Chief of Clinical Leadership and Engagement Lay Member for Patient and Public Participation. Interim Director for Adult Social Care, BHCC

Transcription

1 Governing Body Meeting Agenda Date: 24 th January 2017 Time: Location: Hove Town Hall Council Chambers Members: Dr David Supple (DS) Adam Doyle (AD) Dr George Mack (PhD) (GM) Dr Andy Hodson (AH) Mike Holdgate (MH) Dr Dinesh Sinha (DS) Dr Jennifer Oates (JO) David Sargeant (DSa) Peter Wilkinson (PW) John Child (JC) Pippa Ross-Smith (PRS) Soline Jerram (SJ) Lola Banjoko (LB) Dr Jim Graham (JG) Dr Sean Perera (SP) Dr Manas Sikdar (MS) In attendance: Victoria Rings Apologies: CCG Chairman Accountable Officer Lay Member for Governance Chief of Clinical Leadership and Engagement Lay Member for Patient and Public Participation Independent Clinical Member Secondary Care Independent Clinical Member Registered Nurse Interim Director for Adult Social Care, BHCC Interim Director for Public Health, BHCC Chief Operating Officer Chief Finance Officer Lead Nurse, Director of Patient Safety and Clinical Quality Director of Delivery and Performance Local Member Group GP Lead (Central) Local Member Group GP Lead (West) Local Member Group GP Lead (East) Interim Governing Body Secretary 1

2 Agenda Item no Item description 1/17 Welcome and Apologies Note David Supple 2/17 Introductions to New Members Action Lead Paper Page no Note David Supple 3/17 Public Questions Note David Supple 4/17 Declaration of any conflicts of interests 5/17 (1) Minutes from the meeting held on 22 nd November Note David Supple Approval David Supple 6/17 (2) Matters arising Note David Supple Chair s Report 7/17 (3) Chair s Report Note David Supple Chief Officer s Report Time /17 (3) Chief Officer s Report Note Adam Doyle Commissioning and Strategy 9/17 (4) CCG Clinical Strategy Note John Child /17 (4) Annual Operating Plan Approval Lola Banjoko Governance 11/17 (5) Patient Transport Service Contract Termination 12/17 (5) Corporate Risk Register Approval Lola Banjoko Performance and Quality 13/17 (6) Integrated Contract, Finance & Quality Report 41 13:55 Approval John Child :15 Tea Break Note John Child Lola Banjoko Pippa Ross- Smith : :45 2

3 Minutes of Sub-Committees receipt of minutes and verbal update from Chairs 14/17 (7) Clinical Strategy Group Nov/Dec 16 15/17 (7) Quality Assurance Committee Nov/Dec 16 Note Note David Supple Jenny Oates 16/17 (7) Audit Committee Nov 16 Note George Mack 17/17 (7) Performance and Governance Committee Oct/Nov 16 18/17 (7) Participation and Communication Assurance Committee Nov 16 19/17 (7) Primary Care Commissioning Committee Nov 16 (Chair Approved) AOB Note Note Note George Mack Mike Holdgate Jenny Oates 217/229 15:00 233/ / /17 (8) 15:25 Meeting Part 2 - Private In Confidence IAPT and Community Wellbeing Service Contract Award Decision John Child 15:30 Primary Care Update John Child 15:40 Finance Update Pippa Ross- Smith 15:50 Date of future meetings including Confidential Part 2 (Date; Time; Location) 21/17 22/17 GB Public Meeting - 28 th March; ; Hove Town Hall Council Chambers GB Confidential Part 2-28 th March; Time tbc; Location tbc Freedom of Information Act: Those present at the meeting should be aware that their names and designation will be listed in the minutes of this Meeting which may be released to members of the public on request. Conduct of meetings in relation to attendance by members of the public: Members of the public are asked to note that NHS Brighton and Hove Clinical Commissioning Group Governing Body meetings are meetings of the Governing Body held in public, they are not public meetings where members of the public can speak at any point. Agendas identify when the Chairman will receive questions and comments from the public. For all other agenda items speaking rights are reserved to Governing Body members and agreed representatives sitting at the table; members of the public should not speak or intervene in proceedings unless invited to do so. In all matters the Chairman s decision is final. The introduction by the public or press representatives of recording, transmitting, video or similar apparatus into 3

