Special Educational Needs & Disability (SEND) Diagnostic Checklist For CCGs

Transcription

1 Special Educational Needs & Disability (SEND) Diagnostic Checklist For CCGs CCG Diagnostic checklist INTRODUCTION The Children and Families Act Improving outcomes and experiences for disabled children and young people and those with SEN requires significant input from professionals and services across health, social care and education. The Children and Families Act is a statutory framework for the integration and personalisation of services for children and young people that requires health services in England to work closely alongside education and social care services to provide the right support for children and young people and their families. This is at both a strategic joint commissioning level and integrated services for individuals through Education Health and Care Plans. Implementing the Children and Families Act and developing a shared local vision and strategy with partner local authorities will be key in developing integrated, person centred services for children and young people in line with the existing commitments in the NHS Mandate and the vision of the 5 Year Forward View. These joint working arrangements will be crucial for delivering current system transformation programmes for children and young people, including: Transforming Care Programme CAMHS Local Transformation Plans Local Area Sustainability and Transformation Plans New Care Models Programme Vanguard Meeting the ambitious targets for the increase in Personal Health Budgets or Integrated Personal Budgets. The Tool This tool pulls together in one place the key pieces of evidence that the CCG will wish to assure itself on in terms of its progress in implementing the 2014 Children and Families Act reforms in relation to disabled children and young people and those with SEN. The tool presents this information in an easily accessible at a glance RAG rating system to update the relevant CCG Board on progress in implementation. It also includes a facility for a follow up audit which enables the responsible CCG officer to demonstrate trends in terms of implementation and flag up any areas which are not moving towards full compliance. CQC and Ofsted will view completed audit tools as evidence demonstrating an active commitment to and interest in implementing the reforms. For brevity the document generally talks about CCGs in the singular. However, we are very aware that in some local authority areas up to 7 CCGs may need to work together to enable progress on integration, and this can be reflected in the notes section of the document. It should be noted that this is likely to be less problematic where CCGs have appointed a single DMO or DCO to help co-ordinate implementation across an authority area. The questions provide a framework for considering progress to date; and are divided into the 6 key areas of the role of a CCG in supporting children with SEND. RAG rating scores and trend description options can be chosen from a drop down menu as can the name of your CCG, or this can be overwritten if you are answering on behalf of a consortium of CCGs. 1. LEADERSHIP & GOVERNANCE 4. EHC PLAN 2. JOINT ARRANGEMENTS 5. ENGAGEMENT 3. COMMISSIONING 6. MONITORING & REDRESS

2 Special Educational Needs & Disability (SEND) Diagnostic Checklist for CCGs CLINICAL COMMISSIONING GROUP: 1st Audit 31/05/2016 1st Audit 15% 22% 2nd Audit Date 0% 0% 2ndAudit 0% OVERALL SCORE GREEN AMBER RED GREEN AMBER RED 22% 54% 15% 0% 0% 0% 54% 1st Audit 2ndAudit 1. LEADERSHIP GREEN AMBER RED GREEN AMBER RED 1.1 Senior / executive leadership for SEND in the CCG 43% 43% 14% 0% 0% 0% 1.2 Special/Unusual commissioning requests 20% 80% 0% 0% 0% 0% 1.3 Monitoring and Agreeing Plans 50% 50% 0% 0% 0% 0% 1.4 Resourcing Joint Arrangements 50% 50% 0% 0% 0% 0% OVERALL PERCENTAGE SCORE 40.00% 55.00% 5.00% 0.00% 0.00% 0.00% 1st Audit 2ndAudit 2. JOINT ARRANGEMENTS GREEN AMBER RED GREEN AMBER RED 2.1 Working with Local Authority 0% 83% 17% 0% 0% 0% 2.2 Health and Wellbeing Boards 0% 50% 50% 0% 0% 0% 2.3 Dispute Resolution 0% 67% 33% 0% 0% 0% 2.4 Local Offer 33% 67% 0% 0% 0% 0% OVERALL PERCENTAGE SCORE 7.14% 71.43% 21.43% 0.00% 0.00% 0.00% 1st Audit 2ndAudit 3. COMMISSIONING GREEN AMBER RED GREEN AMBER RED 3.1 Assessing Local Need 0.00% 60.00% 40.00% 0.00% 0.00% 0.00% 3.2 Affordability and Demand 0.00% 0.00% % 0.00% 0.00% 0.00% 3.3 Contracts 50.00% 50.00% 0.00% 0.00% 0.00% 0.00% 3.4 Personal Budgets 50.00% 0.00% 50.00% 0.00% 0.00% 0.00% 3.5 Designated Medical/Clinical Officer % 0.00% 0.00% 0.00% 0.00% 0.00% OVERALL PERCENTAGE SCORE 27% 36% 36% 0% 0% 0% 1st Audit 2ndAudit 4. EHC PLAN GREEN AMBER RED GREEN AMBER RED 4.1 Coordinated Assessment 20.00% 60.00% 20.00% 0.00% 0.00% 0.00% 4.2 Sign Off 33.33% 66.67% 0.00% 0.00% 0.00% 0.00% OVERALL PERCENTAGE SCORE 25% 63% 13% 0% 0% 0% 1st Audit 2ndAudit 5. ENGAGEMENT GREEN AMBER RED GREEN AMBER RED 5.1 Users 40.00% 40.00% 0.00% 0.00% 0.00% 0.00% OVERALL PERCENTAGE SCORE 40.00% 40.00% 0.00% 0.00% 0.00% 0.00% 1st Audit 2ndAudit 6. MONITORING & REDRESS GREEN AMBER RED GREEN AMBER RED 6.1 Data to Monitor Progress 0.00% % 0.00% 0.00% 0.00% 0.00% 6.2 Data Sharing 0.00% 75.00% 25.00% 0.00% 0.00% 0.00% 6.3 Complaints 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 6.4 Mediation 0.00% 66.67% 33.33% 0.00% 0.00% 0.00% OVERALL PERCENTAGE SCORE 0% 50% 13% 0% 0% 0%

3 Senior / executive leadership for SEND in the CCG The CCG governing body (or other executive arrangements) should oversee the joint arrangements for SEND, and the contribution of health and ensure a clear line of accountability.the CCG is subject to a number of statutory duties, and the decisions made by the professionals working for the providers from whom it commissions services may have significant cost implications. CCGs will want therefore to ensure there is appropriate leadership and governance arrangements in place. Senior leadership support will be required to secure strategic partnership arrangements with local authorities. The CCG has to be part of joint arrangements; contributing to the published Local Offer of services for children and young people with SEND, and securing input from provider servcies. A senior champion in the CCG would help to ensure the needs of children and young people with SEND or complex needs are being considered and ensure adequate oversight. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead Does the CCG have a senior champion or Senior Responsible Officer for SEND, who is a member of the CCG governing body (or other executive body). CCG s statutory responsibilities towards SEND are reflected in a formal statement or strategy (or acknowledged in their constitution). Identified role in Job Description, CCG strategy or other documentation. Published or internal statement of arrangements. Jackie Schnieder SEND lead governing body, support from Timothy Shayes Commissioning manager with support from Mark Gower, designated clinical officer for Norfolk & Waveney CCGs Nurse Member for the Governing Body 1st Audit RAG Rating: DD/MM/YY Full Compliance: Fully Achieved/Implemented Partially Achieved: Some Progress/Implemented in some areas 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence DCO member of Child Health & Maternity clinical Network and attends other boards as requested. Documents for CCG or central re strategy for SEND See Document 1.01 N & W CCG leads list CCG Operational Plan for joint commissioning CH&M Network strategic priorities and workplan - see reference 1.02 in evidence Has the CCG governing body (or other executive body) signed off the joint arrangements required by the Children and Families Act? Does the CCG governing body (or other executive body) receive a regular report on SEND? SEND is regularly discussed at a senior level. How does the CCG report into the NHS England Assurance Framework? Published CCG constitution, or published statement. Report and minutes of discussion. Regularity of reports / discussion. Monitoring of progress by CCG against Assurance Framework indicators. Information Governance Lead with approval from Executive members of the Governing Body DCO Mark Gower completes Quarterly report for Child health marternity network, DCO mulit agency meetings SEND Implementation Group, senior health,la, and provider attend SEND or areas within SEND on a number of meeting agendas, and reviews such as short breaks, asd pathway, strategy. The Head of Clinical Commissioning presents to the Executive team. The inclusion of SEND within the CCG operational plan, and potenatially CCG Constitution would provide a baseline upon which to monitor complaince by NHSE. Partially Achieved: Some Progress/Implemented in some areas Partially Achieved: Some Progress/Implemented in some areas Full Compliance: Fully Achieved/Implemented No Compliance: Not started. CCG Operational Plan joint commissioning. Joint Commissioning Framework Norfolk draft in evidence doc ref 1.03 completes Quarterly report for Child health marternity network, all ccgs and other agencies represented, newletters disseminated from local area reports for CHM minutes with reports see body of evidence,? CCG speciifc programme board minutes/reports See ref 1.04 evidence Doc Obtain papers for Short breaks, SEND clinical network set up SAG meeting and actions that included a number of commissioners, Action log from CCG meeting to trouble shoot process. See ref doc in 1.05 Need to clarify what CCGs have to report against this How do the CCG or CSU staff with responsibility for SEND report to the governing body? Agreed line of accountability, e.g. in job description of relevant staff. CCg lead Commissioning with support from Mark Gower, designated clinical officer for Norfolk & Waveney CCGs Full Compliance: Fully Achieved/Implemented? Reports to child health and maternity network see ref in 1.04? CSU and CCG CYP leads all attend the Network Summary RAG Compliance Total Green 3 0 Total Amber 3 0 Total Red 1 0 FURTHER INFORMATION:

4 The Children and Families Act 2014, Special educational needs and disability code of practice: 0 to 25 years. Statutory guidance for organisations who work with and support children and young people with special educational needs and disabilities (2014) The CDC has produced free e-learning for CCGs on the Children and Families Act 2014 Disability Matters is a free training resource for anyone working with those with a disability or special educational need (of all ages) In addition to the above resources, there is a health guide to the SEND Code of Practice NHS England s model CCG constitution guidance

5 Special/Unusual Commissioning Requests: e.g. for complex needs Children with SEND may have high-cost health needs, which the CCG will have to ensure are met under its statutory duties under section 3 of the NHS Act. The CCG will also need to be able to consider an ad hoc requests for care which is not routinely commissioned. Advice on a child s health needs as part of the EHC assessment process will usually be provided by professionals employed by a provider commissioned by the CCG. It could include a wide range of professionals: paediatricians, therapists, nurses etc. The professional may make a recommendation in the plan for care which would need to be commissioned specially, or which goes beyond routine allowance (e.g. a greater volume of SLT than might usually be made available), and there must be a mechanism in the joint arrangements for the CCG to be alerted to these non-routine requests, and to consider them. The continuing care process is similar to that for SEND, involving a multi-disciplinary assessment, and a decision on what care should be commissioned which is not part of universal or specialised services. The same panel, or other arrangements could be used to consider both continuing care packages, and the health element of the EHC plan. CCGs and local authorities may wish for the same oversight arrangements to apply to both. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead What are the arrangements for the CCG to consider requests for high-cost, low incidence care (this would go wider than SEND)? Is there an agreed and publicised protocol setting out how professionals raise these requests with the commissioner? How are these requests scrutinized? What evidence does the CCG draw on in making a decision on such requests? Does the CCG use peer review to consider requests or evidence from other commissioners? How do the arrangements for SEND dovetail with the process of continuing care assessments? Formal communication on the above process with providers, local professionals. Framework / protocol includes procedure for reaching a decision. e.g. panel drawing on assessor recommendation, and executive oversight. Framework includes parameters for evidence gathering e.g. single assessor, as for continuing care, with which local professionals are familiar. CCG is part of a local network for sharing benchmarking information; CCG arrangements include representatives from outside the CCG to provide quality assurance (e.g. on a panel). CCG uses continuing care process as a model for SEND, e.g. in relation to decisions on care, use of multidisciplinary input, and how it monitors timescales for contributions. Rachael Peacock Norwich CCG currently chairs Children Complex case panel for 4 ccgs in Norfolk? Adult CHC for 4 CCGs? Lead for West CCG Sarah taylor and Jayne Lunn have weekly complex case CCG lead with support Rachael Peacock Individual patient pathway manager would liase with clinical quality and patient safety team to review at complex case panel. Rachael Peacock Rachael Peacock this panel is attended by a range of multi professionals with multi agency representation. 1st Audit RAG Rating: DD/MM/YY Full Compliance: Fully Achieved/Implemented Partially Achieved: Some Progress/Implemented in some areas Partially Achieved: Some Progress/Implemented in some areas Partially Achieved: Some Progress/Implemented in some areas Currently Rachael Peacock as chair Partially Achieved: Some of the Complex case panel including Progress/Implemented in tripartite and compass that models some areas on the CC process.? 2nd Audit RAG Rating: DD/MM/YY Total Green 1 0 Trend Comments/Evidence Complex case panel, TOR criteria and other document for porcess. EHCP report and flow chart for additional health provision. Minutes and TOR from CCG specific meeting Continuing Care & Continuing Health care Framework, EHCP additional provision outside of core, flow chart additional health, CCG resonsible commissioning info on Local Complex case Panel TOR, review of Panel, see ref doc 1.08 West CCG weekly panel review meeting? Information CC framework,? Representation multi agency reps in Complex case panel across 4 CCGs, Local Multi agency clinical network? Reports from complex case panel? i Not sure about peer review at this time? Regional group are looking at this Tripartite section of complex case panel and compass referrals see comples case panel ref doc Child health records for SEND EHCP to start to complete reports Summary RAG Compliance Total Amber 4 0 Total Red 0 0 FURTHER INFORMATION: The framework for Children and Young People s Continuing Care has been revised to take account of the new SEND framework.

6 Monitoring and agreeing plans For more detailed advice on monitoring, see the annex. The role of the CSU could be pivotal in providing expertise and engagement with providers to ensure a smooth process, and ensuring that SEND is adequately reflected in commissioning plans. CSUs could provide: Analytical support looking at demand and prevalence Servicing of joint arrangements with LA and other partners Interaction with providers, and monitoring of arrangements and progress. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence Does the CCG has a formal monitoring process for the EHC plan process? Is there a mechanism for monitoring the number and cost of EHC plans to the CCG? CCG has proportionate monitoring in place. This could include: Monitoring via providers of the number of requests for input to plans; Monitoring via providers of progress over time of individual plans; Monitoring requests for specialised / additional commissioning Monitoring complaints about EHC plans. Mark Gower DCO Nurse Members for the Governing Body and Mark Gower, designated clinical officer for Norfolk & Waveney CCGs Partially Achieved: Some Progress/Implemented in some areas Partially Achieved: Some Progress/Implemented in some areas NCH&C have KPI and monthly reports for their involvement & Quality schedule shared to CCG for consideratrion for contract see ref 1.15, Process for additional health funding see ref doc in 1.08, DCO part of procurement for disputes and will be included in oversight. Proposal for reports from child health records noted from meeting see ref Number of notifcaition from preschool see ref 1.15 flow chart and evidence See flow chart in ref 1.08, information on reports from NCC to be included in future quarterly reports. addtitional health provision flow chart, Section G to be agreed by providers and requests for reports as in quallity schedule Does the CCG employ a CSU (or other commissioning support) in relation to services for children with SEND? If a CSU takes responsibility for commissioning for SEND, what is included in the contract, SLA or other arrangement? How is this performance managed or quality assured by the CCG? Agreement, SLA etc. with CSU includes SEND monitoring, need assessment etc. Sally Glover, Head of Child Health Commissioning Support, CSU NA Full Compliance: Fully Achieved/Implemented Full Compliance: Fully Achieved/Implemented The 4 Norrfolk CCGs have an SLA with the CSU and buy in the services of the Child Health Commissioning Support Team. See evidence section 1.15 The CSU supports the agenda but does not have delegated authority or budget so commissioning responsibility sits with the CCGs Total Green 2 0 FURTHER INFORMATION: Summary RAG Compliance Total Amber 2 0 Total Red 0 0

7 Resourcing joint arrangements. Ensuring effective implementation of the new statutory framework for SEND should not be resource intensive as long as providers are set to participate in EHC plan development. Ensuring appropriate strategic links with the local authority will require some senior input. Monitoring implementation on a day-to-day basis can be subsumed within on-going monitoring of commissioning services for children. Where mediation or complaints handling is necessary, more intensive input would be required, but this would be on an occasional rather than a routine basis. The CCG will want to ensure the effectiveness of its role in joint arrangements, and the effectiveness of the services it is commissioning for this cohort. This will require a mix of evidence, some of process (the relationship with the local authority), some of volume (the number of EHC plans, compared with anticipated demand), user experience, and outcomes (both at cohort level, and in terms of the EHC plan delivering the specified outcomes for the individual). Is there a mechanism for adjusting resources to take account of changes in demand? Is there formal workforce development of the team, including time spent with providers? Is the team able to liaise with providers on a routine basis outside of the formal performance management / monitoring routes? How does the CCG quality assure its work in relation to SEND? Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence What personnel has the CCG dedicated to SEND? Is it a small team, or a lead individual, with administration support? Is SEND their sole responsibility, or is it part of a larger portfolio (e.g. children s commissioning)? If the latter, what safeguards are in place to ensure time remains dedicated to SEND? Dedicated team or individual, as reflected in CCG business or workforce plan, job descriptions etc. Mark Gower Designated Clinical Officer in Post Hosted by Great Y & W CCG covers all 5 CCGs, links to all commissioners in each CCG across Norfolk and Waveney. Executive team member within the CCG SEND is supported by the Child Health Commissioning Suppoort team in the CSU. Mark Gower DCO is a Dedicated Role, with some admin made available? Head of Clinical Commissioning Sally Glover CSU, Integrated team Sec 75 CAMHS Full Compliance: Fully Achieved/Implemented Full Compliance: Fully Achieved/Implemented DCO job description REF 1.16 Evidence doc. Other commissioners job and role re SEND? Commissioners Job description. CSU SLA - see evidence section 1.15 CCG Operational Planjoint commissioning? The CSU Child Health Team supports CCGs around the services for which they are responsible i.e. children with additional needs and disability. What governance arrangements cover the team or individual s work? Formal accountability, ultimately, to governing body or other executive, as outlined above. Nurse Member for the Governig Body. Senior Management Team and Governing Body Partially Achieved: Some Progress/Implemented in some areas See ref docs 1.04?Other meetings and docs relevant for CCG? Submit report to Child health maternity network and multi Agency SEND action Group, not sure when and if it reaches governing bodies for CCGs

