27) 1,245 1,393 (149) 1,245 1,449 (204) 0 (55) 55 Sub Total 80,431 82,538 (2,107) 60,455 61,493 (1,038) 19,976 21,044 (1,069) 238, ,918 (5,072) 238, ,381 (4,566) (506) Mental Health Services Tees, Esk and Wear Valleys NHS FT 13,694 13, ,236 10, ,457 3, ,049 41, ,049 41, (0) 0 Out of Contract Placements 1,887 2,419 (532) 1,431 1,796 (365) (167) 5,473 6,792 (1,319) 5,473 6,684 (1,211) (108) SRBI ,689 1, Non-Contracted Activity - MH (26) (26) Other Mental Health (52) (87) 1,388 1,471 (83) 1,388 1, (96) Sub Total 16,744 16,970 (227) 12,117 12,344 (227) 4,063 4,242 (178) 50,011 50,932 (921) 48,322 49,473 (1,151) (230) Community Services York Teaching Hospital NHS FT - Community 6,244 6, ,683 4, ,561 1, ,031 18,381 (350) 18,031 18,381 (350) York Teaching Hospital NHS FT - MSK ,356 2, ,356 2, (10) 10 Harrogate and District NHS FT - Community (44) (15) (29) 2,571 2,718 (147) 2,571 2,676 (104) 0 43 (43) Humber NHS FT - Community ,019 2, ,019 2, Hospices (1) 1,271 1, ,271 1, (4) Longer Term Conditions (9) (5) (4) (8) (4) 0 4 (4) Other Community (7) 2,833 2, ,833 2, (200) Sub total 9,996 9, ,472 7, ,525 2,554 (30) 29,503 29,580 (77) 29,503 29, (241) Financial Period: April 2018 to July 2018 Page 57 of 312

58 NHS Vale of York Clinical Commissioning Group Financial Performance Report YTD Position YTD previous month YTD Movement Forecast Outturn YTD previous month YTD Movement Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual Variance Other Services Continuing Care 8,868 9,233 (365) 6,729 6,999 (270) 2,139 2,235 (96) 25,667 25,721 (55) 25,667 25,808 (141) 0 (87) 87 CHC Clinical Team ,856 1, Funded Nursing Care 1,445 1, ,084 1, ,334 4, ,334 4, (1) 1 Patient Transport - Yorkshire (24) (15) (9) 2,015 1, ,915 1,964 (49) Voluntary Sector / Section (0) 0 Non-NHS Treatment (16) (10) (6) (18) (13) 0 5 (5) NHS Better Care Fund 3,764 3, ,823 2, ,293 11, ,293 11, (68) 68 Other Services (5) (79) 1,641 1,659 (18) 1,861 1, (220) 29 (249) Sub total 16,621 16,645 (25) 12,097 12,255 (158) 3,905 4,060 (156) 48,785 47,740 1,045 47,049 46, (120) (105) (14) Primary Care Primary Care Prescribing 15,772 16,075 (303) 11,620 11,684 (64) 4,152 4,391 (239) 47,272 47,575 (303) 47,272 47,339 (67) (236) Other Prescribing (105) (93) (12) 1,863 1,906 (44) 1,661 1, (53) Local Enhanced Services (19) (25) ,013 1, ,013 1, (0) 0 Oxygen (17) (8) (10) (56) (53) 0 3 (3) Primary Care IT (9) (12) (57) Out of Hours 1,061 1,107 (46) (49) ,184 3,245 (62) 3,184 3,233 (49) 0 13 (13) Other Primary Care (6) 138 2,757 2,898 (141) 2,757 2, (275) Sub Total 18,880 19,007 (127) 13,924 13,950 (26) 4,956 5,057 (101) 58,301 58,877 (575) 58,099 58, (637) Primary Care Commissioning 14,462 14, ,846 10, ,615 3,663 (47) 43,388 43, ,388 43, (313) 313 Trading Position 157, ,303 (2,169) 116, ,968 (1,056) 39,040 40,621 (1,581) 468, ,122 (5,287) 465, ,376 (5,200) 113 1,428 (1,315) Prior Year Balances 0 84 (84) 0 99 (99) 0 (15) (84) 0 99 (99) 0 (15) 15 Reserves (49) 0 (49) 345 (2,783) 3, (2,856) 3, Contingency 2, , , ,461 2, ,383 2,318 2, (1,383) 1,383 Unallocated QIPP Reserves 2, , ,484 (15) 1,499 3,523 (1,765) 5,287 3,401 (439) 3, (1,325) 1,447 Programme Financial Position 159, , , ,067 (305) 40,524 40,606 (81) 472, ,357 (0) 468, ,937 (1,360) In Year Surplus / (Deficit) (3,267) 0 (3,267) (3,500) 0 (3,500) (12,600) 0 (12,600) (14,000) 0 (14,000) 1, ,400 In Year Programme Financial Position 156, ,387 (3,185) 114, ,067 (3,805) 40,757 40, , ,357 (12,600) 454, ,937 (15,360) 1, ,532 Running Costs 2,261 2,341 (80) 1,696 1,745 (49) (31) 6,784 6,784 (0) 6,784 6, (0) Total In Year Financial Position 158, ,728 (3,265) 115, ,812 (3,854) 41,323 41, , ,141 (12,600) 461, ,721 (15,360) 1, ,532 Brought Forward (Deficit) (14,610) 0 (14,610) (10,958) 0 (10,958) (3,653) 0 (3,653) (43,831) 0 (43,831) (43,831) 0 (43,831) Cumulative Financial Position 143, ,728 (17,875) 105, ,812 (14,811) 37,670 41,202 (3,532) 422, ,141 (56,431) 417, ,721 (59,191) 1, ,532 Financial Period: April 2018 to July 2018 Page 58 of 312

59 NHS Vale of York Clinical Commissioning Group Financial Performance Report Appendix 2 Running costs dashboard YTD Position YTD Previous Month YTD Movement Forecast Outturn (FOT) FOT Previous Month FOT Movement Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual Variance Directorate Chief Executive / Board Office (189) (244) (181) (324) Primary Care (27) (122) (100) (22) System Resource & Planning (21) (22) 1,133 1,161 (28) 1,224 1,239 (15) (91) (78) (13) Planning and Governance (8) 1,059 1,061 (3) 1,078 1, (19) 5 (25) Joint Commissioning (12) (60) (30) (31) (314) (248) (66) Medical Directorate (5) (6) 1 Finance (6) 1,327 1, ,209 1, (19) Quality & Nursing (16) (23) 7 Planned Care ,060 1,061 (1) 1,070 1,063 7 (9) (2) (8) Risk 1 10 (8) 1 7 (6) 0 2 (2) 3 28 (25) 4 29 (25) (0) (1) 1 Overall Position 2,261 2,341 (80) 1,696 1,745 (49) (31) 6,784 6,784 (0) 6,784 6, (0) Financial Period: April 2018 to July 2018 Page 59 of 312

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61 Item Number: 8 Name of Presenter: Caroline Alexander Meeting of the Governing Body Meeting Date: 6 September 2018 Integrated Performance Report Month /19 Purpose of Report For Information Reason for Report This document provides a triangulated overview of CCG performance across all NHS Constitutional targets and then by each of the 2018/19 programmes. The report captures validated data for Month 3 for performance and should be read alongside the Month 4 Finance Report (which incorporates planned QIPP targets). Strategic Priority Links Strengthening Primary Care Reducing Demand on System Fully Integrated OOH Care Sustainable acute hospital/ single acute contract Transformed MH/LD/ Complex Care System transformations Financial Sustainability Local Authority Area CCG Footprint City of York Council Impacts/ Key Risks Financial Legal Primary Care Equalities Emerging Risks (not yet on Covalent) East Riding of Yorkshire Council North Yorkshire County Council Covalent Risk Reference and Covalent Description Risks are currently being refreshed by the CCG programme leads and Exec Leads for 2018/19. n/a Recommendations n/a Page 61 of 312

62 Responsible Executive Director and Title Phil Mettam Accountable Officer Report Author and Title Caroline Alexander Assistant Director of Delivery and Performance Page 62 of 312

63 Integrated Performance Report Validated data to June 2018 Month /19 Page 63 of 312

64 Performance Headlines Performance Summary Programme Overviews Planned Care Performance RTT, Cancer, Diagnostics Key Questions Performance CONTENTS Unplanned Care Performance Accident and Emergency, Ambulance Service, Other Services and Measures Key Questions Performance Mental Health, Learning Disability and Complex Care Performance Improving Access to Psychological Therapies, Dementia, CAMHS, Psychiatric Liaison Service Key Questions Performance Primary Care Performance: Primary care dashboard now reported to Primary Care Commissioning Committee Quality Premium Annexes: Annex 1 YTHFT Public Performance Report (not received will follow if received at later date) Annex 2 Cancer Alliance Transformation Funding Reduction Letter Annex /18 CCG Assessments Cancer and Maternity Annex 4 Excess Bed Days Initiative Media release, Letter, Supporting docs and Guide to reducing long hospital stays Page 64 of 312

65 Performance Headlines IMPROVEMENTS IN PERFORMANCE : A&E 4 hr Target: 95% Diagnostics 6 Week Wait Target: 99% York Trust s performance against the 4 hour target dropped very slightly in June 2018 to 90.0% compared to 90.1% in May. Monthly trajectory has therefore been met every month in Q1. There were no 12 hour trolley waits in June. Unvalidated July performance is 88.01% therefore narrowly meeting the Trust s trajectory of 88% for the month. Performance for Vale of York CCG in June 2018 improved to 96.9% against 99% target compared to 95.2% in May. This represents 145 patients waiting over 6 weeks from a cohort of 4,704. While still not meeting target, this represents the highest performance for Vale of York CCG since December MRI continued to be the specialty with the highest number of breaches in June with 71, followed by Colonoscopy and Non Obstetric Ultrasound with 18 each, then Sleep Studies with 17. All other specialties with breaches were in single figures. CT has seen a marked improvement with a reduction from 39 breaches in May to just 6 in June, 3 at York Trust and 3 at Hull and East Yorkshire Hospitals NHS Trust. York Trust s performance also saw a slight improvement from 96.1% in May to 96.3% in June with the issues reported last month remaining the same. These include capacity Page issues 65 in of sleep 312 studies, endoscopy and MRI. SAFER work and associated actions from the complex discharge group/ed streaming group/aedb are all in place; national position remained difficult during the start of July but PSF targets were achieved. August performance so far appears much improved. There were 17 Sleep Studies breaches in June 2018 at York Trust. The new equipment has arrived and staff are being trained to use it which will improve efficiency from July onwards and the Trust hope to clear the backlog by the end of August NHS Elect are currently working with the Trust to understand current and future Radiology demand and capacity. There is a shortage of Radiologists resulting in reporting delays and there has been growth in urgent radiology referrals which is creating pressure on the routine reporting and extending waiting times. The Trust are currently outsourcing some radiology reporting and are also looking to increase Endoscopy capacity by outsourcing. The Cancer Alliance has confirmed that the procurement of the new radiology reporting system is now progressing.

66 Performance Headlines IMPROVEMENTS IN PERFORMANCE : Cancer 2 Week Wait Target: 93% Cancer 62 day Treatment Target: 85% Vale of York CCG met the 93% two week wait target for the eighth consecutive month in June 2018, with performance of 94.9%. This is a slight drop from 95.8% in May 2018 and equates to 54 breaches from a cohort of York Trust s performance also saw a marginal drop in June 2018, but remaining above target with 93.5% compared to 93.7% in May. The CCG s performance against the 85% target improved in June 2018 to 83.2% compared to 78.2% in May. This equates to 20 breaches from a cohort of 119. The specialties which did not meet target individually were Haematological (50%, 2/4 breaches), Lower Gastrointestinal (67%, 4/12 breaches), Urological (73%, 8/30 breaches), Upper Gastrointestinal (75%, 1/4 breaches), and Lung (83%, 2/12 breaches). York Trust s performance also saw an increase to 82% in June compared to 78.4% in May. 25 of the CCG s 54 breaches in June were due to patient cancellations. The CCG s GP Clinical Lead for cancer wrote to all Vale of York CCG GP practices in July asking them to explain the importance of patients being able to attend fastrack appointment within 2 weeks timeframe. Lack of outpatient capacity for Skin clinics is an ongoing problem at both York and Scarborough. York Trust are working with the CCGs to provide alternative models to reduce wait times for Skin patients particularly on the East Coast. The Urology breaches are affected by delays in TRUS biopsies and significant delays in prostatectomies. There is an issue with access to treatment at Hull with a 6-8 week delay to access robotic surgery. These pressures in relation to the Urology and Colorectal pathways have been escalated at the Cancer Alliance Board and to the Commissioners. Treatment and Pathway clinical task and finish groups have been established by the Cancer Alliance Board to address these pathway delays. It was noted that there has also been a significant delay in endoscopies and that the CCG is working with the Trust to pilot a triage referral scheme in Selby for colorectal fast track in August. Page 66 of 312 HCV did not achieve the 62 day target across the STP the Cancer Alliance is anticipating a 740K loss of the Cancer Alliance funding.

67 Performance Headlines IMPROVEMENTS IN PERFORMANCE : IAPT Prevalence Target: 16.5% The local position for June improved to 14.6% from 11.2% in May. Further improvement to the position is anticipated in July. Page 67 of 312

68 Performance Headlines DETERIORATION IN PERFORMANCE : RTT 18 Week Target: 92% Vale of York s performance against the 92% target has dropped further in June to 85.1% compared to 85.3% in May. In 2018/19 the key target set by NHS England is to maintain the waiting list so that in March 2019 the list is no larger than March The waiting list increased in June 2018 to 17,329 compared to our baseline trajectory of 16,473 in March There were 10 x 52 week breaches for Vale of York patients in June 2018, 8 of which were at Leeds Teaching Hospital in General Surgery (1), Other (2), and Trauma & Orthopaedics (5), plus 1 at NLAG in General Surgery and 1 at Bradford Teaching Hospitals in Plastic Surgery. York Trust s performance against the 92% target dropped marginally from 84.2% in May to 84.1% in June, however their total waiting list decreased from 27,480 to 27,425. This is the first time the waiting list has decreased month on month since October/November There were 9 x 52 week breaches at York Trust in June 2018, 1 of which was a Hambleton, Richmondshire & Whitby CCG patient in ENT with the remaining 8 commissioned by NHS England in Oral Surgery. Page 68 of 312 The CCG are currently investigating the 52 week breaches for Vale of York patients, in particular at Leeds Teaching Hospital which has been responsible for 23 of the CCG s 34 x 52 week breaches in the last 7 months. The majority (8/9) of York Trust s 52 week breaches in June were as a continuing result of the issues in Head and Neck detailed in last month s Finance and Performance report. York Trust are reporting a reduction in GP referrals of 8.2% against June 17, however due to significant increases in April and May 18, Q1 shows an increase of 3.18% overall compared to This has impacted on waiting lists and in outpatients with first attendance from GP referral significantly above Trust AIC plan for June.

69 Performance Headlines DETERIORATION IN PERFORMANCE : CAMHS Performance against the % of patients aged 17.5 plus with a transition target of 85%, has declined to 70.5% from 84.1% last month. Performance against the % of patients with a second contact in less than 9 weeks target of 90% has declined to 55.4% from 57.8% last month. Update papers have been provided to previous F&P committees and July s QPEC was focused on the subject. Page 69 of 312

70 Performance Headlines SUGGESTED ISSUES FOR DISCUSSION: 1. To discuss: Cancer 62 Day performance and HCV STP Cancer Alliance transformation funding shortfall (see Annex) 2. Verbal update: Radiology capacity pressures and next steps for defining a local recovery plan 3. To note: Excess bed days initiative proposed approach Unplanned care programme and A&E Delivery Board (see Annex for national guidance and media announcement) 4. To note: NHSE 2017/18 IAF Assessment: confirmation of clinical priorities for Cancer and Maternity (see Annex for formal confirmation correspondence) 5. Verbal update: Waiting list position and HCV STP formal request for submission on elective care pressures required for September Reporting update: Quality Premium in year reporting and datasets are being clarified and developed. Updates on specific indicators and measures will be given each month as available and reconciliation at the intervals required by NHSE. Page 70 of 312

71 Performance Summary: All Constitutional Targets 2018/19 Validated data to June (Month 03) Page 71 of 312

72 * * * * - 52 week breaches showing nationally published figures. However, the CCG is aware of 4 breaches incorrectly reported by Nuffield Trust in March 2018 and April These will be corrected in the NHSE 6 monthly refresh. Correct figures are: March x 52 week breaches (21 in total for 2017/18) Page 72 of 312 April x 52 week breaches (18 in total for Q1 2018/19)

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75 Programme Overview - Planned Care - Cancer Care - Diagnostics Validated data to June (Month 03) Executive Lead: Simon Cox, System Transformation Chief Officer Clinical Lead: Shaun O Connell, GP Lead for Acute Transformation, NHS Vale of York CCG Peter Billingsley, GP Governing Body, NHS Scarborough & Ryedale CCG Dan Cottingham, Macmillan GP Cancer and End of Life Lead, NHS Vale of York CCG Programme Leads: Andrew Bucklee, Head of Commissioning and Delivery Sarah Tilston, Programme Manager, Planned Care Suzanne Bennett, Programme Manager, Planned Care Laura Angus, Lead Pharmacist Fliss Wood, Performance Improvement Manager (Cancer) Michaela Golodnitski, Senior Delivery Manager, Cancer Alliance Page 75 of 312

76 PERFORMANCE PLANNED CARE: REFERRAL TO TREATMENT (RTT) Vale of York CCG s performance was 85.1% in June 2018, a slight reduction on May This equates to 2,575 breaches of the 18 week target, from a cohort of 17,329. York Trust s RTT performance in June 2018 was 84.1% against the planned trajectory of 83.6%. The total number of patients on the incomplete waiting list was 27,425, representing a 4.2% increase on the agreed end of March 2018 position. In 2018/19 the key target set by NHS England is to maintain the waiting list so that in March 2019 the list is no larger than March The Vale of York CCG waiting list increased in June 2018 to 17,329 compared to our baseline trajectory of 16,473 in March York Trust are reporting a reduction in GP referrals of 8.2% against June 17, however due to significant increases in April and May 18, Q1 shows an increase of 3.18% overall compared to This has impacted on waiting lists and in outpatients with first attendance from GP referral significantly above Trust AIC plan for June. The current demand and capacity modelling indicates that across all specialties there is total shortage of 34 appointments each week. Work is progressing on theatre productivity and outpatient productivity as part of the York Trust transformation programme and Cost Improvement Programme (CIP). There is also joint work with CCGs as part of the AlC and this is focusing on transformation around the first outpatient appointments pathway through the Refer for Expert Opinion Page 76 of programme 312 of work.

77 PERFORMANCE PLANNED CARE: REFERRAL TO TREATMENT (RTT) Page 77 of 312 The Planned Care Steering Group (the joint working group delivering transformational work around elective care) is reviewing the initial Q1 referrals data as well as the current waiting list profile as at end of July This analysis will inform where the priority areas are to focus on in each specialty. The specialties with the largest numbers of follow-up patients are Ophthalmology, Gastro, Cardiology and ENT. Referrals growth in Q1 has been highest across the quarter period compared to Q1 in 2017/18 in T&O, urology, ENT and cardiology. There has been an increase in demand seen in urgent referrals as a proportion of overall referrals. There is further analysis of this under the Cancer 2WW performance. There were 10 x 52 week breaches for Vale of York patients in June 2018, 8 of which were at Leeds Teaching Hospital in General Surgery (1), Other (2), and Trauma & Orthopaedics (5), plus 1 at NLAG in General Surgery and 1 at Bradford Teaching Hospitals in Plastic Surgery. The CCG is exploring with those providers the breach analysis and recovery plans. There will be an update at Committee in September. As reported last month, the Trust declared a number of 52 week breaches which were due to the administrative errors affecting the Head and Neck department. A further 9 breaches have been declared in June; these were reported in Head & Neck [oral surgery] (8) and 1 in ENT.

78 PERFORMANCE PLANNED CARE: CANCER TWO WEEK WAITS Vale of York CCG again achieved the 2WW Cancer Standard in June 2018 with performance of 94.9% against the 93% target. York Hospital also achieved the 2WW target in June with 93.5% performance. There were 54 breaches in June of a cohort of 1, of these related to Skin, and 14 to Lower Gastrointestinal. 25 VOYCCG breaches were due to patient cancellations. The CCG s GP Clinical Lead for cancer wrote to all Vale of York CCG GP practices in July asking them to explain the importance of patients being able to attend fastrack appointment within 2 weeks timeframe. Lack of outpatient capacity for Skin clinics is an on-going problem at both York and Scarborough. York Trust are working with the CCGs to provide alternative models to reduce wait times for Skin patients particularly on the East Coast. There is increased pressure on the urgent referrals with Q1 referrals that are cancer increased from 7.85% in Q1 17/18 to 8.54% in Q1 18/19 (an increase of 1.61%). The greatest increases in suspected cancer referrals are in dermatology, ENT, urology, gynaecology and medical oncology. The early assessment around cancer diagnosis rates shows an increase from 17/18 and this will be further reviewed in August and presented to Committee in September. Page 78 of 312

79 PERFORMANCE PLANNED CARE: CANCER 62 DAYS Page 79 of 312 Vale of York CCG failed to meet the 62 Day Cancer Standard in June 2018 achieving 83.2% against the 85% target. York Trust also failed to meet the 62 Day Cancer Standard in May 2018 with performance at 82.0%. 40% of the 62 Day breaches related to Urology patients with 4 Lower Gastro, 2 Lung, 2 Haematology, 2 Breast and 1 each for Upper Gastro and Other. The Urology breaches are affected by delays in TRUS biopsies and significant delays in prostatectomy s. There is an issue with access to treatment at Hull with a 6-8 week delay to access robotic surgery. These pressures in relation to the Urology and Colorectal pathways have been escalated at the Cancer Alliance Board and to the Commissioners. Treatment and Pathway clinical task and finish groups have been established by the Cancer Alliance Board to address these pathway delays. It was noted that there has also been a significant delay in endoscopies and that the CCG is working with the Trust to pilot a triage referral scheme in Selby for colorectal fast track in August. HCV did not achieve the 62 day target across the STP the Cancer Alliance is anticipating a 2m loss of the Cancer Alliance funding. The attached Annex outlines the request from the Chair of the STP Cancer Alliance to reprioritise the remaining transformational funding within local place based Cancer Recovery Plans. There will be further feedback on this following the local Cancer Performance Board at YTHFT reviewing these proposed reductions in funding with partners in August.

80 PERFORMANCE PLANNED CARE: CANCER IAF INDICATORS Cancers diagnosed at early stage The CCG is performing well against peers in this measure based on the IAF dashboard assessment, however there has been a slight decline in performance for the past two years and the CCG has dropped from 55.8% in 2014 to 53.4% in The CCG s performance improvement manager will request that this is added to the agenda for the CCGs Cancer Performance Group. One year survival from all cancers As at latest published position of 2015, the CCG is performing at 71.6% which is 0.7% below the national average and desired trajectory of 72.3%. This performance ranks the CCG at 8/11 against peers and 121/207 nationally. Although under national average, the CCG's performance against this measure has marginally increased every year since The CCG s performance improvement manager will request that this is added to the agenda for the CCGs Cancer Performance Group. Cancer patient experience Key findings from the National Cancer Patient Experience Survey have been published for 2017, however at present results have not been published at local level so we are unable to view our CCG result. In terms of national position, in the 2017 survey 69,072 respondents gave an average rating of 8.80 (out of 10) with Page 80 of % of patients giving a rating of 7 or higher which is a statistically significant increase on the 2016 score.

81 PERFORMANCE PLANNED CARE: DIAGNOSTICS Vale of York CCG achieved 96.9% against the 99% target for patients waiting less than 6 weeks for a Diagnostic Test in June There were a total of 145 breaches out of 4704 on the waiting list. There has been a marked improvement with CT breaches at Hull and East Yorkshire Hospitals NHS Trust with only 3 breaches this month, with an additional 3 at York Trust. June has not shown any significant change to the York Trust Diagnostic position from May, achieving 96.3% with the issues reported last month remaining the same. These include capacity issues in sleep studies, endoscopy and MRI. There were 17 Sleep Studies breaches in June 2018 at York Hospital. The new equipment has arrived and staff are being trained to use it which will improve efficiency from July onwards and the Trust hope to clear the backlog by the end of August NHS Elect are currently working with the Trust to understand current and future Radiology demand and capacity. There is a shortage of Radiologists resulting in reporting delays. The Trust are currently outsourcing some radiology reporting and are also looking to increase Endoscopy capacity by outsourcing. Page 81 of 312

82 Are targets being meet and are you assured this is sustainable? Diagnostics No Cancer 2 week waits Yes Cancer 62 day standard No RTT No KEY QUESTIONS: PERFORMANCE PLANNED CARE What mitigating actions are underway? Diagnostics: Sleep Studies New equipment arrived. Backlog should be cleared by end of August YTHFT are outsourcing work to address radiology reporting backlog whilst a local recovery plan is developed. This work starts with NHS Elect NHS Elect undertaking a demand and capacity review of Radiology. Waiting List non-deterioration No 52 week breaches 50% reduction target - No Cancer: HCV Cancer Alliance has undertaken a Demand & Capacity exercise to understand current and future demand for services across Humber, Coast & Vale STP. The workshop on 20 June 2018 identified gaps in both workforce and equipment to meet future demands. HCV Alliance is progressing the procurement of a new networked radiology system which will allow the sharing of images and reporting across the STP footprint and should improve capacity/performance. NHSI Intensive Support Team are working with York Trust to improve 62 Day process and clinical pathways for Lung and Haematology. Is there a trajectory and a date for recovery / improvement? YTHFT Transformational Plan is being refreshed based on the reductions in funding from Cancer Alliance 62 day performance underachievement. Is further escalation required? HCV STP Cancer Alliance have written to each CCG and local Cancer Board to ask for their views on the proposed reprioritisation of the alliance programmes of work (see annex). Page 82 of 312

83 Programme Overview - Unplanned and Out of Hospital Care Validated data to June (Month 03) Executive Leads: Kev Smith (Out of Hospital care), Simon Cox (Urgent & Emergency Care) and Denise Nightingale (DTOCs) Programme Leads : Fiona Bell, Assistant Director of Transformation & Delivery Becky Case, Head of Transformation and Delivery Locality leads: Shaun Macey and Heather Marsh Clinical Leads: Peter Billingsley, GP Governing Body, S&R CCG Page 83 of 312

84 PERFORMANCE UNPLANNED CARE: NHS111, GP OOH, YAS and ED Page 84 of 312

85 PERFORMANCE UNPLANNED CARE: DELAYED TRANSFERS OF CARE The number of bed days for acute DTOCs at York Trust reduced slightly from 1092 in May to 1020 in June There was also a significant reduction in the bed days for nonacute DTOCs from 358 in May to 240 in June The rise in Acute DTOC days at York in April was investigated by the Complex Discharge Working Group who noted two particular factors impacting on the increase:- Continuing Healthcare delays relating to Fastrack patients which historically were not captured as DTOCs Patients waiting for packages of care at home. Actions to address DTOCs include:- CYC have increased number of home care hours from 600 to 700 per week. Daily review of discharges by YTHFT Discharge Liaison Team and CYC/NYCC Weekly SitRep meetings to support timely discharge YTHFT are holding daily 8.30am operations meeting to identify gold patients and expedite patient discharges earlier in the day Social Workers and Discharge Liaison Team are working 7 days per week to facilitate discharges. Pilot with Fulford Nursing Home 2 time to think beds for self-funders 23 July 2018 YTHFT organising a meeting to agree the Transfer of Care Protocol with Local Authorities and partner organisations. DTOC performance is anticipated to have deteriorated in July Page 85 of due 312 to lack of carers and staff taking annual leave during the school holidays.

86 KEY QUESTIONS : PERFORMANCE UNPLANNED CARE Are targets being meet and are you assured this is sustainable? What mitigating actions are underway? 4-hour standard: Performance fell back in June, with high numbers of attendances locally and nationally. There was a small increase in respiratory condition related attendances due to the weather and potentially more alcohol/violence related attendances linked to sport. Investigation ongoing. Ambulance Handovers: These improved slightly across the system; mostly in S boro. Action on A&E continues with comms day on 23/08. YAS response times: April s reporting discrepancies still being reviewed, however May/June more consistent. Improvements towards all targets with particularly category 1 attendance only 38 seconds outside the 7 minute target on average and category 2 attendances 30 seconds outside their 21 minute target. OOH GP: Performance continues to improve; they saw lower demand over the same period. EDFD: Performance shows improvement data validation has taken place. Project report due at end of August. NHS111: Performance continued to drop off during June, however, the July and August data is looking much better against the 95% 60s target DTOC: DTOCs continue to improve but domiciliary support capacity remains tight across CYC and NYCC. TEWV are part of discussions. Utilisation review: discussed as part of the BCF data proposal. NHS111 50% clinical booking target: awaiting regional update Is there a trajectory and a date for recovery/improvement? 4-hour standard: SAFER work and associated actions from the complex discharge group/ed streaming group/aedb all in place; national position remained difficult during the start of July but STF targets were achieved. August performance much improved. Ambulance Handovers: Dashboard and action plan completed, project officer continues to work with partners to improve. YAS response times: we continue to work across Y&H to review data. Improvements noted. OOH GP: No mitigating actions required at present; monitoring continues. EDFD: Review due shortly. Joint Urgent Care scheme possible for 19/20. NHS111: No mitigating actions required at present; monitoring continues. DTOC: CHC and CYC working well together. Some continued concerns about availability of care home beds as some close. Utilisation review: now combined with winter planning. NHS111 50% clinical booking target: NHSE dental contribution to be added from October 17: 1.7%, local CAS alignment (NELincs): 2.1% Is further escalation required? 4-hour standard: action plans against applicable projects have been shared with Complex Discharge Group and A&E Delivery Board as appropriate. Ambulance Handovers: key actions have been described against Action on A&E timeline, metrics have been agreed, monitoring underway. YAS response times: CCG performance review to take place when possible from data. OOH GP: not applicable at present. EDFD: not applicable at present. NHS111: not applicable at present. DTOC: Integrated direction emerging change to NYCC booking has commenced August, discussions with CYC ongoing. NHS111 50% clinical booking target: as above July date for recovery Page 86 of hour standard: continued monitoring takes place with escalation calls established when required. Recovery is now usually within 24 hours. Ambulance Handovers: No YAS response times: No OOH GP: No EDFD: No NHS111: No DTOC: Continued focus from Complex Discharge Group and associated programmes. AEDB aware of issues. NHS111 50% clinical booking target: No

87 Programme Overview - Mental Health, Learning Disability, Complex Care and Children s Executive Lead and Clinical Lead: Denise Nightingale, Executive Director of Transformation & Delivery (MH/LD/CHC) Programme Leads : Paul Howatson, Head of Partnerships and Integration Bev Hunter, Head of CHC and Vulnerable People Page 87 of 312

88 PERFORMANCE : MENTAL HEALTH DEMENTIA Dementia Diagnosis Rate May-18 Jun-18 Jul-18 DoT 60.7% 60.6% 60.7%. Diagnosis rate increased from 60.6% to 60.7%. The number of registered patients increased by 12 but the estimated prevalence also increased which offset any increased in the diagnosis rate. Targeted support to GP practices continues and negotiations are underway to secure a technical and data quality resource in primary care to assist with identification and coding. Page 88 of 312. Practice Name Movement Performance Beech Tree Surgery % Dalton Terrace Surgery % East Parade Medical Practice (1) 46.2% Elvington Medical Practice % Escrick Surgery (2) 58.8% Front Street Surgery % Haxby Group Practice % Helmsley Surgery % Jorvik Gillygate Practice (2) 69.5% Kirkbymoorside Surgery (2) 57.7% Millfield Surgery (1) 60.6% My Health Group % Pickering Medical Practice % Pocklington Group Practice % Posterngate Surgery % Priory Medical Group % Scott Road Medical Centre % Sherburn Group Practice % South Milford Surgery (1) 44.0% Stillington Surgery (2) 51.0% Tadcaster Medical Centre % Terrington Surgery (2) 28.6% The Old School Medical Practice (4) 55.2% Tollerton Surgery % Unity Health % York Medical Group (1) 47.0% Total 12 Based on Primary Care Data 62.9% Based on NHS Digital Data 60.7%

89 PERFORMANCE : MENTAL HEALTH CAMHS % aged with transition plan Apr-18 May-18 Jun-18 DoT 81.5% 84.1% 70.5% CAMHS % with a second contact < 9 weeks of referral Apr-18 May-18 Jun-18 DoT 52.7% 57.8% 55.4% The position for June is 70.5%, which is attributable to 26 breaches out of 88 patients. The position for June is 55.4%, Breaches continue to predominately relate to issues with staff capacity. 5 breaches related to Selby York Community, 8 breaches related to York Community and 13 breaches related to York East CMHT Page 89 of 312

90 PERFORMANCE : MENTAL HEALTH IAPT Prevalence Apr-18 May-18 Jun-18 DoT 14.5% 11.2% 14.6% IAPT Recovery Apr-18 May-18 Jun-18 DoT 50.3% 50.5% 48.6% The local position for June is 14.6%. The local position for June is 48.6% Changes have been made to the routine assessment process and additional capacity is now in place. A new model to reach 15% prevalence commenced in January Page 90 of 312 Of the 266 patients who completed treatment, 119 have moved to recovery. Of the 126 patients who did not recover 73 made a reliable improvement, 48 showed little improvement and 5 made no change. The service will be including actions to improve and sustain the improvement in recovery in a new action plan.