4 meetings of Brighton and Hove Clinical Commissioning Group Governing Body is not permitted. Written questions from the public: If you would like to ask a question about anything on the agenda at a Governing Body meeting please contact The Governing Body Secretary, Brighton and Hove CCG, Level 3, Lanchester House, Trafalgar Place, Brighton, BN1 4FU or to BHCCG.GovBodySec@nhs.net at least six working days before the meeting. We endeavour to provide answers to these questions in written format circulated at the meeting. Your question will be reproduced in the publicly available minutes. If your question includes personal information about you or someone else we may contact you about safeguarding such information. Governing Body papers: Brighton and Hove Clinical Commissioning Group Governing Body papers are held on the Brighton and Hove CCG website and can be accessed through the following web page link: 4

5 Governing Body Meeting Draft Minutes Date: 22 November 2016 Time: Location: Hove Town Hall Council Chambers Summary of resolutions taken at meeting taken on 22 nd November 2016: Proposed Resolutions Item no Resolution Owner Review Date 115/16 The Governing Body approved the Patient and Public Participation Annual Report. 117/16 The Governing Body approved the Risk Register. LB N/A 120/16 The Governing Body approved the Finance Report. PRS N/A JC N/A 5

6 Members: Dr George Mack (PhD) (GM) Adam Doyle (AD) Mike Holdgate (MH) Peter Wilkinson (PW) David Sargeant (DSa) John Child (JC) Pippa Ross-Smith (PRS) Soline Jerram (SJ) Lola Banjoko (LB) Dr Jim Graham (JG) Dr Sean Perera (SP) Dr Manas Sikdar (MS) In Attendance: Jane Lodge (JL) Owen Floodgate (OF) Alex Holdcroft (AH) Apologies: Dr David Supple (DS) Dr Dinesh Sinha (DSi) Dr Jennifer Oates (PhD) (JO) Lay Member for Governance (Acting Chair) Chief Accountable Officer Lay Member for Patient and Public Participation Acting Director of Public Health Acting Director Adult Social Care Chief Operating Officer Chief Finance Officer Lead Nurse, Director of Patient Safety and Clinical Quality Director of Delivery and Performance Local Member Group GP Lead (Central) Local Member Group GP Lead (West) Local Member Group GP Lead (East) Head of Engagement Head of Corporate Affairs Interim Governing Body Secretary CCG Chairman Independent Clinical Member Secondary Care Independent Clinical Member Registered Nurse 6

7 Item No Item Action 107/16 Welcome and Apologies The Chair welcomed everyone. 108/16 Introduction to New Members The Chair advised he was deputising for the new CCG Chair, Dr David Supple, and introduced Adam Doyle as the new Chief Accountable Officer. He also introduced CCG Chairman, and Adam Doyle, Chief Accountable Officer as the new Governing Body members. He also introduced David Sargeant as the new Interim Director of Adult Social Care for the Brighton and Hove City Council. 109/16 Public Questions Please see Appendix 1 for the written and verbal public questions and Governing Body responses. 110/16 Declaration of Conflicts of Interest The declaration of interests register was up to date, and there were currently no amendments to be made. 111/16 Minutes from the Previous Meeting The minutes from the last meeting were approved by the previous chair, Dr Xavier Nalletamby. They are presented to the committee to approve for factual accuracy. Amendments: Page 5- A post meeting note will be added noting that the Central Sussex Stroke Services Review recommendation was formally approved as delegated on the 11 th October Page 9- Caroline Huff is the Programme Director, not Director. Page 14- There was an unanswered question about the BSUH strategy to ensure reliable data. A post meeting note should be added that we have now received assurance from the COO of BSUH that the data presented will be accurate. Page 19- There are two words missing in the last sentence of the 3 rd paragraph. The sentence should read a do nothing position would reach a deficit in excess of 500M by 2020/ /16 Matters Arising Item 28/16 regarding the Primary Care Strategy Refresh Broader work needs to be completed, including feedback from NHS England, and this item will be brought to the Governing Body in January. 58/16 regarding dates of meetings and quoracy It is part of the legal directions from NHS England that the CAO will conduct a governance review. Timing and attendance of meetings will 7