8 How does the CCG know it has sufficient resources dedicated to SEND? Does it discuss expectations and demand with other CCGs or its LA? Does a local network exist to allow this? Regular management review of SEND arrangements, drawing on performance indicators, and staff feedback. CCG uses networks to formally compare expectations and arrangements with peers. Joint arrangements with the local authority include reviews of joint capacity in relation to servicing the SEND arrangements. Nurse Member for the Governing Body Partially Achieved: Some Progress/Implemented in some areas Total Green 2 0 Not aware that this is formally reviewed across all areas to have oversight Child Health and Maternity Network is where we would review these arrangements, expectations and demands on a system wide basis? SEND Action Group brings together CCGs and LA colleague, the aspiration of the group is that it oversees the SEND agenda, service provision. There is a recognition at Chief Officer level that a robust joint commissioning forum needs to Summary RAG Compliance Total Amber 2 0 Total Red 0 0

9 2. Joint Arrangements Working with the local authority Any formal agreements should be signed-off at executive / Governing body level in the CCG (depending on how the executive function is exercised). There will be lower-level elements of joint working which fall within the delegated authority of the CCG officer. Even then, the CCG would need to ensure it had sufficient oversight to assure itself that it was fulfilling its statutory obligations. Formal section 75 agreements or other formal arrangements are not mandatory, however, many local areas find that once set up they provide a more efficient and streamlined approach to the allocation of resources. The new statutory framework requires CCGs and local authorities to agree joint arrangements, focused on the assessment and planning of an individual Education, Health and Care plan for each child with special educational needs. The joint arrangements are also intended to provide a basis for integrated working to support children with SEND who are not eligible for an EHC plan. The CCG and local authority should agree a reasonable set of arrangements for how they manage their day-to-day interactions. A written agreement is recommended, to ensure parties to the agreement have a common point of reference (dispute resolution in particular will need to refer to the original terms of the joint arrangements). CCGs and health providers are likely to have to work with more than one local authority, each with their own approach and EHC plan format. Each local authority will have to meet the same statutory requirements, and each EHC plan has to have the same sections. These provide a basis for the CCG and providers to take a consistent approach to each local authority; areeing with providers on an approach for their contributions to plans, which individual local authorities would incorporate. A consistent template or methodology could be used for interaction with each local authority, and codified as part of the joint arrangements. The local authority has the lead in implementing the new SEND framework locally, but there has to be partnership working in developing joint arrangements which both parties can support. Ensuring the robustness of arrangements cannot be undertaken by local authorities and CCGs in silos; the arrangements are designed to develop integrated approaches, and should be assessed in an integrated way. The CCG need to work with partners in assessing local demand, and promoting SEND within local health and care strategies. If the local authority cannot work with the CCG, then this will impact significantly on its ability to deliver effective services for children and young people with SEND. Another local authority or CCG might be able to provide peer support or arbitrate where there is a significant disagreement. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: 31/05/16 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence Are the joint arrangements fully documented, and subject to a written agreement? Is there a forum or working group for designing and reviewing joint arrangements? Does this have strategic links to HWB etc.? Is there lay / user involvement representation? Have budget pooling or lead commissioning arrangements been considered? Is there a mechanism for ongoing review of joint arrangements, drawing on evidence of implementation? Documentation of agreement Established routes / fora for joint discussions, at which SEND can be considered. SEND arrangements are part of arrangements for joint / lead commissioning for children. Section 75 agreement or similar. Emma Bugg Head of Integrated Commissioning? Who is lead and responsible as well as attends the HWB for CCG? SEND on agenda Deputy CFO Emma Bugg Head of Integrated Commissioning Partially Achieved: Some Progress/Implemented in some areas Partially Achieved: Some Progress/Implemented in some areas Partially Achieved: Some Progress/Implemented in some areas Partially Achieved: Some Progress/Implemented in some areas Draft Joint Commissioning Framework See doc ref 1.01 in body of evidence under leadership? Integrated teams where there is a Section 75 arrangement: SaLT, CAMHS Point 1, mediation disagreement resolution. See evidence section 2.01? Joint children and young peoples strategic partnership? Who in health CCG commissioning sits on this? Integrated commissioning team for Mental health and LD arrangements if any, Transforming Care Board established, and Child Health and Maternity Integrated Network. commissioning team, Compass, CAMHS Point 1, SaLT, Mediation and disagreement reslution Signed letters and agreements board papers? See reference doc 2.01 Child Health & Maternity Commissioning Network and SEND Action Group Review. Inidividual services subject to regular review. See evidence 2.04 Is there a published statement of joint working / information on the joint arrangements (separate from the Local Offer)? How is the CCG involved in the development of the timetable for transition from statements to EHC plans? CCGs is involved in the development of the local authority transition plans as part of joint arrangement; CCG has articulated the need for statement reviews to providers. Lead ccg? No Compliance: Not started. DCO Mark Gower Partially Achieved: Some Progress/Implemented in some areas Total Green 0 0 Draft framework produced but not signed off or published Not aware that CCGs have been involved in the arrangements for transition plans from Statetment to EHC Plans, DCO meeting regularly with the Inclusions teams to discuss progress and attend Send Action group (see doc ref 1.05). Health providers involved when requests are made and providers have been

10 Summary RAG Compliance Total Amber 5 0 Total Red 1 0 FURTHER INFORMATION: The Joint Commissioning Information pack has abundant evidence on effective collaboration

11 Health and wellbeing boards The Health and Wellbeing Board (HWB) has a pivotal role to play in supporting local services, including schools and colleges to address the needs of children with SEND. HWBs should act as a forum for strategic discussions between local authorities and CCGs. Some areas may also have existing multi-agency groups which lead or co-ordinate on issues relating to children and young people, which the HWB can link with as appropriate. The HWB might provide a good arena for discussing key issues regarding joint arrangements and integration. The local JSNA / JHWS must take account of the needs of children and young people with SEND; however, absence of any explicit reference to SEND should not deter the CCG from meeting its obligations re: SEND. Ideally CCGs and local authorities as members of HWBs should ensure JSNA and JHWS articulate the local SEND need, which joint arrangements will focus on. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence Does the local Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategy include SEND? CCG to advise No Compliance: Not started. Locally it has been recognised that the JSNA does not provide robust information around C&YP with SEND. This has been highlighted to Public Health. How does the CCG engage with the Health and Wellbeing Board and local Healthwatch? CCG as a member of HWB highlights local complex needs. The Chair for NNCCG sits on HWB panel. The CEO for health watch attends the community engagement panel monthly. Partially Achieved: Some Progress/Implemented in some areas Healthwatch attend meetings and boards throughout CCGs, Child Health and maternity clinical network. Reports from Healthwatch received response from CCGs.How is local complex needs discussed and part of the agenda? Who in health CCGssit on the children strategic partnership board NCC? Total Green 0 0 Summary RAG Compliance Total Amber 1 0 Total Red 1 0 FURTHER INFORMATION: Guidance for HWBs on children s complex needs are be found at: Operating Principles for Health and Wellbeing Boards. Rochdale s Joint Health and Wellbeing Strategy: Wiltshire s Joint Health and Wellbeing Strategy:

12 Dispute Resolution Joint arrangements need dispute resolution a basic forum bringing the CCG and LA together, with appropriate senior oversight, directly linked to those with responsibility for determining commissioning strategy / plans, and with financial input. Joint arrangements could include a protocol for decision making and escalation and could plan for challenge points within the process (e.g. at referral, following joint assessment of evidence, mediation) Local authority and CCGs could take stock of existing commissioning plans, and capacity; the significance of the overlap of speech and language therapy would recommend a specific stocktake of SLT services across education and health, and how providers in particular manage demand, with a view to adopting a collaborative approach. Joint commissioning of SLT between schools, LA and CCG would be a sensible basis for an integrated, equitable approach. The SEND framework is about integrated commissioning; CCGs will necessarily have to commission SLT for children with communication support needs and the joint arrangements provide a basis for agreeing joined-up commissioning of SLT across education and health. Schools will often be commissioning SLT through delegated budgets, the pupil premium etc., and the local authority can help broker a joint approach between schools and the CCG. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence Is there an existing framework for strategic dispute resolution which could be adopted for SEND? DCO Mark Gower Partially Achieved: Some Progress/Implemented in some areas CFMS are the current providers of the service and health is 'piggy-backing' on this process since 1 Sept Work is well under way in jointly re-procuring the service. Has peer review, arbitration or lay involvement been considered (e.g. neighbouring CCGs or local authorities giving their views).?lead for CCG No Compliance: Not started. Not to my knowledge Is there a mechanism for resolving fundamental disputes about the joint arrangements, and disputes over who pays? What is the existing framework for disputes / deadlock on the responsible commissioner? Nurse Member for the Governing Body in consulation with the Individual Patient Pathway Manager Partially Achieved: Some Progress/Implemented in some areas The new service being procured will cover every type of dispute including between statutory organisations. In terms of identifying health responsibility the 'who pays' guidance is followed. See NCC Local Offer. Total Green 0 0 FURTHER INFORMATION: Summary RAG Compliance The Communication Council briefing on SLCN for health audiences Total Amber 2 0 Total Red 1 0 The Royal College of Speech and Language Therapists has a range of information resources on speech and language therapy to support effective commissioning.

13 Local Offer The local offer will be published on the local authority website, and this should include details of all services relevant to children and young people with SEND, including to access, eligibility criteria, and details of how individuals may seek more information or make a complaint. CCGs should ensure that, in relation to health, the local offer is not just a summary of services which are commissioned for this group of children, but a useful tool for families, in navigating services and understanding remit and eligibility. CCGs may wish to map with providers the key services available / commissioned, and the development of the health element of the local offer provides an opportunity for dialogue with provides about what is commissioned, and the gaps in provision / service pressures. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead How has the CCG mapped services to inform the Local Offer? Has the CCG been engaged in the design of the Local Offer? Is the CCG able to provide definitive information on eligibility and access? FURTHER INFORMATION: Summary RAG Compliance Health services for children with SEND included in the published local offer. Published local offer includes: (a) speech and language and other therapies, including any criteria that must be satisfied before this provision can be provided; (b) services relating to mental health, including any criteria that must be satisfied before this provision can be provided, and; (c) services for relevant early years Mark Gower DCO and Sally Glover CSU on behalf and with CCGS Mark Gower DCO on behalf of CCGS with Sally Glover from CSU Mark Gower DCO 1st Audit RAG Rating: DD/MM/YY Partially Achieved: Some Progress/Implemented in some areas Full Compliance: Fully Achieved/Implemented Partially Achieved: Some Progress/Implemented in some areas 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence Total Green 1 0 Total Amber 2 0 Total Red 0 0 North Yorkshire County Council interactive local offer map; There is a wide range of examples on how to approach the local offer in the Local Offer Information Pack. DCO a Member of SEND local offer steering group, see notes, health section been reviewed, Templates have been sent to all providers to have information more usable and family friendly, still awating for some to be returned. See link to norfolk SEND local offer health. all other health provision is linked to Heron and Knowldege management Responded to user feedback notes from meeting, templates examples completed, CCG health structure on local offer some work on pathways and eligibility such as service spec? Sally Glover CSU service mapping for NCH&C, information on accessing services being outlined

14 3. Commissioning Assessing local need CCG (or partners, such as Public Health) can determine demand based on: Child and Maternal Health Intelligence Service (CHIMAT) Needs Assessment Report - Children and young people with disabilities GP practice QOF registers of learning disability; provider contracts / historic demand; local authority registers of disability. national prevalence data on key conditions; engagement with Parent Carer Forums; other engagement with children, young people and families. feedback from GP practice members, and from commissioned providers. The local authority should maintain as a statutory duty a register of people with a learning disability; GP practices, to quality for Quality and Outcome Framework points should establish and maintain a register of patients with learning disabilities (ID LD003). The provider perspective on the scope of current provision is essential. CCGs have to ensure that their commissioning plans are appropriate to meet local demand, and to ensure they have an effective relationship with the key providers to ensure the joint arrangements are delivering completed and implemented EHC plans. Services for children with special educational needs could include a wide range of support, including speech and language therapy, assistive technology, children s mental health services, occupational therapy, habilitation training, physiotherapy, specialist equipment, wheelchairs and continence supplies. Where applicable, CCGs should work with neighbouring areas (LAs, CCGs and providers) to identify synergies and where provision can be improved by working across boundaries. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: 31/05/16 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence Does the CCG or CSU acting on its behalf, have a sense of local prevalence of SEND or likely demand? CCG has articulated local need (if not covered in JSNA etc.)? Lead for CCG Partially Achieved: Some Progress/Implemented in some areas JSNA: District Profile, JSNA: CCG Topic Specific Profiles, CHIMAT Child Health Profile. LA have data on numbers of referrals and plans issued not accurate at this time Does the CCG know how many children will need EHC plans? CCG plans include projected activity levels of SEND.? Lead for CCG No Compliance: Not started. I don't think we know this yet? Rquests to submit from preschool liaison groups on needs levels of concern to LA reports to start generating althoug not secured for West CCG, LA been provided with information to share back with CCGs via DCO on numbers referred, for EHCP assessment, declined and issued with a plan Do GP practice members of the CCG keep a register of children with LD, in line with the QOF? Does the CCG have access to the local authority register of disability? Has the CCG mapped existing services for children with SEND, e.g. through provider contracts? How is the CCG assuring itself that there are no gaps in provision? FURTHER INFORMATION: Summary RAG Compliance CCG has mapped need via GP practices. CCG has identified needs through discussions with providers (e.g. assessing levels of need for SLT and other therapies, number of children under care of a relevant paediatrician etc. CCG commissioning plan is informed by a needs assessment of children with complex needs / SEND which could be the JSNA where relevant? CCG Lead No Compliance: Not started.?ccg Lead?CCG Lead Partially Achieved: Some Progress/Implemented in some areas Partially Achieved: Some Progress/Implemented in some areas Total Green 0 0 Total Amber 3 0 Total Red 2 0 We are about to start this - part of the Care and Treatment Review work? Information reuqested from CCGs and provided to Paeds and LD servcies to send reports to GPs to Flag children and YP with LD. Need to consider numbers flagged and those reports from disabilliites register with NCC This happens in part for individual services e.g SLT, ASD, OT, LAC, ADHD reports and coding providing through paediatirc services,? Being requested and? In contracts to provide level of activity etc? Quality Schedule in contracts that outlined activity reporting. CCGs are aware of a gap in provision in support for children with ASD and no LD. Family Voice report 2015 identified issues and gaps and a response was produced from Health. CCG is in process of drawing together commissioning plan? The ChiMat Needs Assessments Reports include one developed for children and young people with disabilities, showing likely prevalence for each local authority area. The Multi-Agency Planning and Improvement Tool (MAPIT) supports service improvement for children and young people with special educational needs and disabilities and their families.

15 Affordability and demand The new arrangements between CCGs and local authorities provide a means of reaching a consensual decision on difficult choices (and possible mitigation of impact e.g. the flexible use of communication support to offset the need for clinical SLT). They also provide a basis for strategic discussions on contractual flexibilities, informing dialogue between the CCG and the provider on changing demand. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence Is there a local mechanism for anticipating changes in demand? CCG has a mechanism for dialogue with providers on local SEND prevalence.?ccg Lead No Compliance: Not started. Not aware.? Reports and data from Providers on activity, waiting times and staff numbers sickness? Summary RAG Compliance Total Green 0 0 Total Amber 0 0 Total Red 1 0 Contracts Contracts or other agreements with providers may not have to change (although the new framework provides an opportunity for looking at what is commissioned). For instance agreement with providers that the EHC process would be appropriately supported and that information on services would be provided for the Local Offer. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence How does the CCG communicate with its providers on SEND? CCG has a mechanism for communication with providers on SEND.?CCG Lead with DCO support Full Compliance: Fully Achieved/Implemented (Quaility Schedule see ref doc 1.15) DCO completes training sessions, shares information through named SEND leads and set up a SEND health lead network. Providers have informed the local offer by How is the provider supported in Pathway design e.g. with development money, clinical reference group; is the redesign demand-led? CCG is active in supporting pathway design for children with complex needs.? CCG lead and support from CSU Partially Achieved: Some Progress/Implemented in some areas 2 examples of this happening is ASD and ADHD pathway work. See evidence 3.08 Summary RAG Compliance Total Green 1 0 Total Amber 1 0 Total Red 0 0

16 Personal Budgets Under the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) (Amendment) Regulations 2013, the families of a child or young person eligible for continuing care have a right to have a personal health budget, covering the part of their care package which would be provided by the NHS. Personal health budgets are not restricted to children and young people eligible for continuing care. They can be offered to other children on a discretionary basis. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence Has the CCG considered its response to requests for PHBs for continuing care? Has the CCG considered the options for personal budgets? - a direct payment made to the young person or their family; - the agreement of a notional budget to be spent by the CCG following discussions with the child or young person, and their family (or other representative) as to how best to secure the provision they need; - the transfer of a real budget agreed as above, to a person or organisation which applies the money in a way agreed between the CCG and the child or young person, and their family (or other representative). CCG local plans meet 5 Year Forward View expectations of offering PHBs to children with continuing care needs, and SEND. CCG publicises and promotes the availability of personal health budgets to children and young people eligible for continuing care, and provides information, advice and other support to children and young people who are eligible, and their families or representatives. CSU Personal Health Budget team and Jackie Schneider Jackie Schneider and support from CSU Personal Health Budgets team Full Compliance: Fully Achieved/Implemented No Compliance: Not started. Process in place for continuing care eligible children to have a personal budget. This is managed by CSU PHB team for 4 Norfolk CCGs.?evidence FURTHER INFORMATION: Summary RAG Compliance NHS England s information hub on personal budgets: Total Green 1 0 Total Amber 0 0 Total Red 1 0 For more guidance on personal health budgets, see Guidance on the right to have a Personal Health Budget in Adult NHS Continuing Healthcare and Children and Young People s Continuing Care (September 2014). Understanding the Resource Allocation System (RAS). Developing a self-directed support approach to resource allocation for children, young people and families (2013) Making It Personal 2 is a resource for families and commissioners and providers to support developing personalisation in care, through use of personal budgets. The SEND Pathfinder Information Pack - Personal Budgets.