91 PERFORMANCE : MENTAL HEALTH / CONTINUING HEALTHCARE EIP % seen within 2 Weeks Apr-18 May-18 Jun-18 DoT 42.9% 15.4% 44.4% Continuing Health Care The position is attributable to 4 breaches out of 9 patients. A number of these clients had a DST and have been to panel but panel were unable to make a decision and outstanding information is await from CYC. 4 due to staff capacity meaning there were no earlier appointments available. 1 due to a patient choosing to rearrange the appointment originally offered which caused a delay in pathway completion. Page 91 of 312

92 PERFORMANCE : MENTAL HEALTH / CONTINUING HEALTHCARE Implementation of the discharge to assess approach has continued to deliver this target. All Acute Hospital DSTs are approved prior to assessment and occur due to patient need. 80% of DSTs undertaken from referral to decision within 28 days not achieved Page 92 of 312

93 KEY QUESTIONS: MENTAL HEALTH, LEARNING DISABILITY SERVICES, COMPLEX CARE & CHILDREN Are targets being met and are you assured this is sustainable? Mental Health: IAPT : No Dementia : No CAMHS : No EIP: No Psych Liaison: No CHC : Monthly Acute Hospital DST Activity : Yes Decision Support Tool : No Is there a trajectory and a date for recovery / improvement? IAPT : Trajectory agreed but is below national target. Dementia : The tasks in the action plan support progress towards delivery of the national target CAMHS : Action plan developed with TEWV to support meeting required performance targets. New trajectory requested following confirmation of 120k investment. EIP : Trajectory and investment for 18/19 agreed Psychiatric Liaison : Performance is being monitored monthly at CMB CHC : 28 day performance compliance achieved in June and ongoing delivery anticipated once clearance of backlog achieved What mitigating actions are underway? IAPT : The significant drop in performance has now been escalated through performance sub group and CMB and advice sought from NHSE regarding key lines of enquiry. CMB have agreed a letter at this stage to the Trust requiring an updated action plan prior to considering a contract notice. There is an improvement in performance in July. Dementia : The CCG continues to support primary care with coding and education events. Further support has been requested and approved at Executives for EMIS practices. Refreshed data from TEWV has been requested from memory services CAMHS : CVs for additional funding have been transacted. QPEC focus on CAMHs in July with lead clinicians EIP : 54k (recurrent) increase has been allocated to TEWV to cover new roles. CMB clarified that delivery of this target is a TEWV priority as well. Posts will not be operational until Q3 CHC: DSTs to verification of decision (80% within 28 days) performance deteriorated to 69% in July based on the clearance of some long waiters Is further escalation required? IAPT recovery: Verbal update to F & P Committee. Dementia : Verbal update to F & P Committee. CAMHS : Update papers to F & P in both May and June and QPEC minutes EIP : No further escalation at present, awaiting recruitment of new posts Psychiatric Liaison : No escalation required at this stage. CHC : No escalation required at this stage. Page 93 of 312

94 2018/19 CCG Quality Premium Page 94 of 312

95 QUALITY PREMIUM Guidance for the 2018/19 CCG Quality Premium has been released, and the table opposite summarises the potential funding available to the Vale of York CCG broken down by section and indicator. The structure of the Quality Premium has changed compared to previous years, placing more emphasis on Emergency Demand Management so as to incentivise moderation of demand for emergency care in addition to maintaining and/or improving progress against key quality indicators. Approximately 75.5% of potential funding is allocated to the Emergency Demand Management Indicators, and 24.5% to the Quality Indicators. As in previous years the Quality Premium includes three gateways. The Finance and Quality gateways apply to all sections of the Quality Premium. However in 2018/19, the Constitutional gateway only applies to the Quality indicators, and has no influence on the Emergency Demand Management Indicators. Therefore even if both indicators within the Constitutional gateway are failed (RTT pathway volumes and Cancer 62 days waits), the CCG is still able to achieve the Emergency Demand Management Indicators and therefore access the majority of the Quality Premium funding. The CCG are currently working on producing baselines and tracking for the 2018/19 Quality Premium and updates will be provided here as and when available. Page 95 of 312

96 ANNEXES Annex 1: Public Performance Report York Trust overview of Performance. Annex 2: Cancer Alliance Transformation Funding Reduction Letter Annex 3: 2017/18 CCG Assessments Cancer and Maternity Annex 4: Excess Bed Days Initiative national media announcement and supporting guidance documents Page 96 of 312

97 Acronyms 2WW A&E ADHD AEDB AHC AIC CAMHS CC CEP CGA CHC CIP CMB COPD CQC CQUIN CRUK CSF CT CWTs CYC CYP DEXA DNA DQIP DTOC Two week wait: Urgent Cancer Referrals Target Accident and Emergency Attention Deficit Hyperactive Disorder A and E Delivery Board Annual Health Check Aligned Incentive Contract Child and Adolescent Mental Health Services Continuing Care Capped Expenditure Process Comprehensive Geriatric Assessment Continuing Healthcare Cost Improvement Plan Contract Management Board Chronic Obstructive Pulmonary Disease Care Quality Commission Commissioning for Quality and Innovation (framework) Cancer Research UK Commissioner Sustainability Funding Computerised Tomography Scan Cancer Waiting Times City of York Council Children & Young People Dual energy X-ray absorptiometry scan Did not attend Data Quality Improvement Plan (in standard acute contract) Delayed Transfer of Care Page 97 of 312

98 Acronyms continued ECS ED EDFD EMI ENT F&P/ F&PC FIT FNC GA GI GPFV H&N HCV HR&W HaRD IAF IAPT IFR IPT IST LA LD LDR MCP MDT MH Emergency Care Standard (4 hour target) Emergency Department Emergency Department Front Door Elderly Mentally Infirm Ear Nose & Throat Finance & Performance Committee (CCG) Faecal Immunochemical Test Funded Nursing Care General Anaesthetic Gastro-intestinal GP Forward View Head and Neck Humber, Coast & Vale (Sustainable Transformation Plan or STP) NHS Hambleton, Richmondshire and Whitby CCG NHS Harrogate and Rural District CCG Improvement & Assessment Framework (NHS England) Improving Access to Psychological Therapies Individual Funding Review (Complex care) Inter-provider transfer (Cancer) Intensive Support Team Local Authority Learning Disabilities Local Digital Roadmap Multi-Care Practitioner Multi Disciplinary Team Mental Health Page 98 of 312

99 Acronyms continued MHFV MIU MMT MNET MRI MSK NHS NHSE NHSI NYCC NYNET ONPOS OOH PCH PCU PIB PID PLCV PM PMO PNRC POD PSF PTL QIPP Mental Health Forward View Minor Injuries Unit Medicines Management Team Medical Non Emergency Transport Magnetic Resonance Imaging Musculo-skeletal Service National Health Service NHS England NHS Improvement North Yorkshire County Council NYNET Limited (created by North Yorkshire County Council, provides WAN connectivity and broadband services to private and public sector sites) Online Non Prescription Ordering Service Out of hours Primary Care Home Partnership Commissioning Unit Permanent Injury Benefit Project Initiation Document Procedures of Limited Clinical Value Practice Manager Programme Management Office Procedures Not Routinely Commissioned Point of Delivery Provider Sustainability Funding Patient Tracking List Quality, Innovation, Productivity and Prevention QP Quality Premium Page 99 of 312

100 Acronyms continued RRV RSS RTT SOP S&R / SRCCG SRBI STF STP STT SUS TEWV T&I T&O TIA ToR UCC UCP VoY VoY CCG VCN WLIs YAS YDUC Y&H YTHFT/York Trust YDH YHEC Rapid Response Vehicle Referral Support Service Referral to treatment Standard Operating Procedure NHS Scarborough and Ryedale CCG Special Rehabilitation Brain Injury Sustainability and Transformation Fund Sustainability and Transformation Plan Straight to Triage Secondary Uses Service (data) Tees, Esk and Wear Valleys NHS Foundation Trust Trauma and Injury Trauma and Orthopaedics Transient Ischaemic Attack Terms of Reference Urgent Care Centre Urgent Care Practitioner Vale of York NHS Vale of York CCG Vale of York Clinical Network Waiting List Initiatives Yorkshire Ambulance Service Yorkshire Doctors Urgent Care Yorkshire & Humber (region) York Teaching Hospital NHS Foundation Trust York District Hospital York Health Economics Consortium Page 100 of 312

101 Item Number: 9 Name of Presenter: Michelle Carrington Meeting of the Governing Body Date of meeting: 6 September 2018 Report Title: Quality and Patient Experience Report Purpose of Report (Select from list) For Information Reason for Report To update Governing Body about all the Quality Team s work streams and activity Key Messages 1. The Committee continued to focus on access to both Adult and Children s Mental Health Services. Further assurance on engagement between providers and carers was required in respect of the former; the presentation had provided assurance in terms of quality but concerns remained about capacity and ability to improve access. 2. The Committee welcomed the support from York Teaching Hospital NHS Foundation Trust in providing improved assurance on Serious Incidents and Never Events. 3. The Committee congratulated those who had contributed to the Outstanding North Yorkshire Children s Service Ofsted Inspection Report. 4. The Committee expressed continuing concerns about adult care home provision. 5. The Committee welcomed the new format of the Risk Report. Strategic Priority Links Primary Care/ Integrated Care Urgent Care Effective Organisation Mental Health/Vulnerable People Planned Care/ Cancer Prescribing Financial Sustainability Local Authority Area CCG Footprint City of York Council Impacts/ Key Risks Financial Legal Primary Care Equalities East Riding of Yorkshire Council North Yorkshire County Council Covalent Risk Reference and Covalent Description Page 101 of 312

102 Recommendations N/A Responsible Chief Officer and Title Michelle Carrington (Chief Nurse) Report Author and Title Quality Team Page 102 of 312

103 NHS Vale of York Clinical Commissioning Group Quality and Patient Experience Report August Page 103 of 312

104 Contents Purpose of the Report... 3 Patient Story... 3 Quality in Primary Care... 3 Infection Prevention & Control (IPC)... 4 Serious Incidents (SIs)... 6 Quality Assurance from other providers... 8 Maternity... 8 Screening and Immunisations updates... 9 Patient Experience Update... 9 Patient Engagement Update Care Homes and Adult Safeguarding Update Quality in Care Homes Children and Young People Safeguarding Children Safeguarding Adults Children s Mental Health Adult Mental Health Page 104 of 312

105 Purpose of the Report The purpose of this report is to provide an overview of the Vale of York Clinical Commissioning Group in relation to the quality of services across our main provider services. In addition, it provides an update about the Vale of York CCG s Quality team s important work relating to quality improvements that affect the wider health and care economy. Key pieces of improvement work that the team is involved in include Special School Nursing Review as part of review of the 0 19 pathway Care Home Strategy development Maternity services transformation Workforce transformation Patient Story The Quality and Patient Experience Committee members heard a patient story which described the carer s experience of adult mental health experiences relating to their daughter. The details of the story are captured in the Quality and Patient Experience Committee minutes and describe the carers experience in relation to having to navigate Mental Health services. It was recognised that there is a need for improved communication, coordination and consistency for carers and the CCG will continue to monitor this through the sub Contract Management Board with Tees, Esk and Wear Valleys Trust (TEWV) that focuses on quality assurance as well as the planned quality visits. Quality in Primary Care Quality Concerns CQC conducted a comprehensive inspection at a Unity Practice on 23rd May 2018, rating them as inadequate overall. Overall rating Are services safe? Are services effective? Are services caring? Are services responsive? Are services well-led? Inadequate Inadequate Inadequate Requires improvement Inadequate Inadequate Their population group ratings were also assessed and found to be inadequate for all groups i.e. older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia). The full report can be found here: The practice has been put into special measures based on breaches of the regulations. Services placed in special measures will be inspected again within 6 3 Page 105 of 312

106 months. The CQC also required the practice to close their list to any new patients and issued warning notices for complaints management and staff training. The practice opted to close their list prior to this instruction by the CQC. The CQC have agreed to re-inspect progress against breaches of the regulations on 10 September in order to hopefully lift the sanction on the closed list. They will then do a full inspection 3 months after that. The CCG are working very closely with the practice. As described on the Risk register, measures are in place to mitigate further risk. The CCG and Practice attended the City of York Council Health Overview and Scrutiny Committee in June Continued media publications include a recent patient data breach. Salient themes of this CQC report and others are being identified with a view to targeting practices most in need and offering support e.g. practice visit templates, arranging IPC education sessions, preparing for CQC inspections. Infection Prevention & Control (IPC) York Teaching Hospital Foundation Trust (YTHFT) Klebseilla, Pseudomonas BSI and MSSA BSI are all decreasing. Further understanding of reasons for this improving picture is required and the Lead IPC Nurse is investigating this. MRSA As reported previously updates to the categorisation of methicillin-resistant staphylococcus aureus blood stream infections (MRSA BSI s) commenced in April Cases will be reported by time of infection onset as opposed to time of patient admission. Cases where the infection onset is greater than 2 days after admission will be considered hospital-onset cases; all other cases will be considered to be community-onset. MRSA remains a zero tolerance measure in 2018/19. YTHFT reported one case of MRSA BSI in June which is currently going through the post infection review process. The May case affected a patient with multiple co- morbidities and who was readmitted with sepsis. The June pre case is a patient who had a fall at home and was admitted with signs of sepsis relating to a chest infection. The patient had had no contact with primary care in the previous 2 weeks and the case was determined unavoidable. Clostridium Difficile Following the amended guidance meetings are underway to agree a process for reviewing community and secondary care cases of clostridium difficile with representation from both care settings present. A Consultant Microbiologist from YTHFT has attended an established meeting in Hull to learn from their approach and a meeting is being organised with all stakeholders to progress this. The yearly threshold for clostridium difficile for 2018/19 remains at 48, and overall the CCG have continued to see a rise in cases following the trend of the last few months. YTHFT report on-going challenges in achieving timely reviews of cases due to clinicians capacity. Where lapses in care have been identified YTHFT continue to 4 Page 106 of 312

107 identify themes of delay in sampling, delay in isolation, environmental issues and antibiotic prescribing. The East Riding CCG (ERCCG) hosts the IPC Nurse that supports the CCG and she is expected to continue to actively develop relationships with practices to improve understanding of their challenges and improvement plans. All community cases continue to be reviewed at the multi-agency review meeting with any identified learning fed back to primary care. The CCG are 5 cases over objective at the end of Quarter 1 which is a significant increase in the cases reported based on quarter 1 in 2017/18. This represents an increase of 11 cases which are predominantly secondary care attributed cases. 3 cases have been agreed as lapses in care. YTHFT are currently over objective by 5 cases at the end of Quarter 1. This represents an increase of 9 cases based on the number reported at the end Quarter /18. 4 cases have been declared as a lapse in care. 6 cases are awaiting review. Contributing factors for the lapses in care include: delay in sampling delay in isolation (patient not isolated until positive result) Ward environment (Excess clutter and concerns regarding cleaning) Antibiotic prescribing both primary and secondary care. Clostridium Difficile Monthly infections and against objective York Teaching Hospital Trust Number of patients A M J J A S O N D J F M Month Actual Year to Date Previous year Objective current year Escherichia coli (E Coli) Escherichia coli Blood Stream Infections (E.coli BSI) 86 cases of E.coli BSI have been attributed to the CCG at the end of Quarter /19 which is an increase of 8 cases from the end of Q /18. The CCG are 5 Page 107 of 312

108 currently 13 cases over objective. The number of secondary care attributed cases has decreased and the number of pre cases increased in Quarter /19 compared to Quarter /18. Serious Incidents (SIs) Key Issues from provider Trusts York Teaching Hospital Foundation Trust Serious Incident Learning - Gaining Assurance QPEC have been briefed about the continued challenges relating to YTHFT in responding to queries raised by the CCG arising from completed SI reports. In response the CCG s Chief Nurse has escalated this and the newly appointed Deputy Director of Patient Safety has provided us with an agreed plan in response. Never Events (NE) Relevant to the similarly themed Never Events relating to surgical procedures the CCG has lead further conversations with YTHFT. The response from the Deputy Director of Patient Safety has been favourable and a meeting is planned in August to reach agreement on key action identified earlier in the year. Serious Incidents Number of SIs by Category York Hospitals Treatment Delay Diagnostic incident Medication incident Surgical invasive procedure Pressure ulcer Falls Q1 Falls and Pressure Ulcers As the tables and graphs above illustrate the number of Slips/Trips/Falls causing harm has increased in Quarter 1 and the number of reported pressure ulcers meeting the criteria for a serious incident has increased by 1. Similar themes in falls and pressure ulcers with harm continue to be evident. Increased assurance is required on the strategic oversight. Whilst progress is clear in some areas of practice, noted by CCG attendance at falls and pressure ulcer SI panels, the CCG continues to challenge YTHFT s consistent adherence to guidance. 6 Page 108 of 312

109 A meeting is scheduled to discuss this with the new Deputy Director of Patient Safety. Aligned Incentive Contract (AIC) The governance structures to support the newly established AIC with YTHFT are being established. The final Quality and Performance Contract Management Board meeting was held in July and the CCG is leading the development of a new Quality Board that will replace this. Tees, Esk and Wear Valleys Trust (TEWV) Key Issues The CCG Head of Quality Assurance dials into Directors panel where SI reports are reviewed and scrutinised before final submission allowing CCG participation in review of the report. Due to a role change the clinician who was providing the CCGs with mental health expertise in reviewing SI s is no longer able to fulfil this function. This does present a risk and a bank reviewer has been approached as an interim measure as the CCG plans to propose an alternative model to support the review of mental health Serious Incidents. TEWV continue to be committed to improve processes, provide assurance and are responsive to requests. The issues attributed to the administrative management of the SI reports and update to outstanding queries is being managed by TEWVs Director of Quality Governance is currently looking into this. SI s reported by TEWV for York and North Yorkshire areas by quarter 2018/19 Q1 2017/18 Q4 2017/18 Q3 2017/18 Q2 Number of SIs CCG 2018/19 Q1 2017/18 Q4 2017/18 Q3 2017/18 Q2 VoY SR HaRD TEWV have recently been inspected by the CQC and the final report is expected in September. Clinical Quality Visits The schedule of quality visits to TEWV services has continued with a visit to the learning disabilities services in June. The CCG were made extremely welcome, witnessing compassionate, individualised and respectful care. The increase in complexity of some cases was discussed with an agreement for increased collaborative working. The Head of Service discussed serious concerns and risks relating to implementation of the NHSE Transforming Care agenda and the resultant impact for patients. This has been and will continue to be discussed at CMB. 7 Page 109 of 312

110 Quality Assurance from other providers NHS 111/Yorkshire Ambulance Service (YAS) Sub Regional Quality Board The Yorkshire Ambulance Service (YAS) recently conducted a mock Care Quality Commission (CQC) inspection run at various sites across Yorkshire. The Senior Quality Lead was invited to accompany a YAS colleague and participated in inspections at a number of ambulance stations. This proved a positive experience for increasing understanding of operations, recognising challenges and achievements. The exercise developed positive working relationships and collaborative working. The CCG continue to represent at the 111/999 Quality Group. Assurance was provided regarding the provision of Ventricular Fibrilation training for crews, a structured training programme is scheduled and will be provided in October. Extended hours must be in place nationally by October and the group recommended this be noted on risk registers and to be vigilant for unintended consequences. St Leonard s Hospice The opportunity to link with St Leonards Hospice in a quality assurance capacity has been explored and will be developed in the coming months. This will look to identify how a supportive forum for quality governance could operate and link to the offer of support build on good practice. The Retreat The Quality and Nursing team have planned to meet with the Retreat again in response to their most recent update about changes to their registration status. In May they provided all stakeholders with an update about their strategic review and the work they have been carrying out to transform their services. The organisation is proposing to withdraw from providing inpatient beds by the end of this year and to offer the following services: The expansion of their community mental health services at the Tuke Centre including their Autism and ADHD service. The expansion of domiciliary care and supported living services, providing support for a wide range of learning disabilities, neuro-developmental conditions and complex mental health needs. A new residential care service for people with complex dementia and enduring mental health needs. This service will be CQC registered under social care regulations. Maternity The regional maternity dashboard for Yorkshire and the Humber (Y&H) published its data for Quarter 4. YTHFT continues to perform in line with the majority of indicators with no areas of significant concern reported. Stillbirth rates remain low and work continues to improve smoking in pregnancy although York data for quarter 4 shows a combined rate of 13.4% at booking, against a Y&H average of 17.7%, and smoking 8 Page 110 of 312

111 at time of delivery rate of 14% against a Y&H average of 16.9%. City of York Council has undertaken a deep dive of the smoking data and remain committed to improvement. The Local Maternity System Board continues to make some progress against implementation of the plan. The Regional Maternity Transformation Board and regional teams are supporting the PMO team in providing additional clarity to allow further funding (tranch 2) to be released, in line with other STP s. Screening and Immunisations updates 2018/19 Flu Planning Planning for the 2018/19 flu season is well underway. The York and North Yorkshire seasonal flu group continues to meet regularly with representation from both the Nursing and Quality team and Winter Planning committee. The CCG Flu plan is due to be received at Executive Committee imminently. Communication is awaited from Public Health England clarifying whether Health and Social Care workers will be eligible for free vaccinations. Local clarity is required on practice plans to ensure all housebound patients are vaccinated. YTHFT District Nursing teams have supported this previously by vaccinating patients on their caseloads. Issues and concerns persist relating to lack of confirmation of delivery dates of the adjuvanted trivalent flu vaccine for over the 65 year old cohort as well as the delivery schedule which will require practices to prioritise how they invite patients. The local Screening and Immunisation team are preparing a Frequently Asked Questions worksheet to support primary care. The School Immunisation team are working with other stakeholders to reduce the risk relating to the 4-9 year old at risk cohort potentially being invited and/or vaccinated twice as they may be called by both primary care and the School Immunisation team. All practices are to be asked about their intentions for this cohort as the Service Specification is not specific. A detailed Vale of York CCG flu newsletter has recently been circulated to all practices and practice nurses showing uptake data for each cohort on a practice by practice basis. The Head of Quality of Assurance and Maternity and local Screening and Immunisations Co-ordinator are planning to visit practices with the highest uptake as well as visiting practices with lower uptake to try to understand good practice and any barriers or challenges with the aim of trying to support overall uptake. Patient Experience Update Vale of York CCG Complaints 14 complaints were registered in the CCG during May and June 2018: 9 Page 111 of 312

112 7 complaints related to communication/information and delays regarding Continuing Healthcare (CHC). 3 complaints related to Medicines Management and prescribing policies. 2 complaints related to the BMI (Body Mass Index) and smoking threshold policy for elective surgery. 1 complainant was unhappy with the transfer of the anti-coagulation service from the clinic within York Teaching Hospital NHS Foundation Trust to their GP Practice. 1 complaint was about the eligibility criteria for wheelchair provision. 1 complaint (closed in May 2018) which related to the BMI policy has been referred to the Parliamentary & Health Service Ombudsman (PHSO; the second stage of the complaint process, once local resolution is at an end). A copy of the complaint file was sent to the PHSO on 18/7/18 for their review and we are awaiting the outcome. Vale of York CCG Concerns 104 concerns/enquiries were managed by the Patient Relations Team including: 17 concerns/enquiries were about the anti-coagulation/warfarin monitoring service. Following consultation and discussions with patients, York Hospital and GP Practices, to understand how best to provide health services locally, the service is transferring from a clinic within York Hospital to GP Practices. This means that patients will have a quick 10 minute appointment and they won t have to wait for blood taking. The new service does not involve taking blood from the arm, instead it is a finger prick blood test and the results are available immediately. Some of the patients who contacted us had been visiting the hospital clinic for a long time and were anxious about the change. The Patient Relations Team and/or GP Practice Managers have offered clarification and reassurance. 19 contacts were raising concerns and/or seeking clarity about the CCGs BMI/smoking thresholds for elective surgery. 19 contacts were from a persistent contactor which required no further action. 8 people had concerns/enquiries regarding prescribing policies. 38 contacts were signposted to other organisations for help and advice. Compliments The CHC Team received a letter from the family of a patient with dementia. They felt that all concerned with the CHC process had helped to make it as straight forward and simple as it could be. The family said that staff handled it 10 Page 112 of 312

113 with care and consideration for them and, more importantly, for their mum who had her dignity respected throughout. A staff member left positive feedback about the Yor-Insight method of communication. Yor-Insight is a soft intelligence tool accessed via the CCGs website for staff to share insights and feedback about gaps, issues or good practice with the CCG, and is monitored by the Patient Relations Team. Action arising from complaints/concerns A GP contacted us on behalf of a patient who had been assessed by the IAPT service (Improving Access to Psychological Therapies) provided by TEWV but who had been waiting 14 months for treatment to begin. Patient Relations contacted the Clinical Lead who apologised to the patient for the failure to initiate treatment within the set timescale and rectified this. We also updated the GP that TEWV (Tees, Esk & Wear Valley NHS Trust) have recently undertaken to review the service delivery model to reduce waiting times and clear a backlog of referrals. As a result the service is offering a new treatment pathway for new patient referrals and there is improved access to the service for patients. A GP raised a concern regarding an urgent (2 weeks) referral for a patient to be seen in the urology department for a PSA test (Prostate Specific Antigen) and whether the form could be made more appropriate if there was clear guidance on the form as to what the normal age specific levels were, and at what level a PSA result should trigger a referral in men of different ages. The CCG s Macmillan GP Cancer & End of Life Lead and the GP Lead for Acute Service Transformation advised that the CCG is working with the urologists to provide clarity and ensure priority for patients who are most likely to have significant prostate cancer. Recently the hospital service has seen a large increase in referrals following media attention around prostate cancer. At the time of writing this report, negative feedback is starting to come through from service users and York Carers Centre (on behalf of local carers) about a recent change in provision of continence products. On investigation, York Teaching Hospital NHS Foundation Trust has procured a new supplier. Some service users and carers are complaining that the items are an inferior quality and are causing pain and discomfort. The CCGs Deputy Chief Nurse is liaising with the Trust s Operational Manager who has given assurance that these issues will be addressed swiftly with the individuals and the Trust will also arrange a meeting with the Carer s Centre and the provider to discuss issues face to face. The CCG will continue to monitor this situation and seek assurance of a satisfactory resolution. CCG activity for all types of contact during May and June is shown in the pie chart at the end of this section. Other Sources of Patient Feedback 11 Page 113 of 312

114 These include Healthwatch, Friends & Family Test and the NHS Choices website. Providers (in primary and secondary care) review themes, trends or potential issues, in conjunction with formal complaints and concerns made directly to them, so that themes and trends can hopefully be identified early, escalated and resolved where possible. Below are the current hospital ratings available at the time of writing, based on feedback by users on NHS Choices. Providers not listed have not yet been rated. Hospital Rating (out of a score of 5) Number of ratings York Scarborough Bridlington 5 26 Malton Nuffield York 2 2 Clifton Park 5 17 White Cross Court Rehabilitation 5 1 St Helen's Rehabilitation Ratings for individual GP Practices can also be found on NHS Choices. NHS England (NHSE) shared their annual complaints report with the CCG for Vale of York GP Practices. These are complaints that have been made directly to NHSE for investigation. The report does not include complaints made to the GP Practices. 16 complaints about VOY Practices were received by them from April 2017 to March Only 1 complaint (relating to clinical treatment) was upheld. The complaints lead at NHSE intends to provide a quarterly report to the CCG in the future. Healthwatch Update Healthwatch York has published their annual report (available via their website: During the coming year their work plan (chosen by the public via a survey) will firstly look at the proposal for Priory Medical Group (PMG) to provide a health centre at Burnholme Community Hub. This health centre would replace three of the existing Priory Medical Group surgeries; Tang Hall, Parkview and Heworth Green. Healthwatch will be working with PMG to run a public consultation to hear people s hopes and concerns for the new facility. Other topics include, pain services, podiatry services and people s experience of the BMI and smoking threshold for orthopaedic surgery. Healthwatch North Yorkshire s annual report for 2017/2018 is not available at the time of writing. 12 Page 114 of 312

115 NHSBSA - PHB 1% YTHFT - Scarborough 1% SCRCCG 1% TEWV 1% May/June 2018 YTHFT - York Hospital 4% CCG - Adult mental health 1% GP - Unity Health 5% CYC - Records 1% GP - Anticoag clinic 1% GP 2% CCG - Anti coag clinic 13% Yorkshire Drs - OOH 1% CCG - SI process 1% CCG - York House Brain Injury Unit 1% Contact-Persistent 7% CCG - BMI/Smoking Policy 9% CCG - Oncology 1% CCG - TEWV 1% CCG - YorInsight 1% CCG - Podiatry 1% CCG - Radiology 1% CCG - Neurology 1% CCG - Medicine Management 6% CCG - Maternity 1% CCG - RSS 6% CCG - IFR 1% CCG - GP 7% CCG - Gluten Free Prescribing 1% CCG - Enquiry 1% CCG - CHC 6% NHSE - Opticians 1% CCG - Communication/Information 1% CCG - Community Equipment 3% CCG - Dermatology 1% CCG - District Nurse 1% CCG - Contact- Persistent 6% 13 Page 115 of 312

116 Patient Engagement Update Engagement update: This section of the report covers the latest engagement activity in the Vale of York. NHS70 - roundup The National Health Service (NHS) turned 70 on 5 July Across the country there were celebrations to commemorate the achievements, innovations and individuals that have shaped the NHS as we know it today. During June and July NHS Vale of York CCG organised a number events with our local communities, health partners, local authorities and voluntary sector which focused on acknowledging the great work of the NHS, whilst raising awareness for our key priorities. Keeping yourself and your community healthy and well (self-care, prevention, exercise, diet) Supporting mental health and well being Tackling loneliness and isolation It was important to create a legacy for the Vale of York and we asked members of our community to share their pledges to show how they will help health and care services, by telling us: How they would improve their own health and wellbeing How they could support their neighbours and local community The engagement process Meetings were held to work collaboratively across the council, health and voluntary sector, and it was agreed to host a series of joint events to actively engage with the local community about their health and wellbeing. Over the six-week period the CCG attended and hosted over 20 events across the patch and helped facilitate and promote even more 14 Page 116 of 312

117 through GP surgeries, libraries, care homes and local employers such as LNER. Support was received from local MPs, Lord Mayors, providers, businesses and voluntary sector organisations. These included: A business briefing session, hosted jointly with the Public Health team and the local MP to work with local employers and look at how they can help support the health and wellbeing of their workforce. A double-decker bus tour of various sites in York, Selby and Easingwold, where members of the public were invited to come along to receive healthcare advice, signposting and health check-ups. Our GP practices, Care Homes within the patch were encouraged to hold an event on the day. Working with the library to support their health and wellbeing sessions. Hosting an internal NHS Vale of York CCG 1940s-themed event to celebrate 70 years of the NHS that the public were invited and encouraged to take part in. The celebrations included food, music and other attractions. The CCG s giant NHS 70 birthday card, which had been touring the Vale of York on the double-decker bus, was also available to sign and write goodwill messages in. Date Event 8 May 18 Voluntary Sector Forum, 10am-12pm 18 May 18 Acomb Library Explore, 10am-3pm 30 May 18 Mumbler maternity event at York Mount School 1 June 18 Bus Tour York Central 4 June 18 People Helping People Launch (CVS and CYC) 7 June 18 Tommy Whitelaw: What matters to you? Two sessions 8 June 18 Employers meeting at West Offices June 18 West Offices Foyer, 11am-1pm 15 Page 117 of 312

118 12 June 18 Festival of Ideas, 12pm-2pm 15 June 18 Bus Tour Easingwold and Monks Cross 18 June 18 Bus Tour Selby and surrounding areas 2-6 July 18 Acomb, York, Clifton and Tang Hall Libraries NHS7tea party celebrations 2 July 18 Tea and cake at East Riding Carers Advisory Group 3 July 18 Pocklington Carers forum tea and cake 4 July 18 Staff NHS 70 Celebration, 1-2pm 5 July 18 West Offices Tea Party in the foyer, 1-3pm 5 July 18 NHS 70 celebration at York Minster 7 July 18 Selby War Memorial NHS70 celebrations, 1pm-4pm 19 July 18 Health and wellbeing session with LNER (trains) Communications and media As part of the NHS70 engagement project a range of methods were adopted to encourage participation and involvement from a variety of patients, the public and stakeholders. The public events and drop-in sessions were advertised and communicated through the following channels: CCG stakeholder and public list Press release Local MPs GP practice communications Partner organisations Local Healthwatch and voluntary sector Community groups Health and Wellbeing Board Posters in shops, libraries and public buildings in the areas where the events were taking place CCG website and twitter account Internal staff newsletter 16 Page 118 of 312

119 We had several articles in the York press and local papers, and our Clinical Chair, Dr Nigel Wells was interviewed by York TV. We were also supported by leaders across the patch. Partners, voluntary sector and local health organisations got involved and shared information, pictures and events through their networks. Key messages and themes We collated the verbatim written comments pledged at our public engagement events. The key themes are outlined below, complete with examples. Theme 1: Leading a healthy lifestyle People felt strongly about maintaining their health and wellbeing by leading a healthy lifestyle. This included, keeping active and participating in more regular and consistent exercise: To run three times a week. To walk instead of using the car whenever possible and to encourage my son and family to do the same. I will continue to walk every day now that I m seventy! To keep up with the walking, football and Yoga whilst also supporting the NHS To be more active every day People also pledged to eat more healthily in order to live better: To reduce my BMI and eat more healthily Reduce sugar intake and exercise more To teach the importance of medicine as food and of food as medicine To exercise more and eat more fruit and vegetables and also use the NHS services appropriately to educate my family to do the same To feed my daughter more veg (peas)! Theme 2: Mental Health The theme of looking after our mental health recurred throughout the pledges, with people listing it as one of their health priorities: To continue promoting mental health and compassion focused therapy to the young and the vulnerable. To keep my mental health healthy and in check. 17 Page 119 of 312

120 I do exercise to improve my mental and physical health To continue walking to reduce isolation and loneliness Theme 3: Awareness and correct use of NHS Services Some people recognised the importance in ensuring that they use the NHS in the correct way and pledged to always ensure they used the most appropriate service first: To collect and share leaflets to spread awareness of available services in the community and encourage their use To use the appropriate service to meet my needs, e.g. talk to a pharmacist before making a GP appointment or to call NHS111 before going to A&E. To prioritise asking a pharmacist for advice before booking an appointment at the doctors. To use the services of the NHS where needed and properly. Theme 4: Celebrating the NHS As NHS 70 was a time to reflect on the NHS, some people took the opportunity to thank the NHS for the services, care and treatment they had experienced: The maternity services I had was the best care! My first baby was with private, my second was with the NHS and it was much better The treatment I received over the past three years when I needed hospital treatment was extremely good, caring and to be praised My son who was very ill with his chest and received treatment from the NHS which has been amazing. Though there are imperfections, the most wonderful people work there! I had a fantastic experience and personally can t speak highly enough of the NHS Next steps and legacy: The CCG worked closely with its partners across the local authorities, voluntary sector and statutory bodies (including Healthwatch and CVS) and other healthcare providers. The CCG will work together across the organisations involved to share feedback across services and to look at common themes and develop and action plan. In particular the CCG will look at continuing the work with York employers to promote staff engagement sessions around health and well being. Working age adults is an area of the population that the CCG has not always been able to actively engage in conversation. This demographic has been identified as a group to focus on for 2018/19 engagement, looking at mental health, healthy hearts and working with the public health team on lifestyle choices. Our recommendations: 18 Page 120 of 312

121 To work across sector to continue educating the public on correct service use To work with our colleagues across health and social care, and the voluntary sector to encouraging our community to look after their own health by leading a healthy lifestyle To continue to recognise the extraordinary staff that work for the NHS Other engagement and updates: Carers update: NHS Vale of York CCG has been attending several carers meetings over the last few months, including meetings regarding the development of the new Carers Strategy for York and Carers groups in East Riding and Pocklington. Feedback: The carers on the East Riding border raised concerns around equity of access to services, and conflicting information provided between CCG areas Desire to keep up to date with service development in York (living in Pocklington) despite residing in East Riding. Both CCGs need to ensure that they communicate and share information between areas. Ensuring that access to services in Pocklington is equal for ERCCG and VOYCCG residents. Eg access to weight loss services. They would like a universal patient passport, that is accepted by all practices/providers. Having the correct information, and likes/dislikes about the service user is crucial as part of their care Sharing of information and records across hospitals is poor eg between York and Hull and vice versa. Increased awareness within GP practices Change in continence product provider is causing concern and distress amongst family members that people care for Feedback has been shared within the organisation. As a result meetings have taken place between the neighbouring local authorities and CCGs about the impact across three local authority areas. It was agreed that they would look at addressing policy and procedural differences across different local authority areas, including community service provision, continuing healthcare, Section 75 agreement (how costs are recharged) and Mental Health Services. National drive to increase awareness and support for carers within Primary Care. NHS England has been working on a project on how to increase awareness and support of carers within primary care. It is well documented that carers report worse experiences of accessing and using GP than non-caring patients. Linking in to the health and social care action carers action plan , there is a national move towards ensuring that GP practices are identifying and supporting carers. 19 Page 121 of 312

122 David Ross, patient experience lead within NHSE, gave a presentation on the carers project. Later this year a new framework will be released, which asks GP practice to rate themselves based on these areas: identification and recognition of carers in-practice support for cares mental health support information for carers accessibility and appropriateness of appointments carer friendly culture This framework will be linked in to CQC inspections and GP practices will be asked to provide examples of how they identify and support carers. Healthwatch Annual Meeting 25 July 2018 The Healthwatch Annual Meeting took place on 25 July It covered the latest annual report and achievements over the last year. Over the coming year the Healthwatch York work plan will focus on changes to services in York. They are going to focus on: 1. The proposal for Priory Medical Group to provide a new Health centre at Burnholme Community hub 2. Provision of services at the pain clinic 3. Impact of change in provider on podiatry services 4. Experiences of BMI and smoking thresholds for orthopaedic operations 5. Anti-coagulation They led an hour session with the public around service changes, asking for positive and negative experiences. Positive experiences: A positive experience was had by a lady registered with Sherburn in Elmet practice and she was referred to Selby Scott Road for an ultrasound this was much better than going to the hospital Provision of social prescribing Introduction of open door at York University now offering evening appointments and have appointed a link practitioner Malton Hospital one-stop shop for urology Concerns about service changes: 20 Page 122 of 312