8 be part of this review. This action will be modified to be put into a wider action around governance review which will come to the committee in January. Chief Accountable Officer s Report 113/16 Chief Accountable Officer s Report Chief Accountable Officer, Adam Doyle (AD) presented the item for the Governing Body to note. AD thanked everyone for making him feel welcomed during his first 4 weeks at the CCG and thanked Dr Christa Beesley for her thorough handover and strong insights to the climate in Brighton and Hove. He also thanked the director team and Dr David Supple, CCG Chair, for their help and resilience to his questioning. The move to Hove Town Hall has been positive and it marks a change for the organisation as we are now in the building with a number of public sector organisations. We will continue to work across the system. The lease for the building was signed on the 20 th October by Dr Christa Beesley and using our corporate seal. A wider clinical strategy for the CCG will be developed, which will be brought to the Governing Body in January There will be concrete deadlines and milestones and the membership will be engaged. We are working to remove the conditions in our Legal Directions as soon as possible and we have started conversations about our roadmap for the future. A governance review has been sponsored and the Terms of Reference and scope of work are being finalised. An independent organisation will review how we operate and report in January. NHS England will be involved in this process. The Terms of Reference and scope will be agreed by everyone before being finalised. The level of working across the Senior Management Team has been aligned and AD has spent time with the Executives to repurpose roles. Everything will be seen in one place before going to the board and public moving forward. The CCG savings target for 2017/18 is 13M which is bigger than ever before. We will not be aiming to cut services, but remodel them in a different way to ensure the best value for money. Investment decisions will be paused until we have a balanced position for 17/18. We will ensure all contracts we currently hold are in good shape for the next 2 years and submit our operating plan. We are working on performance in a number of areas including improving health outcomes and ensuring adequate performance reporting. We will be meeting with Western and BSUH to establish what 8

9 their new partnership will mean going forward. Delegated commissioning will be applied for and we need to ensure we have sized and scoped those risks. The Governing Body noted the report. Commissioning and Strategy 114/16 Legal Directions Chief Operating Officer, John Child (JC), presented the item for the Governing Body to note. During the 2015/16 assurance process the CCG was rated inadequate against performance, planning, and leadership. The same ratings were given for the first quarter of 16/17. The legal directions received from NHS England are in the appendix. In regard to the leadership capacity of the CCG, we carried out a capacity and capability review and submitted an action plan. It was requested that we submit a recovery plan and commissioning plans as well, which were submitted by the 30 th September. NHS England was also involved in the recruitment of the new CAO. In addition to the recovery plan there will be a whole governance review, and we will ensure we do not have 2 separate actions plans covering the same steps. The plans submitted were plans the CCG had in place anyway and were not written just for legal directions. A Chief of Clinical Leadership and Engagement was recently recruited. At the time of writing, there was no formal feedback; however feedback has now been received which has been positive. It will be shared in due course. The CCG will continue to work with NHS England around these plans. Overall, all requested plans and strategies were submitted on time and we have received some positive feedback. The Governing Body noted the report. 115/16 Patient and Public Participation Annual Report Head of Engagement, Jane Lodge (JL) presented the report for the Governing Body s approval. The Annual Report for Patient and Public Participation is a legal requirement and will go to the Health and Wellbeing Board after the meeting today. There will also be a public meeting to discuss the content of the report. 9

10 The My Life Website is a one-stop-shop for information on health conditions, services, and voluntary sector resources. The team will be building further on this website to include further aspects of self-management and care. A lot has been done this year to improve the way people find information the CCG website now includes a get involved section. There is also a you said, we did section. Work with the community and voluntary sector has been excellent and they are willing and able to be involved in discussions. There is also a specific post to ensure the voluntary sector is involved in work around integrated care. Patient Participation Groups (PPGs) were difficult to develop but Community Works has been able to support the small organisations and now most GP surgeries have PPGs which are running event to support practices and gain publicity. Going forward, there is a big recommissioning exercise of engagement and the CCG is pooling funds with the Brighton and Hove City Council to do the commissioning jointly. There is a legal requirement that the CCG involves those who receive our services to be engaged in commissioning. All CCG commissioners work on engaging people. When we re-design services, we ensure patients and carers are at the heart of that. The priority for next year is to ensure we capture the data and metrics that will allow us to know if we have been successful. We will also ensure the strategy for next year includes the proper impact statements, case studies, and metrics. Questions and comments from the Governing Body: The Director of Clinical Quality and Patient Safety noted that we recognise how much work has gone into improving patient and public participation. There is a further opportunity around supporting research in Primary Care. We will need to ensure these research projects are part of participation going forward. The CAO noted there are always areas to improve, but in reading this report, it is clear there is a body of work that is incredibly strong and the team has done a brilliant job. The Participation and Communication Assurance Committee has done excellent work. The Lay Member for Patient and Public Participated agreed that an enormous amount of work has gone into this. At the last Locality Member Group meeting the Chair and the Lay Member for Patient and Public Participation gave a presentation on the PPG network and there was a positive response from GPs. The first event will be on the 15 th December and will include some exciting guest speakers. The Chair noted that this is an outstanding piece of work and there is a vibrant level of engagement and innovation. The process of developing activated patients is a crucial part of our clinical strategy. This work is a strong enabler to help the CCG and practices to develop activated patients. 10