17 Designated Medical Officer / Designated Clinical Officer Partners should ensure there is a Designated Medical Officer or Clinical Officer (DMO / DCO) to support the CCG in meeting its statutory responsibilities for children and young people with SEND, primarily by providing a point of contact for local partners, when notifying parents and local authorities about children and young people they believe have, or may have, SEND, and when seeking advice on SEND. This does not alter the CCG s responsibility for commissioning health provision. The DMO / DCO provides the point of contact for local authorities, schools and colleges seeking health advice on children and young people who may have SEND, and provides a contact (or contacts) for CCGs or health providers so that appropriate notification can be given to the local authority of children under compulsory school age who they think may have SEND. The DMO / DCO should have an appropriate level of clinical expertise to enable them to exercise these functions effectively, and should be designated as the DMO / DCO in their job description. There may be one DMO / DCO for several CCGs and local authorities, where there are joint arrangements or shared commissioning responsibilities, and given the age range of EHC plans from birth to 25, the DMO / DCO may need to liaise with colleagues outside paediatrics. This is a non-statutory role. When carried out by a paediatrician the role is a Designated Medical Officer, when undertaken by a nurse or other health professional the role would be a Designated Clinical Office. Nurses can be dual registered and this can be an advantage when considering the remit of the role from Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence CCG have agreed resourcing for the DMO/DCO Role? The post has been appointed to and has sufficient PA s to carry out the role. Formally identified local health professional, with job description and dedicated time. DMO name is contactable (information for example on the Local Offer pages). DCO for Norfolk and Waveney CCG Mark Gower Full Compliance: Fully Achieved/Implemented Information on SEND local offer for Norfolk of role, See SEND local offer website for health and job description (see ref 1.15), PA will need ongoing review as role progresses FURTHER INFORMATION: Summary RAG Compliance The BACD have published a model job description for a DMO: Total Green 1 0 Total Amber 0 0 Total Red 0 0 Dr. Karen Horridge, Chair of the BACD has published a presentation capturing the scope of the DMO role in an effective SEND system.

18 4. Education, Health & Care Plan Coordinated Assessment The Education, Health and Care plan is a key focus for the new SEND arrangements. The plan is a statutory document, which captures: the child or young person s special educational needs and any health and social care needs; the services which the relevant commissioners intend to secure; the outcomes which they will aim to deliver, based on the child or young person s needs and aspirations. If the plan specifies health care provision, the responsible commissioning body usually the CCG - must arrange the specified health care provision for the child or young person. There is no easy answer to the issue of capacity constraints. It is vital that the CCG talks to the local authority, so that the EHC process is not held up for a diagnosis which may take months and a methodology can be agreed for allowing for pending assessments, and for reviews following an assessment. There will be cases where a child or young person has been discharged from a clinic but where a programme of care advised by the clinic is being followed. In such instances it is important that this programme of care is provided to the local authority as the health advice, rather than the information that the child has been discharged, and it is important that the CCG ensures that providers understand this. There will also be cases where a child is not known to clinical services but where it has been identified that there is a health need. In such instances CCGs will wish to consider a process which supports the timetable for completion of the plan. Some areas are holding spare appointments whilst others are including a health assessment as an action for the EHC plan. Where a child does have a special educational need arising from a significant health issue, their health needs must be captured in the EHC plan, along with the services required to help deliver improved outcomes for them. It may be the case that the CCG would not need to commission any service which wasn t already being secured, but they must ensure that their health needs are adequately covered by the EHC assessment and planning process. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY Has the CCG been involved in developing the EHC plan templates for its relevant local authorities? Does the CCG have a clear process / pathway for referrals directed to it? Does the CCG oversee providers and ensure they have a pathway? Does the CCG have a strategy for mitigating impact of service pressures on EHC process? CCG has ensured that key personnel are familiar with the EHC plan templates, and its statutory elements (which are consistent for all plans). CCG has been involved in development of all relevant plan formats, or failing that, has seen and discussed all relevant formats with local authorities, so expectations are clear. CCG has an agreed process in place (with appropriate personnel to oversee and manage) for receiving requests for EHC plan input. Similarly, relevant providers (NHS Trusts, FTs, Community DCO Mark Gower DCO Mark Gower DCO Mark Gower Full Compliance: Fully Achieved/Implemented Partially Achieved: Some Progress/Implemented in some areas Partially Achieved: Some Progress/Implemented in some areas 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence? Not aware No Compliance: Not started. Not aware? Held health focus group in Norfolk with LA lead with template for Health Advice that has been shared and reviewed with NCH&C and shared at training sessions with other organisations embed action log. Recently DCO and NCH&C SEND lead involved in the rewrite of the EHCP documents Health provider leads group set up, pathways shared and issues raised and worked through? Reports NCH&C have KPI reports on process and activity action log and TOR Quality Schedule reviewed for actitivity reporting? Included in contracts? And? Reports NCH&C provide reports as have a KPI

19 How are local health providers able to respond to requests for input? CCG ensures that all relevant health providers are aware of the EHC process, and the expectations of the plan. CCG has in place light-touch monitoring of response times (monitored via the local authority if necessary), and considers performance implications for contract management. CCG has a strategic approach to managing the logistics of the health input to the EHC process. DCO Mark Gower Partially Achieved: Some Progress/Implemented in some areas Meet with teams regularly, contact with child health information teams to consider overisght reports, LA centre of Excellent have link and agree to sent monthly reports and highlight areas and gaps. Quality schedule in contracts and reports to start being submitted. Embed Quality Schedule and report from LA, meeting schedule for inclusion teams local SEND clinical network been set up. Action log notes from Meetings. Summary RAG Compliance Total Green 1 0 Total Amber 3 0 Total Red 1 0

20 Sign off The CCG has discretion under section 3 of the NHS Act 2006 as to what it chooses to commission, and therefore, what services it will make available to the children and young people for whom it has responsibility. It is likely to be already commissioning paediatric and other services for children who would be eligible for EHC plans, so there would be no reason for not including these in a plan. If a CCG were to change its commissioning for children, and this meant some services were no longer made available, it would have to review the plans affected (and clearly the CCG would need to consider carefully the evidence on which it drew in making that decision). Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY How does the CCG resolve disputes on individual plans Is there sufficient scope for an iterative process before plan signoff? Does the CCG have a clear signoff process in place? FURTHER INFORMATION: How does the CCG resolve disputes on individual plans? CCG has mechanism for plan sign-off, which is the culmination of plan development and scrutiny by all relevant parties. CCG either has its own sign-off arrangements in place (e.g. by suitable personnel with appropriate links to strategy and finance), or has a protocol for delegation to a senior clinician or the DMO. Summary RAG Compliance Nottinghamshire County Council s EHC plan animation: DCO Mark Gower Partially Achieved: Some Progress/Implemented in some areas Partially Achieved: Some Progress/Implemented in some areas Full Compliance: Fully Achieved/Implemented 2nd Audit RAG Rating: DD/MM/YY Total Green 1 0 Total Amber 2 2 Total Red 0 0 The British Academy of Childhood Disability has developed detailed guidelines for professionals who are asked to contribute to an EHC plan: NB. DH is developing guidance for health services on responding to requests for information on a child s health, for the EHC plan assessment process. The SEND Pathfinder Information Pack - Coordinated Assessment Process and Education, Health and Care (EHC) Plan: A guide to EHC plans for health professionals. Trend Comments/Evidence No experience of this yet? But health included in procurement of mediation and dispute resolution service which would apply?dco would be informed to be involved if unable to be resolved a local provider level.? Reports from Providers to progress embed process for all that is shared out and agreed with local offer information on CCG responsible commissioner. DCO regualr meetings with EHCP inclusion teams CCGS have a process but not always inlcuded as yet by LA Yes, we have clear sign off process: Commissioning Manager receives and reviews plans before lead clinician (Dr Tony Burgess, Governing Body Member) signs off, or Chair in his absence. Embed process for sign off health Section G? Agreed for each CCG but not receiving consistently

21 5. Engagement Users The NHS has a duty to promote the participation of the patient and public in decisions about their health and care. These duties are brought together in the NHS Constitution and apply to children and young people as well as adults. To fulfil these statutory obligations there are a number of elements which should be in place: A policy on engaging with hard to reach groups and an active strategy for its implementation which includes events and activities. Able to demonstrate how it responds to the feedback which results from engagement activities, particularly in relation to commissioning. A mechanism for engagement with children and young people and their families this may be through its local parent carer forum. Children, young people and families should experience well coordinated assessment and planning leading to timely, well-informed decisions. Local authorities must consult the child and the child s parent or the young person throughout the process of assessment and production of an EHC plan, and families should be closely involved in the process, by: being provided with access to the relevant information in accessible formats; given time to prepare for discussions and meetings, and being allowed dedicated time in discussions and meetings to air their views. The lay representation in the CCG s Governing Body would provide a means for lay scrutiny of joint arrangements, but there does need to be a clear line of sight from the CCG executive. Senior understanding of the statutory duties could be assured through a regular, although not too frequent standing item on the agenda of executive meetings (or an appropriate sub-group). Note that local Parent Carer forums and other patient / user representation groups are likely to be determined in their wish to hold CCGs to account for their role in relation to children's disability, an area which can attract significant local press attention. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead Has the CCG been involved in developing the EHC plan templates for its relevant local authorities? CCG has a [published] policy on engaging with hard to reach groups and is active in ensuring this is implemented. CCG has specific events or engagement activities with hard to reach groups. CCG is able to demonstrate how it responds to the feedback from engagement in its policies, particularly in relation to commissioning. DCO Mark Gower 1st Audit RAG Rating: DD/MM/YY Partially Achieved: Some Progress/Implemented in some areas 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence What evidence is there for user involvement engagement on service and their development? Family voice reps at many meetings arranged, Child health maternity network, action log for meeting with CCGs re SEND process, action log and rep for workforce development. Discuss with Sally Child on their work and groups to feedback. Does the CCG link with its Parent Carer Forum? CCG has regular contact with its local PCF.?commissioning and engagement integrated commissioning Full Compliance: Fully Achieved/Implemented Dco attends a number of groups and meeting with parent care forum reps (Family Voice) family voice included in meetings child health maternity network, How does SEND feature in the CCG s exercise of its statutory duties in relation to engagement? CCG has a mechanism for engagement with children and young people with SEND and their families. CCG is able to demonstrate how it responds to the feedback from engagement with children and young people with SEND, and their families, in its policies, particularly in relation to commissioning. DCO Mark Gower What information have each CCG got to put in this section? RAG rating aware from discussins that there is a lot of this happening?

22 Has the CCG worked with children and young people and their families in developing its role in joint arrangements? CCG (or its providers) have involved children or young people with SEND and their families in their contribution to the: - Local Offer - EHC plan or have made sure that the local authority, in its engagement with children and young people, takes account of children s health CCG measurement of user / patient experience allows experiences of children and young people with SEND to be identified. Engagement Manager Full Compliance: Fully Achieved/Implemented DCO attends Local offer steering group that includes feedback from the Local offer officers going out to young people, completed questionnniare with SEND lcoal offer officers that was sent out CCG or its providers uses the Parent Carer Forum to survey experiences of children and young people and their families. How can the CCG measure the patient experience of children with SEND? Friends and Family test allows experiences of children and young people with SEND to be identified. Partially Achieved: Some Progress/Implemented in some areas Unsure as many organsisation talk about surveys! Who receives these? Can these be included,? Focus groups for experiences?? RAG Implications of NHS National Children's Inpatient and Day Case survey results from local Trusts for children and young people with complex needs are considered. CCG or its providers use bespoke feedback gathering (e.g. survey, feedback forms, focus groups). Summary RAG Compliance Total Green 2 0 Total Amber 2 0 Total Red 0 0

23 FURTHER INFORMATION: The SEND Pathfinder Information Pack - Engagement & Participation has a very extensive collection of good practice and resources on engaging with children, young people and their families: Contact a Family: for examples of how parent carer forums have helped improve services and resources on parent participation, see A full list of Parent Carer forums can be found at the National Network of Parent Carer Forums: NHS England s guidance on patient and public involvement is Transforming Participation in Health and Care. The NHS belongs to us all.

24 Data to Monitor Progress Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence What evidence does the CCG use to monitor progress of its SEND arrangements? 6. Monitoring & Redress Effective implementation can only be ensured through appropriate monitoring of the joint commissioning arrangements between CCG and local authority, of the process for developing individual EHC plans, and the success of the plans in delivering the outcomes specified for the child or young person. Given the comparative paucity of data collected on children s disability, the CCG will need to identify and collect its own dataset of indicators of effective implementation, covering both process measures, and health and wellbeing outcomes for the child or young person. Engagement with children, young people and their families will also allow evidence of the user-reported experience to inform a view of implementation. Deep dive scrutiny of individual plans might identify gaps between need and provision (e.g. for SLT). The Children and Young People's Dataset has been mandated for central flow from all NHS providers to HSCIC since September This will, when fully implemented provide a rich source of data for CCGs and they will wish to ensure that providers are implementing the dataset. See the annex for suggestions for monitoring information. Does the CCG consider evidence of: - the effectiveness of joint arrangements; - the effectiveness of engagement with stakeholders and service users; - progress on individual EHC plans; - the numbers of requests for EHC plans / requests for input by the LA; - how providers are participating in the progress; - timeliness of advice; - progress against outcomes in EHC plans; - improvements in health and wellbeing outcomes for children and young people with SEND for whom the CCG is responsible? CCG has monitoring embedded in its joint arrangements, with appropriate executive oversight. CCG produces regular performance reports using a range of relevant indicators, and reflects on their implications. Head of Clinical Commissioning Partially Achieved: Some Progress/Implemented in some areas NCH&C have KPIs in contrats to report, Quality Shcedule, reports from NCC, looking at reports from Child health information systems

25 Has the CCG considered potential gaps and new collections, e.g. - questionnaires of service users - a regular data return from designated providers etc. - data from the local authority on requests and timeliness of response. CCG has mapped existing data sources and collects new data and intelligence where relevant. DCO Mark Gower Partially Achieved: Some Progress/Implemented in some areas NCC reports for numbers of healht advice and those returned To be included on quarterly reports What evidence does the CCG use to demonstrate compliance with its statutory duties, and to inform National Assurance (e.g. by NHS England, or CQC / Ofsted joint inspections). CCG has a process of collecting evidence systematically to support assurance, informed by CCG Assurance Framework and CQC / Ofsted inspection framework. Partially Achieved: Some Progress/Implemented in some areas As above Summary RAG Compliance Total Green 0 0 Total Amber 3 0 Total Red 0 0

26 Data Sharing Consent for sharing of personal data should be fundamental to the EHC process; consent should be obtained initially for sharing plan documentation with potential contributors, and sharing evidence to inform co-ordinated assessment. Plan portability will support better data sharing. Some local authorities have developed web-based portals / electronic records, which allow contributors to be granted consent by the child or young person, and to add their advice remotely. The new NHSmail encryption feature means that health and social care staff now benefit from a secure service which allows them to communicate across organisation boundaries and industry sectors. NHSmail can now be used securely across the entire health and social care community in fact with anyone using any account. This feature will allow health professionals to submit their contributions to EHC plans, and to discuss cases involving confidential data, by . Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence Has the CCG worked with the local authority to map data flows to support EHC plans? DCO Mark Gower Partially Achieved: Some Progress/Implemented in some areas Investigated nd areas of need identified Is there a policy in place for local data sharing, fundamental to a coordinated assessment and planning process? Different professional teams may have different systems (e.g. GPs, community nurses, hospital paediatricians) has the CCG checked with providers how effectively if at all these can talk to each other? Are arrangements in place for data sharing via secure networks (or by using the encryption function in NHSmail s)? - data from the local authority on requests and timeliness of response. Has the CCG ensured there is a proportionate way for different professionals both to contribute advice to the plan, and to scrutinise and sign-off the draft e.g. through an electronic plan?? Lead No Compliance: Not started. DCO mark gower Partially Achieved: Some Progress/Implemented in some areas IT teams and CSU, CCGS S1 sahring information Lists of details and s single point etc In the absence of electronic data sharing, has the CCG overseen a protocol for or paper-based communication, which meets the expectations of the EHC template, and can support a co-ordinated process (e.g. s to a central local authority or CCG mailbox)? Partially Achieved: Some Progress/Implemented in some areas investigsate and CCG meeting with LA lead on porcess and sharing of plans. Embed action log and record from CCG & LA meeting Summary RAG Compliance Total Green 0 0 Total Amber 3 0 Total Red 1 0