123 If moving services from centralised areas (such as the hospital) to the community, we need to ensure that the provision in the community is available so that expectations are met. This includes the relevant information, advice, expertise and ease of access to appointments. Staff engagement and training We are encouraging our staff to sign up for a number of free courses from NHSE to help us improve how we involve patients and public in our work, via It is important as part of our statutory duty that our staff are trained and up to date with information in this area including health inequalities, patient engagement and participation, data analysis and developing relationships with Patient and Public Voice Partners. Care Homes and Adult Safeguarding Update A small number of Care Homes have been subject to voluntary or enforced suspensions due to quality concerns being raised by the CQC, Local Authority and/or CCG. The collective impact for the system is resulting in less beds being available for those living with complex conditions, specifically dementia. The CCG are working with partners to understand the full impact of this as well as providing ongoing support and education to Care Homes. Quality in Care Homes Out of Hospital Steering Group As part of the out of hospital Steering group work, Quality Leads from NHS VOY CCG and Scarborough and Ryedale CCG (SRCCG) continue to work closely, ensuring a joint up approach. Aimed at preventing unnecessary admissions from care homes and promoting flow/ discharge, key schemes include the Capacity Tracker Tool, the Red Bag initiative and React to Red. Engagement with Providers The Senior Quality Lead has been invited by a GP to be involved in considering different models of working to improve the efficiency of support offered to care homes by the practice. Care Home engagement: The Senior Quality Lead has continued visits to understand priorities of the different care homes and identify where support can be offered. This work ensures the care home strategy continues to reflect residents and carer s priorities, sharing progress and celebrating achievements. The Senior Quality Lead will be supporting a local care home manger in establishing a task and finish group who aim to agree a charter of standards. The charter will articulate standards that can be expected from the home. This ambition is to 21 Page 123 of 312

124 address promotion of positive perceptions of the care home sector with NHS colleagues and other stakeholders. It links with the national recruitment campaign and the Excellence Centre promoting health and social care sector as a positive environment. React to Red and Safety Huddles: To date 46 care homes (total number of 81) are undergoing training for React to Red. This includes approximately 1372 eligible staff, of which 883 have received training. 14 homes have achieved full sign off with all (360) staff trained and competent. Certificates have been awarded to recognise the success. 3 further care homes are due to commence training next month. React to Red has also seen its first road trip, visiting several independent communities across the Vale of York. So far 4 communities have been visited to raise awareness to tenants, carers and relatives with a further booked next month. The District nursing services in Tang Hall has recognised an increase in pressure ulcer reporting and shown interest in the programme. A meeting is scheduled in September to discuss collaborative working with the service. React to Red updates and patient/carer information has been ed out to all GP surgeries who care for residents in care homes participating in the programme. Information has also been included in the CCG communications with all practices. Post training evaluation continues to be very positive with care staff reporting the training easy to understand, improving baseline knowledge of pressure prevention, recognition and actions to take. There is really good engagement with some homes, who are evidencing fantastic examples of how the programme has helped to improve their practice. Homes from the new cohort are following example by previous participants and are making pressure ulcer prevention training mandatory for care workers as an annual refresher. A poster previously presented at the Tissue Viability Society Conference in April 2018 has since been displayed at the Patient Safety Congress in Manchester during July This describes the experience of implementing React to Red with Safety Huddles in the pilot homes across the CCG. NHS England have also recognised this work and included it in their North Region Independent Care Sector Leads newsletter. Focussed support for reducing falls in two care homes continues which includes education and Safety Huddles. A number of homes have expressed an interest in becoming involved in this work and the quality team are working with them. NHS England are continuing to develop a falls programme which the Senior Quality Lead is contributing towards. 22 Page 124 of 312

125 Supporting Care Homes The Senior Quality Lead aims to play an active role in work that prevents non elective admissions. This includes support for domiciliary care organisations as well as Care Homes. A Quality Improvement project to support the early identification and communication of deterioration in care home residents has now started. This includes the use of a softer signs tool combined with National Early Warning Score (NEWS) and Situation, Background, Assessment, Recommendation (SBAR) communication tool. Supported by the Improvement Academy it is anticipated to build on work published by Wessex Academic Health Science Networks (AHSN) and include sepsis awareness. There are already early examples where the tool has supported early intervention for residents. A bid for funding was submitted in June via the Q community and is now amongst a final shortlist of 25 projects. If successful up to 30k may be awarded from the Health Foundation on September 19 th following a presentation and voting process by peers. The bid is generating interest from across the Q Community with a number of supportive messages continuing to be received recognising the value in this area of work. The bid hopes to achieve support for extending scope of the RAPID work into the domiciliary care setting. Preliminary work has commenced, collaborating with a domiciliary care agency who employ 120 staff and have an education centre willing to support implementation. The Red Bag initiative is still in the planning phase due to infection prevention and control challenges. Discussions with stakeholders continue to ensure the plan for roll out is safe, effective and sustainable. A pilot to support care homes not to dip stick urine continues to be led by the Infection Prevention Team. This aims to reduce the use of unnecessary antibiotics, promote appropriate antibiotic stewardship and links with good hydration. Care Home Bed State Tool now called Capacity Tracker This is described as a web based capacity portal developed by NECS North of England Commissioning Support) in conjunction with NHS England North region and is aimed at reducing delayed transfers of care. The tool has been procured by NHS England and is free. It aims to enables care homes to share real time bed availability with NHS providers and Local Authorities. The tool is live and progressing alongside implementation in the East Riding CCG (ERCCG) and SRCCG. The NHS VOY CCG is leading on this initiative for the vale of York with support from colleagues in North Yorkshire County Council (NYCC), City of York Council (CYC), East Riding County Council (ERCC) and York Teaching Hospitals NHS Foundation Trust (YTHFT). At the current time the uptake of homes is 65% (53 out 0f 81using). The VOY CCG is contributing towards a user group to inform on development of the tool and to support adoption and spread. Capacity reports which can be pulled from the system are not included in this paper as the data is not valid at the moment due to reporting anomalies. NECS aim to trial the tracker for use with domiciliary care agencies and potentially develop public access. 23 Page 125 of 312

126 The Partners in Care forum The June meeting had a full agenda with good attendance from all stakeholders including colleagues from TEWV who will commence monthly standing agenda items alongside colleagues from York Hospital NHS Trust and the Continuing Health Care (CHC) Team. The Partners in Care Lessons Learned Bulletin continues bimonthly with contributions from the social care sector to ensure it is relevant and appropriate to the audience. The next meeting is scheduled for September and a weekly bulletin has now commenced to ensure updates for messages are communicated in a more user friendly way. Health and Social Care Joint Working The Senior Quality Lead continues to link with local authority colleagues as required to support action and improvement plans or where concerns are raised. This continues to be supportive to the care homes, ensuring appropriate interventions can be facilitated. NYCC have appointed a Quality Improvement Team and opportunities for joint working will be explored. Pippa Equipment Selection in Community Work to ensure the quality perspective and good governance processes are integral in the commissioning agreements for equipment is being led by the Chief Nurse for Hambleton, Richmondshire and Whitby CCG. The Senior Quality Lead has been invited to chair a sub group of the Equipment Review Group to consider mattresses and seating. It is anticipated this should be for a period of 12 months to realise financial savings associated with the appropriate selection and use of mattresses which account for 50% of the spend. A case study looking at the benefits of using the Mercury Hybrid mattress within a Nursing Home commenced in early December. The findings have been written and a poster will be submitted for presentation at Wounds UK conference later this year. A care home setting has not published a study like this as yet and it is hoped will help inform on best practice. Research and Development In July a Research and Development manager line managed by the Senior Quality Lead commenced in post. This is very positive for the VOY CCG and demonstrates the commitment the organisation has towards research. Work to support current research and develop opportunities and collaboration across stakeholders will be greatly enhanced, providing a point of contact within the VOY CCG. Children and Young People Continence Provision The CCG has been working with the City of York Council and YTHFT to better describe Level 1 and Level 2 continence provision for children living across the Vale of York. Historically the Level 1 service was provided by School Nurses but following the transition of this service to the local authority s Healthy Child Programme (HCP), concerns about a lack of clarity of what the service now offers have been raised. 24 Page 126 of 312

127 Without a defined service outline, children with continence issues are being inappropriately referred into secondary care. In response the CCG is Developing a referral form for Primary Care that specifies when to refer to the HCP and when to refer to secondary care Developing easy signposting to tools and guidance for parents on the CCG website via the RSS Planning a GP Education session in October to launch the referral form and presentations from the HCP service and secondary care service Planning for a session that brings key stakeholders together to review the pathway and improve the experience of those requiring access to it. The added complexity is that this work needs to consider 3 different HCP services across 3 Local Authorities. The work so far has included City of York Council but any information will need to be agreed with North Yorkshire and East Riding of Yorkshire County Council. Children s and Young Peoples Senior Quality Lead The CCG were successful in recruiting to this post and the successful candidate will start in September Safeguarding Children North Yorkshire Children Service Ofsted Inspection The August Quality and Patient Experience Committee commended the CCG s Designated Nurse, Safeguarding Children s contribution to the achievement of Outstanding for the recent North Yorkshire Children s Service Ofsted Inspection City of York Safeguarding Children Board The Board last met on 18 July. Following publication of Working Together to Safeguard Children (WT 2018) the Acting Chief Constable for North Yorkshire Police, the Director of Children s Services for City of York LA and the Chief Nurse for CCG presented more detailed proposals regarding the City of York Safeguarding Children Partnership. The proposals were well received by Board members and it was agreed that final comments will be forwarded to the Board Business Unit before the 18th of August. It is anticipated the Board will be in a position to publish new arrangements by the end of Department for Education have notified the Board that they have been successful in their application for Early Adopter Funding. This funding will be used to further develop processes for engaging education in the new partnership arrangements. 25 Page 127 of 312

128 Safeguarding Adults The Modern Slavery Act 2015 introduced changes in UK law, focused on increasing transparency in supply chains. Specifically, large businesses are now required to disclose the steps they have taken to ensure their business and supply chains are free from modern slavery (that is, slavery, servitude, forced and compulsory labour and human trafficking). Commercial organisations that supply goods or services and have a minimum turnover of 36 million are required to produce a slavery and human trafficking statement each financial year. This should set out the steps taken to ensure modern slavery is not taking place in the organisation's own business and its supply chains. It needs to be approved at Board level, signed by a Director and published in a prominent place on the organisation s website. NHS England reported that as a result of the commercial undertakings of commissioning support units, they had non-nhs income over the required threshold in 2016/17 and therefore met the requirements for producing a statement. This was published in March York Teaching Hospital NHS Foundation Trust has published a Slavery and Human Trafficking statement in 2017 and The North Yorkshire Modern Slavery Partnership is encouraging all partners to publish a statement as good practice. The safeguarding designated team represent the CCG on this partnership. Children s Mental Health CAMHs (Child and Adolescent Mental Health Services) and Community Eating Disorder Service Members will be aware that the CCG has committed additional investment in CAMHS, eating disorder services and autism assessment services: there will be 120K recurrently for CAMHS and eating disorders and 90K non-recurrently in the current financial year for autism assessments. In addition, TEWV is investing an additional 50K recurrently in the service. This additional investment will not resolve the problems of long waiting lists but will enable more children and young people to be seen and treated more quickly, with better outcomes. The investment demonstrates very strongly the continued commitment of both CCG and TEWV to ensuring best possible care for children and young people to improve the chances of long term improved outcomes. Dr Kath Davies, Clinical Director for CAMHS at Limetrees/Selby is attended the August QPEC to talk about the impact on quality both for the existing service and the potential that these new investments will have. The presentation provided assurance in terms of the quality of the service but concerns remained about capacity and the services ability to improve access. Improvement plans for CAMHS and eating disorders have been agreed, which include quality measures around patient outcomes; in addition, NHS England is developing an outcome measure for 2019/2020 relevant to measuring demonstrable 26 Page 128 of 312

129 improvement in symptoms. The CCG has received the Q1 report for TEWV which gives the details of the Friends and Families Test and shows 87% positive feedback for the service; this measure will be reported to QPEC in the future. The City of York FIRST project (Family Intensive Rapid Support Team) is bidding to NHS England for capital funds (up to 800K) to support the development of a centre of excellence. This will include intensive short breaks for children and families where highly challenging behaviours mean the family is at risk of breakdown. It is also expected to negate the need for expensive out of area placements and retain the integrity of individual family units. NHS England has encouraged the City Council to submit the bid, which falls within the terms of the Transforming Care Programme for those with autism/ld and challenging behaviours. Special Educational Needs and Disabilities (SEND) Preparations continue for the anticipated joint CQC/Ofsted inspection of City of York area inspection of SEND; this will examine the joint arrangements locally for SEND, providing high quality support, and improving outcomes for children and young people. Additionally the CCG is working with City of York Council on a joint commissioning strategy for SEND: this will cover areas of work including decisions on funding, workforce development, and alignment of strategic and individual commissioning. Two bids to NHS England which were facilitated by the CCG for funds to support the Youth Offending Teams (YOT) in City of York and North Yorkshire County have been successful: 36K for 0.5 WTE clinical psychologist to work with children and young people in the youth justice system. An separate bid to the OPCC for a further 0.5WTE psychologist is big submitted 67K for 1.0 WTE speech and language clinicians to work with YOT staff and children and young people: speech, language and communication difficulties are widespread in the youth justice system. Adult Mental Health IAPT (Improving Access to Psychological Therapies) The CCG worked with Tees and Esk and Wear Valley NHS Foundation Trust (TEWV) in supporting an external review in 2017 by NHSE for the IAPT services. As a result a significant action plan was put in place to address a whole range of issues related to the service model, waiting times and access. The service has made significant progress achieved the agreed local target for access by the end of March 2018 at 15%. In clearing the waiting list a large number of patients (around 40%) did not take up the service. TEWV are in the process of auditing the reasons for this to inform future practice and waiting list management. The CCG worked with Tees and Esk and Wear Valley NHS Foundation Trust (TEWV) in supporting an external review in 2017 by NHSE for the IAPT services. As a result a significant action plan was put in place to address a whole range of issues 27 Page 129 of 312

130 related to the service model, waiting times and access. The service has made significant progress achieved the agreed local target for access by the end of March 2018 at 15%. In clearing the waiting list a large number of patients (around 40%) did not take up the service. TEWV are in the process of auditing the reasons for this to inform future practice and waiting list management. The position for June is 14.56% of people have entered treatment against the level of need, which is an increase from 11.24% in May. Changes have been made to the routine assessment process and additional capacity is in place. Sufficient appointments are available within the service to achieve target. The service has discussed with the CCG, plans for marketing and is in the process of revising and improving service information. A communications strategy with the aim of increasing public awareness of the service has been developed with the TEWV communications team. Additionally, a service specific website is being developed, which as well as providing information on the service, will also allow for self-referrals. The position for June is 48.57% of people who have moved to recovery, which is a decrease from 50.50% in May. The service will be including actions to improve and sustain the improvement in recovery in the new action plan, however it is acknowledged that the interim pathway work may have an impact on recovery until the backlog is cleared. A validated waiting list is now available. This has been shared with the service to enable patients with the longest waits to assessment to be targeted across York & Selby to ensure that all patients are offered an appointment with the next available practitioner. Early Intervention in Psychosis (EIP) The CCG has invested additional funding for the EIP service to expand the range for therapies available for patients and their families in the EIP team. This will move the service closer to providing fully NICE compliant service. TEWV are currently in the process of recruitment. The service is currently receiving an unusually high number of referrals which is resulting in staff operating with a high caseload. The team also has 3 vacancies and a member of staff off on long term sick. The vacancies have been recruited to and will start in September. In the interim they are prioritising referrals and working as effectively as possible to support this and an action plan is in place. However, improvements in performance will not be seen until they are fully staffed. 28 Page 130 of 312

131 Item Number: 10 Name of Presenter: Phil Mettam Meeting of the Governing Body Date of meeting: 6 September 2018 Report Title Emergency Preparedness, Resilience and Response NHS Vale of York CCG Arrangements Purpose of Report For Approval Reason for Report Approval of nationally mandated Emergency Preparedness, Resilience and Response (EPRR) arrangements. Strategic Priority Links Strengthening Primary Care Reducing Demand on System Fully Integrated OOH Care Sustainable acute hospital/ single acute contract Transformed MH/LD/ Complex Care System transformations Financial Sustainability Local Authority Area CCG Footprint City of York Council Impacts/ Key Risks Financial Legal Primary Care Equalities East Riding of Yorkshire Council North Yorkshire County Council Covalent Risk Reference and Covalent Description Page 131 of 312

132 Emerging Risks (not yet on Covalent) NHS organisations are mandated to plan for and be able to respond to a wide range of incidents and emergencies that could affect health or patient care. The Vale of York EPRR Policy; the Vale of York Buisness Continuity Policy and supporting procedural documentation are to ensure NHS Vale of York CCG acts in accordance with the Civil Contingency Act 2004, the Health & Social Care Act 2012 and relevant national policy and guidance as issued by the Department of Health in our role as a Category 2 Responder. The CCG has assessed itself as Substantial overall, in relation to compliance with the NHS core standards for Emergency Preparedness, Resilience and Response (EPRR) which is part of the annual EPRR assurance process for 2018/19. Recommendations To approve the CCG s EPRR Assurance Self-Assessment for and current Compliance Level. Responsible Executive Director and Title Phil Mettam Accountable Officer Report Author and Title Fliss Wood EPRR and Performance Manager Annexes (please list) EPRR Core Standards Statement of Compliance EPRR Policy Business Continuity Policy EPRR Improvement Plan Page 132 of 312

133 Ref Domain Standard Detail Clinical Commissionin Evidence - examples listed below g Group 1 Governance Appointed AEO The organisation has appointed an Accountable Emergency Officer (AEO) responsible for Emergency Preparedness Resilience and Response (EPRR). This individual should be a board level director, and have the appropriate authority, resources and budget to direct the EPRR portfolio. Y Name and role of appointed individual 2 Governance EPRR Policy Statement A non-executive board member, or suitable alternative, should be identified to support them in this role. The organisation has an overarching EPRR policy statement. This should take into account the organisation s: Business objectives and processes Key suppliers and contractual arrangements Risk assessment(s) Functions and / or organisation, structural and staff changes. The policy should: Have a review schedule and version control Use unambiguous terminology Identify those responsible for making sure the policies and arrangements are updated, distributed and regularly tested Include references to other sources of information and supporting documentation. Y Evidence of an up to date EPRR policy statement that includes: Resourcing commitment Access to funds Commitment to Emergency Planning, Business Continuity, Training, Exercising etc. The Chief Executive Officer / Clinical Commissioning Group Accountable Officer ensures that the Accountable Emergency Officer discharges their responsibilities to provide EPRR reports to the Board / Governing Body, no less frequently than annually. Public Board meeting minutes Evidence of presenting the results of the annual EPRR assurance process to the Public Board 3 Governance EPRR board reports These reports should be taken to a public board, and as a minimum, include an overview on: training and exercises undertaken by the organisation business continuity, critical incidents and major incidents the organisation's position in relation to the NHS England EPRR assurance process. Y 4 Governance EPRR work programme The organisation has an annual EPRR work programme, informed by lessons identified from: incidents and exercises identified risks outcomes from assurance processes. Y Process explicitly described within the EPRR policy statement Annual work plan Page 133 of 312

134 The Board / Governing Body is satisfied that the organisation has sufficient and appropriate resource, proportionate to its size, to ensure it can fully discharge its EPRR duties. EPRR Policy identifies resources required to fulfill EPRR function; policy has been signed off by the organisation's Board Assessment of role / resources Role description of EPRR Staff Organisation structure chart Internal Governance process chart including EPRR group 5 Governance EPRR Resource Y 6 Governance Continuous improvement process The organisation has clearly defined processes for capturing learning from incidents and exercises to inform the development of future EPRR arrangements. Y Process explicitly described within the EPRR policy statement The organisation has a process in place to regularly assess the risks to the population it serves. This process should consider community and national risk registers. Evidence that EPRR risks are regularly considered and recorded Evidence that EPRR risks are represented and recorded on the organisations corporate risk register 7 Duty to risk assess Risk assessment Y The organisation has a robust method of reporting, recording, monitoring and escalating EPRR risks. EPRR risks are considered in the organisation's risk management policy Reference to EPRR risk management in the organisation's EPRR policy document 8 Duty to risk assess Risk Management Y Domain 3 - Duty to maintain plans Page 134 of 312

135 Plans have been developed in collaboration with partners and service providers to ensure the whole patient pathway is considered. Partners consulted with as part of the planning process are demonstrable in planning arrangements 9 Duty to maintain plans Collaborative planning Y 10 Duty to maintain plans Planning arrangements In line with current guidance and legislation, the organisation has effective arrangements in place to respond to the following risks / capabilities: In line with current guidance and legislation, the organisation has effective arrangements in place to respond to a critical incident (as per the EPRR Framework). Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required 11 Duty to maintain plans Critical incident Y Page 135 of 312

136 12 Duty to maintain plans Major incident In line with current guidance and legislation, the organisation has effective arrangements in place to respond to a major incident (as per the EPRR Framework). Y Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required 13 Duty to maintain plans Heatwave In line with current guidance and legislation, the organisation has effective arrangements in place to respond to the impacts of heat wave on the population the organisation serves and its staff. Y Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required 14 Duty to maintain plans Cold weather In line with current guidance and legislation, the organisation has effective arrangements in place to respond to the impacts of snow and cold weather (not internal business continuity) on the population the organisation serves. Y Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required 15 Duty to maintain plans Pandemic influenza In line with current guidance and legislation, the organisation has effective arrangements in place to respond to pandemic influenza as described in the National Risk Register. Y Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required Page 136 of 312

137 16 Duty to maintain plans Infectious disease 17 Duty to maintain plans Mass Countermeasures In line with current guidance and legislation, the organisation has effective arrangements in place to respond to an infectious disease outbreak within the organisation or the community it serves, covering a range of diseases including Viral Haemorrhagic Fever. These arrangements should be made in conjunction with Infection Control teams; including supply of adequate FFP3. In line with current guidance and legislation, the organisation has effective arrangements in place to distribute Mass Countermeasures - including the arrangement for administration, reception and distribution, eg mass prophylaxis or mass vaccination. There may be a requirement for Specialist providers, Community Service Providers, Mental Health and Primary Care services to develop Mass Countermeasure distribution arrangements. These will be dependant on the incident, and as such requested at the time. Y Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required CCGs may be required to commission new services dependant on the incident. 18 Duty to maintain plans Mass Casualty - surge In line with current guidance and legislation, the organisation has effective arrangements in place to respond to mass casualties. For an acute receiving hospital this should incorporate arrangements to increase capacity by 10% in 6 hours and 20% in 12 hours. Y Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required 19 Duty to maintain plans Mass Casualty - patient identification 20 Duty to maintain plans Shelter and evacuation The organisation has arrangements to ensure a safe identification system for unidentified patients in emergency/mass casualty incident. Ideally this system should be suitable and appropriate for blood transfusion, using a non-sequential unique patient identification number and capture patient sex. In line with current guidance and legislation, the organisation has effective arrangements in place to place to shelter and / or evacuate patients, staff and visitors. This should include arrangements to perform a whole site shelter and / or evacuation. Y Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required Page 137 of 312

138 21 Duty to maintain plans Lockdown 22 Duty to maintain plans Protected individuals 23 Duty to maintain plans Excess death planning Domain 4 - Command and control 24 Command and control On call mechanism In line with current guidance and legislation, the organisation has effective arrangements in place safely manage site access and egress of patients, staff and visitors to and from the organisation's facilities. This may be a progressive restriction of access / egress that focuses on the 'protection' of critical areas. In line with current guidance and legislation, the organisation has effective arrangements in place to respond to manage 'protected individuals'; including VIPs, high profile patients and visitors to the site. Organisation has contributed to and understands its role in the multiagency planning arrangements for excess deaths, including mortuary arrangements. A resilient and dedicated EPRR on call mechanism in place 24 / 7 to receive notifications relating to business continuity incidents, critical incidents and major incidents. Y Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required Arrangements should be: current in line with current national guidance in line with risk assessment tested regularly signed off by the appropriate mechanism shared appropriately with those required to use them outline any equipment requirements outline any staff training required Process explicitly described within the EPRR policy statement On call Standards and expectations are set out Include 24 hour arrangements for alerting managers and other key staff. This should provide the facility to respond or escalate notifications to an executive level. On call staff are trained and competent to perform their role, and are in a position of delegated authority on behalf on the Chief Executive Officer / Clinical Commissioning Group Accountable Officer. Process explicitly described within the EPRR policy statement 25 Command and control Trained on call staff The identified individual: Should be trained according to the NHS England EPRR competencies (National Occupational Standards) Can determine whether a critical, major or business continuity incident has occurred Has a specific process to adopt during the decision making Is aware who should be consulted and informed during decision making Should ensure appropriate records are maintained throughout. Y Domain 5 - Training and exercising Page 138 of 312

139 26 Training and exercising EPRR Training The organisation carries out training in line with a training needs analysis to ensure staff are competent in their role; training records are kept to demonstrate this. Y Process explicitly described within the EPRR policy statement Evidence of a training needs analysis Training records for all staff on call and those performing a role within the ICC Training materials Evidence of personal training and exercising portfolios for key staff The organisation has an exercising and testing programme to safely test major incident, critical incident and business continuity response arrangements. Exercising Schedule Evidence of post exercise reports and embedding learning Organisations should meet the following exercising and testing requirements: a six-monthly communications test annual table top exercise live exercise at least once every three years command post exercise every three years. 27 Training and exercising EPRR exercising and testing programme The exercising programme must: identify exercises relevant to local risks meet the needs of the organisation type and stakeholders ensure warning and informing arrangements are effective. Y Lessons identified must be captured, recorded and acted upon as part of continuous improvement. 28 Training and exercising Strategic and tactical responder training 29 Training and exercising Computer Aided Dispatch Domain 6 - Response 30 Response Incident Co-ordination Centre (ICC) Strategic and tactical responders must maintain a continuous personal development portfolio demonstrating training in accordance with the National Occupational Standards, and / or incident / exercise participation Manual distribution processes for Emergency Operations Centre / Computer Aided Dispatch systems have been tested annually The organisation has a preidentified an Incident Co-ordination Centre (ICC) and alternative fall-back location. Both locations should be tested and exercised to ensure they are fit for purpose, and supported with documentation for its activation and operation. Y Y Training records Evidence of personal training and exercising portfolios for key staff Exercising Schedule Evidence of post exercise reports and embedding learning Documented processes for establishing an ICC Maps and diagrams A testing schedule A training schedule Pre identified roles and responsibilities, with action cards Demonstration ICC location is resilient to loss of utilities, including telecommunications, and external hazards Version controlled, hard copies of all response arrangements are available to staff at all times. Staff should be aware of where they are stored; they should be easily accessible. Planning arrangements are easily accessible - both electronically and hard copies 31 Response Access to planning arrangements Y Page 139 of 312

140 32 Response Management of business continuity incidents The organisations incident response arrangements encompass the management of business continuity incidents. Y Business Continuity Response plans 33 Response Loggist The organisation has 24 hour access to a trained loggist(s) to ensure decisions are recorded during business continuity incidents, critical incidents and major incidents. Y Documented processes for accessing and utilising loggists Training records 34 Response Situation Reports 35 Response Access to 'Clinical Guidance for Major Incidents Access to CBRN incident: Clinical Management and health protection The organisation has processes in place for receiving, completing, authorising and submitting situation reports (SitReps) and briefings during the response to business continuity incidents, critical incidents and major incidents. Emergency Department staff have access to the NHSE Clinical Guidance for Major Incidents handbook. Y Documented processes for completing, signing off and submitting SitReps Evidence of testing and exercising Guidance is available to appropriate staff either electronically or hard copies 36 Response Domain 7 - Warning and informing Clinical staff have access to the PHE CBRN incident: Clinical Management and health protection guidance. The organisation has arrangements to communicate with partners and stakeholder organisations during and after a major incident, critical incident or business continuity incident. Guidance is available to appropriate staff either electronically or hard copies Have emergency communications response arrangements in place Social Media Policy specifying advice to staff on appropriate use of personal social media accounts whilst the organisation is in incident response Using lessons identified from previous major incidents to inform the development of future incident response communications Having a systematic process for tracking information flows and logging information requests and being able to deal with multiple requests for information as part of normal business processes Being able to demonstrate that publication of plans and assessments is part of a joined-up communications strategy and part of your organisation's warning and informing work 37 Warning and informing Communication with partners and stakeholders Y Page 140 of 312

141 38 Warning and informing Warning and informing The organisation has processes for warning and informing the public and staff during major incidents, critical incidents or business continuity incidents. Y Have emergency communications response arrangements in place Be able to demonstrate consideration of target audience when publishing materials (including staff, public and other agencies) Communicating with the public to encourage and empower the community to help themselves in an emergency in a way which compliments the response of responders Using lessons identified from previous major incidents to inform the development of future incident response communications Setting up protocols with the media for warning and informing The organisation has a media strategy to enable communication with the public. This includes identification of and access to a trained media spokespeople able to represent the organisation to the media at all times. Have emergency communications response arrangements in place Using lessons identified from previous major incidents to inform the development of future incident response communications Setting up protocols with the media for warning and informing Having an agreed media strategy which identifies and trains key staff in dealing with the media including nominating spokespeople and 'talking heads' 39 Warning and informing Media strategy Y Domain 8 - Cooperation 40 Cooperation LRHP attendance The Accountable Emergency Officer, or an appropriate director, attends (no less than 75%) of Local Health Resilience Partnership (LHRP) meetings per annum. Y Minutes of meetings 41 Cooperation LRF / BRF attendance 42 Cooperation Mutual aid arrangements 43 Cooperation Arrangements for multi-region response 44 Cooperation Health tripartite working The organisation participates in, contributes to or is adequately represented at Local Resilience Forum (LRF) or Borough Resilience Forum (BRF), demonstrating engagement and co-operation with other responders. The organisation has agreed mutual aid arrangements in place outlining the process for requesting, co-ordinating and maintaining resource eg staff, equipment, services and supplies. These arrangements may be formal and should include the process for requesting Military Aid to Civil Authorities (MACA). Arrangements outlining the process for responding to incidents which affect two or more Local Health Resilience Partnership (LHRP) areas or Local Resilience Forum (LRF) areas. Arrangements are in place defining how NHS England, the Department of Health and Social Care and Public Health England will communicate and work together, including how information relating to national emergencies will be cascaded. Y Y Minutes of meetings Governance agreement if the organisation is represented Detailed documentation on the process for requesting, receiving and managing mutual aid requests Signed mutual aid agreements where appropriate Detailed documentation on the process for coordinating the response to incidents affecting two or more LHRPs Detailed documentation on the process for managing the national health aspects of an emergency 45 Cooperation LHRP Arrangements are in place to ensure an Local Health Resilience Partnership (LHRP) meets at least once every 6 months. LHRP terms of reference Meeting minutes Meeting agendas Page 141 of 312

142 46 Cooperation Information sharing The organisation has an agreed protocol(s) for sharing appropriate information with stakeholders. Y Documented and signed information sharing protocol Evidence relevant guidance has been considered, e.g. Freedom of Information Act 2000, General Data Protection Regulation and the Civil Contingencies Act 2004 duty to communicate with the public. Domain 9 - Business Continuity 47 Business Continuity BC policy statement The organisation has in place a policy statement of intent to undertake Business Continuity Management System (BCMS). Y Demonstrable a statement of intent outlining that they will undertake BC - Policy Statement 48 Business Continuity BCMS scope and objectives The organisation has established the scope and objectives of the BCMS, specifying the risk management process and how this will be documented. Y BCMS should detail: Scope e.g. key products and services within the scope and exclusions from the scope Objectives of the system The requirement to undertake BC e.g. Statutory, Regulatory and contractual duties Specific roles within the BCMS including responsibilities, competencies and authorities. The risk management processes for the organisation i.e. how risk will be assessed and documented (e.g. Risk Register), the acceptable level of risk and risk review and monitoring process Resource requirements Communications strategy with all staff to ensure they are aware of their roles Stakeholders 49 Business Continuity Business Impact Assessment 50 Business Continuity Data Protection and Security Toolkit 51 Business Continuity Business Continuity Plans The organisation annually assesses and documents the impact of disruption to its services through Business Impact Analysis(s). Organisation's IT department certify that they are compliant with the Data Protection and Security Toolkit on an annual basis. The organisation has established business continuity plans for the management of incidents. Detailing how it will respond, recover and manage its services during disruptions to: people information and data premises suppliers and contractors IT and infrastructure Y Y Y Documented process on how BIA will be conducted, including: the method to be used the frequency of review how the information will be used to inform planning how RA is used to support. Statement of compliance Documented evidence that as a minimum the BCP checklist is covered by the various plans of the organisation These plans will be updated regularly (at a minimum annually), or following organisational change. 52 Business Continuity BCMS monitoring and evaluation The organisation's BCMS is monitored, measured and evaluated against the Key Performance Indicators. Reports on these and the outcome of any exercises, and status of any corrective action are annually reported to the board. Y EPRR policy document or stand alone Business continuity policy Board papers 53 Business Continuity BC audit 54 Business Continuity 55 Business Continuity BCMS continuous improvement process Assurance of commissioned providers / suppliers BCPs The organisation has a process for internal audit, and outcomes are included in the report to the board. There is a process in place to assess and take corrective action to ensure continual improvement to the BCMS. The organisation has in place a system to assess the business continuity plans of commissioned providers or suppliers; and are assured that these providers arrangements work with their own. Y Y Y EPRR policy document or stand alone Business continuity policy Board papers Audit reports EPRR policy document or stand alone Business continuity policy Board papers Action plans EPRR policy document or stand alone Business continuity policy Provider/supplier assurance framework Provider/supplier business continuity arrangements Page 142 of 312

143 Yorkshire and the Humber Local Health Resilience Partnership (LHRP) Emergency Preparedness, Resilience and Response (EPRR) assurance STATEMENT OF COMPLIANCE NHS Vale of York CCG has undertaken a self-assessment against required areas of the EPRR Core standards self-assessment tool v1.0 Where areas require further action, NHS Vale of York CCG will meet with the LHRP to review the attached core standards, associated improvement plan and to agree a process ensuring noncompliant standards are regularly monitored until an agreed level of compliance is reached. Following self-assessment, the organisation has been assigned as an EPRR assurance rating of Substantial (from the four options in the table below) against the core standards. I confirm that the above level of compliance with the core standards has been agreed by the organisation s board / governing body along with the enclosed action plan and governance deep dive responses. Signed by the organisation s Accountable Emergency Officer Date signed Date of Board/governing body Date presented at Public Board Date published in organisations meeting Annual Report Page 143 of 312

144 EMERGENCY PREPAREDNESS, RESILIENCE & RESPONSE POLICY August 2018 Authorship: Reviewing Committee: Performance & Improvement Manager/ Risk & Assurance Manager Senior Management Team Date: Approval Body Governing Body Approved date: September 2017 Review Date: September 2019 Equality Impact Assessment Sustainability Impact Assessment Related Policies Target Audience: Policy Reference No: COR 18 On Call Policy COR 16 Business Continuity Policy OPEL Escalation Plan A&E Delivery Board Escalation Framework and Delivery Plan On-Call Pack COR 05 Mobile Working Policy HR 20 Home Working Policy All employees, members, committee and sub-committee members of the group and members of the governing body and its committees. COR17 Version Number: 2.2 The on-line version is the only version that is maintained. Any printed copies should, therefore, be viewed as uncontrolled and as such may not necessarily contain the latest updates and amendments. Page 144 of 312

145 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY POLICY AMENDMENTS Amendments to the Policy will be issued from time to time. A new amendment history will be issued with each change. New Version Number Issued by Nature of Amendment Approved by & Date 0.1 Performance & Improvement Manager Policy & Assurance Manager Performance & Improvement Performance Improvement Manager First Draft VOYCCG Policy Formatting Update to definitions Update to accountabilities and responsibilities Updates to Action Cards Checklists APPROVED Remove NHSE tel. number Update NHSE Area Team ref. and incident level definitions to bring into line with NHSE published EPRR framework. SRG ref updated to A&E Delivery Board APPROVED Governing Body December 2014 Governing Body: Oct 16 Chief Operating Officer: 11 Oct 16 Date on Intranet Performance Improvement Manager Risk and Assurance Manager 2.2 Performance Improvement Manager Replaced NHSE North Yorkshire & Humber with NHSE Area Team (North). Para 5.2: addition of reference to CCG Constitution emergency powers Formatting in compliance with CCG Policy on Policies Links to National Risks Update to National Threat Levels Updated risk assessments published by the North Yorkshire Resilience Forum Updated Section 10.3 Risks to include Yorkshire & Humber LHRP Risk Register Updated Plans Governing Body, September 2017 Governing Body September 2018 To request this document in a different language or in a different format, please contact: Sharron Hegarty, Communications Manager Telephone: Sharron.hegarty@nhs.net Page 145 of Page