11 Governance The Governing Body approved the Patient and Public Participation Annual Report. 116/16 EPRR Assurance Chief Finance Officer, Pippa Ross-Smith (PRS) presented the item for the Governing Body to note. The CCG has representation at the Local Health Resilience Partnership (LHRP) board. There is an annual requirement to be monitored by NHS England through an assurance process for planning and response. The CCG received the status partially assured, which means we were not fully compliant on 6-10 of the core standards, although we were compliant with the remaining standards. A work plan has been created for the areas of improvement, 3 of the areas of not fully compliant were due to the office move. An update will be given to the Governing Body in January. The CCG was also responsible for the assessment of Sussex Community Foundation NHS Trust (SCFT) and Brighton and Sussex University Hospitals NHS Trust (BSUH). Both providers were assessed as non-compliant. They do have far more standards to be monitored against and we are working with them to review their work plans to improve their status. There is a quarterly meeting to ensure improvement. The CCG was an active member of the group and was represented in all of the exercises during 2015/16. Questions and comments from the Governing Body: The Chair was assured that the CCG is confident to achieve the work plan by March The report held many acronyms and the appendix font size was very small. Going forward, the team will ensure that the reports come in a more public-friendly format. We are not the lead commissioner for SCFT, but we are their assessor due to the way the work load is spread out across the CCGs. Other CCGs have a higher quantity of smaller providers. The Governing Body noted the update on EPRR Assurance. 117/16 Corporate Risk Register The Director of Delivery and Performance, Lola Banjoko (LB), presented the report for the Governing Body to approve. One of the previous actions from the Governing Body was for the BSUH risk register to be brought to the meeting. This was brought in March. However, we have only now received their most recent risk register, which will be brought to the next meeting. The key themes from provider s risk registers are around 11

12 workforce and finance. There are 11 new risks on the corporate risk register and 3 were escalated from team risk registers. The total risks now number 21. There are a number of new finance risks and a few risks that are increasing in scoring, rather than being mitigated down. Questions and comments from the Governing Body: The Chair noted that it is disappointing to see so many new risks and escalated risks so the total risk direction seems to be up rather than down. A lot of work is going into developing the risk register and more work needs to be done on mitigating and anticipating problems earlier. The Chair also noted it also seems a long time to wait for an updated BSUH risk register. It would be helpful to look at their process and see how we can be more up to date. Action: LB to reflect on the BSUH risk register process and how it fits in to the Governing Body cycle, so the committee can be more up to date on their risks. The CAO reflected that the CCG is starting to change the way we use the risk register and is challenging people to voice their concerns on the risk register. We anticipate we will see more lowlevel risks in the future as people start to report more risks. Currently the register seems to be backward and internally focused, and it needs to be external and forward looking. For example, the achievement of 16/17 QUIP should have been a risk that started from the 1 st April, not October. Increased risks will be seen when the CCG takes on delegated co-commissioning and it will need to address those risks and mitigate them. Some risks will be helped by co-commissioning as it may reduce demand on the acute trust as the CCG will have a greater lever to support Primary Care to take on more of a role in reducing demand for acute services. LB However, when we manage one risk, we might create another. For example, a greater demand on Primary Care is a risk for their workforce although it relieves pressure on the Acute Trust. The CAO noted that the COO will need to pull together the Primary Care Transformation team and articulate the risks going forward as part of the clinical strategy that we all sign up to. We will quantify these risks in the best possible way. The Governing Body approved the risk register. Performance and Quality 118/16 Contract and Performance Report Director of Delivery and Performance, Lola Banjoko (LB), presented the item for the Governing Body to note. 12