27 FURTHER INFORMATION: The revised Caldicott Principles: A guide to confidentiality in health and social care. Treating confidential information with respect (HSCIC, 2013). Information Sharing: Advice for practitioners providing safeguarding services to children, young people, parents and carers (HM Government, 2015). Further resources to support safe and effective information sharing can be found at the Centre for Excellence for Information Sharing ( and the Information Governance Alliance ( For a step-by-step guide for senders in the NHS using NHSmail see Sending an encrypted from NHSmail to a non-secure address (January, 2015) For recipients, see Guidance for recipients of an encrypted NHSmail (January, 2015) Further information on the encryption feature in general can be found at: Complaints As per the legislative framework in the Local Authority Social Services and National Health Service Complaints Regulations 2009 [SI 2009; No 309], a complaint may be made to an NHS body, and when the complaint is dealt with, to the Parliamentary and Health Service Ombudsman, if the complainant is still dissatisfied. The joint arrangements for SEND must include arrangements for ensuring that disputes between the parties to those arrangements are resolved as quickly as possible, and arrangements for dealing with complaints in relation to the EHC plan. Analysis of complaints in relation to EHC plans would reflect on the efficacy of assessment and planning for health. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence Does the CCG have a clear policy for complaints handling which can be applied in relation to SEND? CCG complaints handling policy or system recognises the particular issues relevant to SEND. CCG monitors complaints relevant to SEND, and has a mechanism for reflecting on / acting on issues raised Information Governance Lead complaints procedures and monitored from analysis, child health maternity network? RAG Has the CCG or providers identified likely foci for complaints in the new framework (e.g. a long-standing long wait for assessment, delays in providing children s wheelchairs). A potential KI would be the % of complaints relating to SEND (as % of complaints overall. One would expect the percentage of complaints to be broadly in line with local prevalence of SEND - e.g. less than 3%). Complaints team within CSU? Repested complaints themes how are they identified?rag Does the CCG have a PALS- type service for patient / user liaison? Is it fully sighted on the new SEND arrangements? Has the CCG / local authority worked with local Healthwatch, or other partners, to ensure clear advice is available locally on the SEND arrangements? CCG has a PALS-type service, with published contact details. The service is primed for supporting families in the SEND process (e.g. representatives have training or supporting information on SEND, and onward routes of contact for resolving issues). Contact details are included in the published local offer. CSU? Send arrangements? RAG Healhtwatch attend amny meetnigs? Health send arrangemeent on lcoal offer?rag Steering groups and Family Voice SEND partnership

28 Has the CCG / local authority a coordinated or common framework for handling complaints. CCG and Local Healthwatch have routine contact on SEND, complex needs. looking at mediation and dispute resolution to be jointly commissioned Is the PALS service appropriate for the joint arrangements? Is there a way for the PALS service to act as an advisor along the EHC plan process timeline (or to liaise with the local authority plan lead)? CCG and local authority have an agreed approach to complaints handling, and share information, feedback etc. between them. CCG and local authority have a single point for making complaints in relation to an EHC plan (which could be via the local authority). Summary RAG Compliance Total Green 0 0 Total Amber 0 0 Total Red 0 0

29 Mediation Mediation must be offered to any child or young person (or their family), dissatisfied with the health element of the EHC plan. The local authority will have arrangements for mediation for the education element of the EHC plan, and as part of the joint arrangements, the LA and CCG could agree to use the same mediators or participate in a single framework or contract for the provision of independent mediation. Some CCGs have agreed to spot purchse mediation from the local authority mediation provider. Effective working with the family in developing the plan and managing expectations should avoid the need for mediation in relation to the health element of the plan. Mediation is typically only a valuable process if there is the potential for a compromise or alternative option on each side; a CCG entering into mediation will need to consider what the possible additional options might be in relation to a child s EHC plan health element. Prompts for Implementation Key Indicatiors / Evidence CCG Named Lead 1st Audit RAG Rating: DD/MM/YY 2nd Audit RAG Rating: DD/MM/YY Trend Comments/Evidence Has the CCG arrangements in place to provide meditators? CCG has a contract or other supply arrangements in place with an independent mediator. DCO Mark Gower Partially Achieved: Some Progress/Implemented in some areas Procurement of service and through the DCO Is there a procedure in place for initiating mediation? CCG has an agreed process for escalating a request for mediation (agreed with local authority). DCO Mark Gower Partially Achieved: Some Progress/Implemented in some areas procuremnt of service currently spot purchase and through DCO Copy of signed letter to NCC agreement Historic data on mediation / complaints etc. obtained from local authority. Has the CCG considered the capacity needed for mediation, and factored this into capacity planning? CCG has projected potential referrals based on this data, anticipated demand etc. No Compliance: Not started. Awaiting to test oout over next year with conttract and procurement with MDR servcie CCG has included costs of mediation in annual admin resources for SEND. Summary RAG Compliance Total Green 0 0 Total Amber 2 0 Total Red 1 0

30 The Clinical Commissioning Groups for Great Yarmouth and Waveney, North Norfolk, Norwich, South Norfolk and West Norfolk Supported by North East London Commissioning Support Unit Policy Statement Title: Cataract Surgery Policy Date: Great Yarmouth and Waveney CCG North Norfolk CCG Norwich CCG South Norfolk CCG West Norfolk CCG Please check the Knowledge Anglia website for the latest version of this policy. 1

31 Implementation date: Review date: Prepared by: Norfolk and Waveney Clinical Policy Development Group (CPDG) Approved by: CCG Date approved Variance Great Yarmouth and Waveney CCG North Norfolk CCG Norwich CCG South Norfolk CCG West Norfolk CCG Version Control Version Control Sheet Version Section/Para/ Appendix Description Amendments of Date Amended by Equality Statement The CCGs and the CPDG are committed to ensuring equality of access and non-discrimination as enshrined in the Health and Social Care Act In carrying out its functions, the CPDG will have due regard to the different needs of protected equality groups, in line with the Equality Act This document is compliant with the NHS Constitution and the Human Rights Act Clinical Governance statement It is important that the implementation of this policy is seen as an opportunity to encourage team working and cooperation between commissioners, primary and secondary care providers. Service Providers will be expected to collect and provide audit data on request as part of a professionally-led clinical review and audit cycle. Exceptionality For patients not meeting the policy criteria or where a treatment is not routinely funded, an application should be made to the Individual Funding Request (IFR) panel if the referrer considers that there are clinically exceptional circumstances. IFR policy and procedure documents can be found on Knowledge Anglia. 2

32 Policy Statement Title/topic: Status: Cataract Surgery Prior Approval Norfolk and Waveney CCGs will fund cataract surgery where there is a clinical impression that it is in the best interests of the patient AND where ALL of the following criteria apply: 1. First Eye: BCVA* of 6/12 Snellen or worse in that eye. 2. Second Eye: BCVA* of 6/18 Snellen or worse in that eye. 3. The cataract(s) is/are producing symptoms resulting in detriment to quality of life, in particular compromising independence. NB: Where both eyes are eligible for surgery, the eye with the poorer BCVA must be operated upon first except where either: the reduced level of acuity in the poorer eye is due to a condition other than cataract or: the patient s symptoms are more pronounced in the eye with the better BCVA *Best Corrected Visual Acuity (BCVA) i.e. visual acuity after correction of any refractive error, achieved after correction with spectacles / contact lenses / other adjustments Cataract surgery will be funded without consideration of the level of BCVA where it is in the patient s best interests and where ANY of the following criteria apply: Where posterior sub-capsular and/or cortical cataract is resulting in significant and disabling glare. Where cataract surgery is necessary to permit the surveillance for/of, or treatment of, diabetic retinopathy. To treat existing angle closure glaucoma, or prevent future angle closure glaucoma (in eyes with cataract deemed at significant risk of future angle closure). To improve intraocular pressure control in eyes with glaucoma and inadequate intraocular pressure control. To correct significant anisometropia (asymmetry of right and left eye refractive error of sufficient magnitude to compromise spectacle tolerance); where anisometropia of at least 1.50 dioptres is present (where anisometropia is defined as asymmetry of either the spherical equivalent refraction or the principal refractive meridians of the two eyes), or where anisometropia of at least 1.00 dioptres is present AND the patient has suffered spectacle intolerance attributable to the refractive asymmetry. To treat lens-induced ocular disease (e.g. phacolytic glaucoma, phacomorphic glaucoma, phaco-anaphylactic uveitis etc.) Where there is a rapid cataract-induced myopic shift in refractive error progressing at a rate of no less than 1 dioptre per year (documented by subjective refraction). Where the presence of cataract is preventing a patient from meeting the DVLA visual requirements for their current form of driving licence. Where a reliable measurement of visual acuity is not possible due to learning disability / cognitive impairment (or similar circumstance) but cataract surgery is deemed to be in the patient s best interests. Clinical Codes for audit/monitoring C71.- Extracapsular extraction of lens C72.- Intracapsular extraction of lens C73.- Incision of capsule of lens C74.- Other extraction of lens C75.- Prosthesis of lens C77.- Other operations on lens 3

33 Evidence Summary This policy is based on NICE guidance, the Royal College of Ophthalmologists Commissioning Guide for Cataract Surgery. The commissioning guide states that that visual acuity measurement is only one part of the assessment of visual performance as this does not take into account other elements which impact on patients' quality of life. Currently there is no generally recognised instrument which combines impact on quality of life and vision. Cost utility studies (Rasanen 2006, Brown et al 2014) report financial returns on investment based on recognised quality of life outcome measurements. Only a small number of clinical trials report quality of life outcomes for second-eye cataract surgery, and these have not been conducted in recent years (Cooper et al 2015). References Brown GC, Brown MM, Menezes A, Bushbee BG (2013) Cataract surgery cost utility revisited in 2012: a new economic paradigm. Ophthalmology ; 120(12): Cooper K, Shepherd J, Frampton G, Harris P, Lottery A. (2015) The cost-effectiveness of second-eye cataract surgery in the UK. Age and Ageing Vol 44, pp Cambridgeshire and Peterborough Clinical Commissioning Group (2015) Surgical Thresholds Policy : Cataract. [online] accessed on 28/01/16 at Ishikawa T, Desapriya E, Puri M, Kerr J M, Hewapathirane D S, Pike I (2013) Evaluating the Benefits of secondeye cataract surgery among the elderly. Journal of Cataract and Refractive surgery Vol 39, pp Lowth M (2015) Patient.co.uk Cataracts and Cataract Surgery [Online] accessed on 28/01/16 at: Mid Essex Clinical Commissioning Group Service Restriction Policies (2015). Cataract Surgery [Online] accessed on 28/01/16 at: NICE (2015) Clinical Knowledge Summary: Cataracts [Online] accessed on 28/01/16 at: Rasanen P, Krootila K, Sintonen H, Leivo T (2006) Cost utility of routine cataract surgery. Health & Quality of Life Outcomes Sep 29;4:74 Royal College of Ophthalmologists (2010) Cataract Surgery Guidelines. [Online] accessed on 28/01/16 at: Royal College of Ophthalmologists (2015) Commissioning Guide: Cataract Surgery. [Online] accessed on 28/01/16 at: The Driver and Vehicle Licensing Agency (2014) Driving Eyesight rules: Standards of vision for driving. [Online] accessed on 04/02/16 at: and 4

34 North Norfolk Clinical Commissioning Group Finance Report 2016/17 Month 5

35 Introduction and contents Finance Report August 2016 (M5) Section Item The purpose of this report is to brief the Finance & Performance Committee / Governing Body / Council of Members on the financial performance of the CCG for the 2016/17 financial year to August (month 5). The CCG is reporting a surplus of 191k, which is a 3k favourable variance against plan. The forecast year end position is 450k surplus as per the plan. Variance analysis is detailed in section 1.2. Acute spend is 1,175k (2.7%) above plan as a result of QIPP slippage and over activity, particularly non-elective long stays. There has been 1 allocation change for an additional 15k for GP Development Programme - reception and clerical training. Details of allocation and budget changes are detailed for authorisation by the Finance and Performance committee in section 1.3. Finance 1.1 Statutory Finance Reporting 1.2 Variance Analysis 1.3 Budget Adjustments 1.4 Reserve Position 1.5 QIPP Reporting 2.1 Acute Commissioning 2.2 Community Health Services 2.3 Continuing Healthcare 2.4 Primary Care Services (Prescribing) 2.5 Packages of Care QIPP reporting is detailed in section 1.6. Reported QIPP achievement is 4,003k which represents 82.6% of target at M05. The main schemes incurring slippage are primary care variation, procedure of limited clinical value and the crisis response team. Underlying position is a 3,185k surplus which is 250k adverse from the annual plan. Underlying Position Definition The underlying position shows the recurrent financial commitment (i.e. removes all the one-off expenses such as set up costs) compared against the recurrent level of funding (i.e. the baseline allocation the CCG receives).

36 Commentary Month /17 Acute The Norfolk and Norwich University Hospital (NNUH) is showing a contract overspend of 2,292k against a plan of 34,133k which equates to 6.7% at month 4 (see section 2.1 for details). This value excludes any of the embedded QIPP schemes and the local price review that is being undertaken (and will be back dated to 1st April 2016). There has been an improvement in the previously reported high level increase in non-elective long stay admissions. In July 2016 non-elective admissions were 5% below July This has reduced the year to date increase from 13% (at Month 3) to 9.4%. Despite this improvement non-elective admissions remains the number 1 financial priority at the QIPP programme board. The Finance and Business Information teams are continuing to update and issue the in-depth analysis of non-elective admissions on a monthly basis. There is also over activity in elective activity of 340k but this is offset by under activity at both BMI and Spire (the latter solely undertakes sub contract activity for NNUH). The Queen Elizabeth Hospital (QEH) is 1k underspent against plan. The James Paget Hospital (JPH) is 59k underspent against plan. For the Non-NHS providers there has been an increase in usage of Bourne Hall (IVF) and Anglia Community Eye Service (Cataracts). However, as mentioned above, there is a significant underspend in both BMI and Spire ( 440k) which is a result of a reduction in hip & knee procedures. Non-Contracted Activity is below target but this is expected to catch up during the financial year so isn t showing as a forecast underspend. Ambulance Services The Emergency ambulance activity is currently 3.2% above contract for month 4. This represents an increase in activity of 7.2% above April, May, June & July 2015, which is consistent with the increase in non-elective activity, being seen at NNUH. In order to establish the activity drivers, EEAST have agreed to gather information on what they believe to be the main triggers causing the increase in demand, from their intelligence. One clear influence is the reduction in people calling 111. From October 2016 the new Ambulance Response Programme (ARP) is being implemented by EEAST. This will include Dispatch on Disposition (DoD), which allows the call taker an extra 180 seconds to establish the response requirement (this excludes Red 1 calls). This has been trialled at 2 ambulance trusts in England and there have been significant performance improvements attributed to the scheme. High Cost Drugs NNUH High Cost Drug (HCD) expenditure is currently 54k under planned expenditure level (the plan has been reduced to include QIPP). HCD expenditure is irregular due to home care deliveries, and it s anticipated that with the continued challenge and the implementation of new bio-similars that expenditure will come in on target at year end.

37 Continuing Health Care (CHC) Adult CHC is underspent by 323k. There has been a decrease in patients of 1.7% (5 cases) below levels. There has also been a release of 200k pertaining to an over estimation in the 2015/16 accruals. Child CHC is overspent by 107k due to 1 new patient commencing in April The patient s needs were reassessed in July and additional nursing is now being provided from this date. Community Services There is an underspend of 59k on intermediate spot bed usage. The Better Care Fund (BCF) is underspent by 78k, this is due to the gross value for ICES being included in the BCF plan and NNCCG has maintained the reduction in ICES expenditure levels reported in Mental Health & Learning Disabilities Adult Mental Health packages of care are overspent due to 1 temporary high cost placement commencing in April This placement was due to end in July 2016, however due to a deterioration in condition this is now likely to be extended until at least 30 th September NNCCG quality team are reviewing the patient on an ongoing basis. Children & Adolescence Mental Health Services (CAMHS) is underspent due to a non-recurrent refund on services delivered in Planned expenditure level on Mental Health, Learning Disabilities and CAMHS is forecast to achieve the national mandate for Parity of Esteem in 2016/17 (this is defined as the increase in expenditure levels on MH being at least the same as the growth in funding received i.e. 3.05%). Prescribing GP prescribing figures are nationally 2 months in arrear therefore only April, May & June 2016 figures were available when reporting the Month 5 position. The actuals for the first 3 months in 2016/17 show a reduction on expenditure over the same period in of 1.2%.

38 Reserves 481k of contingency reserve has been used in the month 5 reported position, this is commensurate with 5 months of the total contingency. The CCG has set aside 1% of allocation ( 2.3m) in accordance with NHS England. The CCG has been instructed to keep this reserve and have no spending plans against it, nor to assume it can be used in mitigation of overspend during the year. Underlying Position The underlying position has deteriorated from a 3.4m surplus to a 3.2m surplus. This is due to non-recurrent mitigations (in the form of accrual releases) being utilised to cover recurrent cost pressures and QIPP slippage.