146 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY CONTENTS SECTION A-POLICY INTRODUCTION POLICY STATEMENT IMPACT ANALYSES SCOPE of POLICY PRINCIPAL LEGISLATION AND STANDARDS ROLES / RESPONSIBILITIES / DUTIES DISSEMINATION, TRAINING & REVIEW... 8 SECTION B: IDENTIFYING SIGNIFICANT INCIDENTS OR EMERGENCIES THE ROLE OF THE CCG WITHIN THE LOCAL AREA PLANNING AND PREVENTION RISKS ESCALATION, ACTIVATION AND RESPONSE SECTION C: ACTION CARDS ACTIVATION / ESCALATION FLOWCHART CONSULTATION, APPROVAL AND RATIFICATION PROCESS DOCUMENT CONTROL INCLUDING ARCHIVING ARRANGEMENTS IMPLEMENTATION TRAINING & AWARENESS MONITORING & AUDIT REVIEW REFERENCES ASSOCIATED POLICIES/DOCUMENTS CONTACT DETAILS LIST OF APPENDICES APPENDIX 1: EQUALITY IMPACT ANALYSIS FORM APPENDIX 2: SUSTAINABILITY IMPACT ASSESSMENT APPENDIX 3 ABBREVIATIONS Page 146 of Page

147 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY 1. INTRODUCTION SECTION A-POLICY 1.1. The NHS needs to be able to plan for and respond to a wide range of incidents and emergencies that could affect health or patient care. These could be anything from severe weather to an infectious disease outbreak or a major transport accident. Under the Civil Contingencies Act (2004), NHS organisations and sub-contractors must show that they can deal with these incidents while maintaining services to patients. This work is referred to in the health service as emergency preparedness, resilience and response (EPRR) As detailed in NHS England s framework the emergency preparation, resilience and response role of CCGs is to: Ensure contracts with provider organisations contain relevant emergency preparedness, resilience (including business continuity) and response elements Support NHS England in discharging its emergency preparedness, resilience and response functions and duties locally Provide a route of escalation for the Local Health Resilience Partnership (LHRP) should a provider fail to maintain necessary emergency preparedness, resilience and response capacity and capability Fulfil the responsibilities as a Category 2 Responder under the Civil Contingencies Act 2004 including maintaining business continuity plans for their own organisation Be represented on the LHRP Be represented at the LHRP sub-group Seek assurance that provider organisations are delivering their contractual obligation. 2. POLICY STATEMENT 2.1. This policy outlines how NHS Vale of York CCG will meet the duties set out in legislation and associated statutory guidelines, as well as any other issues identified by way of risk assessments as identified in the national risk register The aims of this procedural document are to ensure NHS Vale of York CCG acts in accordance with the Civil Contingency Act 2004, the Health & Social Care Act 2012 and any relevant national policy and guidance as issued by the Department of Health in our role as a Category 2 Responder. Page 147 of Page

148 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY 3. IMPACT ANALYSES Equality 3.1. As a result of performing the screening analysis, the policy does not appear to have any adverse effects on people who share Protected Characteristics and no further actions are recommended at this stage. The results of the screening are attached. Sustainability 3.2. A Sustainability Impact Assessment has been undertaken. Positive and negative impacts are assessed against the twelve sustainability themes. The results of the assessment are attached. 4. SCOPE OF POLICY 4.1. This policy applies to those members of staff that are directly employed by NHS Vale of York CCG and for whom NHS Vale of York CCG has legal responsibility. For those staff covered by a letter of authority / honorary contract or work experience this policy is also applicable whilst undertaking duties on behalf of NHS Vale of York CCG or working on NHS Vale of York CCG premises and forms part of their arrangements with NHS Vale of York CCG. As part of good employment practice, agency workers are also required to abide by NHS Vale of York CCG policies and procedures, as appropriate, to ensure their health, safety and welfare whilst undertaking work for NHS Vale of York CCG. 5. PRINCIPAL LEGISLATION AND STANDARDS 5.1. The following legislation and guidance has been taken into consideration in the development of this procedural document: The Civil Contingencies Act 2004 and associated formal Cabinet Office Guidance The Health and Social Care Act 2012 The requirements for Emergency Preparedness, Resilience and Response Framework. The requirements for Emergency Preparedness, Resilience & Response as set out in the applicable NHS standard contract NHS England s EPRR documents and supporting materials, including NHS England s Business Continuity Management Framework (service resilience) 2013, NHS England s Command and Control Framework for the NHS during significant incidents and emergencies (2013), NHS England s Model Incident Response Plan (national and regional teams) 2013, and NHS England s Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Page 148 of Page

149 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY National Occupational Standards (NOS) for Civil Contingencies Skills for Justice BSI PAS 2015 Framework for Health Services Resilience ISO Societal Security - Business Continuity Management Systems Requirements The CCG Constitution 5.2. The section in the CCG Constitution referring to emergency powers and urgent decisions applies 6. ROLES / RESPONSIBILITIES / DUTIES 6.1. LHRP responsibilities Facilitate the production of local sector-wide health plans to respond to emergencies and contribute to multi agency emergency planning. Provide support to NHS England and PHE in assessing and assuring the ability of the health sector to respond in partnership to emergencies at an LRF level. Each constituent organisation remains responsible and accountable for their effective response to emergencies in line with their statutory duties and obligations. The LHRP has no collective role in the delivery of emergency response NHS England EPRR Guidance 2013 outlines key Responsibilities as: the Accountable Officer is responsible for ensuring that the CCG has an incident response plan and is able to respond to an emergency; the board is regularly briefed with reports on the CCGs preparedness; additional risks, training and exercises; an Accountable Emergency Officer is appointed; communications exercise should be carried out every 6 months; a table top exercise should be carried out yearly; and a live exercise should be carried out every 3 years CCG Commitments comply with the Civil Contingencies Act 2004 as a category 2 responder; comply with the NHS England EPRR guidance 2013; publish this plan and distribute it to key partners; provide appropriate resources for EPRR; undertake regular review and testing of the plan; Page 149 of Page

150 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY ensure the NHS Trusts they commission health services from comply with NHS guidance and their duties under the Civil Contingencies Act 2004; attend the North Yorkshire Local Health Resilience Partnership; contribute to an annual report by the NHS England on the health sectors EPRR capability; and produce an annual work programme Overall accountability for ensuring that there are systems and processes to effectively respond to emergency resilience situations lies with the Chief Officer and the Accountable Emergency Officer. The Accountable Emergency Officer 6.5. The Accountable Emergency Officer has responsibility for: Ensuring that the organisation is compliant with the Emergency Preparedness Resilience & Response requirements as set out in the Civil Contingencies Act (2004), the NHS planning framework and the NHS standard contract as applicable. Ensuring that the organisation is properly prepared and resourced for dealing with a major incident or civil contingency event Ensuring the organisation and any providers it commissions, has robust business continuity planning arrangements in place which reflect standards set out in the Framework for Health Services Resilience (PAS 2015) and ISO Ensuring the organisation has a robust surge capacity plan that provides an integrated organisational response and that it has been tested with other providers and parties in the local community(ies) served Ensuring that the organisation complies with any requirements of NHS England, or agents thereof, in respect of the monitoring of compliance Providing NHS England, or agents thereof, with such information as it may require for the purpose of discharging its functions Ensuring that the organisation is appropriately represented at any governance meetings, sub-groups or working groups of the LHRP or Local Resilience Forum (LRF) which locally is the North Yorkshire LRF. Commissioning and Contracting leads 6.6. Commissioning and contracting leads have responsibility for ensuring emergency preparedness, resilience and response requirements are embedded within provider contracts. Page 150 of Page

151 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY The A&E Delivery Board 6.7. The York & Scarborough A&E Delivery Board has responsibility for effectively managing Surge and Escalation within the area. 7. DISSEMINATION, TRAINING & REVIEW Dissemination 7.1. The effective implementation of this procedural document will support openness and transparency. NHS Vale of York CCG will: Ensure all staff and stakeholders have access to a copy of this procedural document via the organisation s website. Communicate to staff any relevant action to be taken in respect of complaints issues. Ensure that relevant training programmes raise and sustain awareness of the importance of effective complaints management This procedural document is located on the NHS Vale of York Y Drive, in the Emergency Planning Policy folder A set of hardcopy Procedural Document Manuals are held by the Governance Team for business continuity purposes. Staff are notified by of new or updated procedural documents. Training 7.4. All staff will be offered relevant training commensurate with their duties and responsibilities. Staff requiring support should speak to their line manager in the first instance. Review 7.5. As part of its development, this procedural document and its impact on staff, patients and the public has been reviewed in line with NHS Vale of York CCG s Equality Duties. The purpose of the assessment is to identify and if possible remove any disproportionate adverse impact on employees, patients and the public on the grounds of the protected characteristics under the Equality Act This procedural document will be reviewed every three years by NHS Vale of York CCG, and in accordance with the following as and when on a required basis: Legislatives changes / Case Law Good practice guidelines Significant incidents reported or new vulnerabilities identified Lessons identified from actual incidents or exercises Changes to organisational infrastructure Changes in practice Page 151 of Page

152 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY 7.7. Procedural document management will be performance monitored to ensure that procedural documents are in-date and relevant to the core business of the CCG. The results will be published in the regular Corporate Assurance Reports. Page 152 of Page

153 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY SECTION B: IDENTIFYING SIGNIFICANT INCIDENTS OR EMERGENCIES Overview: 7.8. This procedure covers the CCG response to a wide range of incidents and emergencies that could affect health or patient care, referred to in the health service as emergency preparedness resilience and response (EPRR). Definition: 7.9. A significant incident or emergency can be described as any event that cannot be managed within routine service arrangements. Each requires the implementation of special procedures and may involve one or more of the emergency services, the wider NHS or a local authority. A significant incident or emergency may include; a. Any occurrence where the NHS funded organisations are required to implement special arrangements to ensure the effectiveness of the organisation s internal response. This is to ensure that incidents above routine work but not meeting the definition of a major incident are managed effectively. b. An event or situation that threatens serious damage to human welfare in a place in the UK or to the environment of a place in the UK, or war or terrorism which threatens serious damage to the security of the UK. The term major incident is commonly used to describe such emergencies. These may include multiple casualty incidents, terrorism or national emergencies such as pandemic influenza. c. An emergency is sometimes referred to by organisations as a major incident. Within NHS funded organisations an emergency is defined as the above for which robust management arrangements must be in place. Types of incident: An incident may present as a variety of different scenarios, they may start as a response to a routine emergency call or 999 response situation and as this evolves it may then become a significant incident or be declared as a major incident. Examples of these scenarios are: Big Bang a serious transport accident, explosion, or series of smaller incidents. Rising Tide a developing infectious disease epidemic, e.g. Pandemic Flu or Ebola; or a capacity/staffing crisis or industrial action. Page 153 of Page

154 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY Cloud on the Horizon a serious threat such as a significant chemical or nuclear release developing elsewhere and needing preparatory action. Headline news public or media alarm about an impending situation. Internal incidents fire, breakdown of utilities, significant equipment failure, hospital acquired infections, violent crime. CBRN(e) Deliberate (criminal intent) release of chemical, biological, radioactive, nuclear materials or explosive device. HAZMAT Incident involving Hazardous Materials. Mass casualties. Incident level: As an incident evolves it may be described, in terms of its level, as one to four as identified in the table below. NHS England Incident levels 1 An incident that can be responded to and managed by a local health provider organisation within their respective business as usual capabilities and business continuity plans in liaison with local commissioners. 2 An incident that requires the response of a number of health providers within a defined health economy and will require NHS coordination by the local commissioner(s) in liaison with the NHS England local office. 3 An incident that requires the response of a number of health organisations across geographical areas within a NHS England region. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level. 4 An incident that requires NHS England National Command and Control to support the NHS response. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level. 8. THE ROLE OF THE CCG WITHIN THE LOCAL AREA 8.1. The CCG is a Category 2 Responder and is seen as a co-operating body. The CCG is less likely to be involved in the heart of the planning, but will be heavily involved in incidents that affect the local sector through cooperation in response and the sharing of information. Although, as a Category 2 Responder, the CCG has a lesser set of duties, it is vital that the CCG shares relevant information with other responders (both Category 1 and 2) if emergency preparedness, resilience and response arrangements are to succeed A significant or major incident could place an immense strain on the resources of the NHS and the wider community, impact on the vulnerable people in our community and could affect the ability of the CCG to work normally. When events like these happen, the CCG s Page 154 of Page

155 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY emergency resilience arrangements will be activated. It is important that all staff are familiar with this procedure and are aware of their responsibilities. Staff should ensure that they are regularly updated to any changes in the emergency response, as notified by the Accountable Emergency Officer. Departments / teams must also maintain accurate contact details of their staff, to ensure that people are accessible during an incident. Major Incident Declared by an Ambulance Service Yorkshire Ambulance Service NHS Trust is responsible for informing receiving hospitals and the NHSE Area Team whenever the service declares a major incident or major incident standby. NHSE Area Team is also responsible for advising the NHS England of any major incidents or other significant incidents. Key Direction of Information for all major incidents and major incident standby declarations Direction of information flow to services and organisations only informed if scale and nature of incident requires it. Major Incident or Major Incident Standby issued by Ambulance Service Receiving Hospitals CCG on-call for affected area NHS England Area Team (North) On-call Local Authority Public Health On-call Public Health England On-call 111 Service All providers in CCG area including primary care CCGs on-call in areas not directly affected Other Ambulance Services Page 155 of Page

156 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY Major Incident Declared By Provider NHS funded organisations are responsible for informing their commissioning CCGs and the ambulance service whenever they are activated or declare a major incident or a major incident standby. The CCG will then inform NHSE Area Team. Incident occurs Manage with internal arrangements NO Does the incident need to be escalated? YES Actions By Provider Provider notifies the CCG for information and action NO Has a major incident or major incident standby been declared? YES Provider informs the ambulance service for cascade Actions By CCG CCG establishes coordination of local NHS Response and maintains contact with NHSE Yorkshire and Humber YES CCG informs NHS Area Team Level of response is agreed and jointly consider declaration of major incident if not already done. Is incident level 1? NO CCG and NHSE Area Team consult regional director oncall to agree level of response required Actions By Area Team NHSE Area Team establishes strategic coordination of NHS response in Yorkshire and Humber YES Page 156 of 312 Is incident level 2,3,4? 13 Page NO

157 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY Major Incident Declared by NHS England The NHS England Area Team is responsible for informing the ambulance services and CCGs of any national, regional or area major incident, major incident standby, or similar message where there is a need to respond locally or cross border mutual aid is required. The Ambulance Service will then inform Acute hospitals and the CCG will inform other providers. Top Down Cascade by NHS England NHS England NHS England North Area (Yorkshire Team and Humber (North) Team) Non-Blue Light Service LRF P t Primary Care Ambulance Services CCGs Other Blue Light Services Acute Hospitals Non-acute and non-nhs commissioned Independent Plan Activation Any on-call manager may activate the Incident Response Plan regardless of any formal alerting message. Such action may be taken when it is apparent that severe weather or an environmental hazard may demand the implementation of special arrangements or when a spontaneous response by members of the public results in the presentation of major incident casualties at any health care setting e.g. acute or community hospital, walk in centre, health centre, GP Practice or minor injuries unit. Page 157 of Page

158 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY 9. PLANNING AND PREVENTION 9.1. Action Card: An Action Card detailing roles and responsibilities is appended to this procedure as Action Card Contracting responsibilities: CCGs are responsible for ensuring that resilience and response is commissioned in as part of the standard provider contracts and that provider plans reflect the local risks identified through wider multi-agency planning. The CCG will record these risks on the internal risk register. In addition, CCGs are expected to ensure delivery of these outcomes through contribution to an annual EPRR assurance process facilitated by NHS England Area Team. The NHS Standard Contract includes the appropriate EPRR provision and this contractual framework will be used wherever appropriate by the CCG when commissioning services. Contract monitoring and review will encompass the review of EPRR and there may be occasions where the Local Health Resilience Partnership uses the CCG as a route of escalation where providers are not meeting expected standards Partnership working: In order to ensure coordinated planning and response across our area, it is essential that the CCG works closely with partner agencies across the area, ensuring appropriate representation. Category 1 and 2 Responders come together to form Local Resilience Forums (LRF) based on Police areas. These forums help to co-ordinate activities and facilitate co-operation between local responders. The North Yorkshire LRF is the vehicle where the multi-agency planning takes place via a variety of groups which relate to specific emergencies like fuel shortage, floods, industrial hazards and recovery. These plans will be retained by the NHSE Area Team. For the NHS, the strategic forum for joint planning for health emergencies is via the Local Health Resilience Partnership (LHRP) that supports the health sector s contribution to multiagency planning through the Local Resilience Forum (LRF) The diagram below shows the NHS England s EPRR response structure and its interaction with key partner organisations. Page 158 of Page

159 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY NHS England NHS England Area Team (North) 10. RISKS LOCAL RISKS Hazard analysis and risk assessment: A hazard analysis & risk assessment is undertaken by the Local Health Resilience Partnership (LHRP) and this includes detailed assessments of potential incidents that may occur. The assessments are monitored through this forum. Risk assessments are regularly reviewed or when such an incident dictates the need to do so earlier. Any external risk may be required to be entered onto the North Yorkshire LRF Community Risk Register if it is felt to pose a significant risk to the population. This action will be co-ordinated through the LHRP. The purpose of producing these lists of hazards and threats is to ensure that each organisation can focus their emergency planning efforts towards those risks that are likely (or could possibly) occur A formal risk assessment of hazards and risks is undertaken by a multi-agency LRF risk assessment group every year as required by the Civil Contingencies Act The Yorkshire & Humber LHRP Risk Register 2018 identifies the following as High Risks :- Pandemic Influenza. Health impacts of poor air quality Infectious Disease Outbreak Failure of Utilities Severe Weather - Cold & Snow Non- Conventional Terrorist Attack Page 159 of Page

160 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY National Risk Register The National Risk Register of Civil Emergencies July 2015 has been published and provides an updated government assessment of the likelihood and potential impact of a range of different civil emergency risks (including naturally and accidentally occurring hazards and malicious threats) that may directly affect the UK over the next 5 years. ata/file/419549/ _2015-nrr-wa_final.pdf National Threat level The level of threat from terrorism is under constant review by the Security Services. Low - an attack is unlikely Moderate - an attack is possible, but not likely Substantial - an attack is a strong possibility Severe - an attack is highly likely Critical - an attack is expected imminently The latest threat level can be viewed: Specific local risks: A number of specific risks that the CCG may potentially have are listed below alongside the planned response. Assurance will be obtained through the contracting route by the Head of Contracting or equivalent, and also via local partnership emergency planning within the local geographic area. International and national shortages of fuel can adversely impact on the delivery of NHS services. Fuel shortage The CCG will seek assurance that commissioned services have plans in place to manage fuel shortages and will work with the Local Health Resilience Partnership (LHRP) and Local Resilience Forum (LRF) on wider community resilience. Local risks identified will be escalated appropriately. The Environment Agency provides a flood warning service for areas at risk of flooding from rivers or the sea. Their flood warning services give advance notice of flooding and time to prepare. Flooding The CCG will seek assurance that commissioned services have plans in place to manage local flooding incidents and will work with the Local Health Resilience Partnership (LHRP) and Local Resilience Forum (LRF) on wider community resilience. Local risks identified will be escalated appropriately. 17 Page Page 160 of 312

161 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY Evacuation & Shelter Pandemic influenza Infectious/ contagious diseases Incidents such as town centre closures, flooding, or significant damage to healthcare premises could lead to the closure of key healthcare premises. The CCG will seek assurance that commissioned services have plans in place to manage local evacuation and shelter incidents, will work in partnership with the Local Authority, and will work with the Local Health Resilience Partnership (LHRP) and Local Resilience Forum (LRF) on wider community resilience. Local risks identified will be escalated appropriately. Pandemics arise when a new virus emerges which is capable of spreading in the worldwide population. Unlike ordinary seasonal influenza that occurs every winter in the UK, pandemic flu can occur at any time of the year. The CCG will seek assurance that commissioned services have plans in place to manage local pandemic, will work in partnership with the Local Authority, will cascade local pandemic communications, and will work with the Local Health Resilience Partnership (LHRP) and Local Resilience Forum (LRF) on wider community resilience. Local risks identified will be escalated appropriately. The CCG will work with and through the A&E Delivery Board to manage unplanned care as a result of pandemic influenza and will manage normal local surge and escalation. E.g. Ebola and Marburg viruses. Alerts are received from NHS England and Resilience Direct. Yorkshire Ambulance Trust and York Hospitals Trust have trained staff in containment of infectious diseases. CCG staff attended Ebola awareness event 4 th November Heat wave The Department of Health and the Met Office work closely to monitor temperatures during the summer months. Local organisations such as the NHS and Local Authorities plan to make sure that services reach the people that need them during periods of extreme weather. The CCG will seek assurance that commissioned services have plans in place that align to the national Heatwave Plan, and that will manage local heatwave incidents. The CCG will cascade local heatwave communications, and will work with the LHRP and LRF on wider community resilience. Local risks identified will be escalated appropriately. The CCG will work with and through the York & Scarborough A&E Delivery Board to manage unplanned care as a result of heatwave and will manage normal local surge and escalation. 18 Page Page 161 of 312

162 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY Each year millions of people in the UK are affected by the winter conditions, whether it's travelling through the snow or keeping warm during rising energy prices. Winter brings with it many hazards that can affect people both directly or indirectly. Severe weather is one of the most common disruptions people face during winter. Severe Winter Weather Diverts The CCG will seek assurance that commissioned services have plans in place to manage local severe winter weather, will cascade local winter communications, and will work with the Local Health Resilience Partnership (LHRP) and Local Resilience Forum (LRF) on wider community resilience. Local risks identified will be escalated appropriately. The CCG will work with and through the York & Scarborough A& E Delivery Board to manage unplanned care as a result of severe winter weather and will manage normal local surge and escalation. The North Yorkshire footprint consists of NHS organisations in the NHS England Yorkshire and Humber locality. An ambulance Divert Policy agreed across Yorkshire and Humber is in place to manage this risk. The Divert Policy should only be used when trusts have exhausted internal systems and local community-wide health and social care plans to manage demand. A total view of system capacity should be taken including acute resource, community response, intermediate care and community in-patient capacity. The CCG will monitor the generic box VOYCCG.Emergencyplan@nhs.net and pick up issues on the next working day directly with Providers The CCG is a partner in a number of specific plans which have been developed across the health community in order to respond to emergencies and escalate actions appropriately. These include: NHS England Incident Response Plan York & Scarborough A&E Delivery Board Escalation Framework Business Continuity Plan Specific multi-agency plans to which the CCG is party such as NYCC Pandemic Flu June 2018 and City of York Outbreak Plan July Assurance in respect of CCG emergency planning will be provided to the CCG Governing Body via the Governing Body Assurance Framework. 11. ESCALATION, ACTIVATION AND RESPONSE Action Card: An Action Card describing the activation process is appended to this procedure as Action Card 2. Page 162 of Page

163 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY CCG: As a Category 2 Responder under the Civil Contingency Act 2004, the CCG must respond to reasonable requests to assist and cooperate with NHSE or the Local Authority should any emergency require wider NHS resources to be mobilised. Through its contracts, the CCG will maintain service delivery across the local health economy to prevent business as usual pressures and minor incidents within individual providers from becoming significant or major incidents. This could include the management of commissioned providers to effectively coordinate increases in activity across their health economy which may include support with surge in emergency pressures. The York & Scarborough A&E Delivery Board work plans and meetings provide a process to manage these pressures and to escalate to NHSE AREA Team as appropriate NHSE North: The NHSE operates an on-call system for Emergency Preparedness, Resilience and Response (EPRR). This system is not restricted to major emergencies and could be mobilised to assess the impact of a range of incidents affecting, or having the potential to affect, healthcare delivery within North Yorkshire and the Humber. In respect of EPRR for incidents/risks that only affect the NHS, the NHSE Area Team covers the following North Yorkshire local authority areas: North Yorkshire County Council York City Council In respect of EPRR for incidents/risks that affect all multi-agency partners, the NHSE Team provides strategic co-ordination of the local health economy and represents the NHS at the North Yorkshire LRF The initial communication of an incident alert to the first on-call officer of the NHSE Team is via any of the organisations. An additional role of the NHSE Team is to activate the response from independent contractors as required Public Health England: Public Health England will coordinate any incident that relates to infectious diseases NHS Property Services: NHS Property Services has robust local contact arrangements which should be used in most cases for local out of hours issues that require the involvement or attention of NHS Property Services. Where local contact cannot be made with NHS Property Services or where situations require escalation to regional and communications team senior managers on-call, messages can be sent via the single number PAGEONE service below Dial: for NHS Property Services On-Call Escalation A call handler will ask for a group code Ask for NHSPS04 and leave your message and contact details Page 163 of Page

164 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY Vulnerable People: The Civil Contingencies Act 2004 places the duty upon Category 1 and 2 Responders to have regard for the needs of vulnerable people. It is not easy to define in advance who are the vulnerable people to whom special considerations should be given in emergency plans. Those who are vulnerable will vary depending on the nature of the emergency. For planning purposes there are broadly three categories that should be considered: Those who for whatever reason have mobility difficulties, including people with physical disabilities or a medical condition and even pregnant women; Those with mental health conditions or learning difficulties; Others who are dependent, such as children or very elderly. The CCG needs to ensure that in an incident people in the vulnerable people categories can be identified via contact with other healthcare services such as GPs and Social Care Communications: From a multi-agency response perspective the Police would lead on the communications and media support. From a non-public health incident perspective, the NHSE Team would lead on the communications. Public Health England will lead on communications if the incident was public health related. The CCG role will be to liaise with the communication lead as appropriate, supply information as requested and cascade communications. See Action Card 1 for further information on roles and responsibilities. Recovery In contrast to the response to an emergency, the recovery may take months or even years to complete, as it seeks to address the enduring human physical and psychological effects, environmental, social and economic consequences. Response and recovery are not, however, two discrete activities and the response and recovery phases may not occur sequentially. Recovery should be an integral part of the combined response from the beginning, as actions taken at all times during an emergency can influence the long-term outcomes for communities. Debriefing and Staff Support The CCG will be responsible for debriefing and provision of support to staff where required following an emergency. This is the responsibility of individual line managers coordinated by the Accountable Emergency Officer. De-briefing may also be on a multi-agency footprint Any lessons learned from the incident will be fed back to staff and actioned appropriately. Page 164 of Page

165 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY Testing & Monitoring of Plans The CCG emergency resilience plans will be reviewed annually by the Accountable Emergency Officer As part of the CCG s emergency preparedness and planning, the organisation will participate in exercises both locally and across the North Yorkshire LRF with our partners. This helps staff to understand their roles and responsibilities when a situation occurs Live incidents which require the plans to be evoked will conclude with a debrief process and lead to review/improvements of the plans. Page 165 of Page

166 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY SECTION C: ACTION CARDS ROLES AND RESPONSIBILITIES These action cards describes the general action required and should be adapted as necessary to apply to the specific circumstances of the incident. Page 166 of Page

167 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY 1. Action Card for Emergency Accountable Officer Your role Your base Your responsibility Your immediate actions Ongoing management Stand down EMERGENCY ACCOUNTABLE OFFICER West Offices, Station Rise, York. You are responsible for directing NHS Vale of York CCG s emergency response. 1. Obtain as much information as practicable and assess the situation. Complete an Initial Risk Assessment, (Template on next page) before implementing the required actions: is this an emergency. METHANE: Major Emergency Declared Exact Location Type of Emergency Hazards present and potential Access / Egress routes Number and types of Casualties Emergency services present and required If the incident is assessed as an emergency, activate the plan. SEE ACTIVATION / ESCALATION ACTION CARD. 2. Assign ACTION CARDS in accordance with the key functions to support you. 3. Proceed to the Incident Control Room. Systematically review the situation and maintain overall control of the CCG response. S urvey A ssess D isseminate Approve content and timings of press releases / statements and attend conferences if required. If it can be dealt with using normal resources, notify the appropriate personnel and maintain a watching brief. Continue to reassess the situation as further information becomes available and determine if any additional action is required In the event of any increase in the scale / impact of the incident reassess the risk and escalate as needed. Page 167 of Page

168 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY Initial Risk Assessment completed by Emergency Accountable Officer Questions to consider What is the size and nature of the incident? Area and population likely to be affected - restricted or Level and immediacy of potential danger - to public and response personnel Timing - has the incident already occurred/ongoing? What is the status of the incident? Under control Contained but possibility of escalation Out of control and threatening Unknown and undetermined What is the likely impact? On people involved, the surrounding area On property, the environment, transport, communications On external interests - media, relatives, adjacent areas and partner organisations. What specific assistance is being requested from the NHS? Increased capacity - hospital, primary care, community Treatment - serious casualties, minor casualties, worried Public information Support for rest centres, evacuees Expert advice, environmental sampling, laboratory testing, disease control Social/psychological care How urgently is assistance required? Immediate Within a few hours Information Collected?* *Key = Yes X = no? = Information awaited N/A = Not applicable Page 168 of Page

169 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY 2. Action Card for Incident Emergency Planning Coordinator Your role Your base Your responsibility Your immediate actions Incident Emergency Planning Coordinator West Offices, Station Rise, York. You are responsible for coordinating the CCG s tactical response and ensuring all aspects of the plan are followed. You will establish and maintain lines of communication with all other organisations involved, coordinating a joint response where circumstances require. 1. Proceed to the Incident Control Room. 2. With the Incident Emergency Accountable Officer, assess the facts and clarify the lines of communication accordingly. 3. Call in Senior Managers as required. 4. Allocate rooms, telephone lines and support staff as required. 5. Notify and liaise as necessary with health community and inter-agency emergency planning contacts. 6. Record all relevant details of the incident and the response. On-going management Stand down Systematically review the situation with the Incident Lead Executive and ensure coordination of the CCG response. Following stand-down, prepare a report for the Chief Officer. Arrange a hot de-brief for all staff involved immediately after the incident. Arrange a structured de-brief for all staff within a month of the incident. Page 169 of Page

170 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY NOTES FOR INCIDENT EMERGENCY PLANNING COORDINATOR 1. Review the status and resources of the local NHS 2. Plan rota 3. Ensure decision logs maintained 4. Monitor staff welfare 5. Confirm emergency contact arrangements to: NHS England Team Yorkshire Ambulance Service Community & Mental Health Trusts York Hospital NHS Foundation Trust Neighbouring CCGs Council Emergency Centres City of York Council Adult and Children s Services Other relevant responding agencies. 6. Maintain regular contact with the NHS responding agencies 7. Plan for prolonged response and to start working shift 8. Ensure a Recovery Team starts to plan the strategy for recovery after the initial response is organised Meetings Meetings held hourly for 15 minutes, chaired by the Emergency Accountable Officer to an agenda with brief factual reports from each lead Decisions Key decisions logged in the decisions log Equipment Availability Television, Phone, Teleconference facility, Laptops Use IS-BAR Briefing Tool I Identify Who you are. Who is present? (Ensure you have all key personnel present for the briefing S Situation What is the current situation? (If it is the initial brief then an overview of the incident will be required). B Background Where are we up to? Each area gives an update on: Risks Staffing levels Resource issues A Assessment Assessment of needs / concerns. R Recommendations Plan for the next 60 minutes. Be clear what is required of each area / person. Confirm time & location of next briefing (on the hour). Page 170 of Page

171 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY 3. Action Card for Communication Lead Your role Your base Your responsibility Your immediate actions Communication Lead West Offices, Station Rise, York. (unless a control room is located to another premise) You are responsible for preparing and disseminating media information by agreement with the Incident Lead Executive. If necessary, you will organise facilities for media visits and briefings. 1. Proceed to the Incident Control Room. 2. After briefing by the Incident Lead Executive, establish lines of communication with Communication Leads at other organisations involved in the emergency and work in conjunction with multi-agency communication leads as required. 3. Draft media releases for Incident Lead Executive approval. 4. Coordinate all contact with the media. 5. Ensure the nominated spokesperson is fully and accurately briefed before they have any contact with the media. On-going management Stand down Make arrangements for any necessary public communications. Participate in a hot de-brief immediately after the incident and any subsequent structured de-brief. Following stand-down evaluate communications effectiveness and any lessons learned and report these to the Incident Emergency Planning Coordinator for inclusion in the report to the Chief Officer. Page 171 of Page

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173 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE POLICY 4. Action Card For Loggist Your role Your base Your responsibility Your immediate actions On-going management Stand down LOGGIST (Admin and Clerical support) West Offices, Station Rise, York. (unless a control room is located to another premise) You will help to set up the incident control room, perform secretarial. Administrative or clerical duties as required by the Incident Control Team and ensure a record / log of the incident is maintained. 1. Proceed to the Incident Control Room as directed. 2. Report to the Incident Emergency Planning Coordinator for briefing 3. Assist in setting up the Incident Control Room with telephones, computers etc. 4. Arrange for all internal rooms to be made available as needed. 5. Maintain a log of decisions taken, communications, and actions taken by the incident control team. NB. The record must be made in permanent black ink, clearly written, dated and initialled by the loggist at start of shift. All persons in attendance to be recorded in the log. The log must be a complete and continuous (chronological) record of all issues/ options considered / decisions along with reasoning behind those decisions /actions. Timings have to be accurate and recorded each time information is received or transmitted. If individuals are tasked with a function or role this must be documented and when the task is completed this must also be documented. See Incident Log template overleaf. Provide support services as directed. All documentation is to be kept safe and retained for evidence for any future proceedings. Participate in a hot de-brief immediately after the incident and any subsequent structured de-brief. Following stand-down evaluate admin effectiveness and any lessons learned and report these to the Incident Emergency Planning Coordinator for inclusion in the report to the Chief Officer. Page 173 of Page

174 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE POLICY Notes For Loggists Completion of Logs 1. Immediately the CCGs start to respond to an incident then a log of actions must be started by key officers and the organisation 2. Master Log all information entering the information cell must be logged including all incoming phone calls and s 3. Action log must be completed by all key Action Card holders Logs will be issued to all Action Card holders who should keep a record of: All instructions received, Actions taken Other information 4. The log should be handed on and signed off if the holder is relieved during the incident and following stand-down it is to be returned to the Emergency Control Centre Co-ordinator for safe storage. 5. Decision log records the key corporate decisions, the process for deciding and the considered alternatives. A decision log must be kept by the CCG incident commander. The Emergency Accountable Officer MUST sign the decision log after each key decision is agreed. LOGS MUST BE KEPT WITH DATED & TIMED ENTRIES BY ALL STAFF MAKING DECISIONS IN A MAJOR INCIDENTS ON APPROVED LOG SHEETS: NO RECORDS NO DEFENCE Prepare Shift Arrangements 6. In the event of a significant / major incident or emergency having a substantial impact on the population and health services, it may be necessary to continue operation of the Incident Management Team for a number of days or weeks. In particular, in the early phase of an incident, the Incident Management Team may be required to operate continuously 24/7. Responsibility for deciding on the scale of response, including maintaining teams overnight, rests with the Incident Manager. 7. A robust and flexible shift system will need to be in place to manage an incident through each phase. These arrangements will depend on the nature of the incident and must take into consideration any requirements to support external (for example SCG) meetings and activities. The Incident Manager is accountable for ensuring appropriate staffing of all shifts. During the first two shift changes 1-2 hours of hand over time is required. 31 P age Version 2.1 Page 174 of 312

175 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE POLICY 12. ACTIVATION / ESCALATION FLOWCHART VERIFY The information provided and the known facts of the incident ASSESS Is it a major incident for the CCG or another health organisation? Is action by the CCG necessary? You could contact other managers to discuss. DECIDE Is it a major incident for the CCG or another health organisation? Is action by the CCG necessary? Monitor developments Activate the Plan ACTIVATE The Plan will be activated by the Chief Officer or relevant Senior Manager ESCALATE Identify the Category 1 Lead for escalation NHS England North (Healthcare incidents) Press Option 1 North Yorkshire and the Humber Leave a message for person on-call NHS Property Services (Buildings / Facilities) NHS Property Services On-Call Escalation. A call handler will ask for a group code and leave your message and contact details. Public Health England (Infectious Diseases) In-Hours: Notify via the local Director of Public Health Out of Hours contact via NHS England If required, activate Incident Control Centre (West Offices, York) and Incident Control Team (Senior Management Team / relevant senior managers) Loggists (CCG admin staff members) set up Incident Control Centre and coordinate a meeting of the identified Incident Control Team Hold initial meeting, agree current situation and decisions to be made. Liaise with multi-agency partners. Agree any communications. Agree frequency of meetings. Ensure the meeting is minuted and a log kept of all decisions. 32 P age Version 2.1 Page 175 of 312