13 A&E Performance The performance report compares the constitutional standards to our providers current performance. The Acute Trust is not currently delivery the national standards for A&E performance. There is a local recovery plan. The CCG is pursuing securing additional capacity to relieve pressure on the system and is referring patients to other providers. However, the A&E performance is going in the opposite direction to the trajectories. Attendances are above plan, and there are issues with flow inside and outside the hospital. Delayed transfers of care have gone up significantly. Additional rigour will be required as we head into winter, where attendances are expected to increase further. Questions and comments from the Governing Body: The Chair expressed his concern for the movement of activity in the wrong direction and questioned whether the recovery plan was inadequate. What is really generating the activity? Brighton and Hove accounts for 3.5% of the over-activity. Other CCGs such as Horsham Mid Sussex and High Weald Lewes Havens and others have generated the rest. There are challenges in embedding best practice, care capacity, and system-wide ownership of the challenges. The Discharge Improvement Group and Discharge to Assess programmes work and have been improving delayed transfers of care, however there is a problem embedding best practice. Often, when people need home-based care there is not capacity in the system to sustain them at home. It is also hard for people to trust being seen at home when they are unwell. The CAO acknowledged the real problems and noted that 90 people per day are waiting in a bed when they should not be there. Processes need to be fixed. An additional director will be coming in to cover the winter pressures and will determine where the blockages actually sit. Over half of the delays are in the Brighton and Hove system and we can change those. There are challenges with social care and we have given resources to address those through the Better Care Fund. The CAO will be looking into ensuring there is value for money and to ensure the funds are being spent in the right areas. LB clarified that the complex cases which need repatriation are only about 5 patients, so it is not a significant issue with the activity. The Director for Clinical Quality and Patient Safety noted that the softer conversations of personal and family responsibilities should also not be forgotten as front-line staff need to have those difficult conversations. We need to build confidence that there is care at home that patients need to accept. Patient choice accounts for 17% of delayed transfers of care. There will be a robust communications campaign around this. 17% of delayed transfers of care are due to disputes in funded health care. There is going to be work done around trusted 13

14 assessor, as no patient should wait in hospital for budgets to be sorted. 40% is due to NHS non-acute, which is a whole system issue including providers such as SPFT and SCFT because of the down-stream effect. Onward accommodation can be challenging in mental health areas. There is care that can happen before patients are in acute care, the roving GP services is underutilised by GPs and ambulance services and its function is to reduce transfers into hospitals. The COO noted the communications campaign regarding patient choice has used Healthwatch designed materials and has engaged patients and carers. Cancer 62 Day Target Questions and comments from the Governing Body: BSUH is not meeting the 62 day target. The key issues are in GI and urology services. The CCG is working closely to deliver their recovery plan and meet targets. RTT Targets The Lay Member for Patient and Public Participation noted his concern around patient choice increasing inequalities as there are many people in the City who cannot take up patient choice as they do not have travel access to other areas. Action: Equality Impact Assessment needs to be done to ensure the patient choice policies do not increase inequalities. The COO will ensure this has been done. JC Sussex Partnership Foundation Trust The 7-day follow up performance is an issue as it has not achieved the 95% target. The main reason is due to patients not attending their appointments and cancellations. Wellbeing Service: The CCG is working with the provider on a recovery action plan to meet the constitutional standard and to improve self-referrals. It was noted the national level of service is not meeting the target, so an action plan is only required if the target is missed in several areas. Questions and comments from the Governing Body: A standardised approach is needed for GPs regarding selfreferrals as many GPs believe they are to refer patients to the service. The concern is that it is not best practice for a GP to ask patients to refer themselves to the service. Improving selfreferrals is meant to reduce health inequalities and reach hard to reach groups by helping patients access the service without going to their GP. Self-referrals are also meant to pick up mild to 14