39 1.1 Statutory Finance Reporting Month /17 Scheme Description 2016/17 YTD Plan k 2016/17 YTD Actual k 2016/17 YTD Variance k Forecast Total Expenditure 2016/17 Forecast k 2016/17 Annual Plan k 2016/17 Forecast Variance k NNUH Contract 34,133 36,425 2,292 79,898 82,759 2,861 QEH 2,003 2,002 (1) 4,808 4,719 (89) JPUH 1,702 1,643 (59) 4,084 3,995 (89) Other NHS Acute Contracts 2,142 2,114 (28) 5,161 5, Independent Sector 1, (440) 3,131 2,552 (579) Other Acute Contracts 1,093 1, ,624 2,574 (50) ACUTE COMMISSIONING 42,378 44,153 1,775 99, ,009 2,303 Emergency Ambulance Contract 2,751 2,748 (3) 6,603 6,600 (3) Non Emergency Patient Transport Contract ,353 1,353 (0) AMBULANCE SERVICES 3,315 3, ,956 7,953 (3) NNUH High Cost Drugs 2,175 2,121 (54) 5,221 5,221 0 Other High Cost Drugs (0) HIGH COST DRUGS 2,337 2,297 (40) 5,610 5,610 (0) CHC Contracts 7,828 7,637 (191) 19,022 19,014 (8) CHC Admin/Assessors CONTINUING HEALTH CARE 8,064 7,903 (161) 19,589 19, Community Contract 7,369 7,368 (1) 17,696 17, Better Care Fund 4,732 4,655 (78) 11,637 11,405 (232) Other Community Services (772) Intermediate Care (59) (50) Long Term Conditions (4) COMMUNITY SERVICES 12,644 12,503 (141) 29,341 29, NSFT Contract 6,339 6,339 (0) 15,214 15,214 0 IAPT Contract (3) 1,783 1,783 0 CAMHS (96) (206) Other Mental Health Services ,205 1, Learning Difficulty Contracts (274) 2,009 1,809 (200) MH AND LD SERVICES 8,597 8,376 (221) 20,978 20,764 (214) GP Prescribing 13,458 12,696 (762) 32,818 31,013 (1,805) Dressings (46) 1,548 1, Other Prescribing Expenditure (0) Prescribing Admin/Advisors PRESCRIBING 14,462 13,656 (806) 35,229 33,449 (1,780) Out of Hours Services (29) 1,474 1,394 (80) NHS 111 Services (12) (35) Local Enhanced Services ,431 1,431 0 Other Primary Care (2) 1,072 1,072 0 PRIMARY CARE 2,000 1,956 (44) 4,648 4,533 (115) Other Expenditure Running Costs 1,605 1,582 (23) 3,734 3,734 0 OTHER 1,729 1, ,013 4, Reserves (481) 3,470 2,311 (1,159) RESERVES/CONTINGENCY (481) 3,470 2,311 (1,159) TOTAL 96,008 96,005 (3) 230, ,539 0 RESOURCE LIMIT (96,196) (96,196) 0 (230,989) (230,989) 0 (SURLPUS)/DEFICIT (187) (191) (3) (450) (450) 0 Note Brackets are favourable (surplus) variances

40 1.2 Variance Analysis Month / /17 YTD Variance k 2016/17 YTD Variance ACUTE COMMISSIONING 1, % AMBULANCE SERVICES % Commentary NNUH - Non-Electives long stays are over plan by 669k (down from 817k in previous month) the main specialities over plan are Geriatric Medicine ( 264k), Respiratory ( 87k) and Trauma & Orthopaedic ( 126k). Emergency long stay Admissions are 9.6% higher than the same period in Elective activity is over plan by 342k, the main specialties over plan are T&O ( 282k) and ENT ( 44k). Further analysis in shown in section 2.1. Please note there is a underspend of similar proportions in BMI & Spire contracts. Other NHS - Underspend on Non-Contract Activity. JPH & QEH are now both reporting contract monitoring on a regular basis. Commissioners still have concerns over the data quality of CUH's reporting. Non-NHS - Based on M04 contract monitoring all providers except Bourne Hall (IVF) and Anglia Eye Service (Cataracts), are on or below plan. BMI and Spire (both primarily T&O) are collectively 440k below plan Emergency contract - over activity by 3.2%. EEAST are continuing to produce a '5 key drivers' report. This is a key factor in the increase in NEL activity being experienced. The new Ambulance Response Program (ARP) - Dispatch on Disposition model is being introduced in October This allows an 180 seconds to establish the response requirement. HIGH COST DRUGS (40) (1.7%) CONTINUING HEALTH CARE (161) (2.0%) NNUH - High cost drugs currently slightly below target. Costs profile is irregular so costs will be monitored closely in subsequent months. Programme to assimilate to bio-similar is on plan Adult CHC under spent by 323k. YTD has seen an decrease of 1.7% in patients (5 cases). This also includes a benefit of 200k that has been released from 2015/16 accruals Child CHC overspent by 108k due to 1 new patient beginning in April-2016 Funded Nursing Care is 25k over plan due to the national increase in tariff, which is only partially offset by a reduction in eligible patients COMMUNITY SERVICES (141) (1.1%) Placement without prejudice beds underspent ( 59k) BCF - Underspend ( 78k) relates to QIPP on ICES MH AND LD SERVICES (221) (2.6%) PRESCRIBING (806) (5.6%) CAMHS - Underspent due to an partial refund for unutilised resources from 15/16 s75 arrangement. Adult and Other Mental Health - Overspend due to high cost placement at Mundesley and increase in compass cases. LD - underspend due to slippage in winterbourne cases being passed down from specialised commissioning GP Prescribing - Only April, May & June 2016 data is available which shows a decrease on the same period in 15/16 of 1.2%. Accruals based on historical trends have been estimated for July & August. PRIMARY CARE (44) (2.2%) Underspend in Primary Care relating to reduced contract price for 111 service OTHER % QIPP slippage in other projects RESERVES/CONTINGENCY (481) (100.0%) Contingency used in M05 position TOTAL (3) (0.0%)

41 1.3 North Norfolk CCG Budget Adjustments Month / M05 Service M04 M05 Budget Comments Budget k Budget k Adjustments k Acute Commissioning 100, ,006 0 Ambulance Services 7,956 7,956 0 MH & LD 21,059 21,059 0 CHC 19,589 19,589 0 Community Services 22,567 21,911 (656) Realignment of Better Care Fund budget to 2016/17 agreement (additional re-enablement) Better Care Fund 6,342 6, Realignment of Better Care Fund budget to 2016/17 agreement (additional re-enablement) Other High Cost Drugs 5,610 5,610 0 IAPT Prescribing 35,289 35,289 0 Primary Care 4,622 4, GP development programme - reception & development training Reserves 3,470 3,470 0 Running Costs 3,734 3,734 0 Allocation 230, , k additional allocation: GP development programme - reception & development training

42 Movements 1.4 Reserve Position Month /17 Recurring Reserve Non-Recurrent Reserve 0.5% Contingency Reserve Description Month Value Description Month Value Description Month Value Baseline Budget 0 Baseline Budget 2,307,705 Baseline Budget 1,155,000 MONTH 1 ADJUSTMENT 2,295 MONTH 2 ADJUSTMENT 5,000 Total Balance as at M05 0 Balance as at M05 2,315,000 Balance as at M05 1,155,000 Balance Committed Balance Committed Balance Committed Month 3 Committed (288,750) Month 4 Committed (96,250) Month 5 Committed (96,250) Balance Uncommitted 0 Balance Uncommitted 2,315,000 Balance Uncommitted 673,750 Comments: The above gives the reserve position as at month 05. It shows that 481k of the contingency reserve has been used in producing the month 05 financial position

43 1.5 QIPP Reporting Month /17 YTD M0 Actual 000s Total 000s Plan 000s Variance 000s Clinical Thresholds/Ratios/A&E Clinical Thresholds/Ratios 1st/Fups Excess Bed Day review Review of NNUH Front Door - UCC Review of NNUH Front Door - Emergency Clinics Local Tariff for zero LoS (Short Stays including Paeds) Day Case without Procedure Code Ophthalmology Tariff (Cromer) Audiology Service Tariff (Cromer) Unwell Neonates Acute Contract Management (10) Audiology AQP Price Reduction Primary Care variation Review of Ophthalmology Procedures of Limited clinical value COPD Admissions Pathology (52) Community - OP Appts Community - IV Service Community - Beds for D2A Community - Beds to Chairs Community - Crisis Response Team (Supported Care) Community - Beds Usage Review (Supported Care) High Cost Drugs (10) CHC package restructuring (58) ICES Community Services Cranmer Community Services Reprovision of MSK (net) Community Services Reprovision of Paed SaLT (net) Community Services Decommissioning Ortho Triage (net) BCF Reduction in Investment 1,500 1,500 1,500 0 MH PoC Reviews LD PoC Reviews Prescribing - GP Prescribing (205) Small schemes NHSPS Grand Total 11,100 4,841 4,

44 000's 12,000 North Norfolk CCG QIPP plan vs actual at M5 (cumulative) 11,100 10,000 9,811 8,966 8,000 7,276 8,121 6,431 6,000 5,586 4,841 4,000 2,554 2,850 3,794 3,261 3,096 2,672 4,003 2, ,103 0 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Original QIPP plan QIPP actual Linear (QIPP actual)

45 Cost & Volume Outpatients Admitted patient care Cost & Volume Outpatients Admitted patient care 2.1 Acute Commissioning Norfolk and Norwich University Hospital (NNUH), Contract Monitoring Summary Month 4* POD type Full year Activity actual vs plan variance by month YTD plan YTD actual YTD var' plan Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar A&E 30,217 10,436 11, Elective day case 18,638 6,252 6,022 (230) 5 (74) (137) (24) Elective ordinary 3,312 1,110 1,106 (4) 2 (7) 9 (8) Non-elective 15,288 5,057 5, (14) MR and readmissions OP new 43,721 14,653 14, (105) OP follow up 88,531 29,782 28,934 (848) (204) 4 (229) (419) OP procs 32,679 10,936 11, OP telephone 8,136 2,723 2,022 (701) (150) (219) (160) (172) Critical Care 1, (53) 19 (13) (13) (46) Maternity 2, Radiology 51,081 17,095 16,956 (139) 248 (164) (191) (32) Other C&V 37,208 12,452 14,687 2, Grand total 332, , ,232 2, POD type Full year Cost actual vs plan variance by month Price Activity YTD plan YTD actual YTD var' plan Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar variance variance A&E 3,002,699 1,036,987 1,144, ,345 24,552 33,063 25,178 24,552 39,734 67,611 Elective day case 11,978,279 4,020,328 4,081,893 61,565 68,334 ( 32,936) ( 26,398) 52, ,632 ( 148,066) Elective ordinary 8,143,454 2,735,230 3,015, ,143 91,798 82,754 25,105 80, ,187 ( 11,044) Non-elective 30,985,926 10,250,617 10,919, , , , ,413 ( 131,576) 114, ,517 MR and readmissions ( 2,030,315) ( 671,659) ( 904,441) ( 232,782) ( 108,162) ( 78,749) ( 65,993) 20,121 OP new 6,374,740 2,135,247 2,142,758 7,510 1,830 17,479 6,622 ( 18,420) ( 26,155) 33,666 OP follow up 6,973,265 2,343,618 2,296,233 ( 47,385) ( 14,172) 3,311 ( 8,672) ( 27,852) 19,377 ( 66,762) OP procs 4,971,395 1,663,734 1,816, ,963 26,702 21,791 40,393 64,078 16, ,711 OP telephone 189,974 63,577 47,214 ( 16,363) ( 3,495) ( 5,107) ( 3,739) ( 4,023) 0 ( 16,363) Critical Care 1,545, , ,159 ( 64,141) 15,411 ( 5,155) ( 23,384) ( 51,013) ( 9,266) ( 54,875) Maternity 2,128, , ,611 84,616 26,428 24,867 34,118 ( 797) 1,621 82,996 Radiology 3,464,184 1,159,328 1,205,638 46,309 28,475 1,342 4,238 12,255 55,732 ( 9,422) Other C&V 2,181, , ,966 ( 41,195) ( 33,950) 11,812 ( 45,412) 26,356 ( 172,255) 131,060 Other 3,075,763 1,439,340 1,851, ,660 63,745 48,859 51, ,855 Grand total 82,985,132 28,098,803 29,517,863 1,419, , , , ,589

46 Comments: The NNUH plan has now been received within contract monitoring and shows at M4: - Non-electives are 669k overspent Emergency long stays are 592k over with highest overspends in Geriatric Medicine ( 264k), Trauma & Orthopaedics ( 126k) and Respiratory Medicine ( 87k). Emergency short stays are 55k over with highest overspends in Paediatrics ( 70k) and Trauma & Orthopaedics ( 42k). Other non-electives are 22k overspent. - Elective ordinary admissions are 342k overspent, with the highest overspends in Trauma & Orthopaedics ( 282k) and ENT ( 44k). - Outpatient procedures are 153k overspent, with the highest overspends in Urology ( 45k), Dermatology ( 17k) and Cardiology ( 15k). - Other notable areas of overspend include Maternity pathways ( 85k), A&E ( 107k) and Radiology ( 46k). *These reports detail activity for the major providers only and is generally received at least 1 month in arrears. This differs from the figures section 1, which includes all providers and an estimate for the activity in arrears. See table below for Section 1 summary: Provider YTD plan ( 000 s) Actual ( 000 s) Variance ( 000 s) NNUH (Incl QIPP) 34,133 36,425 2,292

47 East of England Ambulance Service NHS Trust (EEAST) activity monitoring (responses) Month 4* North Norfolk CCG has purchased an additional 4% above baseline 2015/16 activity levels, but must pay a tariff fee for any activity in excess of the contracted amount. The chart and table below show financial performance for the year to date. Year to date financials Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 YTD Contracted year to date (call outs) 1,979 2,106 1,905 2,206 2,276 1,998 2,142 2,071 2,195 2,190 2,098 2,216 8,196 Actual year to date (call outs) 2,058 2,190 2,105 2,190 8,428 Contracted vs actual variance Total (variance * tariff) 8,154 2,432 37,555-3,502 44,638 1,400 Contracted vs actual activity comparison (ambulance call outs) 1,200 1, R1 contracted R1 actual R2 contracted R2 actual G1-G4 contracted G1-G4 actual URG contracted URG actual 0 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Comments: *These reports detail activity for the major providers only and is generally received at least 1 month in arrears. This differs from the figures in section 1, which includes all providers and an estimate for the activity in arrears. See table below for Section 1 summary: Provider YTD plan ( 000 s) Actual ( 000 s) Variance ( 000 s) EEAST 2,751 2,748 (3)

48 CHILDRENS ADULT 2.2 Community Health Services Norfolk Community Health and Care (NCH&C) Indicative Activity Plan the table below includes service lines included in the block section of the agreement with NCH&C. Activity is measured in units of contacts. Service line group FY plan Plan YTD 16/17 Actual YTD 16/17 Var YTD 16/17 Tolerance (+/- %) 16/17 Adult SaLT 1, % (1) Cardiac Rehabilitation 1, % CN&T** 164,779 55,312 58,040 2,728 4% 992 1,536 1, Continence No Plan No Plan 1,838-2% FootHealth 9,363 3,341 2,443 (898) 2% (254) (200) (146) (279) MskOT 1, % (21) MskPhysio No Plan No Plan 785-2% Phlebotomy % Lymphoedema No Plan No Plan Specialist No Plan No Plan % Wheelchairs No Plan No Plan % HomeWard No Plan No Plan Intermediate Care Beds No Plan No Plan 7, Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Service line group FY Plan Plan YTD 16/17 Actual YTD 16/17 Var YTD 16/17 Tolerance (+/- %) 16/17 CCNT** 1, (110) 5% (17) (8) (22) (65) DASH** - Epilepsy No Plan No Plan 70-10% DASH** - Paediatric Med Clinic No Plan No Plan 479-5% DASH** - Paediatric OT No Plan No Plan 398-5% DASH** - Paediatric Psych No Plan No Plan 194-5% DASH** - Paediatric SaLT No Plan No Plan 0-5% Shortbreaks No Plan No Plan 0-10% Specialist Paediatric Continence No Plan No Plan Neonatal SLT No Plan No Plan 0-0% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 **CN&T = Community Nursing & Therapy, CCNT = Children s Community Nursing & Therapy, DASH = Disability, Additional and Specialist Healthcare. *These reports detail activity for the major providers only and is generally received at least 1 month in arrears. This differs from the figures in section 1, which includes all providers and an estimate for the activity in arrears. See table below for Section 1 summary: Comments: *These reports detail activity for the major providers only and is generally received at least 1 month in arrears. This differs from the figures in section 1, which includes all providers and an estimate for the activity in arrears.

49 Wk 23 Wk 25 Wk 27 Wk 29 Wk 31 Wk 33 Wk 35 Wk 37 Wk 39 Wk 41 Wk 43 Wk 45 Wk 47 Wk 49 Wk 51 Wk 53 Wk 02 Wk 04 Wk 06 Wk 08 Wk 10 Wk 12 Wk 14 Wk 16 W18 W20 W23 W25 W27 W29 W31 W33 W35 W37 W39 W41 W43 W45 W47 W49 W51 W53 W02 W04 W06 W08 W10 W12 W14 W16 W18 W20 Active caseload number Average cost CHILDREN ADULTS 2.3 Continuing Healthcare (CHC) Adult and Children Continuing Healthcare Month /17 Confirmed Patients No. of Packages No. of Patients YTD Cost Learning Disabilities (LD) ,605,618 Mental Health (MH) ,397,808 Physical Disabilities (PD) ,368,547 Fast Track ,261 Zero Packages ,013 Sub total ,703,247 Backlog / Delayed Assessments Current year Backlog ,876 Sub total ,876 Total CHC Adults 294 6,973,123 CHC Children No. of Packages No. of patients YTD Cost Children Total , Est. NHS CHC caseload inc. fast track 2,500 2,000 1,500 1, North Norfolk average cost North Norfolk South Norwich West Norfolk LD North MH North PD North Comments: LD patients of care continue to be significantly more expensive than MH &PD patients. At month 5 there has been a net reduction of 1.7% ( 5 patients) compared to a net growth of 1.8% in These are patients that have been allocated a package, but the cost of the package is not yet agreed 2 These are patients that are being assessed and costs are calculated on the historic conversion rate Provider YTD plan ( 000 s) Actual ( 000 s) Variance ( 000 s) CHC 8,064 7,903 (161)

50 No. of CHC Referrals in week No. of patients awaiting CHC Eligibility Decision CHC Reviews Reviews Patients on annual reviews 218 North Norfolk CCG - week 22 Patients % Completed within the year % Not completed within the year 16 7% Patients on 3 month reviews 26 3 month reviews not yet due 12 46% 3 month reviews completed 9 35% 3 month review overdue 5 19% Patients excluded* 22 *Accounts for patients who have an end date on their care package, next review is not known etc. Awaiting CHC Eligibility Decision Week number 1617 Total adults 1516 Total adults* CHC Referrals Week number 1617 Patients referred 1516 Patients referred