176 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE POLICY 13. CONSULTATION, APPROVAL AND RATIFICATION PROCESS The following committees and individuals have been involved in the consultation and development of this policy: SMT Local Health Resilience Partnership (LHRP) The policy will be approved/ratified by the committees/ccg Governing Body, in line with the CCG s Policy on Policies. 14. DOCUMENT CONTROL INCLUDING ARCHIVING ARRANGEMENTS The previous version of this policy will be removed from the intranet and will be available if required by contacting the author. 15. IMPLEMENTATION This policy will be circulated to all teams to be cascaded to individual members of staff. The document will be made available for staff and users and other stakeholders through the CCG website The CCG has mechanisms in place in order to ensure that: staff can raise issues of concern with their manager(s); staff are consulted on proposed organisational or other significant changes; managers keep staff informed of progress on relevant issues; service users, their relatives, carers and advocates can identify points of concern or worry by using the complaints process or PALS service; the media are accurately advised of developments in the CCG CCG policies are communicated to service providers and support service organisations through commissioning mechanisms and contract requirements. 16. TRAINING & AWARENESS This policy will be published on the CCG s website The policy will be brought to the attention of all relevant new employees as part of the induction process. Further advice and guidance is available from the Corporate Services Manager. 17. MONITORING & AUDIT The CCG monitors and reviews its performance in relation to EPRR performance and the continuing suitability and effectiveness of the systems and processes in place. 33 P age Version 2.1 Page 176 of 312

177 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE POLICY The Executive Committee is responsible for monitoring the effectiveness of this policy/strategy and for providing assurance to the Governing Body Monitoring of this policy/strategy may form part of the Internal Audit review of governance compliance. 18. REVIEW This framework will be reviewed bi-annually. Earlier review may be required in response to exceptional circumstances, organisational change or relevant changes in legislation or guidance. 19. REFERENCES ASSOCIATED POLICIES/DOCUMENTS COR 16 Business Continuity Policy COR 18 On Call Policy OPEL Escalation Plan A&E Delivery Board Escalation Framework and Delivery Plan On-Call Pack COR 05 Mobile Working Policy HR 20 Home Working Policy 21. CONTACT DETAILS Performance and Improvement Manager Telephone: Address: NHS Vale of York Clinical Commissioning Group, West Offices, Station Rise, York. Y01 6GA 22. LIST OF APPENDICES Appendix 1: Equality Assessment Appendix 2: Sustainability Assessment Appendix 3: Abbreviations 34 P age Version 2.1 Page 177 of 312

178 23. APPENDIX 1: EQUALITY IMPACT ANALYSIS FORM NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE POLICY 1. Title of policy/ programme/ service being analysed Risk Management Strategy and Policy 2. Please state the aims and objectives of this work. To define and document the CCG s approach to risk and risk management to ensure: risks within the organisation are identified, assessed, treated and monitored as part of the corporate governance of the CCG. robust risk assessment and monitoring mechanisms are in place for all elements of the commissioning process, including needs assessment, tendering, contract management and evaluation. 3. Who is likely to be affected? (e.g. staff, patients, service users) CCG staff, partner organisations (where applicable), public, patients and member practices. CCG managers and staff (and other providers and partners where applicable). If Risk management arrangements are not effective patients and service providers may be impacted. 4. What sources of equality information have you used to inform your piece of work? NHS England 5. What steps have been taken ensure that the organisation has paid due regard to the need to eliminate discrimination, advance equal opportunities and foster good relations between people with protected characteristics The analysis of equalities is embedded within the CCG s Committee Terms of Reference and project management framework. 35 P age Version 2.1 Page 178 of 312

179 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE POLICY 6. Who have you involved in the development of this piece of work? Internal involvement: Senior Management team Stakeholder involvement: Consultation with Senior Managers Patient / carer / public involvement: This is an Internal policy aimed at staff employed by the CCG and contractors working for the CCG. The focus is on compliance with statutory duties and NHS mandated principles and practice. There are no particular equality implications. 7. What evidence do you have of any potential adverse or positive impact on groups with protected characteristics? Do you have any gaps in information? Include any supporting evidence e.g. research, data or feedback from engagement activities (Refer to Table 1 - Embedding Equality into the Commissioning Cycle if your piece of work relates to commissioning activity to gather the evidence during all stages of the commissioning cycle) Disability Consider building access, communication requirements, making People who are learning disabled, reasonable adjustments for individuals etc. physically disabled, people with mental illness, sensory loss and long term chronic conditions such as diabetes, HIV) N/a Sex Men and Women N/a Race or nationality People of different ethnic backgrounds, including Roma Gypsies and Travelers Consider gender preference in key worker, single sex accommodation etc Consider cultural traditions, food requirements, communication styles, language needs etc. 36 P age Version 2.1 Page 179 of 312

180 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE POLICY N/a Age This applies to all age groups. This can include safeguarding, consent and child welfare N/a Trans People who have undergone gender reassignment (sex change) and those who identify as trans N/a Sexual orientation This will include lesbian, gay and bisexual people as well as heterosexual people. N/a Religion or belief Includes religions, beliefs or no religion or belief N/a Marriage and Civil Partnership Refers to legally recognised partnerships (employment policies only) Consider access to services or employment based on need/merit not age, effective communication strategies etc. Consider privacy of data, harassment, access to unisex toilets & bathing areas etc. Consider whether the service acknowledges same sex partners as next of kin, harassment, inclusive language etc. Consider holiday scheduling, appointment timing, dietary considerations, prayer space etc. Consider whether civil partners are included in benefit and leave policies etc. N/a 37 P age Version 2.1 Page 180 of 312

181 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE POLICY Pregnancy and maternity Refers to the pregnancy period and the first year after birth N/a Carers This relates to general caring responsibilities for someone of any age. N/a Other disadvantaged groups This relates to groups experiencing health inequalities such as people living in deprived areas, new migrants, people who are homeless, ex-offenders, people with HIV. Consider impact on working arrangements, part-time working, infant caring responsibilities etc. Consider impact on part-time working, shift-patterns, options for flexi working etc. Consider ease of access, location of service, historic take-up of service etc N/a 8. Action planning for improvement Please outline what mitigating actions have been considered to eliminate any adverse impact? Please state if there are any opportunities to advance equality of opportunity and/ foster good relationships between different groups of people? An Equality Action Plan template is appended to assist in meeting the requirements of the general duty 38 P age Version 2.1 Page 181 of 312

182 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE POLICY Sign off Name and signature of person / team who carried out this analysis Helen Sikora, Policy and Strategy Manager Audit Committee Date analysis completed December 2014 Name and signature of responsible Director Date analysis was approved by responsible Director 39 P age Version 2.1 Page 182 of 312

183 NHS Vale of York Clinical Commissioning Group EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE POLICY 25. APPENDIX 2: SUSTAINABILITY IMPACT ASSESSMENT Staff preparing a policy, Governing Body (or Sub-Committee) report, service development plan or project are required to complete a Sustainability Impact Assessment (SIA). The purpose of this SIA is to record any positive or negative impacts that this is likely to have on sustainability. Title of the document Risk Management policy and Strategy What is the main purpose of the To effective identify, manage and monitor risk within the organisation. document Date completed November 2014 Completed by Governance Team 40 P age Version 2.1 Page 183 of 312

184 Domain Objectives Impact of activity Negative = -1 Neutral = 0 Positive = 1 Unknown =? Not applicable = n/a Travel Will it provide / improve / promote alternatives to 0 car based transport? Will it support more efficient use of cars (car 0 sharing, low emission vehicles, environmentally friendly fuels and technologies)? Will it reduce care miles (telecare, care closer) to 0 home? Will it promote active travel (cycling, walking)? 0 Will it improve access to opportunities and facilities 0 for all groups? Will it specify social, economic and environmental 0 outcomes to be accounted for in procurement and delivery? Procurement Will it stimulate innovation among providers of 0 services related to the delivery of the organisations social, economic and environmental objectives? Will it promote ethical purchasing of goods or 0 services? Procurement Will it promote greater efficiency of resource use? 0 Will it obtain maximum value from pharmaceuticals 0 and technologies (medicines management, prescribing, and supply chain)? Will it support local or regional supply chains? 0 Will it promote access to local services (care closer 0 to home)? Will it make current activities more efficient or alter 0 Facilities Management service delivery models Will it reduce the amount of waste produced or increase the amount of waste recycled? Will it reduce water consumption? 0 Brief description of impact If negative, how can it be mitigated? If positive, how can it be enhanced? 41 P age Version 2.1 Page 184 of 312

185 Domain Objectives Impact of activity Negative = -1 Neutral = 0 Positive = 1 Unknown =? Not applicable = n/a Workforce Will it provide employment opportunities for local 0 people? Will it promote or support equal employment 0 opportunities? Will it promote healthy working lives (including 0 health and safety at work, work-life/home-life balance and family friendly policies)? Will it offer employment opportunities to 0 Community Engagement Buildings Adaptation to Climate Change disadvantaged groups? Will it promote health and sustainable development? Have you sought the views of our communities in relation to the impact on sustainable development for this activity? Will it improve the resource efficiency of new or refurbished buildings (water, energy, density, use of existing buildings, designing for a longer lifespan)? Will it increase safety and security in new buildings and developments? Will it reduce greenhouse gas emissions from transport (choice of mode of transport, reducing need to travel)? Will it provide sympathetic and appropriate 0 landscaping around new development? Will it improve access to the built environment? 0 Will it support the plan for the likely effects of 0 climate change (e.g. identifying vulnerable groups; contingency planning for flood, heat wave and other weather extremes)? 0 N/a Brief description of impact If negative, how can it be mitigated? If positive, how can it be enhanced? 42 P age Version 2.1 Page 185 of 312

186 Domain Objectives Impact of activity Negative = -1 Neutral = 0 Positive = 1 Unknown =? Not applicable = n/a Models of Care Will it minimise care miles making better use of 0 new technologies such as telecare and telehealth, delivering care in settings closer to people s homes? Will it promote prevention and self-management? 0 Will it provide evidence-based, personalised care 0 that achieves the best possible outcomes with the resources available? Will it deliver integrated care, that co-ordinate 0 different elements of care more effectively and remove duplication and redundancy from care pathways? Brief description of impact If negative, how can it be mitigated? If positive, how can it be enhanced? 43 P age Version 2.1 Page 186 of 312

187 26. APPENDIX 3 ABBREVIATIONS Term Definition CCA Civil Contingencies Act (2004) CCG Clinical Commissioning Groups DPH Director of Public Health EPRR Emergency preparedness, resilience and response LHRP Local Health Resilience Partnership LRF Local Resilience Forum PHE Public Health England COMAH Control of Major Accident Hazards DPH Director of Public Health EPRR Emergency Preparedness Resilience & Response ICC Incident Control Centre for Major Incidents IMT Incident Management Team IRP Incident Response Plan MACA Military Aid to the Civilian Authorities include - Military Aid to the Civil Communities (MACC) - Military Aid to the Civil Minitries (MACM) e.g. assistance in the event of industrial action - Military Aid to the Civil Powers (MACP), assistance to the Police MACR Major Accident Control Regulations OOH Out of Hours PRC Prepared Rest Centre Local authority organised centre for evacuees from an incident RH Receiving hospital A & E Hospital designated to receive casualties from a major incident REPPIR Radiation (Emergency Preparedness & Public Information) Regulations 2001 SCC Strategic Command Centre SCG Strategic Coordinating Group STAC Science & Technical Advice Cell TCG Tactical Coordinating Group - Multi-agency group of operational managers leading the tactical response in North Yorkshire 44 P age Version 2.1 Page 187 of 312

188 BUSINESS CONTINUITY POLICY January 2018 Authorship : Reviewing Committee : Pennie Furneaux, Risk and Assurance Manager Governance Steering Group Date : Approval Body : Circulated Executive Committee Governing Body Approved Date : 07 March 2018 Review Date: January 2020 Equality Impact Assessment : Sustainability Impact Assessment : Related Policies : Target Audience : Policy Reference No. : Yes Yes COR06 Communications Protocol COR17 Emergency Resilience Response Policy COR18 On-Call Policy IG06 Information Risk Policy All CCG staff and commissioning support staff who provide essential support to the CCG. COR16 Version Number : 3.0 The on-line version is the only version that is maintained. Any printed copies should, therefore, be viewed as uncontrolled and as such may not necessarily contain the latest updates and amendments. Business Continuity Policy - v3.0 Page 188 of 312 Page 1 of 30

189 POLICY AMENDMENTS Amendments to the policy will be issued from time to time. A new amendment history will be issued with each change. New Version Number Issued by Nature of Amendment Approved by and Date 2.0 Pennie Furneaux 2.1 Pennie Furneaux Risk and Assurance Manager Reformat Redraft to meet CCG requirements Responsibilities and job titles to reflect changes in organisational structure Update to hazards in line with NHS England guidance: water contamination Audit Committee Governing Body Executive Committee 07 March 2018 Date on Internet Feb March Helena Nowell, Planning and Assurance Manager Clarification as to frequency of updates at 13.3 Executive Committee To request this document in a different language or in a different format, please contact: or valeofyork.contactus@nhs.net Business Continuity Policy - v3.0 Page 189 of 312 Page 2 of 30

190 CONTENTS 1. INTRODUCTION POLICY STATEMENT IMPACT ANALYSES SCOPE POLICY PURPOSE/AIMS & FAILURE TO COMPLY PRINCIPAL LEGISLATION AND COMPLIANCE WITH STANDARDS ROLES / RESPONSIBILITIES / DUTIES UNDERSTANDING THE ORGANISATION POLICY IMPLEMENTATION TRAINING AND AWARENESS MONITORING AND AUDIT POLICY REVIEW STRATEGY TO IMPLEMENT A BUSINESS CONTINUITY MANAGEMENT SYSTEM BUSINESS CONTINUITY PLAN - COMMUNICATIONS REFERENCES ASSOCIATED CCG POLICIES CONTACT DETAILS APPENDIX 1 : EQUALITY IMPACT ANALYSIS FORM APPENDIX 2: SUSTAINABILITY IMPACT ASSESSMENT Business Continuity Policy - v3.0 Page 190 of 312 Page 3 of 30

191 1. INTRODUCTION 1.1. NHS Vale of York Clinical Commissioning Group, (the CCG); must deliver an effective Business Continuity Management System (BCMS) in order to secure the best possible outcomes for patients and to successfully deliver the its strategic objectives and operational plan In addition, the CCG must comply with the Civil Contingencies Act (2004) in developing robust Business Continuity Plans (BCPs) Commissioning is a key function of the NHS and CCGs. The CCG plays a key role within the local health system, therefore, it important that the organisation is able to continue its activities in the face of situations that might be, or could lead to, disruption, loss, emergency or crisis In order to effectively carry out its commissioning functions, the CCG requires access to resources to ensure that all of its activities are delivered effectively. These resources fall into five broad categories : People Premises Technology Information Suppliers and partners 1.5. A business continuity incident becomes possible when access to resources is threatened. Threats can emerge internally or externally, ranging from a technology failure to an influenza pandemic The CCG s strategy for dealing with these threats to resources is to implement a robust BCMS to identify and analyse risks to business continuity, where possible take measures to prevent incidents occurring, and to document and implement BCPs in order to minimise the impact of incidents when they do occur. Business Continuity Policy - v3.0 Page 191 of 312 Page 4 of 30

192 Definitions 1.7. The table below provides definitions of key terms used within this policy, (Source ISO 22301:2012). Definitions BC Business continuity is the capability of the organisation to continue delivery of its products and services at acceptable levels following a disruptive incident. BCM BCMP BCP Business continuity management is a holistic management process that provides a framework for building organisational resilience with the capability of an effective response that safeguards the interests of key stakeholders, reputation, brand and value-creating activities. A business continuity management programme is the ongoing management and governance process supported by top management and appropriately resourced to implement and maintain BCM. A business continuity plan provides documented procedures that guide the organisation to respond, recover, resume and restore to a pre- defined level of operation following disruption. 2. POLICY STATEMENT 2.1. The Vale of York Clinical Commissioning Group is committed to ensuring robust and effective Business Continuity Management (BCM) as a key mechanism to restore and deliver continuity of key services in the event of an incident This policy statement provides a framework for the CCG to follow in the event of an incident, such as fire, flood, bomb, staff absence, power and communication failure. It also states the process for implementing and maintaining a robust BCMS The CCG s business continuity plans will be based on the following standards : NHS Commissioning Board Core Standards for Emergency Preparedness, Resilience and Response (EPRR). ISO 22301: Business Continuity Management Systems - Requirements. ISO / PAS 22399: Guideline for Incident Preparedness and Operational Continuity Management. Recognised standards of corporate governance This policy statement will support the organisation to think ahead in order to avoid or mitigate risk, take corrective action and be in control of the outcome in the event of an incident, emergency or disaster. Business Continuity Policy - v3.0 Page 192 of 312 Page 5 of 30

193 3. IMPACT ANALYSES Equality 3.1. As a result of performing the screening analysis, the policy does not appear to have any adverse effects on people who share Protected Characteristics and no further actions are recommended at this stage. The results of the screening are attached. Sustainability 3.2. A Sustainability Impact Assessment has been undertaken. No positive or negative impacts were identified against the twelve sustainability themes. The results of the assessment are attached. 4. SCOPE 4.1. This policy will apply to all activities that come under the operations of the CCG as well as the activities of the commissioning support, members of which provide essential support to the CCG This policy will be applicable to the main site used by the CCG; namely West Offices, Station Approach, York. The premises are owned and maintained by City of York Council, and the premises are shared with council employed staff The organisation does not operate in isolation and has extensive networks and relationships with external parties, both NHS and those from the private sector This document recognises the importance of managing these third party relationships but they are not included within its scope. The organisation is reviewing and progressing the development of its BCM capacity and capability, those third parties relied upon to deliver the organisation s critical services will be expected to have their own BCM frameworks in place. 5. POLICY PURPOSE / AIMS AND FAILURE TO COMPLY 5.1. To enable the response to business disruptions to take place in a co-ordinated manner, in order to continue key business operations at the highest level achievable in the circumstances. Objectives To identify key services which, if interrupted for any reason, would have the greatest impact on the community, the health economy and the organisation. To identify and reduce the risks and threats to the continuation of these key services To develop plans which enable the organisation to maintain and / or resume key services in the shortest possible time. Priorities 5.2. By implementing and maintaining a business continuity management programme, the CCG seeks to achieve the following priorities should a disruptive incident affect the CCG: Business Continuity Policy - v3.0 Page 193 of 312 Page 6 of 30

194 Protect the safety of people employed by or working with the CCG; Maintain, recover, resume or restore the CCG s priority activities; Protect the interests of CCG stakeholders; Protect the CCG s finances, property, resources and reputation. Disruptions 5.3. The CCG s Business Continuity policy seeks to mitigate disruptions that may arise as a consequence of some form of incident, interruption or termination: Loss of people A range of possible scenarios (e.g. industrial action, severe weather causing transport disruption/closures, an influenza pandemic) could cause the CCG to experience loss of key personnel, knowledge, skills, relationships or contacts Loss of premises Fire, utility failure, civil disorder in a locality or a gas explosion are examples of scenarios that could lead to denial of access to buildings, facilities or accommodation and the inability to undertake CCG activities from a normal place of work Loss of resources Resources that support the CCG s activities, such as IT hardware, IT systems and networks, databases, telephony or other equipment may suffer failure, theft or malicious damage Loss of suppliers Third party providers of goods and services to the CCG may experience disruption themselves or may suspend or cease operations for some reason (e.g. bankruptcy, fraud investigation, statutory breach) 6. PRINCIPAL LEGISLATION AND COMPLIANCE WITH STANDARDS Statutory Instrument Health and Social Care Act 2012, Civil Contingencies Act (2004), NHS/Department of Health Guidance NHS Commissioning Board Business Continuity Management Framework (service resilience) 2013 NHS England Business Continuity Management Toolkit (Jan 2014) NHS England EPRR documents and supporting materials, CCG Scheme of Delegation 6.1. The CCG s Scheme of Delegation requires that the group s arrangements for business continuity and emergency planning are approved by the Governing Body. Business Continuity Policy - v3.0 Page 194 of 312 Page 7 of 30

195 7. ROLES / RESPONSIBILITIES / DUTIES 7.1. For the BCM Programme to be effective and become embedded in the organisation, responsibilities from the Chief Executive downwards need to be agreed and communicated so that everyone is aware of what is expected from them. The sections below provide summary details of the responsibilities of key individuals and committees. Chief Officer Responsibilities 7.2. The Chief Clinical Officer (CCO) of the CCG has overall responsibility for business continuity management within the organisation and is responsible on behalf of the Governing Body for ensuring the implementation of business continuity arrangements throughout the organisation. Senior Officers and Line Managers 7.3. All senior officers and managers will ensure that nominated business continuity leads maintain business continuity management arrangements, including Business Continuity Plans, for prioritised activities within their area of responsibility. This will include assurance from external service providers. All individuals 7.4. All staff must be aware of the Business Continuity Plan (BCP) that affects their business areas and their individual role following invocation It is the responsibility of everyone covered by the scope of this policy to ensure they comply with this policy. 8. UNDERSTANDING THE ORGANISATION Business Critical Functions, Systems and Processes 8.1. The purpose of this document is to ensure the organisation s business critical functions, systems and processes are identified. This will be achieved through partnership working between the BC Manager, Information Asset Owners and relevant BCP Owners to undertake risk assessments and business impact analysis, and then taking action to reduce risks and/or produce BC Plans covering those areas identified as high or medium risk. Non-Critical Functions, Systems and Processes 8.2. For those areas of organisation business deemed non-critical as a consequence of completing the BIA and risk assessment processes, it will be the responsibility of the relevant BCP Owner to ensure these areas are kept under review and take account of any changes which may have an impact on their status. 9. POLICY IMPLEMENTATION 9.1. Following approval by the Governing Body the policy will be sent to: The Communications Manager who will disseminate to all staff via the team newsletter process Business Continuity Policy - v3.0 Page 195 of 312 Page 8 of 30

196 The Chairs of the Governing Body, the Council of Members and all other committees and sub committees for dissemination to members and attendees. The Practice Managers of all member practices for information, (if appropriate). Business partners and stakeholders as appropriate. 10. TRAINING AND AWARENESS This policy will be published on the CCG s website and will be available to staff on the organisation s intranet The policy will be brought to the attention of all new employees as part of the induction process. Further advice and guidance is available from the Policy and Assurance Manager. 11. MONITORING AND AUDIT The Quality and Finance Committee is responsible for monitoring the effectiveness of this policy and for providing assurance to the Governing Body regarding compliance with the policy. The Quality and Finance Committee will receive reports on a bi-annual basis Monitoring of this policy may form part of the Internal Audit review of governance compliance. 12. POLICY REVIEW This policy will be reviewed bi-annually. Earlier review may be required in response to exceptional circumstances, organisational change or relevant changes in legislation/guidance. 13. STRATEGY TO IMPLEMENT A BUSINESS CONTINUITY MANAGEMENT SYSTEM Assigning Responsibilities BCM has the support of senior management. To support implementation of the Business Continuity Management System, each team should nominate a BCM Lead to with responsibility for taking the programme forward BCM Leads have responsibility for : reviewing team BC plans; maintaining their team s BC Plan and supporting Action Card(s); ensuring that supporting Standard Operating Procedures are maintained and made available to staff; staff are appropriately trained to implement the plans; and Business Continuity Policy - v3.0 Page 196 of 312 Page 9 of 30

197 organising exercises to test their plan. Preparing a Business Continuity Plan A Business Impact Analysis, (BIA) should be undertaken to identify and document key products/asset, services and the critical activities. These should be updated on an annual basis. The BIA should also: Outline the resources required to deliver these; the impact that a disruption of these activities would have on the Team s ability to deliver it s objectives and functions; and The resources required to resume activities The CCG has identified relevant risks according to NHS England guidance as follows: Hazards and threats relevant to the CCG Hazard of threat Y or N Why? 1 Fire or flood 2 Loss of electronic records 3 Loss of paper records 4 IT systems/application failure 5 Mobile telephony failure 6 Major IT network outage 7 Denial of premises Y Y Y Y Y Y Y Potential inability to access premises and assets required to conduct business. (See CCG Action Card: Loss of Access to building - Fire Flood or other major incident) Potential inability to access records required to conduct business. (Covered under CCG Action Card: Loss of VDI Network; and Action card - Loss of Power) Potential inability to access records required to conduct business. (Covered under CCG Action Card: Loss of Access to building - Fire Flood or other major incident) Potential inability to access records required to conduct business. (Covered under CCG Action Card: Loss of VDI Network; and Action Card - Loss of Power) Potential inability to maintain contact with business partners and stakeholders. (Covered under CCG Action Card: Loss of Phone Network for West Offices.) Potential inability to access records required to conduct business. (Covered under CCG Action Card: Loss of VDI Network) Potential inability to access premises and assets required to conduct business. (See CCG Action Card: Loss of Access to building - Fire Flood or other major incident; and Action Card - Loss of Power) Business Continuity Policy - v3.0 Page 197 of 312 Page 10 of 30

198 Hazards and threats relevant to the CCG Hazard of threat Y or N Why? 8 Terrorist attack or threat affecting the transport network or office locations 9 Theft or criminal damage 10 Chemical contamination 11 Serious injury to, or death of, staff whilst in the offices. Significant staff 12 absence due to severe weather or t t i 13 Infectious disease outbreak 14 Simultaneous resignation or loss of key staff 15 Industrial action Y 16 Fraud, sabotage or other malicious acts 17 Violence against staff 18 Water Contamination Y Y Y Y Y Y Y Y N Y Shared risk under lease agreement for premises and support services agreement with CSU. (See CCG Action Cards: Loss of Access to building - Fire Flood or other major incident; and Action Card - Loss of Power; and Action Cards: Unplanned Absence and Unplanned Absence - Sickness Epidemic - Governing Body.) (See CCG Action Card: Loss or Theft of Equipment) Risk shared under lease agreement for premises. (See CCG Action Cards: Loss of Access to building - Fire Flood or other major incident) Risk shared under lease agreement for premises. (See CCG Action Cards: Unplanned Absence and Unplanned Absence - Sickness Epidemic - Governing Body.) Potential lack of sufficiently skilled staff to conduct business safely and appropriately and discharge CCG obligations and duties. (See CCG Action Card: Unplanned Absence and Unplanned Absence - Sickness Epidemic - Governing Body.) Potential inability to access records required to conduct business. (Covered under CCG Action Card: Loss of Access to building - Fire Flood or other major incident) Potential inability to access records required to conduct business. (Covered under CCG Action Card: Loss of VDi Network) Not a public facing service. Risk managed under HR policies. Business premises may be uninhabitable May impact delivery of services The outcomes of the BIA are documented in the team s Business Continuity Plan, (BCP). The BCP should assess the impact of disruption or loss of key products/ asset, services and the critical activities over a period of time and agree the maximum length of time that the team can manage the disruption caused without threatening the organisation s viability, either financially, impact on patient care or through loss of reputation. (This is referred to as the Maximum Tolerable Period of Disruption, (MTPD). Business Continuity Policy - v3.0 Page 198 of 312 Page 11 of 30

199 13.6. The BCP should also identify and agree the point in time at which each key product, service, activity needs to be resumed if significant damage or loss to the organisation is to be avoided. This is referred to as the Recovery Time Objective, (RTO). In determining and agreeing the RTO the following should be taken into account: The confidence in the MTPD and mitigation arrangements; and That there is sufficient built-in margin for unforeseen difficulties with recovery The CCG has prepared a template plan The template plan is supported by BC Action Cards. The BC Action Card provides details of risk assessment undertaken for each event, and how likely that a disruption or loss would occur. Risks should take account of : Loss of staff Loss of systems (IT and telecommunications) Loss of utilities e.g. water, electricity etc. Loss of access to premises; Loss of key suppliers; and Disruption to transport This list is not exhaustive Risks should be assessed in reference to the CCG s risk assessment matrix. Risks may then be ranked in order of threats to business continuity and a decision to be taken regarding : Treat, take action to reduce impact/likelihood of disruption; Tolerate, accept risk at the identified level; Transfer, implement insurance or contractual/sla and manage risk under contract; or Terminate, change, suspend product, service, function The BC Action Cards document escalation processes, and SOPs that support the implementation of the plan BC Action Cards should cover threats of loss or disruption to the following : People; Premises; Technology; Information; and Supplies/partners. Business Continuity Policy - v3.0 Page 199 of 312 Page 12 of 30

200 Resource People Premises Technology Information Suppliers and Partners Issues For Consideration What is the optimum number of staff you require to carry out your critical activities? What is the minimum staffing level with which you could provide a minimum level of service? What skills/level of expertise is required to undertake these activities? At what locations do critical activities operate from? What access to alternative premises is there? What equipment and facilities are essential to carry out your critical activities? What IT is essential to carry out the critical activities? What systems and means of voice and data communication are required to carry out critical activities. What information is essential to carry out your critical activities? How is the information stored? Who are the priority suppliers/partners on whom the business depends for critical activities? Are key services managed under contract? What are their Business Continuity arrangements? Business Continuity Policy - v3.0 Page 200 of 312 Page 13 of 30

201 Name of Team * Recovery time objective; the period (in hours or days) within which a business process or function must be restored to avoid an unacceptable break in continuity ** Maximum Tolerable Period of Disruption; the timeframe (in hours or days) within which a recovery effort must succeed before the service 'fails' Unplanned Key staff Absence - unavailable due Sickness, Strike, to sickness (> Work to rule and 30%) Fuel Shortage Sickness epidemic SMT Fire, Flood or other major incident Key staff unavailable due to sickness (> 30%) No access to West Offices Loss or theft of equipment Loss of Phone Network for West Offices Loss of VDi Network Loss of Power to the premises no access to mobile phones or laptops Phone Network Down CCG network down Loss of power in a locality or wider regional area impacting on IT/access to networks and/or mobile phones Business Continuity Policy - v3.0 Page 201 of 312 Page 14 of 30

202 Key customers and clients - contacts Key internal and external stakeholders Customer/Client Contact Name Contact Details Timescale re contact Internal/ External Contact Name Contact Details Business Continuity Policy - v3.0 Page 202 of 312 Page 15 of 30

203 EXAMPLE ACTION CARD Unplanned Absence Sickness, Strike, Work to rule and Fuel Shortage ACTION CARD Description of Event: Potential Impact: Area Impacted: Team staff unavailable due to sickness/other unplanned absence Capacity to handle workload and deliver corporate objectives and targets. Name of Area Risk Tolerance Target Risk Impact Likelihood Score Agreed Tolerance/ Target Risk Matrix Include in Risk Register : Corporate Team N/a Detail arrangements in Assurance Framework Risk Notes Sickness, Strike, work to rule: The Team comprises x members of staff, and also provides cover for the Job Title and support for the Job Title. The level of risk is dependent on cross cover within the team. Cover for the Head of Service is a combination of escalation to name of role; and delegation to the two management posts, (Job Title and Job Title). Cover for the Managers is through cross cover, escalation to Job Title and delegation to Job Title Key risks are: - Potential for failure to meet mandated standards, statutory duties and deliver key organisational objectives. (The level of risk would increase with period of elapsed time with lack of cover). Cover for the Named Post is currently reliant on availability of Manager Job Title, Key risks are: - failure to submit HR returns, (end of month); - non-compliance with recruitment/termination of staff procedures; - lack of follow up on statutory and mandatory training; - weaknesses in issue and return of IT equipment. The Admin Team provides a vital corporate wide administration support service. Cover is within team. Key risks are - lack of meeting support; - minutes not available on a timely basis, (this may also impact mandatory publication schedules if appropriate support is not available for Chief Officers, and GB minutes etc.). The level of risk is more immediate depending on the level of absence within the team). Fuel Shortage relating to extreme weather conditions and staff wouldn t be able to get into the offices, Staff would be required to contact the Job Title of their issues getting into work and what plans they had for the day with regards to meetings. Job Title will then Inform key members of staff, GP Practices and sent a message to the public with contact details for key members of staff who would be covering. If the Manager Titles are unable to get into the offices, they have the ability to work from home, they have the correct equipment and would need to be contactable throughout their period of absence from the office. Business Continuity Policy - v3.0 Page 203 of 312 Page 16 of 30

204 Assumptions Adequate cover within team under normal operating arrangements. Post vacancies are appropriately managed. Risk Assessment Categories Impact Rating Classification HR/Staffing 1 Negligible Short-term low staffing level that temporarily reduces service quality (< 1 day) 2 Minor Low staffing level that reduces the service quality 3 Moderate Late delivery of key objective/ service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale Poor staff attendance for mandatory/key training 4 Serious Uncertain delivery of key objective/service due to lack of staff Unsafe staffing level or competence (>5 days) Loss of key staff Very low staff morale No staff attending mandatory/ key training 5 Catastrophic Non-delivery of key objective/service due to lack of staff On-going unsafe staffing levels or competence Loss of several key staff No staff attending mandatory training /key training on an ongoing basis Probability Rating Classification Broad descriptors of frequency Time framed descriptors of frequency 1 Rare This will probably never happen/recur Not expected for years 2 Unlikely Do not expect it to happen/recur but it is possible it may Expected to occur at least annually do so 3 Possible Might happen or recur occasionally Expected to happen at least monthly 4 Likely Will probably happen/recur but it is not a persisting issue Expected to occur at least weekly 5 Almost Certain Will undoubtedly happen/recur, possibly frequently Expected to occur at least daily Business Continuity Policy - v3.0 Page 204 of 312 Page 17 of 30

205 Actions Risk Assessment Trigger Criteria Action to be taken: Impact Likelihood Score Length of Time Job Title: Inform Team, AMs, Job Title as appropriate. Review diaries; arrange Admin cover for supported meetings. In addition to above, review prioritisation of workloads. In addition to above, consider employing ad hoc temporary staff to cover identified pressures. Job Title: Inform Team, AMs, Job Title as appropriate. Review diaries; arrange Admin cover for supported meetings. Review prioritisation of workloads. Review commitments within team and where necessary with Programme Leads. Deputy Cos. Prioritise diary commitments. Consider cover within delivery teams. In addition to above, consider ad hoc temp cover for Admin Team if needed to meet core services Prioritise diary commitments. Consider cover within delivery teams. Consider ad hoc temp cover for Admin Team if needed to meet core services Team staff, Less than 7½ Hours % Loss of Who Resource 30%> Job Title Team/Key/Core Staff 30%> Job Title More than 7½ Hours up to 2 weeks More than 2 weeks up a 1 month. 30%> More than a month 30%> Job Title All staff, Less than 7½ Hours More than 7½ Hours up to 2 weeks 30%<>60% Job Title 30%<>60% Job Title More than 2 weeks up a 1 30%<>60% Job Title month. More than a month 30%<>60% All staff, 60%< Job Title Less than 7½ Hours up to 2 weeks More than 7½ Hours 60%< More than 2 weeks up a 1 month. 60%< More than a month 60%< Reference to SOPs Business Continuity Policy - v3.0 Page 205 of 312 Page 18 of 30

206 Approvals Name/Job Title Date Name/Job Title Date Next Review Date Reviewed By: Authorised By: (Head of Team) Business Continuity Policy - v3.0 Page 206 of 312 Page 19 of 30

207 14. BUSINESS CONTINUITY PLAN - COMMUNICATIONS During a period of business continuity it is vital that communication is managed effectively with a variety of stakeholders. This plan supports this management before, during and after any incident that is detailed within the business continuity plan For a CCG specific incident the business continuity and communications leads will work together to ensure clear and consistent communications activity. The main aims will be to : Deliver relevant messages about the incident to the relevant stakeholder group/s Utilise media channels (radio and print) to reassure and inform the public and patients Ensure that messages are timely and relevant to the target audience. Stakeholders Our stakeholders are divided into two categories internal and external with specific communications mechanisms for each one. Internal - West Offices based staff, Strategic Clinical Executive members GP leads and Governing Body members External - GP Practices, Media, Local Authority, NHS England Area Team, Services Providers, e.g. York Hospitals NHS Foundation Trust, York Ambulances Services and other provider organisations. Methods of Communication during an incident The communication activity used will be activated in conjunction with any incident detailed in the business continuity plan and will be specific to each of the relevant stakeholder affected. Internal Stakeholders Staff, Governing Body members and GP leads It is essential that we inform staff and keep them up-to-date with any incident that impacts on the ability to undertake their role or has a direct impact on the organisation. This incident could be triggered by a multi-agency source or from within the CCG. The methods used to communicate with staff will be : Text message/phone call used to disseminate an initial message about the incident, containing immediate actions needed and how further messages will be communicated. This is most useful when the incident occurs out of office hours. The CCG maintains a staff contact list. Staff can receive messages via the CCG s distribution lists (held electronically) in normal working hours Intranet Information to be posted on the CCG s home page before and after the incident. Any information during an incident should be communicated through other mechanisms as access may be limited. Business Continuity Policy - v3.0 Page 207 of 312 Page 20 of 30