15 moderate cases. Sussex Community NHS Foundation Trust The community rapid response services are not meeting the 90% target, but performance has improved. Community short terms beds KPIs remain below target. General comment: The presentation of the report is not ideal as it can be difficult to interpret the data, especially for the public. The CAO agreed that the team are aware of this and the format of the report will be changing going forward. It will pick up on 3 areas: constitutional standards, health outcomes framework, and new framework for clinical outcomes. Within those areas we will be looking at how we are performing against those standards, as we can be doing better in many areas and we are working to give greater visibility to the Governing Body on those areas and what we re doing about it. There is a point about the phlebotomy service and the challenges with staffing. There is a problem that GPs are not being told when a patient they have referred cannot be seen. Action: COO to pick up the point on the understaffing of the phlebotomy service and the provider letting GPs know if their patients are not able to be seen. Some patients are not taking up the choice to go to other providers and are going to BSUH, so we see the increase in referrals to BSUH. However, there are also seasonal changes that are affecting the numbers of referrals. JC The Governing Body noted the report. 119/16 Quality Exceptions Report Lead Nurse, Director of Patient Safety and Clinical Quality, Soline Jerram (SJ) presented the item for the Governing Body to note. Brighton and Sussex University Hospitals NHS Trust (BSUH) The quality team work hand in hand with commissioners and attend contract commissioning meetings. We also have separate quality meetings with BSUH. The CQC and NHS Improvement inspections have generated a number of actions plans and meetings. We are working to understand what NHSI is doing so that we are not duplicating work. There are 62 action plans and it is important to ensure information and data are reported in a way that all parties understand and recognise. Quality issues will be picked up through Serious Incident reporting and as part of panels that review patients who have had a long wait time. There have been concerns about infection prevention control and this is being addressed. Maternity services are being reviewed closely and a large piece of work undertaken. Brighton and Hove is highlighted for its positive home birth rates. 15

16 BSUH was rated outstanding for its children s services. Questions and comments from the Governing Body: There were some concerns about the gaining traction for planned care services in BSUH. The CAO noted that he chaired the planned care programme board last week and when the overarching planned care strategy for the CCG is articulated, traction can be gained on the important issues. The 3 CCGs are above plan for planned care. It is a complicated situation and we are dealing with the product of significant referrals. We will slowly unpick each problem in consistent methodology and ensure all organisations are on the same page regarding the Acute Trust before we ask it to deliver. SJ noted we need to work together especially in terms of non-life threatening long waits, especially when they affect mental health. Sussex Partnership NHS Foundation Trust (SPFT) We are the coordinating CCG for SPFT and we have a positive relationship with them locally. We are looking closely at the Children and Adolescent Mental Health Service (CAMHS) The I am Whole initiative was a huge success and was launched on national media. 89% of patients received an assessment within 4 weeks of routine referral to the service against standard of 95%. The focus of work is around Brunswick ward and the quality improvement plan. There is a new Director of Nursing and she is very focused on the areas where improvement needs to be made, including physical and mental health. There needs to be targeted work to employ general nurses in the mental health trust as there is a need for physical and mental health nurses to know about both areas. Sussex Community NHS Foundation Trust (SCFT) The dietetics service was of concern at the last meeting, but there was no evidence that the service was unsafe, although there are capacity issues. There is a national issue around workforce in the community and there are issues around skills and capacity. We are taking this seriously and looking at the skills mix and supporting training and development. Other Services Wellbeing Service there is a remedial action plan and reprocurement is underway. Memory Assessment Service reprocurement is being deferred to improve performance. Musculo-Skeletal Service (MSK) contract meetings are led by the coordinating CCG, Horsham Mid Sussex. SECamb There is a complex mix of commissioners and they are also in special measures. Coproforma The CCG has supported High Weald Lewes 16

17 Havens CCG around the quality review and the board has received information about the future of that contract. Optum There are anecdotal reports about the quality, but there are no notable concerns. It was noted that often when people criticise the Referral Management Service they do not identify which service they are talking about and the service may not be managed by Optum RMS. The report was noted by the Governing Body. 120/16 Finance Report Chief Finance Officer, Pippa Ross-Smith (PRS) presented the item for the Governing Body to approve. The report covers the period to the end of September (Month 6) The CCG is on track to achieve its planned surplus, but it has been necessary to use a further 0.6M of contingency reserves to offset cost pressures on CHC budgets. The Governing Body should note the in-year performance underspend in the Acute Trust due to managing the system. We are also underperforming on some of the other public sector contracts. There is also underspending in the Corporate Budget. There were questions about the longer term clinical strategy for delivering services in the community and how this shift would affect budgets. The CAO noted that our strategy is, where possible, to treat people in the community and in their homes. We have not yet agreed how this will happen. The CFO has not yet seen enough evidence to show a balanced budget for next year. We need to have credibility in our investment portfolio in terms of our out-ofhospital services and generate a financial return in-year. The CCG can no longer pilot services, we need to look at the size and transformation and pace of schemes now and invest some of the acute spend in out of hospital care. We aim to become clearer about how that will look. The Governing Body approved the Finance Report. Minutes of Sub-Committees 121/16 Clinical Strategy Group Minutes Dr Manas Sikdar presented the minutes and noted that the proposed resolutions give a fair summary. There is concern about worsening delayed transfers of care figures for COPD, but are cautiously assured that this will not happen. 122/16 Quality Assurance Committee Minutes Dr George Mack presented the minutes and noted the recent homicide 17