51 2.4 Primary Care Services (Prescribing) Drug and Appliance Expenditure for North Norfolk CCG Month 3* Prescribing data is usually made available eight weeks after a month end, i.e. April data is published at the end of June. Practice name Budget YTD Actual YTD Variance vs budget Cumulative % variance vs budget Cumulative % variance vs 15/16 Actual spend v budget by month Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar No. of items YTD Acle 392, ,650 11, % -9% (- 2,912) (- 4,283) 18,791 53,229 Aldborough 161, ,216 (- 38,270) -23.7% 3% (- 15,812) (- 11,313) (- 11,146) 18,805 Birchwood 520, ,475 (- 50,301) -9.7% -4% (- 17,100) (- 17,451) (- 15,750) 71,878 Blofield 263, ,025 (- 9,693) -3.7% 5% (- 4,986) 2,449 (- 7,156) 43,246 Brundall 354, ,170 (- 14,491) -4.1% 1% (- 3,822) (- 5,488) (- 5,180) 54,646 Coltishall 346, ,338 (- 4,385) -1.3% -1% (- 8,949) 7,009 (- 2,446) 53,208 Cromer 703, ,278 (- 56,376) -8.0% -3% (- 16,921) (- 26,773) (- 12,683) 98,253 Drayton & Horsford 678, ,339 67, % 0% 30,212 17,544 19, ,201 Fakenham 683, ,026 18, % 5% 6,939 1,892 9,560 98,957 Holt 715, ,447 (- 37,006) -5.2% -3% (- 15,379) (- 4,933) (- 16,693) 103,949 Hoveton & Wroxham 496, ,426 (- 56,754) -11.4% 2% (- 12,605) (- 22,773) (- 21,376) 63,598 Ludham & Stalham 308, ,860 (- 5,327) -1.7% -10% 5,048 (- 21,101) 10,726 42,471 Market 389, ,954 (- 33,864) -8.7% -3% 6,906 (- 20,861) (- 19,909) 57,539 Mundesley 361, ,334 (- 32,977) -9.1% 5% (- 7,580) (- 15,661) (- 9,735) 46,991 Paston 338, ,009 (- 6,347) -1.9% -4% 278 (- 3,636) (- 2,989) 51,668 Reepham 377, ,995 (- 35,645) -9.4% -6% (- 11,662) (- 15,154) (- 8,829) 54,495 Sheringham 595, ,918 (- 89,934) -15.1% -1% (- 27,124) (- 32,812) (- 29,998) 72,731 Stalham 400, ,176 (- 82,543) -20.6% 1% (- 29,000) (- 25,259) (- 28,283) 54,732 Wells 151, ,055 (- 9,438) -6.2% 7% (- 3,077) (- 4,396) (- 1,964) 18,374 NNCCG 8,240,362 7,774,691 (- 465,671) -5.7% -1.2% (- 127,546) (- 202,999) (- 135,126) ,171,971 Comments: *These reports detail activity for the major providers only and is generally received at least 2 months in arrears. This differs from the figures in section 1, which includes all providers and an estimate for the activity in arrears. See table below for Section 1 summary: Provider YTD plan ( 000 s) Actual ( 000 s) Variance ( 000 s) - 13,458 12,696 (762)

52 2.5 Packages of Care Patient No. Year to date Est. total FY (M5) Cost Patient 1 45, ,735 Patient 2 42, ,937 Patient 3 24,780 59,116 Patient 4 13,178 31,438 Patient 5 11,099 26,477 Patient 6 9,360 22,329 Patient 7 9,262 22,096 Patient 8 9,223 22,003 Patient 9 8,869 21,158 Patient 10 8,831 21,068 Patient , ,096 Total 290, ,453 2,500 2,000 1,500 1, Care package average cost per month Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Top 20 Est. total cost of care package per patient 120, ,000 80, , ,937 82,554 60,000 59,116 40,000 20,000 31,438 26,477 22,329 22,096 22,003 21,158 21,068 21,068 20,334 19,913 17,729 17,624 16,389 15,631 15,631 15,631 13,592 0 Patient 1Patient 2Patient 3Patient 4Patient 5Patient 6Patient 7Patient 8Patient 9 Patient 10 Patient 11 Patient 12 Patient 13 Patient 14 Patient 15 Patient 16 Patient 17 Patient 18 Patient 19 Patient 20 Patient Tracker Mental Health Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 YTD Full Year Estimate Estimate No. of Patients No. of patients added No. pf patients Discharged Average cost per patient 2,057 1,718 2,123 2,096 2,096 2,028 2,096 2,028 2,096 2,096 1,893 2,096 Total Cost 59,666 51,553 61,576 58,680 58,680 56,787 58,680 56,787 58,680 58,680 53,002 58, , ,453 Learning Difficulties Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 YTD Full Year Estimate Estimate No. of Patients No. of patients added No. pf patients Discharged Average cost per patient 46,128 47,756 44,422 40,440 40,440 39,135 40,440 39,135 40,440 40,440 36,526 40,440 Total Cost 184, , , , , , , , , , , , ,738 1,982,954 LTC - Neuro Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 YTD Full Year Estimate Estimate No. of Patients No. of patients added No. pf patients Discharged Average cost per patient 6,461 6,601 6,438 6,653 6,653 6,438 6,653 6,013 6,213 6,213 5,612 6,213 Total Cost 25,844 26,403 25,753 26,611 26,611 25,753 26,611 18,039 18,640 18,640 16,836 18, , ,382

53 North Norfolk Clinical Commissioning Group Clinical Quality and Patient Safety Report September 2016

54 This report will serve to highlight key Patient Safety and Clinical Quality issues within the North locality. The Key Performance Indicators detailed within the Performance Report will identify both compliance and sub optimal standards that have the potential to impact directly upon Clinical Quality and Safety. ALL risks identified are cross referenced, where appropriate, to the Performance Dashboard and will be reviewed on a monthly basis in line with the production of this document. Key Quality Issues - Contents *Assurance NNUH QEH JPH NCHC NSFT EEAST Care Homes IC24 Infection Prevention & Control Safeguarding Headlines NNUH A&E 4 hour compliance continues to improve towards the 95% with June 2016 performance increasing to 90.70% with month on month improvement since March NCHC Workforce and Capacity issues in relation to Paediatricians EAST Non- compliance with a significant number of Clinical Quality Indicators and subsequent delays specific to the North locality NSFT Care Quality Commission Inspection Initial findings IC24 Continued challenges for the recruitment of an Adult Safeguarding Lead All of the key risks identified are monitored through a number of both strategic and operational meetings. Individual reference will not be given to each provider but outlined in the quality assurance dashboard. ALL issues documented within this report are detailed within the NNCCG Clinical Risk Register and outlined in a bi annual risk report for review at the Patient Engagement, Safety and Quality Committee. *For an overview of the assurance levels please refer to the page that follows

55 Assurance: Assurance levels have been calculated upon compliance or non-compliance with the following data sets : ALL national benchmarks detailed within the provider dashboards (referral / waiting times), Organisational KPIs (treatment response times), National and Local Quality Outcome Indicators (Family and Friends test). Assurance levels will be updated annually and are, as such, open to interpretation so caution should be noted when assessing an organisation. Key to Symbols used below Not Assured Assured, requires improvement Assured as good NNUH QEH JPH NCH&C From a clinical quality and patient safety perspective NNCCG are partially assured with this provider as a result of the key issues Continued breach of some NHS Constitution Standards re waiting times Financial Special measures awarded Serious Incidents (Obstetrics) From a clinical quality and patient safety perspective NNCCG are partially assured with this provider as a result of the key issues The retention and recruitment of staff Mixed Sex Accommodation breaches From a clinical quality and patient safety perspective NNCCG are partially assured with this provider as a result of the key issues The recruitment of clinical staff Recent Infection and Prevention Control outbreak From a clinical quality and patient safety perspective NNCCG are partially assured with this provider as a result of the key issues Non-compliance with some Key Performance Indicators Capacity issues re Paediatricians Delays in referral to Adult Speech and language therapy NSFT EEAST Care Homes IC24 From a clinical quality and patient safety perspective NNCCG are partially assured with this provider as a result of the key issues. Out of Trust placements for clients on the dementia care in later life pathway Ongoing challenges to retain and recruit Registered Nurses Improvements required from the CQC report From a clinical quality and patient safety perspective NNCCG are not assured with this provider as a result of the key issues Poor compliance with Clinical Quality Outcomes Indicators for the North locality Clinical assessment Issues and delayed conveyance Ongoing sub optimal compliance with Stroke indicators. Breach of Floor Targets Breach of response times From a clinical quality and patient safety perspective NNCCG are not assured with this provider as a result of the key issues A consistent number of safeguarding referrals made to safeguarding team CQC reports inspection requiring Improvement in a number of key areas Recruitment issues potentially compromising clinical care Medication management incidents From a clinical quality and patient safety perspective NNCCG are partially assured with this provider as a result of the key issues Ongoing challenges with reference to GPs OOH service in relation to compliance with Adult Safeguarding training and policy implementation Non appointment of Adult Safeguarding lead

56 Norfolk & Norwich University Hospital (NNUH) Performance Targets Key Issues There are currently performance breaches within the following NHS Constitution targets for July 2016 in the following services; Cancer 62 day target for referral to treatment GP Referral - remains unmet. In July 2016 the performance at 80.65% is an increase compared to June 2016 performance of 78.15% - against a target of 85%. 18 week RTT target incomplete % against a target of 92.0% is a decrease compared to June 2016 performance of 88.6% A&E four hour compliance. Further improved performance of 90.70% against the 95% target compared to May and June 2016 (both months at 88.9%). This is up from 85.5% in April 2016 and 79.3% in March Stroke targets not fully achieved in July 2016 however improvement has been made in two of the stroke targets when compared to previous months. 87.5% of patients with primary diagnosis of stroke admitted to HASU within 4hrs against a 90% target. This is an increase from 84.6% reported in June % of urgent stroke patients with access to brain scan within 60 minutes reported for July 16. This is drop in performance compared to June 16. May 16 is the most recent month when performance was above target at 94.4%. 87.5% of high risk TIA patients treated within 24 hours of contact against a target of 90% for July 16. This is a significant decrease when compared to June when performance was met at 93.75% but remains above 71.1% reported in May % of patients with primary diagnosis of stroke admitted to HASU within 4hrs against an 80% target. This is an increase from 84.6% reported in May and June Actions taken to mitigate the risk Cancer performance remains under close scrutiny from local Commissioners and NHS England due to the reported underperformance A&E performance remains a high priority and remains under close scrutiny from local commissioners and NHS England. CCGs, NHSE and MONITOR are in discussion with the Trust to agree a realistic timeframe for meeting the target, with a number of actions being explored Stroke Consultant to attend CQRG 2nd September 2016 Local Audits Out of Hours Discharge Audit A pilot Out of Hours Discharge Audit was recently conducted to identify the reasons for patients to be discharged outside normal hours to understand and reduce the potential negative impact on patient experience. The audit consisted of a random selection of thirty patients from adult in-patient wards discharged between the hours of 23:00hrs and 05:59hrs in the year 2015/16 to their usual place of residence. 18 out of 29 (62%) had no reason for the out of hours discharge documented in the notes. 11 out of 29 (38%) had a reason for discharge documented in the notes. QIRs Overall, QIR reported against the NNUH in August 2016 (61 QIR) when compared to July when 26 QIR were raised this is a significant increase. However, the holiday season can potentially influence this and the numbers for August may demonstrate a correlation between people being on leave in July and the higher number of QIR reported in August. A new emerging trend Admission, for poor-inadequate handover all reports relate to patients admitted into NCH&C care. The annual accumulated figure for this issue as of the end of July was 9 QIR, this figure rose to 22 QIR by the end of August.

57 Norfolk & Norwich University Hospital (NNUH) - continued QIRs (cont d) The only other significant trend in August was within the Discharge category under the sub category of Discharge summary incorrect / incomplete / illegible. With only 11 QIR submitted to the end of July 2016, 10 QIR were then received in August alone. Mitigating actions QIR s themes are reported in the Integrated Performance Report presented to the Trust Board QIR s are a Clinical Quality Review Group (CQRG) monthly agenda item Monitoring of the reporting trend of QIR for the NNUH Serious Incidents (SI s) In August 2016 there were 9 SI s reported. Maternity Services reported two SI s in August 2016 both final reports are awaited. Category Total Fall 3 Information Governance 1 Maternity/Obstetric incident meeting SI criteria: baby only (this include foetus. neonate and 1 infant) Pressure Ulcer grade 3 1 Treatment Delay 1 Unexpected death 1 Unexpected / potentially avoidable injury requiring treatment to prevent death or serious harm 1 Total 9 Maternity Services reported two SI s in August 2016 both final reports are awaited. Themes and Trends Inpatient falls no lying/standing BP There are no identifiable trends in terms of days of the week for a SI to occur. There is no single ward identified in the review of the final reports as a higher reporter of SI s. NNCCG mitigating actions Attendance at SPRG and CQRM from key Senior Clinical Leads Head of Midwifery invited to attend October 2016 CQRG. Review and monitoring of SIs and QIRs by the Quality and Safety team Clinical Quality audits within selected departments.

58 Queen Elizabeth Hospital, Kings Lynn (QEH) Information available at the time of report composition has been based upon June 2016 data available 12th August 2016 Quality Issue Reports (QIR) Key Issues There were 12 QIRs submitted for QEH in July The main themes identified were related to patient discharge from the Trust. Actions taken to mitigate the risk The quality team will be undertaking a visit to review all aspects of the discharge process in September 2016 Reinforcing the use of the discharge check list Review of staff training re the discharge process Audit of the discharge summary to ensure patient history is documented Serious Incidents 3 Sis were reported in July and 2 in August. The main theme being related to patients who sustained Falls. The Trust has appointed a Falls Coordinator and there are key work streams focusing upon Falls prevention. There is a Trust wide Falls action plan which will be monitored at CQRM. Actions taken to monitor the risk The Quality team (WNCCG) continue to attend all Root Case Analysis (RCA) meetings at QEH. Mixed Sex Accommodation (MSA) breaches - Key issues There were 4 mixed sex accommodation (EMSA) breaches reported in June. All of these occurred within the Critical Care Unit. The Trust reported that the breaches occurred due to the bed capacity within the organisation impacting on patient flow through the hospital. RCAs are completed for each incident. Actions taken to minimise the risk Measures are put in place to maintain patients privacy and dignity RCAs are completed for each incident and submitted to WNCCG for review

59 Queen Elizabeth Hospital, Kings Lynn (QEH) - continued The retention and recruitment of Registered Nurses and Midwives - Key Issues A Nursing and Midwifery Skill Mix Review which was recently completed within the organisation, and the findings were communicated to the Trust Board. A more detailed report will be presented to the QEH August Board outlining how the work required to meet the guidance/recommendations from the recent publications (Lord Carter; the Model Hospital; National Quality Board), will be taken forward. The vacancy rate for registered nurses and midwives is (0.06% lower than in May 2016). The highest vacancy rates remain within the Adult in-patient wards. Actions taken to mitigate the risk 19 registered nurse/midwife appointments have been made, however the staff are not yet in post. A further cohort of 13 International recruits commence in August 2016: Ongoing recruitment initiatives A Matrons and practice development nurses to provide clinical cover one day per week The development of new roles e.g. Consultant Nurse for AEC/MAU and Band 4 Associate Practitioner roles

60 James Paget Hospital (JPH) Serious Incidents in July and August 2016 (as at 25/08/2016) 7 Sis in total were reported during this period, they refer to; 3 Falls 1 Infection Control 3 Grade 3 Pressure Ulcers The Infection Prevention and Control incident involved 59 cases of the same strain of Extended Spectrum Beta Lactamases (ESBL) Klebsiella identified in patients who had contact with the hospital within the previous six months. Actions taken to monitor the risk An outbreak action group was convened and all required actions are being monitored internally and externally. The number of cases has significantly reduced. JPUH has been acknowledged for their robust management of this. Two Mixed Sex Accommodation breaches have been reported during June - Key Issues 6th June 2016 One breach affecting four patients on the Stroke Unit due to lack of an available bed to transfer the patient into across the Trust. 28th June 2016 One breach affecting eight patients in the Day Care Unit. This breach occurred in order to prevent a patient s surgery being cancelled on the day of their operation. Male and female patients were in theatre gowns waiting for, or recovering from, surgery and had to share a toilet facility. Actions taken to monitor the risk A root cause analysis report has been compiled The CCG are reviewing the full investigation report to work with the provider to monitor lessons learnt and subsequent implementation into practice Retention and Recruitment of Registered Nurses - Key Issues The June 2016 position for JPUH is below staffing establishment. The nurse staffing metrics report that 96% of planned nursing staff was in place; this is an improved position from the report that detailed May position. Ongoing recruitment continues across the organisation. NHS Constitution Performance Indicators Trust A&E and 18 week performance has declined since the last reporting period. This reflects the national picture of system wide capacity and demand pressures. Compliance for June 2016 was 93.7%. Improved Compliance with Cancer Urgent Referral to treatment 62 day target. May achieved 80% compliance, in comparison to 100% in June. The Trust continues to review all patients case by case to establish levels of harm potentially incurred by these delays. The CQC undertook an announced inspection between 16th and 17th August 2016, the formal report is awaited.

61 Norwich Community Health & Care (NCHC) Key Issues - Non Compliance with a cluster of Key Performance Indicators (KPI) within Central Norfolk The following KPIs, were not met in June 2016 for key service lines, these being; Adult speech and language therapy (routine referrals seen within 12 weeks - 95% target 70.4% achieved ( this percentage equates to 32 patients waiting longer than 12 weeks for assessment) The potential impact upon the patients referred into the above services, could be delayed clinical assessments and interventions that have the capacity to compromise clinically effective care delivery. Data extracted from :NCHC Performance Narrative Report - Central Norfolk (June 2016) Adult Speech and Language therapy (ASLT) All urgent patients are triaged for clinical prioritisation Recruitment is underway to appoint two additional clinical roles that will take the service to over establishment Update A small cluster of Serious Incidents pertaining to ASLT were raised in August and September These impact upon 5 patient s. The theme of the incident being delay in onward referral from the Early Supported Discharge Team. The requirement for clinical interventions in a timely manner to support swallowing and communication difficulties is key to effective rehabilitation. Actions taken to monitor the risk This has been raised at the September CQRM with a request for a deep dive into the system failure. This is an agenda item for October CQRM as a clinical thematic review An action plan to outline lessons learnt and activity required going forward. A clinical review of each Individual patient to establish potential impact and level of harm incurred, if any has been recommended.