208 Website CCG Intranet information where staff can get up-to-date information without having access to CCG specific systems. This section of the public site could be updated remotely and would ensure that everyone could access accurate, timely information. External Stakeholders GP Practices Member practices of the CCG would be informed of any incidents relating to business continuity via . Contact details for the CCG throughout the affected period would be shared and practice staff would be advised to visit the CCG website for updates. Media print and broadcast Managing the media should take place in line with the CCG s Communications protocol. The communications team have good links with the media, which would be utilised for any incident that requires information communicating to local people and patients. Local radio stations would be able to broadcast public information in their regular bulletins. Information would be issued to the local printed media dependent on the incident timing in relation to the paper publication day. Media statement may be required following an incident and once normal business has resumed Information would also be published using the CCG s social media sites with links to the website for more detail. Partners Local Authority, NHS England Area Team, Voluntary Sector and Healthwatch, embed When an incident impacts on the business of the CCG it is imperative that we inform colleagues at our local partner organisations. Depending on the nature of the incident this would be done either by telephone or by via the Chief Officer, Chair or Business Continuity lead. Partner organisations would be encouraged to disseminate the details to their staff via communication channels. Providers All providers from who we commission a healthcare service Depending on the nature of the incident this would be done either by telephone or by via the Chief Officer, Chair or Business Continuity lead. Provider organisations would be encouraged to disseminate the details to their staff via communication channels, providing details of alternative ways to contact the CCG during the period of the incident. Notice would then be given once the incident was resolved and normal business resumed Key contacts within the CCG should advise counterparts in the provider organisations of their contact details during the incident. Out -of-hours communication There is no formal out-of-hours communication service within the CCG, however all senior staff hold work mobiles and senior officers have been provided with the Communication Manager s mobile number should be contacted in the case of an incident that may affect business continuity. Messages and notifications can be posted on the public website using an internet connection in any location and there are a number of officers with the organisation who access to the admin section. Business Continuity Policy - v3.0 Page 208 of 312 Page 21 of 30

209 15. REFERENCES Good Practice Guidelines 2013, A Guide to Global Good Practice in Business Continuity, Business Continuity Institute ISO 22301:2012, Societal security Business continuity management systems Requirements, International Organization for Standardization ISO 22313:2012, Societal security Business continuity management systems Guidance, International Organization for Standardization PAS 2015, Framework for Health Services Resilience, (2010) British Standards Institute How Prepared Are You? Business Continuity Toolkit. HM Government. NHS England Business Continuity Policy, August 2013, Gateway Ref: NHS England Emergency Preparedness Framework 2013, NHS England NHS England Business Continuity Management Framework 2013 (Service Resilience), NHS England NHS England Core Standards for Emergency Preparedness, Resilience and Response, NHS England The Route Map to Business Continuity Management, Meeting the Requirements of ISO 22301, John Sharp, (2012) British Standards Institute 16. ASSOCIATED CCG POLICIES COR06 Communications Protocol COR17 Emergency Resilience Response Policy COR18 On-Call Policy 17. CONTACT DETAILS Governance Team Telephone: voyccg.governance@nhs.net Address: NHS Vale of York Clinical Commissioning Group, West Offices, Station Rise, York. Y01 6GA Business Continuity Policy - v3.0 Page 209 of 312 Page 22 of 30

210 18. APPENDIX 1 : EQUALITY IMPACT ANALYSIS FORM 1. Title of policy/ programme/ service being analysed Business Continuity Policy and Strategy 2. Please state the aims and objectives of this work. The Vale of York Clinical Commissioning Group is committed to ensuring robust and effective Business Continuity Management (BCM) as a key mechanism to restore and deliver continuity of key services in the event of an incident. This policy statement provides a framework for the CCG to follow in the event of an incident, such as fire, flood, bomb, staff absence, power and communication failure. It also states the process for implementing and maintaining a robust BCMS 3. Who is likely to be affected? (e.g. staff, patients, service users) Primarily CCG staff, however, if Business Continuity arrangements are not effective patients and service providers may be impacted. 4. What sources of equality information have you used to inform your piece of work? NHS England guidance 5. What steps have been taken ensure that the organisation has paid due regard to the need to eliminate discrimination, advance equal opportunities and foster good relations between people with protected characteristics The analysis of equalities is embedded within the CCG s Committee Terms of Reference and project management framework. The Business Continuity Policy relates to internal processes only, therefore there is a limited impact of this policy on staff and service users. Related policies where there is an impact, such as Staff Sickness, have undergone a thorough impact assessment. This policy and its framework will be adopted for a range of emergencies and situations. Depending on the nature of such circumstances, managers will liaise with staff to identify any particular needs for interim working arrangements and where possible make any reasonable adjustments. Business Continuity Policy - v3.0 Page 210 of 312 Page 23 of 30

211 6. Who have you involved in the development of this piece of work? Internal involvement: Senior Management team Audit Committee Consultation with Team leads Stakeholder involvement: System Resilience Forum Patient / carer / public involvement: N/A 7. What evidence do you have of any potential adverse or positive impact on groups with protected characteristics? Do you have any gaps in information? Include any supporting evidence e.g. research, data or feedback from engagement activities Disability People who are learning disabled, physically disabled, people with mental illness, sensory loss and long term chronic conditions such as diabetes, HIV) Consider building access, communication requirements, making reasonable adjustments for individuals etc. This policy and its framework will be adopted for a range of emergencies and situations. Depending on the nature of such circumstances, managers will liaise with staff to identify any particular needs for interim working arrangements and where possible make any reasonable adjustments. Sex Men and Women N/A Race or nationality People of different ethnic backgrounds, including Roma Gypsies and Travellers N/A Age This applies to all age groups. This can include safeguarding, consent and child welfare Consider gender preference in key worker, single sex accommodation etc. Consider cultural traditions, food requirements, communication styles, language needs etc. Consider access to services or employment based on need/merit not age, effective communication strategies etc. Business Continuity Policy - v3.0 Page 211 of 312 Page 24 of 30

212 N/A Trans People who have undergone gender reassignment (sex change) and those who identify as trans N/A Sexual orientation This will include lesbian, gay and bisexual people as well as heterosexual people. N/A Religion or belief Includes religions, beliefs or no religion or belief N/A Marriage and Civil Partnership Refers to legally recognised partnerships (employment policies only) N/A Pregnancy and maternity Refers to the pregnancy period and the first year after birth N/A Carers This relates to general caring responsibilities for someone of any age. N/A Other disadvantaged groups This relates to groups experiencing health inequalities such as people living in deprived areas, new migrants, people who are homeless, ex-offenders, people with HIV. N/A Business Continuity Policy - v3.0 Consider privacy of data, harassment, access to unisex toilets & bathing areas etc. Consider whether the service acknowledges same sex partners as next of kin, harassment, inclusive language etc. Consider holiday scheduling, appointment timing, dietary considerations, prayer space etc. Consider whether civil partners are included in benefit and leave policies etc. Consider impact on working arrangements, part-time working, infant caring responsibilities etc. Consider impact on part-time working, shift-patterns, options for flexi working etc. Consider ease of access, location of service, historic take-up of service etc. Page 212 of 312 Page 25 of 30

213 8. Action planning for improvement Please outline what mitigating actions have been considered to eliminate any adverse impact? Sign off Name and signature of person / team who carried out this analysis Helen Sikora, Policy and Strategy Manager Audit Committee Date analysis completed December 2014 Name and signature of responsible Director Date analysis was approved by responsible Director Business Continuity Policy - v3.0 Page 213 of 312 Page 26 of 30

214 19. APPENDIX 2: SUSTAINABILITY IMPACT ASSESSMENT Staff preparing a policy, Governing Body (or Sub-Committee) report, service development plan or project are required to complete a Sustainability Impact Assessment (SIA). The purpose of this SIA is to record any positive or negative impacts that this is likely to have on sustainability. Title of the document What is the main purpose of the document Date completed Completed by Policy Name Domain Objectives Impact of activity Negative = -1 Neutral = 0 Positive = 1 Unknown =? Not applicable = n/a Travel Will it provide / improve / promote alternatives to car based transport? Will it support more efficient use of cars (car sharing, low emission vehicles, environmentally friendly fuels and technologies)? Will it reduce care miles (telecare, care closer) to home? Will it promote active travel (cycling, walking)? Will it improve access to opportunities and facilities for all groups? Will it specify social, economic and environmental outcomes to be accounted for in procurement and delivery? Brief description of impact If negative, how can it be mitigated? If positive, how can it be enhanced? Business Continuity Policy - v3.0 Page 214 of 312 Page 27 of 30

215 Domain Objectives Impact of activity Negative = -1 Neutral = 0 Positive = 1 Unknown =? Not applicable = n/a Procurement Will it stimulate innovation among providers of services related to the delivery of the organisations social, economic and environmental objectives? Will it promote ethical purchasing of goods or services? Procurement Will it promote greater efficiency of resource use? Will it obtain maximum value from pharmaceuticals and technologies (medicines management, prescribing, and supply chain)? Will it support local or regional supply chains? Will it promote access to local services (care closer to home)? Will it make current activities more efficient or alter service delivery models Facilities Management Workforce Will it reduce the amount of waste produced or increase the amount of waste recycled? Will it reduce water consumption? Will it provide employment opportunities for local people? Will it promote or support equal employment opportunities? Brief description of impact If negative, how can it be mitigated? If positive, how can it be enhanced? Business Continuity Policy - v3.0 Page 215 of 312 Page 28 of 30

216 Domain Objectives Impact of activity Negative = -1 Neutral = 0 Positive = 1 Unknown =? Not applicable = n/a Will it promote healthy working lives (including health and safety at work, worklife/home-life balance and family friendly policies)? Will it offer employment opportunities to Community Engagement Buildings disadvantaged groups? Will it promote health and sustainable development? Have you sought the views of our communities in relation to the impact on sustainable development for this activity? Will it improve the resource efficiency of new or refurbished buildings (water, energy, density, use of existing buildings, designing for a longer lifespan)? Will it increase safety and security in new buildings and developments? Will it reduce greenhouse gas emissions from transport (choice of mode of transport, reducing need to travel)? Will it provide sympathetic and appropriate landscaping around new development? Will it improve access to the built environment? 0 N/A Brief description of impact If negative, how can it be mitigated? If positive, how can it be enhanced? Business Continuity Policy - v3.0 Page 216 of 312 Page 29 of 30

217 Domain Objectives Impact of activity Negative = -1 Neutral = 0 Positive = 1 Unknown =? Not applicable = n/a Adaptation to Climate Change Models of Care Will it support the plan for the likely effects of climate change (e.g. identifying vulnerable groups; contingency planning for flood, heat wave and other weather extremes)? Will it minimise care miles making better use of new technologies such as telecare and telehealth, delivering care in settings closer to people s homes? Will it promote prevention and selfmanagement? Will it provide evidence-based, personalised care that achieves the best possible outcomes with the resources available? Will it deliver integrated care, that coordinate different elements of care more effectively and remove duplication and redundancy from care pathways? Brief description of impact If negative, how can it be mitigated? If positive, how can it be enhanced? Business Continuity Policy - v3.0 Page 217 of 312 Page 30 of 30

218 Yorkshire and the Humber EPRR core standards improvement plan Organisation: NHS Vale of York CCG ACTIONS ARISING FROM 2017 / 2018 ASSURANCE PROCESS Core standard reference 3 Core standard description Improvement required to achieve compliance Action to deliver improvement Deadline Organisations have an overarching framework or policy which sets out expectations of emergency preparedness, resilience and response. Refresh EPRR Policy & On-Call Policy Submit EPRR and On-Call Policy to VOYCCG Governing Body for sign-off Sept 2017 Completed 5 Assess the risk, of emergencies or business continuity incidents occurring which affect or may affect the ability of the organisation to deliver its functions. Cyber Attack action plan identifies IT issues which need resolving Assurance re safety of GP IT systems and Embed contract management to be discussed at October CMB Nov 2017 EMBED report received 8 Effective arrangements in place to respond to risk the organisation is exposed to. Sign-off of localised flu outbreak plan by Clinical Executive CCG needs to formalise commissioning arrangements to provide clinical support for a localised flu outbreak ONGOING 31 Those on-call must meet identified competencies and key knowledge and skills for staff. TNA for all new Directors on-call. On-Call Directors to attend Strategic Leadership in Crisis Training. PREVENT training for SMT undertaken August Exec Director of Transformation & Delivery attended Strategic Leadership in Crisis Course. Simon Bell to attend Media Training Nov 2017 Completed Nov 2018 DD3 The organisation has an identified, active Non-executive Director/Governing Body Representative who formally holds the EPRR portfolio for the organisation. David Booker chairs the Finance & Performance Committee which oversees Emergency Planning and approves the CCGs Emergency Plan. David Booker is Non-Executive Director responsible for EPRR and will be copied with the minutes from EPPR/Information & Governance Steering Group. Fliss Wood to report incidents direct to David Booker. August 2018 Completed Page 218 of 312

219 Yorkshire and the Humber EPRR core standards improvement plan DD4 The organisation has an internal EPRR oversight/delivery group that oversees and drives the internal work of the EPRR function BCM and EPRR are standing agenda items at the Information Governance Steering Group bi-monthly meetings BCM and EPRR are standing agenda items at the Information Governance Steering Group bi-monthly meetings Ongoing Page 219 of 312

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221 Item Number: 11 Name of Presenter: Phil Mettam Meeting of the Governing Body Date of meeting: 6 September 2018 Report Title NHS Vale of York CCG s Constitution Purpose of Report For Approval Reason for Report The CCG s constitution has not been refreshed since October 2015 and there have been significant changes within the CCG since then. The constitution has now been reviewed and amended to reflect the changes within the CCG. The main changes are : Appointment of a Clinical Chair The CCG no longer has a Chief Operating Officer The appointment of three locality GPs to the Governing Body Formation of a Finance and Performance Committee Formation of a Quality and Patient Experience Committee Formation of an Executive Committee Amended Scheme of Delegation The constitution has to be submitted to NHS England for formal approval. The constitution has already been approved by the Council of Representatives in January 2018 and CCG Executive in August 2018 but NHS England guidance now requires the approval of the CCG s Governing Body. Once approved by Governing Body the constitution will be submitted to NHS England and it is hoped that approval will be received before the end of the year. Strategic Priority Links Strengthening Primary Care Reducing Demand on System Fully Integrated OOH Care Sustainable acute hospital/ single acute contract Local Authority Area CCG Footprint City of York Council Transformed MH/LD/ Complex Care System transformations Financial Sustainability East Riding of Yorkshire Council North Yorkshire County Council Page 221 of 312

222 Impacts/ Key Risks Financial Legal Primary Care Equalities Covalent Risk Reference and Covalent Description G T - There is a potential risk that the organisation's governance structures are not efficient and effective Emerging Risks (not yet on Covalent) Recommendations The Governing Body is requested to : Note the changes in the constitution; and Approve the constitution for submission to NHS England. Responsible Executive Director and Title Michelle Carrington Executive Director of Quality and Nursing / Chief Nurse Report Author and Title Rachael Simmons Corporate Services Manager Page 222 of 312

223 NHS Vale of York Clinical Commissioning Group Constitution Changes December 2017 Throughout the Constitution the following changes have been made : The job title Chief Nurse has been changed to Executive Director of Quality and Nursing. All references to the Chief Operating Officer have been removed. Article Paragraph Existing Text New Text Introduction what is a constitution? 3 Membership 3.1 Removal of Beech Grove Medical Practice 4 Vision, Mission and Values 5 Functions and General Duties 4.2 Vision : to achieve the best health and well-being for everyone in our community Vision : achieving the best health and wellbeing for everyone in our community. 4.8 NHS Vale of York Clinical Commissioning Group shall look to promote among its Members and shall itself have regard to the Duty of Candour. 5.3a Working in partnership with patients and the local community to secure the best care for them 5.3 l Nominating the Chief Clinical Officer to attend and represent the views of the group as required by the Local Education and Training Board and the Chief Operating Working in partnership with patients and the local community to secure the best care for them through an effective communication and engagement strategy; Nominating the Accountable Officer to attend and represent the views of the group as required by the Local Education and Training Board and the Chief Finance Officer or Executive Director of Page 223 of 312

224 Article Paragraph Existing Text New Text 6 Decision Making The Governing Structure Officer or Chief Nurse to deputise should the Chief Clinical Officer not be able to attend. 5.6 e) Audit and Quality and Finance committee monitoring through performance reports and general reporting mechanisms. 6.1 e) A joint committee established in accordance with articles 6.7 and 6.7A of this constitution. 6.7 JOINT ARRANGEMENTS The group will enter into joint arrangements with other Clinical Commissioning Groups and Local Authorities as appropriate to secure commissioned services for their population. Quality and Nursing to deputise should the Accountable Officer not be able to attend. Audit Committee and Quality and Patient Experience Committee monitoring through performance reports and general reporting mechanisms. A joint committee established in accordance with Article 12 of this constitution. COMMITTEES OF THE GROUP 6.7 The group may establish committees of the group, including joint committees, from time to time by resolution of the Council of Representatives in accordance with Articles and Appendix C (Standing Orders) of this constitution. 6.7a The group may establish joint committees with other clinical commissioning groups (CCGs) and / or NHS England and / or other bodies pursuant to the relevant provisions of the 2006 Act provided the group is satisfied it is reasonable and appropriate for it to do so in accordance with its functions and duties under the 2006 Act. Further provisions in relation to joint committees are set out in Article 12 Page 224 of 312

225 Article Paragraph Existing Text New Text below. 6.9 Order of paragraphs amended : 6.9 a) and 6.9 b) transposed. 6.9 a) The Chair of the Governing Body will have specific responsibility for : 6.7b Committees will only be able to establish their own sub-committees to assist them in discharging their respective responsibilities, if this responsibility has been delegated to them by the group or committee they are accountable to. The Chair (Clinical or Lay depending on whether the Accountable Officer is a clinical or management appointment) of the Governing Body will have specific responsibility for : 6.9 b i) The Chair of the Audit Committee shall also be the Conflicts of Interest Guardian as recommended by NHS England. 6.9 b ii) Lay members shall be appointed from time to time by the Chief Clinical Officer of the CCG, after undertaking an appointment process in line with the best current recruitment practice. In making these appointments, the Chief Clinical Officer shall involve other board members, stakeholders and partners while retaining personally the authority to make the appointment. Lay members shall be appointed from time to time by the Accountable Officer of the CCG, after undertaking an appointment process in line with the best current recruitment practice. In making these appointments, the Accountable Officer shall involve other Governing Body members, stakeholders and partners while retaining personally the authority to make the appointment. Page 225 of 312

226 Article Paragraph Existing Text New Text 6.9 c There will be a minimum number of four General Practitioners. 6.9 c Chief Nurse, other than excluded under Regulation 12(1). 6.9 f The Chief Clinical Officer. The Accountable Officer for the CCG. 6.9 h Chief Operating Officer There will be a minimum number of three General Practitioners, one appointed from each of the three localities within the Vale of York, i.e., North, Central and South. Chief Nurse (Executive Director of Quality and Nursing), other than excluded under Regulation 12(1). The Accountable Officer for the CCG. This can be a clinical or management appointment, dependent on whether the Chair of the Governing Body is a clinical or lay appointment. REMOVED The Chief Operating Officer is responsible for ensuring that arrangements are put in place so that the CCG successfully delivers it strategic business objectives. They ensure effective management systems are in place and direct the operation of the CCG according to the strategic commissioning priorities set by the clinical commissioning group. 6.9 k) See below 6.10 Roles and Appointment Process Appointment process for Key Roles 6.10 Roles and Appointment Process Appointment process for Key Roles Page 226 of 312

227 Article Paragraph Existing Text New Text Paragraph XXX of the group s constitution sets out the composition of the group s Governing Body, whilst section XXX of the group s constitution identifies certain key roles within the group and its Governing Body. These Standing Orders set out how the group elects / appoints individuals to these key roles. The responsibilities of each of these key roles are not included within these Standing Orders as they are set out in chapter XXX of the group s constitution. Individual of the descriptions set out within Schedule 5 of The National Health Service (Clinical Commissioning Groups) Regulations 2012 S.I.2012/1631 are automatically disqualified from membership of the groups Governing Body. Individuals interests will be considered as part of the appointment process for these key roles to determine whether there are any conflicts that warrant individuals being excluded from appointment to the Governing Body. The following general principles will be applied : Paragraph 6.9 of the Group s constitution sets out the composition of the Group s Governing Body, whilst Section 7 of the Group s constitution identifies certain key roles within the Group and its Governing Body. These Standing Orders set out how the Group elects / appoints individuals to these key roles. The responsibilities of each of these key roles are not included within these Standing Orders as they are set out in chapter 7 of the Group s constitution. Individuals of the description set out within Schedule 5 of The National Health Service (Clinical Commissioning Groups) Regulations 2012 S.I.2012/1631 are automatically disqualified from membership of the Group s Governing Body. Individuals interests will be considered as part of the appointment process for these key roles to determine whether there are any conflicts that warrant individuals being excluded from appointment to the Governing Body. The following general principles will be applied : An assessment of the materiality of the interests, in particular whether the individual (or a family member or business partner) could benefit from any decision the Governing Body Page 227 of 312

228 Article Paragraph Existing Text New Text An assessment of the materiality of the interests, in particular whether the individual (or a family member or business partner) could benefit from any decision the Governing Body might make. An assessment of the extent of the interests and whether they are related to a business are significant enough that the individual would be unable to make a full and proper contribution to the Governing Body. Further disqualification criteria specific to individual roles are detailed within Standing Orders to might make. An assessment of whether the extent of the interests and whether they are related to a business are significant enough that the individual would be unable to make a full and proper contribution to the Governing Body. a. Accountable Officer Nominations and Eligibility The Accountable Officer must meet the relevant specifications outlined in Clinical Commissioning Group Governing Body Members: role outlines, attributes and skills as well as the legal requirements in the Act and The National Health Service (Clinical Commissioning Groups) Regulations Appointment Process The CCG will follow the Clinical commissioning group guidance on senior appointments, including Accountable Officer in appointing an Accountable Officer. The Chair of Governing Body will lead the process of appointing the role of Accountable Officer. The CCG will recommend a candidate after following robust recruitment exercises that test the candidates ability to meet the requirements of the role and that they are a fit and proper person, but approval must be sought from NHS England Page 228 of 312

229 Article Paragraph Existing Text New Text Chief Executive. The relevant NHS England Director of Commissioning Operations will be advised of the process at an early stage. The role will be advertised externally, e.g. using NHS Jobs, and candidates will be assessed for competency against an application form or Curriculum Vitae with a covering letter. The assessment of shortlisted applicants would, at a minimum, include an interview by a panel to include at least two of the following: Chair of Governing Body, other Governing Body Member, NHS England Director of Commissioning Operations (or alternate NHS England representative). Where the Chair of the Governing Body is a lay person, the group s Accountable Officer shall be a clinician. Where the Chair is a clinician the Accountable Officer shall be a suitable manager. Grounds for Removal from Office As per contract of employment Notice Period As per contract of employment b Chief Finance Officer Nominations and Eligibility The Chief Finance Officer must meet the Page 229 of 312

230 Article Paragraph Existing Text New Text relevant specifications outlined in Clinical Commissioning Group Governing Body Members: role outlines, attributes and skills as well as the legal requirements in the Act and The National Health Service (Clinical Commissioning Groups) Regulations Appointment Process The CCG will follow the Clinical commissioning group guidance on senior appointments, including Accountable Officer in appointing a Chief Finance Officer. The Accountable Officer will lead the process of appointing the role of Chief Finance Officer. The relevant NHS England Director of Commissioning Operations will be advised of the process at an early stage. The role will be advertised externally, e.g. using NHS Jobs, and candidates will be assessed for competency against an application form or Curriculum Vitae with a covering letter. The assessment of shortlisted applicants would, at a minimum, include an interview by a panel to include at least two of the following: Accountable Officer, Chair of Governing Body, other Governing Body Member, NHS England Director of Commissioning Operations (or alternate NHS England representative). Grounds for Removal from Office Page 230 of 312

231 Article Paragraph Existing Text New Text As per contract of employment Notice Period As per contract of employment c Executive Director of Quality and Nursing Nominations and Eligibility The Executive Director of Quality and Nursing must be a registered nurse and must meet the relevant specifications outlined in Clinical Commissioning Group Governing Body Members: role outlines, attributes and skills (registered nurse) as well as the legal requirements in the Act and The National Health Service (Clinical Commissioning Groups) Regulations The Executive Director of Quality and Nursing cannot be an employee or member (including shareholder) of, or a partner in, a provider of primary medical services, or a provider with whom the CCG has made commissioning arrangements (see Clinical Commissioning Group Governing Body Members: role outlines, attributes and skills for exceptions). Appointment Process The Accountable Officer will lead the process of Page 231 of 312

232 Article Paragraph Existing Text New Text appointing the role of Executive Director of Quality and Nursing. The role will be advertised externally, e.g. using NHS Jobs, and candidates will be assessed for competency against an application form or Curriculum Vitae with a covering letter. The assessment of shortlisted applicants would, at a minimum, include an interview by a panel to include at least two of the following: Accountable Officer, Chair of Governing Body, other Governing Body Member, patient representative. Grounds for Removal from Office As per contract of employment Notice Period As per contract of employment d) Chair of Council of Representatives Nominations and Eligibility The Chair of the Council of Representatives will be a General Practitioner working within a member practice within Vale of York. Appointment Process The Chair of the Governing Body will lead the process to appoint a Chair of the Council of Representatives. All eligible General Practitioners will be invited to express an Page 232 of 312

233 Article Paragraph Existing Text New Text interest in the position and they will be assessed for competency, e.g. the National Leadership Framework, against a Curriculum Vitae and a covering letter. Where more than one eligible individual expresses an interest in the role, a competitive interview will take place by a panel to include at least two of the following: Chair of the Governing Body, Accountable Officer, GP Governing Body Member. Term of Office The Chair of the Council of Representatives will serve a term of office for two years. Based on the CCG s requirements at the time of appointment, however, normal terms of office may be varied to ensure that continuity is maintained between transitions. Eligibility for Reappointment There is no restriction on the number of times that an individual is eligible to be reappointed; however no individual will have the right to be reappointed. After two consecutive terms of office, the CCG must follow the appointment process to re-advertise, even where the existing Chair chooses to be considered for reappointment. Grounds for Removal from Office As per the terms of the statement of Page 233 of 312

234 Article Paragraph Existing Text New Text appointment between the individual and CCG Notice Period As per the terms of the statement of appointment between the individual and CCG. e) Chair of Governing Body Nominations and Eligibility The Chair of the Governing Body must meet the relevant specifications outlined in Clinical Commissioning Group Governing Body Members: role outlines, attributes and skills as well as the legal requirements in the Act and The National Health Service (Clinical Commissioning Groups) Regulations Appointment Process The CCG will follow the Clinical Commissioning Group guidance on senior appointments, including Accountable Officer in appointing a Chair of the Governing Body. The Accountable Officer will lead the process of appointing the role of Chair of the Governing Body. The relevant NHS England Director of Commissioning Operations will be advised of the process at an early stage. The role will be advertised externally, e.g. using NHS Jobs, and candidates will be assessed for Page 234 of 312

235 Article Paragraph Existing Text New Text competency against an application form or Curriculum Vitae with a covering letter. The assessment of shortlisted applicants would, at a minimum, include an interview by a panel to include at least two of the following: Accountable Officer, Lay Member, GP Governing Body Member, NHS England Director of Commissioning Operations (or alternate NHS England representative). Where the Chair of the Governing Body is a lay person, the Group s Accountable Officer shall be a clinician. Where the Chair is a clinician the Accountable Officer shall be a suitable manager. Term of Office The Chair of the Governing Body will serve a term of office for three years. Based on the CCG s requirements at the time of appointment, however, normal terms of office may be varied to ensure that continuity is maintained between transitions. Eligibility for Reappointment There is no restriction on the number of times that an individual is eligible to be reappointed; however no individual will have the right to be reappointed. After two consecutive terms of office, the CCG must follow the appointment process to re-advertise, even where the existing Page 235 of 312

236 Article Paragraph Existing Text New Text Chair chooses to be considered for reappointment. Grounds for Removal from Office As per the terms of the statement of appointment between the individual and CCG Notice Period As per the terms of the statement of appointment between the individual and CCG. f) GP Governing Body Members Nominations and Eligibility The GP Governing Body Members will be a General Practitioner working within the Vale of York geography with one for each of the Vale of York localities, i.e., North, Central and South. GP Governing Body Members must meet the relevant specifications outlined in Clinical Commissioning Group Governing Body Members: role outlines, attributes and skills as well as the legal requirements in the Act and The National Health Service (Clinical Commissioning Groups) Regulations Appointment Process GP Governing Body Member vacancies will be advertised to all GPs (non-principals, salaried and partners) within the relevant Vale of York Page 236 of 312

237 Article Paragraph Existing Text New Text locality, i.e., North, Central or South. All eligible General Practitioners will be invited to express an interest in the position and will be assessed for competency, e.g. the National Leadership Framework, against a Curriculum Vitae and a covering letter. The assessment of shortlisted applicants would, at a minimum, include an interview by a panel to include at least two of the following: Accountable Officer, Chair of Governing Body, Chief Executive of the Local Medical Committee (or alternate), patient representative. Term of Office GP Governing Body Members will serve a term of office for three years. Based on the CCG s requirements at the time of appointment, however, normal terms of office may be varied to ensure that continuity is maintained between transitions. Eligibility for Reappointment There is no restriction on the number of times that an individual is eligible to be reappointed; however no individual will have the right to be reappointed. After two consecutive terms of office, the CCG must follow the appointment process to re-advertise, even where the existing GP Governing Body Member chooses to be considered for re-appointment. Page 237 of 312

238 Article Paragraph Existing Text New Text Grounds for Removal from Office As per the terms of the statement of appointment between the individual and CCG Notice Period As per the terms of the statement of appointment between the individual and CCG g) Lay Members (and Deputy Chair of Governing Body) Nominations and Eligibility CCG Lay Members must meet the relevant specifications outlined in Clinical Commissioning Group Governing Body Members: role outlines, attributes and skills as well as the legal requirements in the Act and The National Health Service (Clinical Commissioning Groups) Regulations At least two lay members will be appointed. One lay member must have the qualifications, expertise or experience such as to enable the person to express informed views about financial management and audit matters. One lay member must have knowledge about the area of the constitution such as to enable the person to express informed views about the discharge of the CCG s functions. All lay members will be eligible to also have Page 238 of 312

239 Article Paragraph Existing Text New Text responsibility as Deputy Chair of the Governing Body provided that the applicable legal requirements in the Act and The National Health Service (Clinical Commissioning Groups) Regulations 2012 are met. Appointment Process The Chair of Governing Body will lead the process of appointing the role of Lay Member. The role will be advertised externally, e.g. using NHS Jobs, and candidates will be assessed for competency against an application form or Curriculum Vitae with a covering letter. The assessment of shortlisted applicants would, at a minimum, include an interview by a panel to include at least two of the following: Accountable Officer, Chair of Governing Body, other Governing Body Member, patient representative. One lay member will also take on responsibility as Deputy Chair of Governing Body for the duration of their tenure as lay member. Where the tenure of the Deputy Chair comes to an end, all lay members will be offered the opportunity to take on the role as Deputy Chair for the duration of their tenure as lay member. Term of Office Lay members will serve a term of office of three Page 239 of 312

240 Article Paragraph Existing Text New Text years. Based on the CCG s requirements at the time of appointment, however, normal terms of office may be varied to ensure that continuity is maintained between transitions. Eligibility for Reappointment There is no restriction on the number of times that an individual is eligible to be reappointed; however no individual will have the right to be reappointed. After two consecutive terms of office, the CCG must follow the appointment process to re-advertise, even where the existing lay member chooses to be considered for reappointment. Grounds for Removal from Office As per the terms of the statement of appointment between the individual and CCG Notice Period As per the terms of the statement of appointment between the individual and CCG h) Secondary Care Specialist Doctor Nominations and Eligibility The Secondary Care Specialist Doctor will be a clinically qualified consultant, either currently employed, or in employment at some time in the Page 240 of 312

241 Article Paragraph Existing Text New Text period of 10 years ending with the date of the individual s appointment to the governing body. The Secondary Care Specialist Doctor cannot be an employee or member (including shareholder) of, or a partner in, a provider of primary medical services, or a provider with whom the CCG has made commissioning arrangements (see Clinical Commissioning Group Governing Body Members: role outlines, attributes and skills for exceptions). The Secondary Care Specialist Doctor must meet the relevant specifications outlined in Clinical Commissioning Group Governing Body Members: role outlines, attributes and skills as well as the legal requirements in the Act and The National Health Service (Clinical Commissioning Groups) Regulations Appointment Process The Chair of Governing Body will lead the process of appointing the role of Secondary Care Specialist Doctor. The role will be advertised externally, e.g. using NHS Jobs, and candidates will be assessed for competency, e.g. the National Leadership Framework, against an application form or Curriculum Vitae with a covering letter. The assessment of shortlisted applicants would, at a minimum, Page 241 of 312

242 Article Paragraph Existing Text New Text include an interview by a panel to include at least two of the following: Accountable Officer, Chair of Governing Body, GP Governing Body Member, Chief Executive of the Local Medical Committee (or alternate), patient representative. Term of Office The Secondary Care Specialist Doctor will serve a term of office of three years. Based on the CCG s requirements at the time of appointment, however, normal terms of office may be varied to ensure that continuity is maintained between transitions Eligibility for Reappointment There is no restriction on the number of times that an individual is eligible to be reappointed; however no individual will have the right to be reappointed. After two consecutive terms of office, the CCG must follow the appointment process to re-advertise, even where the existing Secondary Care Specialist Doctor chooses to be considered for re-appointment. Grounds for Removal from Office As per the agreement between the individual and the CCG Notice Period As per the agreement between the individual Page 242 of 312

243 Article Paragraph Existing Text New Text and the CCG 6.11 a) Chief Clinical Officer Accountable Officer 6.11 b Chief Clinical Officer Accountable Officer 6.11 c Primary Care Commissioning Committee 6.11 c) Quality and Finance Committee responsibilities Plan including needs assessment, primary (medical) care services within Vale of York CCG boundaries; Undertake reviews of primary (medical) care services within Vale of York CCG boundaries; Co-ordinate a common approach to the commissioning of primary care services generally; and Manage the budget for commissioning of primary (medical) care services within Vale of York CCG boundaries. Removed due to formation of Quality and Patient Experience Committee and Finance and Performance Committee 6.10 d) Finance and Performance Committee - The Committee shall undertake the scrutiny of all financial recovery plans on behalf of the Governing Body of NHS Vale of York CCG and Page 243 of 312

244 Article Paragraph Existing Text New Text provide assurance to the Governing Body that appropriate actions are being taken in relation to financial and performance recovery. The Committee shall advise and support the Governing Body in scrutinising and tracking delivery of key financial and service priorities, outcomes and targets as specified in the CCG s Strategic and Operational Plans. The Committee shall pro-actively challenge and review delivery against the performance expectations for the CCG against the Constitution, NHS mandate and associated NHS performance regimes, agreeing any action plans or recommendations as appropriate e) Quality and Patient Experience Committee - The overall objective of the Committee will be to ensure that services commissioned are safe, effective, provide good patient experience and ensure continuous improvement in line with the NHS Constitution (2011) underpinned by the CCG Quality Assurance Strategy. In line with the NHS Constitution, this also includes: Actively seeking patient feedback on health services and engage with all sections of the population with the intention of improving services. As a membership organisation, working with NHS England, support primary medical and pharmacy services to deliver Page 244 of 312

245 Article Paragraph Existing Text New Text 6.11 f) Executive Committee high quality primary care, including patient experience. 7 Roles and Responsibilities Responsible for the business of the CCG, including approving QIPP programmes and projects, operating plan development and implementation and operational decisions; for example, HR and IG policy, procurements and policy amendments as delegated from Governing Body, staffing and resource allocation g) Clinical Executive 7.4 The Council of Representatives includes a clinical representative nominated from each practice. Each clinical representative must also provide a named deputy to attend in their absence, who Responsible for clinical leadership in commissioning, including clinical lead and appraisal of QIPP proposals, review and endorsement of clinical policy and research proposals, receive and clinical y appraise recommendations from Clinical Research and Effective sub-committee (CREC) and Medicines Commissioning Committee. Lead on developing clinical networks across the clinical community and with the CCG membership. Council of Representatives includes a clinical representative nominated from each practice. Each clinical representative must also provide a named deputy to attend in their absence, who must be clinically qualified in order to vote on Page 245 of 312

246 Article Paragraph Existing Text New Text Council of Representatives must be clinically qualified in order to vote on behalf of the practice. Each practice may also have a practice manager in attendance; however the practice manager will not be a voting member of the Council. The Council will meet at least four times a year with one meting being the Annual General Meeting for the CCG. behalf of the practice. Each practice may also have a practice manager in attendance; however the practice manager will not be a voting member of the Council. The Council will meet at least four times a year with one meting being the Annual General Meeting for the CCG when the annual reports will be presented to the Council of Representatives. Addition : 7.6 The Council will delegate powers to the Governing Body to set the direction, strategy, and delivery of commissioning responsibilities, in consultation with the Council. The Accountable Officer and the Governing Body will be responsible on behalf of the members for carrying out the statutory responsibilities of an NHS commissioning organisation. Purpose of the Council of Representatives To ensure that there is close and effective communication between the member practices and the Governing Body. To engage in the clinical commissioning process and provide local intelligence to inform commissioning decisions. To support the Governing Body in Page 246 of 312

247 Article Paragraph Existing Text New Text managing, monitoring and redesigning service delivery. To help develop new leadership capabilities within the Vale of York Clinical Commissioning Group which will support succession planning and the sustainability of the organisation GP Governing Body Member vacancies will be advertised to all GPs (non- Remit The Council has the authority to make requests to the NHS Commissioning Governing Body for amendments to the Vale of York Clinical Commissioning Group constitution. The Council has the authority to delegate authority to the Governing Body to carry out the duties of the organisation. The Council has the authority to call an Extraordinary Meeting and to apply its power of recall should the leadership of the Vale of York Clinical Commissioning Group be brought into doubt. The Council will review performance reports, financial reports and strategic plans. GP Governing Body Member vacancies will be advertised to all GPs (non-principals, salaried Page 247 of 312

248 Article Paragraph Existing Text New Text principals, salaried and partners) within the Vale of York. Any GP can apply to a vacant Governing Body Member post and they will be assessed for competency, e.g., the National Leadership Framework, against a Curriculum Vitae and a letter of application. Assessment shall be in accordance with any arrangements made by the Governing Body. The assessment of shortlisted applications would, at a minimum, include an interview by a panel to include the Chief Clinical Officer, the Chief Executive of the Local Medical Committee (or alternative) and a patient representative. and partners) within the Vale of York. Any GP can apply to a vacant Governing Body Member post and they will be assessed for competency, e.g., the National Leadership Framework, against a Curriculum Vitae and a letter of application. Assessment shall be in accordance with any arrangements made by the Governing Body. The assessment of shortlisted applications would, at a minimum, include an interview by a panel to include the Accountable Officer, the Chief Executive of the Local Medical Committee (or alternative) and a patient representative The Chair of the Governing Body must be a clinician if the Accountable Officer is a management appointment. If, however, the Accountable Officer is a clinician, then a Lay Chair should be appointed Where the Chair is a clinician, they will be the senior clinical voice of the group and will take the lead in interactions with stakeholders, including NHS England e) Supporting the Chief Clinical Officer in discharging the responsibilities of the organisation; 7.23 The Deputy Chair will be appointed by the Chief Operating Officer of the Governing Supporting the Accountable Officer in discharging the responsibilities of the organisation; The Deputy Chair will be the Chair of the Audit Committee. Page 248 of 312

249 Article Paragraph Existing Text New Text Body. The post will be reviewed by the Chief Operating Officer annually. The post holder may resign in writing to the Chief Operating Officer. The post holder may be removed from office following the performance management procedures in operation at the time The Chair of the Audit Committee shall also be the Conflicts of Interest Guardian as recommended by NHS England REMOVED : In addition to the general duties as, as the senior clinical voice of the Group, they will take the lead in interactions with stakeholders, including NHS England The Chief Clinical Officer of the Group is a member of the Governing Body. The Accountable Officer of the Group is a member of the Governing Body. The role of the Chief Clinical Officer will : The role of the Accountable Officer will : 7.26 The Accountable Officer must be a clinician if the Chair of the Governing body is a lay member. If, however, the Accountable Officer is a management appointment, then a Clinical Chair should be appointed Where the Accountable Officer is a clinician, they will be the senior clinical voice of the Group and will take the lead in interactions with stakeholders, including NHS England. Page 249 of 312

250 Article Paragraph Existing Text New Text 7.25 c) Work closely with the Chair of the Governing Body, the Chief Clinical Officer will ensure that proper constitutional, governance and development arrangements are put in place to assure the members (through the Governing Body) of the organisations on-going capability and capacity to meet its duties and responsibilities. This will include arrangements for the on-going development of its members and staff Roles and responsibilities of the Chief Operating Officer removed due to change in governance structure see below The Chief Operating Officer is responsible for ensuring that arrangements are put in place so that the CCG successfully delivers it strategic business objectives. They ensure effective management systems are in place and direct the operation of the CCG according to the strategic commissioning priorities set by the clinical commissioning group ROLE OF THE CHIEF OPERATING OFFICER 7.26 The COO is responsible for : a) Ensuring that arrangements are Work closely with the Chair of the Governing Body, the Accountable Officer will ensure that proper constitutional, governance and development arrangements are put in place to assure the members (through the Governing Body) of the organisations on-going capability and capacity to meet its duties and responsibilities. This will include arrangements for the on-going development of its members and staff. The Accountable Officer is responsible for ensuring that arrangements are put in place so that the CCG successfully delivers it strategic business objectives. They ensure effective management systems are in place and direct the operation of the CCG according to the strategic commissioning priorities set by the Clinical Commissioning Group. ROLE OF THE EXECUTIVE DIRECTOR OF QUALITY AND NURSING 7.26 As well as sharing responsibility with the other members for all aspects of the CCG Governing Body business, as a Page 250 of 312

251 Article Paragraph Existing Text New Text put in place so that the CCG successfully delivers its strategic business objectives. b) Ensuring effective management systems are in place and will be required to direct the operation of the CCG according to the strategic commissioning priorities set by the CCG, bringing high-level strategic leadership and management skills and experience, to support and empower the clinical leadership at the heart of clinical commissioning. c) Assist the Chief Finance Officer to ensure that the CCG has a financial framework in place, which will enable it to operate within its resource limit to meet its financial obligations, continue to improve the value for money (economy, efficiency and effectiveness) and ensure an integrated governance approach d) Overseeing the successful delivery of the CCG annual commissioning plan and develop a culture of continual quality improvement; e) Maintaining general oversight of all Registered Nurse on the Governing Body, this person will bring a broader view, from their perspective as a Registered Nurse, on health and care issues to underpin the work of the CCG especially the contribution of nursing to patient care. a) The Executive Director of Quality and Nursing will have the following specific attributes and competencies: Be a Registered Nurse who has developed a high level of professional expertise and knowledge; Be competent, confident and willing to give an independent strategic clinical view on all aspects of CCG business; Be highly regarded as a clinical leader, probably across more than one clinical discipline and/or specialty demonstrably able to think beyond their own professional viewpoint; Be able to take a balanced view of the clinical and management agenda and draw on their specialist skills to add value; Be able to contribute a generic view from the perspective of a Registered Nurse Page 251 of 312

252 Article Paragraph Existing Text New Text operational, commissioning and business functions : including service design; commissioning cycle coherence; research and development; and regulatory affairs administration and operations; f) Taking responsibility for ensuring that the CCG complies with all legal requirements (including equality and human rights legislation); g) Implementing effective systems to monitor and review, where appropriate, the implementation of decisions made by the CCG; and institute processes that facilitate effective and efficient work flow; h) Keep the Accountable Officer, the Chair and the wider Governing Body informed about potential risks and opportunities; and recommend appropriate courses of action; i) Taking charge in high priority crises of an operational nature and ensue that suitable arrangements are in place to ensure business continuity at all times; whilst putting aside specific issues relating to their own clinical practice or employing organisation s circumstances; Utilise evidence based methodology to bring detailed insights from a nursing perspective into discussions regarding service re-design, clinical pathway development and system reform b) The Deputy Executive Nurse will deputise for the Executive Director of Quality and Nursing where he or she has a conflict of interest or is otherwise unable to act. Page 252 of 312

253 Article Paragraph Existing Text New Text j) Ensuring that systems are implemented that maintain high standards of public service, public accountability and probity, subject to the role of the Governing Body and Audit Committee. 8 Standards or Business Conduct and Managing Conflicts of Interest 9 Transparency in Procuring Services 8.5 As required by section 14O of the 2005 Act, as inserted by section 26 of the 2012 Act, 8.11 The document will be available upon request 8.14 The Chair of the Audit Committee will ensure that the The Chair of the Audit Committee will ensure that for every Arrangements for the management of conflicts of interest are to be determined by the Chair of the Audit Committee and. 9.2 The Group has published a Procurement Policy approved by its Governing Body. The Group will also publish a Procurement Strategy which will ensure that : 9.3 The Procurement Policy is available on the group s website As required by Section 14o of the NHS Act 2006, as inserted by Section 25 (14o) of the Health and Social are Act 2012,.. The registers will be available upon request. The Chair of the Audit Committee, as Conflicts of Interest Guardian, will ensure that the.. The Chair of the Audit Committee, as Conflicts of Interest Guardian, will ensure that for every.. Arrangements for the management of conflicts of interest are to be determined by the Chair of the Audit Committee, as Conflicts of Interest Guardian, and. The Group has published a Procurement Policy, which contains a Procurement Strategy, approved by its Governing Body which will ensure that : The Procurement Policy is available on the group s website at Page 253 of 312

254 Article Paragraph Existing Text New Text 12 Joint Commissioning Arrangements Appendix B List of Member Practices Appendix C Standing Orders See below. Quorum Decision making at This is where the Procurement Strategy will also be published. In exceptional circumstances where all the GP members have a conflict of interest, the decisions will be made by a minimum of four of the remaining Governing Body members, including either the Executive Director of Planning and Governance or the Chief Finance Officer. Eligibility all members of the relevant meeting have a single vote with the exception of the Council of Representatives. List of practices updated. In exceptional circumstances where all the GP members have a conflict of interest, the decisions will be made by a minimum of four of the remaining Governing Body members, including either the Executive Director of Quality and Nursing or the Chief Finance Officer. Eligibility all members of the relevant meeting have a single vote with the exception of the Council of Representatives where each practice has a weighted vote Casting vote in the event of an equality of votes, the Chair of the meeting shall have a second and casting vote. Casting vote in the event of an equality of votes, the Chair of the meeting shall have a second and casting vote, with the exception of the Council of Representatives. If the Governing Body is contemplating a course of action that raises an issue not of formal propriety or regularity but affects If the Governing Body is contemplating a course of action that raises an issue not of formal propriety or regularity but affects the Page 254 of 312

255 Article Paragraph Existing Text New Text Emergency powers and urgent decisions the Chief Clinical Officer s responsibility for value for money, the Chief Clinical Officer should draw the relevant factors to the attention of the Governing Body. If the outcome is that the Chief Clinical Officer is overruled, it is normally sufficient to ensure that the Chief Officers advice and the overruling of it are clearly apparent from the papers. Exceptionally, the Chief Clinical Officer should information NHS England and the Department of Health. In such cases the Chief Officer should, as a member of the Governing Body, vote against the course of action rather than merely abstain from voting. The powers which the Governing Body has reserved to itself within these Standing Orders may in emergency or for an urgent decision be exercised by the Chief Clinical Officer and the Chair after having consulted at least two members of the Governing Body. The exercise of such powers by the Chief Clinical Officer and Chair shall be reported to the next formal meeting of the Governing body in public session for formal ratification. Accountable Officer s responsibility for value for money, the Accountable Officer should draw the relevant factors to the attention of the Governing Body. If the outcome is that the Accountable Officer is overruled, it is normally sufficient to ensure that the Chief Officers advice and the overruling of it are clearly apparent from the papers. Exceptionally, the Accountable Officer should information NHS England and the Department of Health. In such cases the Chief Officer should, as a member of the Governing Body, vote against the course of action rather than merely abstain from voting. The powers which the Governing Body has reserved to itself within these Standing Orders may in emergency or for an urgent decision be exercised by the Accountable Officer and the Chair after having consulted at least two members of the Governing Body. The exercise of such powers by the Accountable Officer and Chair shall be reported to the next formal meeting of the Governing body in public session for formal ratification. Page 255 of 312

256 Article Paragraph Existing Text New Text Appointment of committees and Admission of public and the press Appointment of committees and The Governing Body and Part 2 of the Quality and Finance Committee (Primary Care Co-Commissioning function) meetings will be held in public. For the Governing Body, this will be a minimum of six per year. There will be an item of Public Participation where members of the public who have registered to speak will be able to air their views. Those who are interested in speaking at the Governing Body or Part 2 of the Quality and Finance Committee (Primary Care Co-Commissioning function) will contact the Executive Assistant to the Governing Body via letter or . The Governing Body and Part 2 of the Quality and Finance Committee (Primary Care Co-Commissioning function) may by resolution exclude members of the press or public where it considers that it would not be in the public interest for an agenda item or items to be dealt with in public such as are envisaged in Section 1(2) of the Public Bodies (admission to meetings) Act The Group may appoint and subcommittees of the Group, subject to any The Governing Body and Primary Care Commissioning Committee meetings will be held in public. For the Governing Body, this will be a minimum of six per year. There will be an item of Public Participation where members of the public who have registered to speak will be able to air their views. Those who are interested in speaking at the Governing Body or Primary Care Commissioning Committee will contact the Executive Assistant to the Governing Body via letter or . The Governing Body and Primary Care Commissioning Committee may by resolution exclude members of the press or public where it considers that it would not be in the public interest for an agenda item or items to be dealt with in public such as are envisaged in Section 1(2) of the Public Bodies (admission to meetings) Act The Group may appoint and sub-committees of the Group, subject to any regulations made by Page 256 of 312

257 Article Paragraph Existing Text New Text sub-committees sub-committees regulations made by the Secretary of State 1 and Articles 6.7 and make provision for the appointment of committees and sub-committees of its Governing Body. Where such committees and sub-committees of the Group, or committees or sub-committees of its Governing body are appointed, they are included in Article 6 of the Group s constitution. Duty to report non-compliance with standing orders and prime financial policies Terms of reference Approval of appointments to committees and sub-committees Terms of reference shall have effect as if incorporated into the constitution and shall be added to this document as an appendix. The Group shall approve the appointments to each of the committees and sub-committees which it has formally constituted, including the Governing Body. The Group shall agree such travelling or other allowances as it considers appropriate. If for any reason these standing orders are not complied with, full details of the non-compliance and the justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of the the Secretary of State 2 and Articles 6.7 and make provision for the appointment of committees and sub-committees of its Governing Body. Terms of reference shall have effect as if incorporated into the constitution. The Group shall approve the appointments to each of the committees and sub-committees which it has formally constituted, including the Governing Body. If for any reason these standing orders are not complied with, full details of the non-compliance and the justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of the Governing Body for action or ratification. All 1 See Section 14N of the 2006 Act, inserted by section 25 of the 2012 Act. 2 See Section 14N of the 2006 Act, inserted by section 25 of the 2012 Act. Page 257 of 312

258 Article Paragraph Existing Text New Text Use of seal and authorisation of documents Clinical Commissioning Group s seal Governing Body for action or ratification. All members of the Group and staff have a duty to disclose any non-compliance with these Standing Orders to the Chief Clinical Officer as soon as possible. The Group may have a seal for executing documents where necessary. The following individuals or officers are authorised to authenticate its use by their signature : members of the Group and staff have a duty to disclose any non-compliance with these Standing Orders to the Accountable Officer as soon as possible. The Group may have a seal for executing documents where necessary. The following individuals or officers (or their named deputy) are authorised to authenticate its use by their signature : The Chief Clinical Officer The Accountable Officer The Chair of the Governing Body The Chair of the Governing Body The Chief Finance Officer The Chief Finance Officer The Executive Director of Planning and Governance Executive of a document by signature The Executive Director of Quality and Nursing Executive of a document by signature The following individuals are authorised to execute a document on behalf of the Group by their signature The following individuals (or their named deputy) are authorised to execute a document on behalf of the Group by their signature The Chief Clinical Officer The Accountable Officer The Chair of the Governing Body The Chair of the Governing Body The Chief Finance Officer The Chief Finance Officer The Executive Director of Planning and Governance The Executive Director of Quality and Nursing Page 258 of 312

259 Article Paragraph Existing Text New Text Appendix D : Scheme of Reservation and Delegation Appendix D Scheme of Reservation and Delegation Schedule of matters reserved to the Clinical Commissioning Group and Scheme of Delegation Headings in scheme of delegation and reservation chart 1.3 The Clinical Commissioning Group permits the specified persons, or a class of persons (namely nominated GPs on the individual Funding Request Panel and the Director of the Partnership Commissioning Unit) to take decisions on its behalf as delegated clinical decision makers. Such persons not part of the NHS Vale of York CCG member practices or an employee of the NHS Vale of York CCG will enter into an honorary contract with the CCG for this purpose. Chief Clinical Officer Quality and Finance Com. (Part 2 delegated Primary Care Function) 1.3 The Clinical Commissioning Group permits the specified persons, or a class of persons (namely nominated GPs on the individual Funding Request Panel) to take decisions on its behalf as delegated clinical decision makers. Such persons not part of the NHS Vale of York CCG member practices or an employee of the NHS Vale of York CCG will enter into an honorary contract with the CCG for this purpose. Accountable Officer Throughout Chief Clinical Officer Accountable Officer Primary Care Commissioning Committee Section 9 9 Approval of Joint Commissioning arrangements (save for the establishment of joint committees with other CCGs and/or NHS England and/or other bodies, which shall be reserved to the 9a Approval of Joint Commissioning arrangements Reserved or Delegated to Governing Body. Page 259 of 312

260 Article Paragraph Existing Text New Text membership) Reserved or Delegated to Governing Body. 9b Establishment of joint committees with other CCGs and/or NHS England and/or other bodies Reserved to the Membership. Section 68 Section 73 Section 83 Approval of contracts (May want to set different limits according to value of contract) 83 Approval of the groups detailed financial policies and procedures Accountable Officer. ADDITION : 68b Appointment of External Auditors Reserved or Delegated to Governing Body. ADDITION : 68c Engagement of External Auditors for non-audit services Audit Committee Approval of contracts (Limits per detailed scheme of delegation) 83 Approval of the Group s detailed financial policies and procedures Audit Committee. Appendix E Prime Financial Policies Section Approval of Virement limits (Limits to be determined) (If accepted would need to be reflected in prime financial policies) Reserved or Delegated to Governing Body 1.2 The prime financial policies are part of the Group s control environment for managing the organisation s financial affairs. They contribute to good corporate 87 Approval of virement limits (Limits per detailed scheme of delegation) (If accepted would need to be reflected in prime financial policies) Reserved or Delegated to Governing Body The prime financial policies are part of the Group s control environment for managing the organisation s financial affairs. They contribute to good corporate governance, internal control Page 260 of 312

261 Article Paragraph Existing Text New Text governance, internal control and managing risks. They enable sound administration, lessen the risk of irregularities and support commissioning and delivery of effective, efficient and economical services. They also help the Chief Clinical Officer and Chief Finance Officer to effectively perform their responsibilities. They should be used in conjunction with the scheme of reservation and delegation found at Appendix D. 1.3 In support of these prime financial policies, the Group has prepared more detailed policies, approved by the Chief Clinical Officer, known as detailed financial policies. The Group refers to these prime and detailed financial policies together as the Clinical Commissioning Group s financial policies. 1.4 These prime financial policies identify the financial responsibilities which apply to everyone working for the Group and its constituent organisations. They do not provide detailed procedural advice and should be read in conjunction with the detailed financial policies. The Chief Clinical Officer is responsible for approving all detailed financial policies. and managing risks. They enable sound administration, lessen the risk of irregularities and support commissioning and delivery of effective, efficient and economical services. They also help the Accountable Officer and Chief Finance Officer to effectively perform their responsibilities. They should be used in conjunction with the scheme of reservation and delegation found at Appendix D. In support of these prime financial policies, the Group has prepared more detailed policies, approved by the Accountable Officer, known as detailed financial policies. The Group refers to these prime and detailed financial policies together as the Clinical Commissioning Group s financial policies. These prime financial policies identify the financial responsibilities which apply to everyone working for the Group and its constituent organisations. They do not provide detailed procedural advice and should be read in conjunction with the detailed financial policies. The Accountable Officer is responsible for approving all detailed financial policies. Page 261 of 312

262 Article Paragraph Existing Text New Text 1.12 Any contractor of employee of a contractor who is empowered by the Group to commit the Group to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Chief Clinical Officer to ensure that such persons are made aware of this To ensure that these prime financial policies remain up-to-date and relevant, the Chief Finance Officer will review them at least annually. Following consultation with the Chief Clinical Officer and scrutiny by the Governing Body s Audit Committee, the Chief Finance Officer will recommend amendments, as fitting, to the Governing Body for approval. As these prime financial policies are an integral part of the Group s constitution, any amendment will not come into force until the Group applies to the NHS Commissioning Board and that application is granted. 2.2 The Chief Clinical Officer has overall responsibility for the Group s system of internal control. 3.1 In line with terms of reference for the Governing Body s Audit Committee, the person appointed by the Group to be responsible for internal audit and the Any contractor of employee of a contractor who is empowered by the Group to commit the Group to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Accountable Officer to ensure that such persons are made aware of this. To ensure that these prime financial policies remain up-to-date and relevant, the Chief Finance Officer will review them at least annually. Following consultation with the Accountable Officer and scrutiny by the Governing Body s Audit Committee, the Chief Finance Officer will recommend amendments, as fitting, to the Governing Body for approval. As these prime financial policies are an integral part of the Group s constitution, any amendment will not come into force until the Group applies to the NHS Commissioning Board and that application is granted. The Accountable Officer has overall responsibility for the Group s system of internal control. In line with terms of reference for the Governing Body s Audit Committee, the person appointed by the Group to be responsible for Internal Audit and External Audit will have direct and Page 262 of 312

263 Article Paragraph Existing Text New Text Audit Commission appointed external audit will have direct and unrestricted access to Audit Committee members and the chair of the Governing Body, Chief Clinical Officer and Chief Finance Officer for any significant issues arising from audit work that management cannot resolve, and for all cases of fraud or serious irregularity. 3.2 The person appointed by the Group to be responsible for Internal Audit and the external auditor will have access to the Audit Committee and the Chief Clinical Officer to review audit issues as appropriate. All Audit Committee members, the Chair of the Governing Body and the Chief Clinical Officer will have direct and unrestricted access to the Head of Internal Audit and external auditors. 4.2 The Governing Body s Audit Committee will ensure that the Group has arrangements in place to work effectively with NHS Protect 5.1 The Group is required by statutory provisions to ensure that its expenditure does not exceed the aggregate of allotments from the NHS Commissioning Board and any other sums it has received unrestricted access to Audit Committee members and the chair of the Governing Body, Accountable Officer and Chief Finance Officer for any significant issues arising from audit work that management cannot resolve, and for all cases of fraud or serious irregularity. The person appointed by the Group to be responsible for Internal Audit and the external auditor will have access to the Audit Committee and the Accountable Officer to review audit issues as appropriate. All Audit Committee members, the Chair of the Governing Body and the Accountable Officer will have direct and unrestricted access to the Head of Internal Audit and external auditors. The Governing Body s Audit Committee will ensure that the Group has arrangements in place to work effectively with NHS Counter Fraud Authority (NHSCFA). The Group is required under the NHS Act 2006 (as amended) to ensure that its expenditure in a financial year does not exceed its income. Page 263 of 312

264 Article Paragraph Existing Text New Text and is legally allowed to spend. 5.2 The Chief Clinical Officer has overall executive responsibility for ensuring the Group complies with certain of its statutory obligations, including its financial and accounting obligations, and that it exercises its functions effectively, efficiently and economically and in a way which provides good value for money. 6 ALLOTMENTS 6.1 The Group s Chief Finance Officer will : a) periodically review the basis and assumptions used by the NHS Commissioning Board for distributing allotments and ensure that these are reasonable and realistic and secure the Group s entitlement to funds; b) Prior to the start of each financial year submit to the Governing Body for approval a report showing the total allocations received and their proposed distribution, including any sums to be held in reserve; and The Accountable Officer has overall executive responsibility for ensuring the Group complies with certain of its statutory obligations, including its financial and accounting obligations, and that it exercises its functions effectively, efficiently and economically and in a way which provides good value for money. ALLOCATIONS 6.1 The Group s Chief Finance Officer will : a) periodically review the basis and assumptions used by the NHS Commissioning Board for distributing allocations and ensure that these are reasonable and realistic and secure the Group s entitlement to funds; b) Prior to the start of each financial year submit to the Governing Body for approval a report showing the estimated allocation to be received and its proposed distribution, including any sums to be held in reserve; and c) Regularly update the Governing Body on significant changes to the initial allocation and the uses of such funds. Page 264 of 312

265 Article Paragraph Existing Text New Text c) Regularly update the Governing Body on significant changes to the initial allocation and the uses of such funds. 7.1 The Chief Clinical Officer will compile and submit the Governing Body a commissioning strategy which takes into account financial targets and forecast limits of available resources for approval. 7.2 Prior to the start of the financial year the Chief Finance Officer will, on behalf of the Chief Clinical Officer, prepare and submit budgets for approval by the Governing Body. 7.3 o CCG will engage and liaise with the LMC when issues pertinent and relevant to quality in general practice are discussed. 7.4 The Chief Clinical Officer is responsible for ensuring that information relating to the Group s accounts or to its income or expenditure, or its use of resources is provided to the NHS Commissioning Board as requested The Governing Body shall approve the banking arrangements c Take into account as appropriate any application NHS Commissioning Board or The Accountable Officer will compile and submit the Governing Body a commissioning strategy which takes into account financial targets and forecast limits of available resources for approval. Prior to the start of the financial year the Chief Finance Officer will, on behalf of the Accountable Officer, prepare and submit budgets for approval by the Governing Body. The Accountable Officer is responsible for ensuring that information relating to the Group s accounts or to its income or expenditure, or its use of resources is provided to the NHS Commissioning Board as requested. The Accountable Officer shall approve the banking arrangements. Take into account as appropriate any application NHS Commissioning Board or the Page 265 of 312

266 Article Paragraph Existing Text New Text the Independent Regulator of NHS Foundation Trusts (monitor) guidance that does not conflicts with (b) above In all contracts entered into, the Group shall endeavour to obtain best value for money. The Chief Clinical Officer shall nominate an individual who shall oversee and manage each contract on behalf of the Group The Chief Clinical Officer will establish arrangements to ensure that regular reports are provided to the Governing Body detailing actual and forecast expenditure and activity for each contract The Governing Body will approve the level of non-pay expenditure on an annual basis and the Chief Clinical Officer will determine the level of delegation to budget managers The Chief Clinical Officer shall set out procedures on the seeking of professional advice regarding the supply of goods and services. NHS Improvement guidance that does not conflicts with (b) above. In all contracts entered into, the Group shall endeavour to obtain best value for money. The Accountable Officer shall nominate an individual who shall oversee and manage each contract on behalf of the Group. The Accountable Officer will establish arrangements to ensure that regular reports are provided to the Governing Body detailing actual and forecast expenditure and activity for each contract. The Governing Body will approve the level of non-pay expenditure on an annual basis and the Accountable Officer will determine the level of delegation to budget managers. The Accountable Officer shall set out procedures on the seeking of professional advice regarding the supply of goods and services The Chief Clinical Officer will : The Accountable Officer will : 19.1 The Chief Clinical Officer shall : The Accountable Officer shall : Appendix F The Nolan Principles In 1994, the UK government established a Committee on Standards in Public Life which Page 266 of 312

267 Article Paragraph Existing Text New Text Selflessness Integrity Objectivity Accountability Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends. Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties. In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit. Holders of public office are accountable for their decisions and actions to the public and must submit themselves to was chaired by Lord Nolan. The committee was tasked with making recommendations to improve standards of behaviour in public life and were revolutionary because the focused on behaviour and culture, rather than processes. The Seven Principles of Public Life have been amended over the years. As of 2015, they are : Holders of public office should act solely in terms of the public interest. Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests and relationships Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias. Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to Page 267 of 312

268 Article Paragraph Existing Text New Text Appendix G The Seven Key Principles of the NHS Constitution Openness Honesty Leadership whatever scrutiny is appropriate to their office. Holders of public office should be as open as possible about all the decisions and actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. Holders of public office have a duty to declare any private interests relating to the public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. Holders of public office should promote and support these principles by leadership and example. Source : The First Report on the Committee on Standards in Public Life (1995) 1 The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty ensure this. Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing. Holders of public office should be truthful. Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support the principles and be willing to challenge poor behaviour wherever it occurs. 7-principles-of-public-life It is available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status. The service is designed to improve, prevent, diagnose and treat both physical and mental health problems with equal regard. It has a duty to each and Page 268 of 312

269 Article Paragraph Existing Text New Text to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population. In the provision of high-quality care that is safe, effective and focussed on patient experience; in the planning and delivery of clinical and other services in provides; in the people it employs and the education, training and development they receive; in the leadership and management of its organisations; and through its commitment to innovation and to the promotion and conduct of research to improve the current and future health and care of the population. 4 NHS services must reflect the needs and preferences of patients, their families and their carers patients, with their families and carers, where appropriate, will be involved in and consulted on all decisions about their care and treatment. every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population. It provides high-quality care that is safe, effective and focused on patient experience; in the people it employs, and in the support, education, training and development they receive; in the leadership and management of its organisations; and through its commitment to innovation and to the promotion, conduct and use of research to improve the current and future health and care of the population. Respect, dignity, compassion and care should be at the core of how patients and staff are treated not only because that is the right thing to do but because patient safety, experience and outcomes are all improved when staff are valued, empowered and supported. The patient will be at the heart of everything the NHS does - It should support individuals to promote and manage their own health. NHS services must reflect, and should be coordinated around and tailored to, the needs and preferences of patients, their families and their carers. As part of this, the NHS will ensure that in line with the Armed Forces Covenant, those in Page 269 of 312

270 Article Paragraph Existing Text New Text Appendix H Dispute Resolution Policy 5 The NHS is committed to working jointly with local authorities and a wide range of other private, public and third sector organisations at national and local level to provide and deliver improvements in health and wellbeing. Source : The NHS Constitution the NHS belongs to all of us. 1.4 If it is considered by the Council of Representatives that the Governing Body continues to act inappropriate, they Council of Representatives, by a vote of 66% majority of member practices at the Special General Meeting, can censure any decision or action, inform the Governing Body it has done so and request a meeting with the Governing Body. Such a meeting will, at a minimum, include the Chair, Chief Clinical Officer the armed forces, reservists, their families and veterans are not disadvantaged in accessing health services in the area they reside. Patients, with their families and carers, where appropriate, will be involved in and consulted on all decisions about their care and treatment. The NHS will actively encourage feedback from the public, patients and staff, welcome it and use it to improve its services. The NHS is committed to working jointly with other local authority services, other public sector organisations and a wide range of private and voluntary sector organisations to provide and deliver improvements in health and wellbeing. If it is considered by the Council of Representatives that the Governing Body continues to act inappropriate, they Council of Representatives, by a vote of 66% majority of member practices at the Special General Meeting, can censure any decision or action, inform the Governing Body it has done so and request a meeting with the Governing Body. Such a meeting will, at a minimum, include the Chair, Accountable Officer and Chief Finance Officer who will be invited to attend the meeting Page 270 of 312

271 Article Paragraph Existing Text New Text Appendix J Council of Representative Terms of Reference Appendix K - Audit Committee Terms of Reference Appendix L - Remuneration Committee Terms of Reference Appendix M - PCU and Chief Operating Officer / Chief Finance Officer who will be invited to attend the meeting to answer questions relating to the Governing Body s actions. A minimum of 10 working days notice of the meeting will be given and background information provided to the Governing Body regarding the Council of Representative s concerns. to answer questions relating to the Governing Body s actions. A minimum of 10 working days notice of the meeting will be given and background information provided to the Governing Body regarding the Council of Representative s concerns. Terms of Reference are referenced at Appendix J but not included within the constitution. This is to make it possible to make changes to committee Terms of Reference if necessary. All committee Terms of Reference will be on the CCG s website. The Terms of Reference listed are : Audit Committee Council of Representatives Executive Committee Finance and Performance Committee Primary Care Commissioning Committee Quality and Patient Experience Committee Remuneration Committee Removed due to the changes in organisation. Page 271 of 312

272 Article Paragraph Existing Text New Text Management Board Terms of Reference Changes 6.9 k Overview of Governing Body membership EXISTING TEXT : Role Vote (1 per person) Chair (Lay Member) Yes (casting vote) 3 years Lay Member(s) a nominated Lay Member will take the role of Deputy Chair Yes 3 years Accountable Officer Yes N/A Chief Finance Officer Yes N/A Chief Operating Officer Yes N/A Chief Nurse Yes N/A GP Member(s) minimum of four GP Members Yes Secondary Care Clinician Yes N/A Council of Representatives Yes Member(s) In Attendance Healthwatch Representative No N/A Local Medical Committee No N/A Health and Wellbeing Board No N/A Tenure (if applicable) 1 years Page 272 of 312

273 Representative(s) Practice Manager Representative No N/A Executive Assistant No N/A NEW TEXT : Role Vote (1 per person) Chair (Lay Member or Clinician) Yes (casting vote) 3 years Lay Member(s) a nominated Lay Member will take the role of Deputy Chair Yes 3 years Accountable Officer Yes N/A Chief Finance Officer Yes N/A Chief Operating Officer Yes N/A Tenure (if applicable) Executive Director of Quality and Yes N/A Nursing GP Member(s) minimum of three GP Members Yes 2/3 years 3 Secondary Care Specialist Doctor Yes N/A Chair of Council of Representatives Yes 2 years Vice Chair of Council of Yes 2 years Representatives In Attendance Local Medical Committee No N/A Health and Wellbeing Board No N/A Representative(s) Director of Public Health No N/A Executive Assistant No N/A For the purposes of the above, Medical Directors will follow GP member vote and tenure. 3 This does not apply to current members with a permanent contract. Page 273 of 312

274 ROLE OF THE CHIEF OPERATING OFFICER Responsibility currently aligned to the Chief Operating Officer Ensuring that arrangements are put in place so that the CCG successfully delivers its strategic business objectives. Ensuring effective management systems are in place and will be required to direct the operation of the CCG according to the strategic commissioning priorities set by the CCG, bringing highlevel strategic leadership and management skills and experience, to support and empower the clinical leadership at the heart of clinical commissioning. Assist the Chief Finance Officer to ensure that the CCG has a financial framework in place, which will enable it to operate within its resource limit to meet its financial obligations, continue to improve the value for money (economy, efficiency and effectiveness) and ensure an integrated governance approach Overseeing the successful delivery of the CCG annual commissioning plan and develop a culture of continual quality improvement; Maintaining general oversight of all operational, commissioning and business functions : including service design; commissioning cycle coherence; research and development; and regulatory affairs administration and operations; Taking responsibility for ensuring that the CCG complies with all legal requirements (including equality and human rights legislation); Assigned to : Accountable Officer Accountable Officer Removed Executive Director of Quality and Nursing Page 274 of 312

275 Implementing effective systems to monitor and review, where appropriate, the implementation of decisions made by the CCG; and institute processes that facilitate effective and efficient work flow; Keep the Accountable Officer, the Chair and the wider Governing Body informed about potential risks and opportunities; and recommend appropriate courses of action; Taking charge in high priority crises of an operational nature and ensue that suitable arrangements are in place to ensure business continuity at all times; Ensuring that systems are implemented that maintain high standards of public service, public accountability and probity, subject to the role of the Governing Body and Audit Committee Executive Director of Quality and Nursing Executive Director of Quality and Nursing Executive Director of Quality and Nursing Executive Director of Quality and Nursing 12 ARTICLE 12 : JOINT COMMISSIONING ARRANGEMENTS Joint commissioning arrangements with other clinical commissioning groups EXISTING TEXT : 12.1 The Clinical Commissioning Group (CCG) may wish to work together with other CCGs in the exercise of its commissioning functions The CCG may make arrangements with one or more CCG in respect of : Delegating any of the CCG s commissioning functions to another CCG; Exercising any of the commissioning functions of another CCG; or Exercising jointly the commissioning functions of the CCG and another CCG. Page 275 of 312