62 Norwich Community Health & Care (NCHC) Key Issues Sepsis training for the workforce Following the Sepsis CQIN successfully achieved in 2015/16, assurance is required of ongoing implementation of current Sepsis training throughout the workforce. In order to ensure a consistent approach in line with National sepsis pathways (NG ) the following activity is being completed; To upload the new E-Learning function to the Trust Intranet Align the E Learning tool to the Modified Early Warning Score (MEWS) Incorporate this into Core programmes (Mandatory) Workforce issues re Paediatricians and capacity The Trust are currently experiencing a decline in the number of appointed Paediatricians. This has the potential to impact upon both the on call service and the Initial health assessments for Looked after Children (LAC) Actions taken to mitigate the risk; A clinical plan is being compiled to address this Dialogue is underway to enable partnership working with NNUH Service models are being reviewed (Suffolk) to establish potential new ways of working. Serious Incidents (SI) 22 Sis were reported in August for this provider. Only one was for a North Norfolk patient. QIRs 5 QIRs were reported for NNCCG for this provider in August All related to clinical assessment and treatment delay. Actions taken by NNCCG to mitigate risks identified for this provider; Monthly quality safety, performance meetings with the North team are held to review the North locality report and discuss any clinical issues. All provider issues that impact upon patient quality and safety are reviewed at the Patient Engagement Safety and Quality Committee (PESQ) for NNCCG.

63 Norfolk and Suffolk Foundation Trust (NSFT) Key Issues - Care Quality Commission (CQC) Inspection July 2016 Following the comprehensive CQC inspection of the Trust in July 2016, initial feedback was given and a corresponding action plan produced and this will be shared with Commissioners. The key areas of concern are; Seclusion within secure services- NHSE contract West 136 suite and application of seclusion policy. Staffing of 136 suites in East and West localities Recording of seclusion 136 environments furniture & entrance and exits ( mainly East and West ) Ligatures- this was described as being staffs understanding when and what works are due to be completed a monthly meeting between estates, risk and the matrons has been initiated to ensure staff have access to current information and plans. Application of the MHA under DOLS- this relates to the use of covert medication Endorsed the findings of the VERITA report. Record keeping and recording. The initial action plan will be monitored at CQRM monthly. The Trust communicated that there were also some positive feedback concerning a change in the organisational culture, staff morale and the overall feel of the organisation. Actions taken to mitigate the risk Progress against plan will be presented to CQRM Key Issues - Workforce Development Mandatory training levels continue to improve. The trajectory is to achieve 90% compliance by the end of September 16. Current levels are 85.33% against a monthly trajectory of 82%.The Trust have highlighted some risk regarding the Advanced and basic life support elements and this will be closely monitored. Serious Incidents (SIs) 8 Sis were received for this provider in August. 2 of these pertain to NN patients. 2 QIRs were received for NNCCG, that refer to assessment and treatment delay NNCCG mitigating actions Attendance at monthly CQRMS and Stakeholder events CSU representation and liaison to monitor quality and safety issues e.g. QIRs. Conduct quality audits within inpatient services.

64 Norfolk and Suffolk Foundation Trust (NSFT) continued Key Issues - Out of Trust Bed (OOT) Placements within the Older Persons service line 16 out of trust placements were reported on 1st September 16 for the central CCGs (6 South, 7 Norwich and 3 North) - 3 of these are older Adults. There is also a waiting list of service users waiting for admission. 9 clients are recorded as not being active to the trust at the point of admission. An increase in numbers of not active clients has been raised at CQRM and will continue to be monitored This performance issue has the potential to impact upon the quality of care provision and positive patient outcomes. The OOT placements re Taunton, present significant challenges to family members ability to visit and provide ongoing support. This can result in social isolation which may impact upon client well-being and re enablement. Actions taken to mitigate the risk The Trust are completing Root Cause Analysis reviews to identify the circumstances that resulted in these placements Learning from the review will inform processes that may prevent future admissions OOT

65 East of England Ambulance Service Trust (EEAST) Performance Outcomes; Ambulance Clinical Quality Indicators (ACQIS) - Key Issues Compliance in Six out of the Eight CQI Indicators was achieved in June The Stroke HASU indicator has declined further 54.5% to 52.5% against a target of 56%. In relation to compliance with CQI Indicators NNCCG has the lowest achievement in comparison to colleagues within the central and south locality. Compliance with Stroke performance and HASU< 60 minutes in June ranged from 50% in Norwich CCG to South CCG achieving 45%. Whilst NNCCG still has the lowest levels of performance compliance, achieving 5.9%.The position has deteriorated from 25% in May This continued poor performance in relation to Stroke targets has the potential for patients within the North locality in relation to timely intervention and clinically effective recovery. Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 NNCCG 40.9% 27.8% 21.9% 9.5% 5.9% 16.7% 8.3% 0.0% 13.6% 24.0% 5.6% 17.6% 18.2% 25.0% 5.9% NCCG 69.2% 75.0% 85.7% 83.3% 78.9% 75.0% 76.9% 45.5% 86.7% 61.5% 64.3% 64.0% 58.3% 77.8% 50.0% SNCCG 33.3% 62.5% 39.3% 42.1% 50.0% 27.3% 50.0% 33.3% 25.0% 50.0% 46.2% 31.6% 23.1% 35.0% 40.0% WNCCG 75.0% 42.9% 63.6% 50.0% 56.3% 60.0% 42.9% 70.0% 84.6% 45.5% 65.0% 76.5% 51.9% 73.3% 70.6% EEAST 62.4% 52.5% 52.7% 49.1% 51.0% 44.6% 51.5% 43.4% 45.1% 46.2% 46.5% 41.2% 43.3% 54.4% 52.5% Action Taken to Improve Clinical Quality and Safety A deep dive into response times has been requested initial information received on 4th August 2016 identified arrival at hospital ranging from minutes across the central locality.

66 East of England Ambulance Service Trust (EEAST) - cont'd Key Issues - Floor target breaches A series of interim floor standards relating to maximum response times towards improving patient safety and experience were set following the Risk Summit as part of the Trusts work towards improving patient safety and experience. Red 1 - maximum response time 30 minutes, Red 2 - maximum response time 40 minutes. In July 2016, 21 NNCCG patients were affected by breach of these targets ranging from minutes as the longest wait for a first to arrive on scene response. This was in comparison to a total of 7 patients in June. Key Issues - Response time within the North locality in relation to Red 1 and Red 2 These are calls that are classified as immediately life threatening and require an emergency response (with blue lights). The target is to arrive at these patients within eight minutes in 75% of cases. The R1, 8 minute response target has declined within the North locality from 46.5% in June 2016 to 43.6%. A slightly improving result with the R2 8 minute response rate, increasing from 31.8% in June 2016 to 33.1% in July. Serious Incidents and trends 4 SIs have been reported July Key themes and trends are; Ambulance delay Non- Conveyance Actions taken to mitigate the risks Ongoing recruitment of paramedics to increase capacity and reduce delays The implementation of the Quality and Safety strategy focusing upon service improvement and workforce development in clinical competence. Mentoring enabled through the appointment of the Area Clinical Leads. CQC Inspection EEAST were inspected by the CQC April 2016, and their final report was published on 9th August 2016, the organisation was rated as Requires Improvement.In relation to the concept of Caring staff, they were awarded Outstanding. Key points identified were; Governance arrangements varied across the trust, Staff training and morale was low. Lack of training available to staff in mental health & learning disability awareness. The current Remedial Action Plan (RAP) aims to address underperformance and staffing levels, however more comprehensive documents will require composition to address other areas of concern identified. Actions taken to mitigate the risks Improvement plans will be developed to implement the recommendation of the (RAP) and monitored through CQRM Actions taken to mitigate the risk by NNCCG Attendance at Quarterly meetings Partnership working with the Business Analysts in NNCCG to identify performance issues that have the potential to impact upon patient safety Monitor of QIRs and SI s received for North locality with key leads in CSU

67 Care Homes A number of Care Homes within the North locality are currently under surveillance. The key risks are; 1) Incomplete or inaccurate documentation and risk assessments (MUST/ Waterlow) 2) Safeguarding Referrals primarily in relation to neglect 3) Frequent change of Home Manager 4) National shortage of Registered Nurses applying for posts within these organisations. 5) Clinical Competence of Registered Nurses currently practicing within the home setting 6) Poor clinical assessment of residents prior to transfer from the acute setting, resulting in a small number of homes being unable to safely and effectively support people living with complex cognitive impairment Actions taken to mitigate the risks A schedule of Professional and Strategy meetings are ongoing with key stakeholder representation Continued dialogue with the CQC and home owners where intervention is required Quality and Safety visits are conducted by NNCCG and integrated care colleagues. Care homes where health and social care partners notify CCGs of suspension of placements, are not selected for residents Activity to enhance resident quality and safety initiated by NNCCG A care home within the North locality has significant recruitment issues in relation to Registered Nurses and the safe and effective management of medications Below are actions taken to support resident safety:- Professional and Strategy meetings are ongoing with all key health and social care stakeholders, action plans are developed and initiated by these forum Agency staff are being employed to ensure RN shortfalls are being addressed Safeguarding leads and CSU are devising a definitive schedule of visits Care Homes are now a standing agenda item at the PESQ committee forum Attendance at the Norfolk and Suffolk partnership service transformation care home steering group to address retention and recruitment

68 IC24 Adult Safeguarding training compliance - Key Issues Compliance with training was 97.4% against a target of 100 % in July Ongoing challenges remain in relation to GPs within OOH service providing evidence of current Safeguarding training. Actions taken to mitigate the risk The development of a local SA SOP available to all staff system wide. CCG Safeguarding team to deliver training and develop Champions within call centres. A lead for Adult Safeguarding is to be appointed Update The Adult Safeguarding post has been re- advertised as no candidates were appointed following a series of interviews. The lead for Adult Safeguarding for the CCGs who has actively delivered training to teams within IC24 is leaving. The provider will need to evidence a contingency plan to demonstrate what processes are in place to ensure ongoing training and currency of competence. The time to hire to both Adult lead posts will present a risk to quality and safety in terms of assurance of statuary safeguarding compliance. This has the potential to impact upon patient safety if vulnerable patients are not identified and appropriate referrals made. Actions taken by NNCCG Attendance at the monthly CQRM to raise issues and local concerns Monitoring of QIRs and SIs in partnership with CSU A request for the provider to complete and submit the local Safeguarding dashboard has been submitted Key Issues - Clinical Hub update The pilot to build a clinical hub within 111 service has been temporarily paused to allow a review of the clinical governance processes. This is to ensure that the lessons learnt from the inception and delivery of other clinical hubs are embedded. CQC Report The CQC inspection report was published on 5th July Four regulation notices were issued to the provider where further action is required. Actions taken to improve quality IC24 are working with commissioners to address the issues identified and recommendations by the CQC. An action plan is in place for the commissioners to monitor through CQRM.

69 Infection Prevention and Control (IPAC) Clostridium difficile (C diff) - Key Issues In July 2016 NNCCG have 6 reported cases with a cumulative total to date of 15 for 2016/17. Actions taken to remain within trajectory Comprehensive joint community and acute strategic Clostridium difficile action plans have been developed and updated in lie with RCA findings. Each case of Clostridium difficile is reviewed to determine whether the case was linked to a lapse in the quality of patient care by the relevant provider. A review of the use of appropriate use of specific antibiotics in Primary care with reference to UTIs is ongoing at the Antimicrobial Sub Group for Norfolk and Waveney. Monitoring of the impact of the microbiology changes to the reporting of Community Co-amoxiclav and the testing of pivmecillnam upon community C diff cases. The C diff database annual information is being collated to produce reports to identify trend analysis for Primary care There have been no cases of MRSA for NNCCG in Quarter Necrotizing Fasciitis incident June 2016 update A patient admitted to an inpatient unit within the North locality acquired this infection and subsequently passed away. The case was reported as a serious incident and a stringent screening programme was completed. The following precautions have been implemented; All staff screened were found to be negative Screening of patients who were in contact with the index case are in the process of completing the screening process All visitors to the index case have been screened Public Health England are leading on this to establish any other cases within the area in the last six months

70 Infection Prevention and Control (IPAC) - continued Update The final Root Cause Analysis report has been received for this incident and highlighted some key points for lessons learnt, these being; Contemporaneous record keeping by all multi professionals involved in patient care Effective inter professional communication between the laboratory and NCHC on-call manager The learning will be shared internally via locality and team meetings and externally via the Healthcare Acquired Infection (HCAI) System Wide Group, this is hosted by Public Health with Infection Prevention and Control Colleagues from around the county sharing information and best practice ESBL Klebsiella Pneumoniae Outbreak JPUH In May and June JPUH saw an increase in the number of ESBL Klebsiella pneumoniae positive patients. These results were reported mainly from Urine specimens. The patients affected were spread across several wards. The cases have been typed to establish common strains and a significant number were noted to be the same strain suggestive of patient to patient transmission. Actions taken to contain the risk IP&C team in Public Health have attended IMT meetings and gained assurance that the trust have put robust plans in place. A separate support team including senior staff from PHE visited and were equally assured by the actions that had been taken. Case numbers have significantly decreased Actions taken by NNCCG to monitor the risk Ongoing attendance by the Nurse Member for the Governing Body at RCA review meetings for NNUHT Bi monthly presentations at the PESQ Committee to inform and update forum members of IP&C issues NNCCG representation at the Health Surveillance forum.

71 Safeguarding Safeguarding Children key headlines Key concerns have been identified in relation to Huntercombe Hospital within the North locality. This is a low secure facility providing inpatient CAMHS services for children and adolescents of both genders aged with a range of mental health disorders and who are detained under the Mental Health Act. The core aim of the service is to promote recovery and rehabilitation within the least restrictive environment. The Nurse Member for the Governing body and Designated Safeguarding Children s (DSC) lead have liaised with NHS England who commission this service to raise the following concerns; Compliance with policies and procedures Capacity issues with temporary workforce The consistent clinical quality and safety of children requiring supervision and monitoring. The informed withdrawal of a site based General Medical Service (GMS) by a local practice. Services to this hospital have been suspended, currently six beds are empty. The impact of this is a reduced capacity of CAMHS tier four beds in a system that is already pressured. Whilst NNCCG does not directly commission services from this provider, the focus is to support the DSCN by providing expertise and influence to monitor quality processes, through escalation to NHS England. The DSC is working with the Clinical Governance lead to establish quality assurance processes. Update A Risk Summit took place on 25 August 2016 chaired by the Regional Chief Nurse with Huntercombe Group Senior Management Team and representatives from CQC, NMC and GMC which the agreed outcomes were that an improvement plan will be developed, and an oversight group will be developed within the next four weeks.

72 North Norfolk Clinical Commissioning Group Performance Standards Report September 2016

73 This report provides an update on the progress of performance indicators. Performance Standards The 2016/17 Performance Tracker produced by the Performance Team (North & East London Commissioning Support Unit) is the source for the performance indicators. Breach details - highlighted on the Dashboard A&E attendances <4 hours (NNUH only) Performance data at NNUH for July 2016 was 90.7% (target 95%). Referral to Treatment (RTT) - admitted (adj), non admitted and incomplete <18 weeks (NNCCG) In June 2016 all RTT indicators breached. Details of the '18 weeks RTT - incomplete' indicator is shown on the seperate worksheets. - RTT admitted (adj) performance was 71.8% (target 90%); - RTT non admitted performance was at 92.0% (target 95%); and - RTT incomplete performance was 88.8% (target 92%). Diagnostic wait times <6 weeks (NNCCG) - Performance against this indicator for June 2016 was 98.2% (99%). Cancer wait times (NNCCG) For June 2016 the performance figure for the following 'cancer' indicators have been highlighted as being below target: - Cancer 31 day - surgery performance was 91.3% (94%); - Cancer 62 days - urgent GP referral performance was 80.4% (85%); and - Cancer 62 days - screening referral performance was 80% (90%). Ambulance response / transport times (NNCCG) - R1 (8min) response times for July performance was 43.6% (target 75%); - R2 (8min) response times for July performance was 33.1% (target 75%); and - R1/R2 (19 min) transport times for July performance was 63.9% (target 95%)

74 NHS NORTH NORFOLK CCG (06V) Additional Theme Ref Indicator Stnd Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Apr16 May16 Jun16 Jul Trend Trend EA3 Improving access to psychological therapies ,713 #VALUE! Mental Health EAS2 People who complete treatment who are moving to recovery 50% 55.6% 41.8% 38.1% 40.0% 70.5% 54.7% 50.4% 42.6% 44.3% 52.1% 35.3% 40.3% 48.6% 43.6% EBS3 CPA discharged patients followed-up within 7 days 95% 77.8% 88.9% 85.7% 92.9% 100.0% 100.0% 100.0% 100.0% 90.9% 100.0% 100.0% 87.5% 86.8% 94.6% EB01 18 weeks RTT - admitted (adjusted) 90% 80.3% 79.4% 75.2% 77.5% 77.3% 73.8% 75.8% 74.2% 74.6% 73.8% 71.8% 78.0% 73.5% EB02 18 weeks RTT - non-admitted 95% 93.1% 91.9% 92.0% 93.0% 92.5% 94.2% 93.7% 92.5% 91.4% 91.9% 92.0% 93.4% 91.8% Referral to EB03 18 weeks RTT - incomplete 92% 89.9% 88.6% 88.2% 87.5% 87.4% 87.4% 88.0% 86.9% 87.7% 88.6% 88.8% 88.9% 88.4% Treatment EBS4i Admitted pathways (unadjusted) > 52 weeks EBS4ii Non-admitted pathways > 52 weeks EBS4iii Incomplete pathways > 52 weeks Diagnostics EB04 Diagnostic tests < 6 weeks 99% 97.0% 96.0% 95.0% 96.0% 93.9% 95.1% 96.7% 98.9% 98.7% 98.4% 98.2% 96.7% 98.4% EB06 Cancer 2 weeks urgent GP referral 93% 96.4% 95.0% 97.6% 98.6% 98.4% 98.3% 99.0% 98.3% 97.7% 99.1% 99.8% 97.0% 98.9% EB07 Cancer 2 weeks urgent GP referral breast symptoms 93% 100.0% 100.0% 96.2% 100.0% 98.6% 93.2% 98.1% 98.5% 98.2% 98.3% 98.5% 97.9% 98.4% EB08 Cancer 31 days - first definitive treatment 96% 96.7% 98.1% 97.1% 98.1% 99.0% 96.2% 100.0% 99.0% 95.1% 97.1% 96.5% 98.2% 96.3% Cancer EB09 Cancer 31 days - surgery 94% 96.6% 93.1% 96.8% 100.0% 96.2% 96.2% 100.0% 100.0% 89.2% 100.0% 91.3% 95.1% 92.5% Waiting EB10 Cancer 31 days - drug treatment 98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.6% 100.0% 100.0% 99.8% 99.1% Standards EB11 Cancer 31 days - radiotherapy 94% 100.0% 90.0% 98.0% 97.2% 100.0% 93.0% 97.7% 95.7% 97.2% 95.9% 100.0% 97.4% 97.5% EB12 Cancer 62 days - urgent GP referral 85% 78.7% 81.5% 80.8% 80.0% 88.5% 75.5% 86.7% 83.8% 84.3% 81.4% 80.4% 80.7% 81.9% EB13 Cancer 62 days - screening referral 90% 100.0% 87.5% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 75.0% 80.0% 80.0% 96.9% 78.9% EB14 Cancer 62 days - consultant upgrade referral no stnd 100.0% 25.0% 100.0% 71.4% 66.7% 57.1% 100.0% 85.7% 100.0% 33.3% 100.0% 69.6% 69.2% Infection EAS4 MRSA Control EAS5 Clostridium difficile #VALUE! EB15i Ambulance Red 1 8m 75% 61.9% 57.9% 51.5% 44.7% 48.1% 47.5% 35.8% 38.5% 43.9% 47.6% 46.5% 43.6% 47.7% 45.3% Ambulance EB15ii Ambulance Red 2 8m 75% 43.6% 42.2% 40.5% 38.0% 41.1% 35.6% 33.1% 32.5% 32.8% 40.8% 31.8% 33.1% 40.6% 34.6% Response EB16 Ambulance A19 95% 77.9% 75.3% 78.9% 75.1% 77.5% 69.8% 68.5% 62.7% 69.8% 74.6% 70.3% 63.9% 76.2% 69.5%