276 12.3 For the purposes of the arrangements described at paragraph 12.2, the CCG may : Make payments to another CCG; Receive payments from another CCG; Make the services of its employees or any other resources available to another CCG; or Receive the service of the employees or the resources available to another CCG Where the CCG makes arrangements which involve all the CCGs exercising any of their commissioning functions jointly, a joint committee may be established to exercise those functions For the purposes of the arrangements described at paragraph 12.2 above, the CCG may establish and maintain a pooled fund made up of contributions by any of the CCGs working together pursuant to paragraph 12.2 bullet 3 above. Any such pooled fund may be used to make payments towards expenditure incurred in the discharge of any of the commissioning functions in respect of which the arrangements are made Where the CCG makes arrangements with another CCG as described at paragraph 12.2 above, the CCG shall develop and agree with that CCG an agreement setting out the arrangements for joint working, including details of: How the parties will work together to carry out their commissioning functions; The duties and responsibilities of the parties; How risk will be managed and apportioned between the parties; Financial arrangements, including, if applicable, payments towards a pooled fund and management of that fund; Contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements The liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph [12.2] above The CCG will act in accordance with any further guidance issued by NHS England on co-commissioning. Page 276 of 312

277 12.9 Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the governing body The governing body of the CCG shall require, in all joint commissioning arrangements with other clinical commissioning groups, that the lead clinician and lead manager of the lead CCG make a quarterly written report to the governing body and hold at least annual engagement events to review aims, objectives, strategy and progress and publish an annual report on progress made against objectives Should a joint commissioning arrangement prove to be unsatisfactory the governing body of the CCG can decide to withdraw from the arrangement, but has to give six months notice to partners, with new arrangements starting from the beginning of the next new financial year. Joint commissioning arrangements with NHS England for the exercise of CCG functions The CCG may wish to work together with NHS England in the exercise of its commissioning functions The CCG and NHS England may make arrangements to exercise any of the CCG s commissioning functions jointly The arrangements referred to in paragraph [12.13] above may include other CCGs Where joint commissioning arrangements pursuant to [12.13] above are entered into, the parties may establish a joint committee to exercise the commissioning functions in question Arrangements made pursuant to [12.13] above may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and the CCG Where the CCG makes arrangements with NHS England (and another CCG if relevant) as described at paragraph above, the CCG shall develop and agree with NHS England a framework setting out the arrangements for joint working, including details of: How the parties will work together to carry out their commissioning functions; The duties and responsibilities of the parties; How risk will be managed and apportioned between the parties; Financial arrangements, including, if applicable, payments towards a pooled fund and management of that fund; Page 277 of 312

278 Contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements The liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph above The CCG will act in accordance with any further guidance issued by NHS England on co-commissioning Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the governing body The governing body of the CCG shall require, in all joint commissioning arrangements with NHS England for the exercise of CCG functions that the Accountable Officer of the CCG (or designated manager on behalf of the Accountable Officer) make a quarterly written report to the governing body and hold at least annual engagement events to review aims, objectives, strategy and progress and publish an annual report on progress made against objectives Should a joint commissioning arrangement prove to be unsatisfactory the governing body of the CCG can decide to withdraw from the arrangement, but has to give six months notice to partners, with new arrangements starting from the beginning of the next new financial year after the expiration of the six months notice period. Joint commissioning arrangements with NHS England for the exercise of NHS England s functions The CCG may wish to work with NHS England and, where applicable, other CCGs, to exercise specified NHS England functions The CCG may enter into arrangements with NHS England and, where applicable, other CCGs to : Exercise such functions as specified by NHS England under delegated arrangements; Jointly exercise such functions as specified with NHS England Where arrangements are made for the CCG and, where applicable, other CCGs to exercise functions jointly with NHS England a joint committee may be established to exercise the functions in question. Page 278 of 312

279 12.26 Arrangements made between NHS England and the CCG may be on such terms and conditions (including terms as to payment) as may be agreed between the parties For the purposes of the arrangements described at paragraph above, NHS England and the CCG may establish and maintain a pooled fund made up of contributions by the parties working together. Any such pooled fund may be used to make payments towards expenditure incurred in the discharge of any of the commissioning functions in respect of which the arrangements are made Where the CCG enters into arrangements with NHS England as described at paragraph above, the parties will develop and agree a framework setting out the arrangements for joint working, including details of: How the parties will work together to carry out their commissioning functions; The duties and responsibilities of the parties; How risk will be managed and apportioned between the parties; Financial arrangements, including payments towards a pooled fund and management of that fund; Contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements The liability of NHS England to carry out its functions will not be affected where it and the CCG enter into arrangements pursuant to paragraph above The CCG will act in accordance with any further guidance issued by NHS England on co-commissioning Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the governing body The governing body of the CCG shall require, in all joint commissioning arrangements with NHS England to exercise NHS England functions that the Chair of the Joint Commissioning Committee (Quality and Finance) of the CCG make a quarterly written report to the governing body and hold at least annual engagement events to review aims, objectives, strategy and progress and publish an annual report on progress made against objectives. Page 279 of 312

280 12.33 Should a joint commissioning arrangement prove to be unsatisfactory the governing body of the CCG can decide to withdraw from the arrangement, but has to give six months notice to partners, with new arrangements starting from the beginning of the next new financial year after the expiration of the six months notice period. NEW TEXT : 12.1 The group may wish to work together with one or more other CCGs and / or NHS England and / or other bodies 4 in the exercise of its commissioning functions in accordance with the relevant provisions of the 2006 Act Where the Group makes arrangements which involve exercising any of their commissioning functions jointly with one or more CCGs, NHS England and / or another body, the Group may establish a joint committee to exercise those functions in accordance with the relevant provisions of the 2006 Act. Such joint committee shall be established by the Group in accordance with Articles 6.7, 6.7A and Appendix C (Standing Orders) of this constitution Where the Group makes arrangements with one or more CCGs, NHS England and / or another body or bodies 5 as described at Article 12.1 above, the Group shall develop and agree with said relevant body / bodies an agreement setting out the arrangements for joint working, including details of : How the parties will work together to carry out their respective commissioning functions; The duties and responsibilities of the parties; How risk will be managed and apportioned between the parties; Financial arrangements, including, if applicable, payment towards a pooled fund and management of that fund; Contributions from the parties, including details around assets, employees and equipment to be used under joint working arrangements; The circumstances in which the parties may withdraw from the arrangements; 4 Other bodies include combined authorities and such other bodies as are prescribed under the relevant provisions of the 2006 Act. 5 Other bodies include combined authorities and such other bodies as are prescribed under the relevant provisions of the 2006 Act. Page 280 of 312

281 Where a joint committee is established, the reporting arrangements on the joint working arrangements to the Governing Body and the Council of Representatives, are to include, as a minimum, quarterly written reports and an annual report on progress made against objectives; Where a joint committee is established, the reporting arrangements between the joint committee, the Council of Representatives and the Governing Body, are to include, as a minimum, the sharing of joint committee meeting minutes and an annual report of the work of the joint committee The liability of the Group to carry out its functions will not be affected where the Group enters into arrangements pursuant to this Article Where the Group enters into arrangements with NHS England under which the Group exercises NHS England s functions in accordance with the relevant provisions of the 2006 Act, the CCG will act in accordance with any guidance issued by NHS England on co-commissioning Only joint commissioning arrangements that are safe and in the interests of patients registered with member practices will be approved by the Group. Amendments to the detailed Scheme of Delegation Section Existing Text New Text Throughout Senior Management Team Executive Committee Throughout Director of Partnership Commissioning Chief Nurse Support Unit for Continuing Care 2.b Authorisation for cash limit Chief Operating Officer Chief Finance Officer drawdown and subsection and 2.c Authorisation for cheque requests and section 16.m Redundancy, 16.n Ill Chief Operating Officer Chief Finance Officer Page 281 of 312

282 Section Existing Text New Text Health Retirement, o) Dismissal and p) Facilities for staff not employed by the Trust to gain practical experience 3. Non Pay Expenditure Up to 25,000 and in line with existing budget - Budget Holder Up to 250,000 - Senior Management Team Which must include the Chief Finance Officer or Deputy Chief Finance Officer Up to 500,000 - Quality and Finance Committee Which must include the Chief Finance Officer or Deputy Chief Finance Officer Up to 25,000 and in line with existing budget - Budget Holder Up to 500,000 - Executive Committee which must include the Chief Finance Officer or Deputy Chief Finance Officer Over 500,000 - Governing Body which must include the Chief Finance Officer or Deputy Chief Finance Officer Over 500,000 - Governing Body Which must include the Chief Finance Officer or Deputy Finance Officer 3.b Where competitive tendering or competitive quotations are not required e.g. below 30,000 then in the first instance NHS Supply Chain must be used 4.a Waiving of requirement to Authority Delegated to: Chief Finance Officer obtain quotations and tenders subject to the Detailed Financial Policies Where competitive tendering or competitive quotations are not required e.g. below 5,000 then in the first instance NHS Supply Chain must be used Authority Delegated to: Chief Finance Officer (from Accountable Officer) 5. Authorisation for Payment Up to 10,000 -Senior Manager or Head of Up to 10,000 - Head of Department. Page 282 of 312

283 Section Existing Text New Text 8. Accounts Receivable Authorisation 9 Engagement of Staff Not on the Establishment Department. Up to 50,000 Relevant Senior Manager. Up to 150,000 Deputy Chief Finance Officer, Chief Operating Officer or Accountable Officer or Director of Partnership Commissioning Unit for Continuing Health Care only. Over 150,000-Chief Finance Officer and Chief Operating Officer or Accountable Officer. a) Invoices raised Over 500, Deputy Chief Finance Officer Up to 500,000 Head of Finance b) Credit Memos Over 500, Deputy Chief Finance Officer Up to 500, Head of Finance a) Non-Medical Consultancy Staff Below 600 per day Authority Delegated to Budget Holder (within budget). Authority Delegated to Senior Management Team (not within budget). Up to 50,000 Relevant Senior Manager. Up to 150,000 Deputy Chief Finance Officer, Accountable Officer or Chief Nurse. Over 150,000 - Chief Finance Officer or Accountable Officer. a) Invoices raised Up to 500, Head of Finance Over 500, Deputy Chief Finance Officer b) Credit Memos Up to 500, Head of Finance Over 500, Deputy Chief Finance Officer a) Non-Medical Consultancy Staff Below 600 per day Authority Delegated to Executive Committee. Page 283 of 312

284 Section Existing Text New Text Senior Managers should check with the Finance Department regarding Inland Revenue implications where consultancy staff are considered self-employed. 16 Personnel and Pay a) Authority to fill funded post In line with establishment with permanent staff, subject to finance approval as part of the Organisational Procedure - Authority Delegated to Chief Finance Level. b) Job Description Review All requests for Job Description Review shall be dealt with in accordance with Organisational Procedure - Authority Delegated to Agenda for Change Matching Process. e) Leave iii) Annual Leave In extreme cases approval of carry over in excess of 1 working week Authority Delegated to Relevant Senior Manager. viii) Maternity Leave - paid and unpaid- Authority Delegated to Automatic approval Senior Managers must check with the Finance Department regarding HMRC implications where consultancy staff are considered self-employed. Finance staff must then check the employment status for tax using the HMRC Employment Status Indicator so that the correct employment status is determined. a) Authority to fill funded post In line with establishment with permanent staff, subject to finance approval as part of the Organisational Procedure-Authority Delegated to Executive Director Level. b) Job Description Review All requests for Job Description Review shall be dealt with in accordance with Organisational Procedure and Agenda for Change Matching Process-Authority Delegated to Line Manager. e) Leave iii) Annual Leave In extreme cases approval of carry over in excess of 1 working week Authority Delegated to Executive Director Level. viii) Parental Leave-paid and unpaid-authority Delegated to Automatic approval with guidance Page 284 of 312

285 Section Existing Text New Text 18 Authorisation of Research Projects with guidance from HR. ix) Additional Paternity Leave Authority Delegated to Automatic approval with guidance from HR. f) Sick Leave ii) Return to work part-time on full pay to assist recovery - Authority Delegated to on advice from Occupational Health in conjunction with HR. Authority Delegated to Accountable Officer and Head of Integrated Governance & Business Committee. from HR. f) Sick Leave ii) Return to work part-time on full pay to assist recovery on advice from Occupational Health in conjunction with HR.-Authority delegated to Relevant Senior Manager. Authority Delegated to Accountable Officer and Chief Nurse to act jointly in this decision. Amendments to the Detailed Financial Policies Section Existing Text New Text Throughout Chief Clinical Officer Accountable Officer Throughout Chief Officer Executive Director Throughout Counter Fraud Specialist Local Counter Fraud Specialist 1.1.9f Director is defined as a voting member of the 2.4 External Audit Under the Health and Social Care Act 2012, NHS England will arrange for the Audit Commission to appoint External Auditors for the CCG. Governing Body NHS England arranged for the Audit Commission to appoint External Auditors for the CCG under the Health and Social Care Act 2012 in From , NHS Vale of York CCG appointed External Auditors after a Page 285 of 312

286 Section Existing Text New Text competitive tendering process Cash and Resource Limits 3.2.1d Allocations The definition of use of resources is set out in Resource Accounting and Budgeting directions on use of resources which are available on the Department of Health Finance Manual website: establish a system for management of the Capital Resource Limit and the approval of investment proposals. The definition of use of resources is set out in Resource Accounting and Budgeting directions. establish a system for management of the capital resource and the approval of investment proposals Banking Arrangements The Governing Body shall approve the banking arrangements Information Technology In order to ensure compatibility and compliance with the NHS Vale of York CCGs IT strategy, no computer hardware, software or facility will be procured without the authorisation of an officer specifically appointed by the Accountable Officer. The Accountable Officer shall approve the banking arrangements. In order to ensure compatibility and compliance with the NHS Vale of York CCGs IT policy, no computer hardware, software or facility will be procured without the authorisation of an officer specifically appointed by the Accountable Officer. Page 286 of 312

287 Item Number: 12 Name of Presenter: Keith Ramsay Meeting of the Governing Body Date of meeting: 6 September 2018 Report Title Remuneration Committee Terms of Reference Purpose of Report (Select from list) To Ratify Reason for Report Governing Body will be aware that the Terms of Reference for all CCG committees were discussed at the last meeting as part of the overall committee review. At that time, however, the Remuneration Committee had not met and thus not approved the Committee s Terms of Reference. The Remuneration Committee has since met, on 26 July 2018, and approved the Terms of Reference. The amendment to the Terms of Reference are : Paragraph 2 Purpose of the Committee to read staff who are employed by the CCG and not members of the Governing Body will have their terms and conditions, remuneration Paragraph 5 Membership Lay Chair of Governing Body to be replaced by Lay Chair of Primary Care Commissioning Committee and Quality and Patient Experience Committee Strategic Priority Links Strengthening Primary Care Reducing Demand on System Fully Integrated OOH Care Sustainable acute hospital/ single acute contract Local Authority Area CCG Footprint City of York Council Impacts/ Key Risks Financial Legal Primary Care Equalities Transformed MH/LD/ Complex Care System transformations Financial Sustainability East Riding of Yorkshire Council North Yorkshire County Council Covalent Risk Reference and Covalent Description G T - There is a potential risk that the organisation's governance structures are not efficient and effective Page 287 of 312

288 Emerging Risks (not yet on Covalent) N/A Recommendations Governing Body is asked to ratify the Remuneration Committee Terms of Reference. Responsible Executive Director and Title Michelle Carrington Executive Director of Quality and Nursing / Chief Nurse Report Author and Title Rachael Simmons Corporate Services Manager Page 288 of 312

289 REMUNERATION COMMITTEE Terms of Reference 1 Constitution and Authority NHS Vale of York Clinical Commissioning Group Governing Body resolves to establish a Remuneration Committee which has delegated decision making authority as set out in these Terms of Reference. The Remuneration Committee is authorised by the Governing Body to approve any activity within its Terms of Reference. The Remuneration Committee is authorised to create working groups as necessary to fulfil its responsibilities within these Terms of Reference. 2 Purpose of the Committee The Remuneration Committee is responsible for determining the terms and conditions, remuneration and travelling or other allowances for staff who are members of the Governing Body. Those staff who are employed by the CCG and not members of the Governing Body will have their terms and conditions, remuneration and travelling or other allowances determined by the Executive Committee of the Governing Body. This includes those employees not currently working under the terms of Agenda for Change. 3 Remit The Committee shall approve the terms and conditions, remuneration and travelling or other allowances for Governing Body members, including pensions and gratuities. The Committee shall make recommendations to the Governing Body on: The terms and conditions of employment for all Governing Body members of the Clinical Commissioning Group (the Group). Pensions, remuneration, fees and allowances payable to employees and to other persons providing services to the Group. Retention Premia. Annual salary awards [where applicable]. Allowances under any pension scheme it might establish as an alternative to the NHS pension scheme. The severance payments of NHS Vale of York Clinical Commissioning Group employees and contractors, seeking HM approval as appropriate in accordance with the guidance Managing Public Money. Policies and instructions relating to remuneration. Any significant amendments to the terms and conditions of employment which affects all employees of the Clinical Commissioning Group generally (for example changes to the Agenda for Change terms and conditions) Page 1 of 3 Page 289 of 312

290 4 Frequency Meetings shall be held as and when required upon receipt of a request to the Chair or Vice Chair. The Committee will meet a minimum of twice per financial year. Seven calendar days notice will be provided of the meeting and any documents to be considered / discussed at the meeting will be circulated to the Committee at least two calendar days prior to the meeting. 5 Membership The Committee shall be appointed by the NHS Vale of York Clinical Commissioning Group from amongst its Governing Body members. The membership of the Committee shall comprise the following: Lay Chair of Primary Care Commissioning Committee and Quality and Patient Experience Committee Lay Member and Chair of Audit Committee Lay Member and Chair of Finance and Performance Committee Other directors and external advisers such as Human Resources representatives may be invited to attend for all or part of any meeting as and when appropriate. The role of other individuals who attend and external advisors will be to draw the Committee s attention to best practice, national guidance and other relevant documents as appropriate. Full time employees or individuals who claim a significant proportion of their income from the NHS Vale of York Clinical Commissioning Group are not permitted to be voting members of the Committee. No individual should be in attendance for discussion about their own remuneration and terms of service. A Chair and Vice Chair must be appointed. 6 Quoracy The quorum shall be the Chair plus one other member. Where a quorum cannot be convened from the membership of the meeting, owing to the arrangements for managing conflicts of interest or potential conflicts of interests, the Chair of the meeting shall consult with the Chair of the Audit Committee on the action to be taken. This may include: requiring another of the Group s committees or sub-committees, the Group s Governing Body or the Governing Body s committees or subcommittees (as appropriate) which can be quorate to progress the item of business, or if this is not possible, inviting on a temporary basis one or more Governing Body members to make up the quorum so that the group can progress the item of business. Page 2 of 3 Page 290 of 312

291 7 Accountability The minutes of the Committee meetings will be submitted by the Committee Chair within seven calendar days of the meeting. 8 Decision Making All Members of the Remuneration Committee will have voting rights. 9 Administrative Support A Secretary will be identified by the NHS Vale of York Clinical Commissioning Group. The Secretary will be responsible for supporting the Chair in the management of remuneration business. This will include arranging, formally minuting and archiving of all reports and documentation associated with the business of the Committee. 10 Committee Effectiveness The Committee shall review its effectiveness annually. 11 Review of Terms of Reference The Committee shall review its terms of reference at least annually. Author Committee Approved (including date) Approval Date Issue Date Review Date Version Number 2 Abigail Combes Head of Legal and Governance Remuneration Committee 26 July 2018 Governing Body Page 3 of 3 Page 291 of 312

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293 Item 13 Chair s Report: Audit Committee Date of Meeting Chair 25 July 2018 Phil Goatley Areas of note from the Committee Discussion The Committee: Accepted the work plan for 2018/19 noting that it was comprehensive and balanced across the year. Requested more precision in reporting, particularly in relation to Internal Audit and External Audit actions and completion dates. Approved the Local Antifraud, Bribery and Corruption Policy subject to a minor amendment. Approved the nomination of Chris Park, Management Accountant, to fulfil the role of local Sponsor for Registration Authority purposes. External Audit readily acknowledged that since publication of the 2017/18 Annual Audit Letter the CCG had made positive progress which External Audit would convey to any third parties if questioned. Areas of escalation N/A Urgent Decisions Required/ Changes to the Forward Plan N/A Page 293 of 312

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295 Item 14 Chair s Report: Executive Committee Date of Meeting Chair 20 June, 4 and 18 July and 1 August 2018 Phil Mettam Areas of Note from the Committee Discussion 1. The Executive have been overseeing the transition from a Payment by Results contract to an Aligned Incentive Framework with York Teaching Hospital NHS Foundation Trust. The risks and benefits have been reported and discussed in furl at the Finance and Performance Committee. 2. Additionally the Executive have considered a number of commissioning issues. These have included: Free Style Libre further work required Optimise Rx contract renewal Minor Eye Conditions procurement update Cholesterol management in primary care pilot approved Dementia case finding approved Extension of Proactive Health Coaching further work required Oral anticoagulants pilot to be developed 3. A number of wider system governance issues have been considered and approved. These include a new dispute resolution policy for continuing healthcare for City of York residents and new terms of reference for the North Yorkshire Mental Health and Learning Disabilities Partnership. Areas of escalation None Urgent Decisions Required/ Changes to the Forward Plan None Page 295 of 312

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297 Chair s Report: Finance and Performance Committee Item 15 Date of Meeting Chair 3 and 26 July 2018 David Booker Areas of note from the Committee Discussion 3 July The Committee supported the prioritisation of mental health services as a principle to guide any available resources. The Committee noted that the overall financial position at Month 2 was slightly ahead of plan and would continue to review and monitor opportunities and challenges, including the growing concerns about the cost of continuing healthcare, with particular emphasis on the system-wide financial environment. 26 July The Committee noted that the financial position was stabilising but had continuing concerns about a number of areas and in particular maintaining the progress of the Aligned Incentives Contract. The Committee expressed concern about the timing and delivery of QIPP, emphasising the need to maintain robust analysis. The Committee had ongoing concerns about continuing healthcare and mental health out of contract placements and requested an urgent review of the latter. The Committee approved the progression of the procurements for Improving Access to GP Services and an Anticoagulation Warfarin Monitoring and Management Service. Areas of escalation As described above. Urgent Decisions Required/ Changes to the Forward Plan N/A Page 297 of 312

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299 Item 16 Chair s Report: Primary Care Commissioning Committee Date of Meeting Chair 26 July 2018 Keith Ramsay Areas of note from the Committee Discussion The Committee: Received an update on the Care Quality Commission assessment of Unity Health and associated action plan. Sought clarification on a number of the primary care estates capital bids prior to approving the recommendations of the technical team. Requested a solution be developed working with other commissioners to maximise any underspends from 2017/18 and 2018/19 PMS Premium and 3 per head Transformation Funding for sustainability in primary care. Areas of escalation N/A Urgent Decisions Required/ Changes to the Forward Plan N/A Page 299 of 312

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301 Item 17 Chair s Report: Quality and Patient Experience Committee Date of Meeting Chair 9 August 2018 Keith Ramsay Areas of note from the Committee Discussion The Committee continued to focus on access to both Adult and Children s Mental Health Services. Further assurance on engagement between providers and carers was required in respect of the former; the presentation had provided assurance provided in terms of quality but concerns remained about capacity and ability to improve access. The Committee welcomed the support from York Teaching Hospital NHS Foundation Trust in providing improved assurance on Serious Incidents and Never Events. The Committee congratulated those who had contributed to the Outstanding North Yorkshire Children s Service Ofsted Inspection Report. The Committee expressed continuing concerns about adult care home provision. The Committee welcomed the new format of the Risk Report. Areas of escalation N/A Urgent Decisions Required/ Changes to the Forward Plan N/A Page 301 of 312

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303 Item Number: 18 Name of Presenter: Dr Kevin Smith Meeting of the Governing Body Date of meeting: 6 September 2018 Report Title Medicines Commissioning Committee Recommendations Purpose of Report For Information Reason for Report These are the latest recommendations from the Medicines Commissioning Committee June and July 2018 Strategic Priority Links Strengthening Primary Care Reducing Demand on System Fully Integrated OOH Care Sustainable acute hospital/ single acute contract Local Authority Area CCG Footprint City of York Council Impacts/ Key Risks Financial Legal Primary Care Equalities Transformed MH/LD/ Complex Care System transformations Financial Sustainability East Riding of Yorkshire Council North Yorkshire County Council Covalent Risk Reference and Covalent Description Emerging Risks (not yet on Covalent) Recommendations For information only CCG Executive Committee have approved these recommendations Page 303 of 312

304 Responsible Executive Director and Title Dr Kevin Smith Director of Primary Care and Population Health Report Author and Title Jamal Hussain Senior Pharmacist Page 304 of 312

305 Recommendations from York and Scarborough Medicines Commissioning Committee June 2018 Drug name Indication Recommendation, rationale and place in therapy RAG status Potential full year cost impact CCG commissioned Technology Appraisals 1. Nil NHSE commissioned Technology Appraisals for noting 2. TA520: Atezolizumab for treating locally advanced or metastatic non-small-cell lung cancer after chemotherapy Atezolizumab is recommended as an option for treating locally advanced or metastatic nonsmall-cell lung cancer (NSCLC) in adults who have had chemotherapy (and targeted treatment if they have an EGFR- or ALKpositive tumour), only if: atezolizumab is stopped at 2 years of uninterrupted treatment or earlier if the disease progresses and the company provides atezolizumab with the discount agreed in the patient access scheme. Red No cost impact to CCGs as NHS England commissioned. 3. TA521: Guselkumab for treating moderate to severe plaque psoriasis Guselkumab is recommended as an option for treating plaque psoriasis in adults, only if: the disease is severe, as defined by a total Psoriasis Area and Severity Index (PASI) of 10 or more and a Dermatology Life Quality Index (DLQI) of more than 10 and the disease has not responded to other systemic therapies, including ciclosporin, methotrexate and PUVA (psoralen and longwave ultraviolet A radiation), or these options are contraindicated or not tolerated and the company provides the drug according to the commercial arrangement. Stop guselkumab treatment at 16 weeks if the psoriasis has not responded adequately. An adequate response is defined as: a 75% reduction in the PASI score (PASI 75) from when treatment started or Page 305 of Red Do not expect this guidance to have a significant impact on resources; that is, it will be less than 5 million per year in England (or 9,100 per 100,000 population). This is because the technology is an option alongside current standard treatment options and is available at a similar price. Expect approx. 5 patients across VoY and S&R CCGs.

306 a 50% reduction in the PASI score (PASI 50) and a 5 point reduction in DLQI from when treatment started. If patients and their clinicians consider guselkumab to be one of a range of suitable treatments, including ixekizumab and secukinumab, the least costly (taking into account administration costs and commercial arrangements) should be chosen. Formulary applications or amendments/pathways/guidelines 4. Risedronate 5mg Approved for addition to DNP list Black No significant cost to CCGs expected. May result in some small cost saving as alternative bisphosphonates are less costly. 5. ADHD Prescribing Algorithm Children & Young People Updated guideline based in revised recommendations in NICE NG87. n/a No significant cost impact expected as updated version of existing guideline. 6. ADHD Prescribing Algorithm Adults New guideline based on recommendations from NICE NG87. n/a No significant cost impact expected as updated version of existing guideline. 7. Methylphenidate Shared Care Guideline Produced by TEWV. Updated with revised monitoring requirements from NG87. n/a No significant cost impact expected as updated version of existing guideline. 8. Atomoxetine Shared Care Guideline Produced by TEWV. Updated with revised monitoring requirements from NG87. n/a No significant cost impact expected as updated version of existing guideline. 9. Lisdexamfetamine Shared Care Guideline Produced by TEWV. Updated with revised monitoring requirements from NG87. n/a No significant cost impact expected as updated version of existing guideline. Page 306 of 312 2

307 Recommendations from York and Scarborough Medicines Commissioning Committee July 2018 Drug name Indication Recommendation, rationale and place in therapy RAG status Potential full year cost impact CCG commissioned Technology Appraisals 1. Nil NHSE commissioned Technology Appraisals for noting 2. TA520: Atezolizumab for treating locally advanced or metastatic non-small-cell lung cancer after chemotherapy 3. TA522: Pembrolizumab for untreated locally advanced or metastatic urothelial cancer when cisplatin is unsuitable TA523: Midostaurin for untreated acute myeloid leukaemia Atezolizumab is recommended as an option for treating locally advanced or metastatic nonsmall-cell lung cancer (NSCLC) in adults who have had chemotherapy (and targeted treatment if they have an EGFR- or ALKpositive tumour), only if: atezolizumab is stopped at 2 years of uninterrupted treatment or earlier if the disease progresses and the company provides atezolizumab with the discount agreed in the patient access scheme. Pembrolizumab is recommended for use within the Cancer Drugs Fund as an option for untreated locally advanced or metastatic urothelial carcinoma in adults when cisplatincontaining chemotherapy is unsuitable, only if: pembrolizumab is stopped at 2 years of uninterrupted treatment or earlier if the disease progresses and the conditions of the managed access agreement for pembrolizumab are followed Midostaurin is recommended, within its marketing authorisation, as an option in adults for treating newly diagnosed acute FLT3- mutation-positive myeloid leukaemia with standard daunorubicin and cytarabine as induction therapy, with high-dose cytarabine as consolidation therapy, and alone after complete response as maintenance therapy. It is recommended only if the company provides Page 307 of Red Red Red No cost impact to CCGs as NHS England commissioned. No cost impact to CCGs as NHS England commissioned. No cost impact to CCGs as NHS England commissioned.

308 midostaurin with the discount agreed in the patient access scheme. TA524: Brentuximab vedotin for treating CD30-positive Hodgkin lymphoma Brentuximab vedotin is recommended as an option for treating CD30 positive Hodgkin lymphoma in adults with relapsed or refractory disease, only if: Red No cost impact to CCGs as NHS England commissioned. they have already had autologous stem cell transplant or they have already had at least 2 previous therapies when autologous stem cell transplant or multi-agent chemotherapy are not suitable and the company provides brentuximab vedotin according to the commercial arrangement TA525: Atezolizumab for treating locally advanced or metastatic urothelial carcinoma after platinum-containing chemotherapy TA526: Arsenic trioxide for treating acute promyelocytic leukaemia Atezolizumab is recommended as an option for treating locally advanced or metastatic urothelial carcinoma in adults who have had platinum-containing chemotherapy, only if: atezolizumab is stopped at 2 years of uninterrupted treatment or earlier if the disease progresses and the company provides atezolizumab with the discount agreed in the patient access scheme. Arsenic trioxide is recommended, within its marketing authorisation, as an option for inducing remission and consolidation in acute promyelocytic leukaemia (characterised by the presence of the t[15;17] translocation or the PML/RAR-alpha gene) in adults with: Red Red No cost impact to CCGs as NHS England commissioned. No cost impact to CCGs as NHS England commissioned. untreated, low-to-intermediate risk disease (defined as a white blood cell count of 10x103 per microlitre or less), when given with all-trans-retinoic acid (ATRA) relapsed or refractory disease, after a retinoid and chemotherapy. TA527: Beta interferons and glatiramer acetate for treating multiple sclerosis Interferon beta 1a is recommended as an option for treating multiple sclerosis, only if: Page 308 of Red No cost impact to CCGs as NHS England commissioned.

309 the person has relapsing remitting multiple sclerosis and the companies provide it according to commercial arrangements. Interferon beta 1b (Extavia) is recommended as an option for treating multiple sclerosis, only if: the person has relapsing remitting multiple sclerosis and has had 2 or more relapses within the last 2 years or the person has secondary progressive multiple sclerosis with continuing relapses and the company provides it according to the commercial arrangement. Glatiramer acetate is recommended as an option for treating multiple sclerosis, only if: the person has relapsing remitting multiple sclerosis and the company provides it according to the commercial arrangement. Interferon beta 1b (Betaferon) is not recommended within its marketing authorisation as an option for treating multiple sclerosis. Formulary applications or amendments/pathways/guidelines 4. Apraclonidine eye drops 1% and 0.5% for glaucoma Approved for use in management of complicated glaucoma in patients who do not current fit current uncomplicated glaucoma pathway. The 1% Preservative free preparation is only to be used in patients with known allergy to preservative containing eye drops or with ocular surface disorders pre-disposing them to sensitivity to preservative containing eye drops. Page 309 of Amber Specialist Initiation Product Brimonidine 0.2% 5ml (approx. 100 drops) Apraclonidine 0.5% 5mL (approx 100 drops) Apraclonidine 1% single dose - 24 doses Monthly primary care cost (Drug Tariff) / 24 ( 272 per 28 days at TDS dosing)

310 In the last 9 months at York FT 35 patients have had prescriptions for the 0.5% and 8 patients for the 1%. Note these products are already in use and being prescribed by some GPs in primary care. 5. Ibuprofen 5% topical gel Approved Green No significant cost to CCGs expected. As these Topical NSAID & size Cost ( ) Ibuprofen 5% Gel 100g Piroxicam 0.5% topical gel Approved Green 7. Diclofenac 1.16% topical gel Approved as 3 rd line topical NSAID after Ibuprofen and Piroxicam. Green Ibuprofen 10% Gel g Ketoprofen 2.5% Gel g Diclofenac 1.16% Gel g Piroxicam 0.5% Gel g are the three most commonly prescribed topical NSAIDs locally. 8. Ketoprofen 2.5% topical gel Approved for addition to DNP list Black No significant cost to CCGs expected. May result in some small cost saving as alternative topical NSAIDs are less costly. 9. Ibuprofen 10% topical gel Approved for addition to DNP list Black No significant cost to CCGs expected. May result in some small cost saving as alternative topical NSAIDs are less costly. 10. Guanfacine Shared Care Guideline 11. Paliperidone LAI Shared Care Guideline 12. Aripiprazole LAI Shared Care Guideline Approved. New shared care guideline produced by TEWV covering use in ADHD. To be used in management of paediatric ADHD only as per NICE NG87. Approved. New shared care guideline produced by TEWV. Approved. New shared care guideline produced by TEWV. n/a n/a n/a No significant cost to CCGs expected. 3 rd line agent similar in price to atomoxetine. No significant cost to CCGs expected. Already classed as AMBER on formulary. No significant cost to CCGs expected. Already classed as AMBER on formulary. Page 310 of 312 4

311 Item 19 Chair s Report: Joint Acute Commissioning Committee Date of Meeting Chair 25 July 2018 Simon Cox, Chief Officer NHS Scarborough and Ryedale Clinical Commissioning Group Areas of note from the Committee Discussion Updated Terms of Reference circulated and discussed. Proposals regarding any potential changes to CCG schemes of delegated to be referred to CCG Governing Body meetings when necessary. Lay Chair to be advertised The committee recognised the developing system governance structure as emerging from the Aligned Incentive Contract (AIC) implementation Q1 financial position for all CCGs consistent with their planning targets and where appropriate their requirements to achieve the Commissioner Support Fund (CSF) Orthopaedic elective capacity development is still being progressed and the implementation timescales will be revised based on further discussion with partners. The impact assessment was shared and reviewed. Engagement between the CCG quality leads and the Trust quality leads was progressing and agreement was now in place to assess clinical impact of service change. Ophthalmology remained a pressured acute service area and the CCG has agreed a date and representation at a deep dive to review the service and proposed actions to address service risks and improve performance. The tender to secure consultancy support for the Scarborough Acute Review was complete and in standstill stage. The successful bidder will be communicated to partners after the end of the standstill period. The resilience (winter) plan was reviewed at the A&E delivery board and would then be further review based on the financial impact of schemes that required further resources. Areas of escalation The NHS Vale of York Clinical Commissioning Group needs to recognise the establishment of the Scarborough acute review and recognise its potential implications on service provision in York and for the patients in the Ryedale area. Page 311 of 312

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