75 NHS NORTH NORFOLK CCG (06V) EAS2 People who complete treatment who are moving to recovery EAS2 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Numerator Denominator Outturn 44.3% 52.1% 35.3% 40.3% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A 44.5% #N/A #N/A #N/A 43.6% Standard 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% EAS2 Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Numerator Denominator Outturn 47.3% 49.5% 48.9% 46.7% 55.6% 41.8% 38.1% 40.0% 70.5% 54.7% 50.4% 42.6% 48.5% 47.9% 50.6% 48.0% 48.6% Standard 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% R. Mouland (NEL CSU - 15/09/16)) We are still in discussions with NHS England over possible change in recording that would improve the performance of this KPI. Initial proposal was rejected, but a revised version is being considered by NHS England. July s data for the North is up from last month and is now 40% against the target of 50%. The trust have proposed a pilot for an advanced care pathway model to deal with the issue regarding cluster 4 / non IAPT patients. NHS NORTH NORFOLK CCG (06V) EBS3 CPA discharged patients followed-up within 7 days EBS3 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Numerator Denominator Outturn 90.9% 100.0% 100.0% 87.5% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A 96.6% #N/A #N/A #N/A 94.6% Standard 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% EBS3 Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Numerator Denominator Outturn 58.3% 88.2% 61.5% 92.9% 77.8% 88.9% 85.7% 92.9% 100.0% 100.0% 100.0% 100.0% 71.4% 87.5% 92.3% 100.0% 86.8% Standard 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% R. Mouland (NEL CSU - 15/09/16). For North Norfolk 1 patient breached in July. Percentage is volatile due to small numbers involved. A request has been made to the Trust for an exception report

76 NHS NORTH NORFOLK CCG (06V) EB01 18 weeks RTT - admitted (adjusted) EB01 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Numerator Denominator Outturn 74.6% 73.8% 71.8% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A 73.5% #N/A #N/A #N/A 73.5% Standard 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% EB01 Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Numerator Denominator Outturn 81.2% 80.3% 81.7% 79.2% 80.3% 79.4% 75.2% 77.5% 77.3% 73.8% 75.8% 74.2% 81.1% 79.6% 76.7% 74.6% 78.0% Standard 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% June 16 breaches by specialty - Gastroenterology 87.5%, Other 86.2%, Cardiology 78.8%, Urology 63.4%, Gynaecology 62.7%, Trauma & Orthopaedics 53.5%, General Surgery 52%, Plastic Surgery 50.9%, ENT 46.7%. NHS NORTH NORFOLK CCG (06V) EB02 18 weeks RTT - non-admitted EB02 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Numerator Denominator Outturn 91.4% 91.9% 92.0% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A 91.8% #N/A #N/A #N/A 91.8% Standard 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% EB02 Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Numerator Denominator Outturn 95.1% 95.2% 94.2% 93.6% 93.1% 91.9% 92.0% 93.0% 92.5% 94.2% 93.7% 92.5% 94.8% 92.9% 92.5% 93.5% 93.4% Standard 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% June 16 breaches by specialty - Urology 94.5%, General Surgery 93.9%, Gynaecology 92.8%, Gastroenterology 92.2%, Thoracic Medicine 91.1%, Other 90.3%, ENT 90%, Trauma & Orthopaedics 86.5%, Ophthalmology 86%, Plastic Surgery 85%, Neurosurgery 66.7%.

77 NHS NORTH NORFOLK CCG (06V) EB03 18 weeks RTT - incomplete EB03 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Numerator Denominator Outturn 87.7% 88.6% 88.8% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A 88.4% #N/A #N/A #N/A 88.4% Standard 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% EB03 Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Numerator Denominator Outturn 90.5% 90.4% 90.6% 90.8% 89.9% 88.6% 88.2% 87.5% 87.4% 87.4% 88.0% 86.9% 90.5% 89.8% 87.7% 87.4% 88.9% Standard 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% June 16 breaches by specialty - Other 91.5%, Trauma & Orthopaedics 89.1%, Urology 85.1%, ENT 83.8%, Gynaecology 80.7%, Plastic Surgery 76.5%, Neurosurgery 75.0%, General Surgery 73.5%. Remedial action plan has now been accepted. The national RTT Intensive Support Team from NHSI are now working with the trust and commissioners to quantify the extent of the RTT pressures and identify the steps that need to be taken to resolve the problems. The initial presentation of findings will take place on 5th October. It is expected that the remedial action plan will be updated following this report. NHS NORTH NORFOLK CCG (06V) EBS4i Admitted pathways (unadjusted) > 52 weeks EBS4i Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Outturn Standard EBS4i Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Outturn Standard Week Breaches. General Surgery (1), ENT (1). No further details at this time.

78 NHS NORTH NORFOLK CCG (06V) EBS4ii Non-admitted pathways > 52 weeks EBS4ii Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Outturn Standard EBS4ii Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Outturn Standard NHS NORTH NORFOLK CCG (06V) EBS4iii Incomplete pathways > 52 weeks EBS4iii Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Outturn Standard EBS4iii Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Outturn Standard Speciality General Surgery (1). NNCCG, Commissioner.

79 NHS NORTH NORFOLK CCG (06V) EB04 Diagnostic tests < 6 weeks EB04 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Numerator 2,666 2,979 2,830 8,475 8,475 Denominator 2,701 3,027 2,882 8,610 8,610 Outturn 98.7% 98.4% 98.2% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A 98.4% #N/A #N/A #N/A 98.4% Standard 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% EB04 Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Numerator 2,977 2,787 3,003 2,756 2,737 2,856 2,769 2,806 2,737 2,792 2,838 2,806 8,767 8,349 8,312 8,436 33,864 Denominator 3,025 2,836 3,072 2,842 2,822 2,976 2,915 2,924 2,914 2,935 2,934 2,836 8,933 8,640 8,753 8,705 35,031 Outturn 98.4% 98.3% 97.8% 97.0% 97.0% 96.0% 95.0% 96.0% 93.9% 95.1% 96.7% 98.9% 98.1% 96.6% 95.0% 96.9% 96.7% Standard 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% The following diagnostic specialties are in exception (percentage over 6 weeks and breaches in parenthesis): MRI (3.1%, 25), CT (3.1%, 11), Non obstetric Ultrasound (0.4%, 4), Barium Enema (0.0%, 0), Dexa Scan (0.0%, 0), Audiology Assessments (0.0%, 0), Echocardiography (0.0%, 0), Electrophysiology (0.0%, 0), Peripheral Neurophys (0.0%, 0), Sleep Studies (0.0%, 0), Urodynamics (0.0%, 0), Colonoscopy (2.6%, 3), Flexi Sigmoidoscopy (0.0%, 0), Cystoscopy (16.2%, 6), Gastroscopy (2.0%, 3). The NNUH failed to meet the agreed trajectory in August and therefore the contractual process will be followed. NHS NORTH NORFOLK CCG (06V) EB09 Cancer 31 days - surgery EB09 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Numerator Denominator Outturn 89.2% 100.0% 91.3% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A 92.5% #N/A #N/A #N/A 92.5% Standard 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% EB09 Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Numerator Denominator Outturn 96.8% 89.3% 87.1% 96.4% 96.6% 93.1% 96.8% 100.0% 96.2% 96.2% 100.0% 100.0% 91.1% 94.3% 97.5% 98.7% 95.1% Standard 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 2 breaches, longest wait 43 daysdue to capacity issues. Please note that if Q1 data adds up differently to the last 3 months worth of data., this is because of the way data is aggregated and adjusted by Open Exeter. Q1 data in Open Exeter shows the performance as 92.8%. Numerator/Denominator are 77/83.

80 NHS NORTH NORFOLK CCG (06V) EB12 Cancer 62 days - urgent GP referral EB12 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Numerator Denominator Outturn 84.3% 81.4% 80.4% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A 81.9% #N/A #N/A #N/A 81.9% Standard 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% EB12 Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Numerator Denominator Outturn 81.4% 84.3% 76.6% 72.7% 78.7% 81.5% 80.8% 80.0% 88.5% 75.5% 86.7% 83.8% 80.4% 77.9% 83.1% 81.5% 80.7% Standard 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 11 breaches, longest wait 134 days. Breaches due to patient choice, capacity, diagnostics and further assessments or treatments needed. Please note that if Q1 data adds up differently to the last 3 months worth of data, this is because of the way data is aggregated and adjusted by Open Exeter. Q1 data in Open Exeter shows the performance as 82%. Numerator/Denominator are 137/167. The trust are expected to recover by October 2016 as per the agreed remedial action plan. NHS NORTH NORFOLK CCG (06V) EB13 Cancer 62 days - screening referral EB13 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Numerator Denominator Outturn 75.0% 80.0% 80.0% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A 78.9% #N/A #N/A #N/A 78.9% Standard 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% EB13 Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Numerator Denominator Outturn 66.7% 100.0% 100.0% 100.0% 100.0% 87.5% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.5% 94.7% 100.0% 100.0% 96.9% Standard 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% Please note that if Q1 data adds up differently to the last 3 months worth of data, this is because of the way data is aggregated and adjusted by Open Exeter. Q1 data in Open Exeter shows the performance as 78.9%. Numerator/Denominator are 15/19.

81 NHS NORTH NORFOLK CCG (06V) EB15i Ambulance Red 1 8m EB15i Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Numerator Denominator Outturn 43.9% 47.6% 46.5% 43.6% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A 45.8% #N/A #N/A #N/A 45.3% Standard 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% EB15i Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Numerator Denominator Outturn 38.9% 55.6% 58.3% 40.6% 61.9% 57.9% 51.5% 44.7% 48.1% 47.5% 35.8% 38.5% 50.9% 54.5% 48.0% 41.0% 47.7% Standard 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% Actions taking place to improve ambulance performance: Increase use of Rapid Response Vehicles (RRV) to allow faster response to incidents Reducing the times RRVs are deployed to Green calls, meaning the resources are free to respond to more Red calls Reducing the time that RRVs remain on scene once a Double Manned Ambulance has arrived in order to create more capacity. Reducing staff sickness levels to increase availability of staff. Allowing staff to take RRV cars home to respond to calls when not on shifts. Reduce delays at acute trusts once a patient has been handed over. NHS NORTH NORFOLK CCG (06V) EB15ii Ambulance Red 2 8m EB15ii Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Numerator ,242 Denominator ,634 3,592 Outturn 32.8% 40.8% 31.8% 33.1% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A 35.1% #N/A #N/A #N/A 34.6% Standard 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% EB15ii Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Numerator , , ,945 Denominator ,117 2,358 2,540 2,707 9,722 Outturn 53.5% 45.8% 45.3% 41.2% 43.6% 42.2% 40.5% 38.0% 41.1% 35.6% 33.1% 32.5% 48.2% 42.3% 39.9% 33.7% 40.6% Standard 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% As per comments for EB15i

82 NHS NORTH NORFOLK CCG (06V) EB16 EB16 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Q1 Q2 Q3 Q4 2016/17 Numerator ,986 2,622 Denominator ,775 3,770 Outturn 69.8% 74.6% 70.3% 63.9% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A 71.6% #N/A #N/A #N/A 69.5% Standard 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% EB16 Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Q1 Q2 Q3 Q4 2015/16 Numerator ,905 1,900 2,050 1,913 7,768 Denominator ,013 2,219 2,458 2,655 2,860 10,192 Outturn 89.3% 85.2% 82.9% 78.6% 77.9% 75.3% 78.9% 75.1% 77.5% 69.8% 68.5% 62.7% 85.8% 77.3% 77.2% 66.9% 76.2% Standard 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% As per comments for EB15i

83 Assurance Framework Key Strategic Risks Initial Risk Assessment Tolerated Impact if Implementation of Controls Successful Current Status Risk Reference and Register Entry Date Objective Provider Risk Description Cause Consequence Risk Owner Initial Impact Initial Likelihood RAG Tolerated Impact Tolerated Likelihood Completed Controls New and On-going controls Current Impact Current Likelihood Risk ref What is NHS North Norfolk CCG's objective? Describe the risk which threatens the achievement of the objective What might cause the risk to occur? What are the possible consequences if the risk occurs? Individual ultimately accountable for managing the risk Rating of 1 to 5 Rating of 1 to 5 RAG Status Rating of 1 to 5 Rating of 1 to 5 What existing controls and processes are in place to manage the risk? Rating of 1 to 5 Rating of 1 to 5 Q&S1 Strategic Objective 1 Strategic Objective 2 East of England Ambulance Trust (EEAST) Failure to provide a safe ambulance service Delays in handover between EEAST and Acute Trust Skill mix and untenable reliance on high levels of new / junior workforce Patients fail to receive timely, necessary care Possible longterm or permanent impairment or loss of life Chief Officer Head of Clinical Quality and Patient Safety Deputy Chief Finance Officer Ambulance handover plan and performance trajectory agreed between EEAST and NNUH, NHSE and TDA. Implementation in progress but impacted by high levels of demand and ongoing handover delays experienced within A&E at the NNUH; National and local funding agree to HALO within A&E at the NNUH; Current Chief Executive apprised by the CCG of its concerns regarding current performance standards and the need to provide adequate support to newly appointed inexperienced staff. Chief Executive of EEAST attended the CCG's Governing Body meeting in May 2016 CCG routinely monitors Trust's ability to avoid 40 minute breaches which are an actual measure of the performance of the service; NNUH and CCG committed to exploring the use of Cromer Hospital to provide a more equitable services to patients in North Norfolk; Joint working across Central Norfolk CCGs to manage the impact of distribution of resources across the county as a result of increased demand within Norwich and its surrounding suburbs; 4 5 Noticed issued by EEAST stating that should there be patients waiting in the community for urgent ambulance response, crews will answer call and handover the patient that has been in their care for longer than 30 minutes, to the NNUH as a result. This has now been incorporaetd in an escalation policy at the NNUH. Q&S2 Strategic Objective 1 Strategic Objective 2 East of England Ambulance Trust (EEAST) Failure to meet the Stroke 60 minute Response target Inadequate provision of training to ensure staff are suitably skilled to manage a potential stroke at the scene of the incident Patient harm Clinical Lead for Acute Services; Chief Operating Officer; Head of Clinical Quality and Patient Safety Trust has appointed a Clinical Governance lead who is tasked with conducting a training needs analysis and implementing improvements to ensure staff appropriately skilled to deliver stroke care at the scene of the incident; CCG engagement in Locality Meetings to ensure performance trajectory is routinely monitored Awaiting breakdown of data for analysis to identify when Stroke 60 targets have not been met and potential locality hot spots. 4 4 Q&S3 Strategic Objective 1 Strategic Objective 2 Norfolk and Norwich University Hospital NHS Foundation Trust (NNUH) Failure to manage Stroke Care in accordance with national targets and best practice (delivery of timely scans, 7-day cover, availability of HASU beds) Trust's inability to guarantee capacity to care for patients within a Hyperacute Stroke Unit bed Patient harm Chief Operating Officer; Clinical Lead for Acute Services; head of Clinical Quality and Patient Safety Regular reporting to the Governing Body, via the Quality and Patient Safety Report and Performance Standards Report; Health and Social Care rehabilitation capacity sustained (Henderson Ward, Julian Hospital) CQC identified that the Trust are delivering the best Stroke Care pathway on a national basis CCG to continue to monitor contract performance data against Sentinel Stroke National Audit Programme (SSNAP) data, which suggests that patients are receiving more timely access to services, even though use of a HASU bed cannot be guaranteed. 3 3 Q&S4 Strategic Objective 1 Strategic Objective 2 Norfolk and Norwich University Hospital NHS Foundation Trust (NNUH) Failure to achieve the 4- hour A&E Waiting Time Target; Failure to manage unsustainable pressure on the unplanned care system Capacity to manage patient demand; Internal improvements required within the Trust Patient harm and poor experience Clinical Lead for Acute Services; Chief Operating Officer Escalation meeting held on 17/02/16 resulted in generation and agreement of new Urgent Care Recovery Plan. Weekly oversight by System Resilience Group (SRG) and associated capacity planning groups Urgent Care Recovery Plan completed. Trajectory agreed between Central Norfolk CCGs, NNUH, NHS Improvement and NHS England - 9-% in June rising to 95% by December 2016 Urgent Care Recovery Plan 3 5