18 review which had been covered in the Quality Exceptions Report 119/ /16 Audit Committee Minutes Dr George Mack presented the minutes. 124/16 Performance and Governance Committee Minutes Dr George Mack presented the minutes. 125/16 Participation and Communication Assurance Committee Mike Holdgate presented the minutes and noted that there was a great example of the Council and CCG working together around recommissioning of engagement services. 126/16 Primary Care Commissioning Committee Any Other Business Mike Holdgate presented the minutes. 127/16 Any Other Business Lead Nurse, Director of Patient Safety and Clinical Quality, Soline Jerram (SJ) presented the item for the Governing Body to note. There is a great piece of work that has just been completed around Stop, Look, Care as part of the bigger picture of workforce development. This booklet has been produced as an aid to ensure there is an adequate standard of care across the system and common language around recognising and preventing frailty. There was one Governing Body comment, which is that in a second edition of the book GP could be replaced by GP Practice. 128/16 Dates of Future Meetings 24 th January 2017; ; Hove Town Hall Council Chambers 28 th March 2017; ; Hove Town Hall Council Chambers Appendix 1: Questions Submitted by Members of the Public to the Governing Body 22 nd November 2016 (i) Athene Crouch We understand from the last public engagement meeting that the Sustainability and Transformation Plan was likely to be rejected as regional deficits were insufficiently addressed. Can the CCG explain why the Plan was submitted with little or no likelihood of it being agreed? Response: 18

19 The draft Sustainability and Transformation Plan was submitted to NHS England on the 21 st October and we are waiting for formal feedback. As we have previously stated the financial challenge for the next five years across the health and social care system in Sussex and East Surrey is substantial. The plan provides a framework for improving patient care, providing services for patients, families and carers in more appropriate settings and improving the efficiency of the wider system. At this stage we do not know whether the plan will be agreed or not but given the timetable is over five years the plan should be seen as an iterative process. (ii) Neil Younger What are the implications of the local CCG plan for Primary Care with the creation of clusters and the growing involvement of Multi-Specialty Community providers? In particular will there be further cuts in the number of GP practices in the city? We are thinking specifically of the quote by the outgoing chair of the CCG to the effect that seeing a GP in three years time will be a luxury. Response: The CCG meets regularly with GP practices to discuss issues affecting the primary care in the Brighton and Hove. In recent months we have been we have discussed the forward approach to primary care commissioning and our memberships has asked the us to apply for delegated responsibility for co-commissioning primary care. This means that, should our application be successful, Brighton and Hove CCG will become the commissioner of GP practices within Brighton and Hove. We have also been discussing the feasibility of establishing a GP federation amongst our membership, the models that it might take and most importantly the benefits to our members and patients. Although there is still much work to do, our members are clear on the potential benefits and must now begin to establish a road map towards federation. Ultimately this is a decision for our members, but we have discussed GP federation in public at our Primary Care Co-Commissioning Committee and we will support our membership to federate. Our membership has developed clusters responsible for patient lists of between 30,000 and 50,000 patients. As they develop they will begin to consider how they can best provide a comprehensive range of services to meet the needs of their patients. Working with groups of patients of such a size will enable clusters to think about services for a larger group than their individual patient lists and is likely to provide economies of scale to address local needs, without commissioning city wide services. Part of this up scaled service provision may well be the development of Multi-Speciality Community Providers as described in the NHS 5 Year forward view. It is not possible to give a detailed description of what primary care will look like in the long term, but it is very likely to change from its current model of 40 individual practices across the city. Practices may remain independent, or merge to become bigger and provide a wider range of services. What is clear is that we will continue to work with our members and NHS England to ensure that sufficient primary care services are commissioned in the city, howsoever they may be structured. Opportunities such as federation and co-commissioning will enhance our ability to ensure these services remain robust and meet the needs of our patients. To this end we have developed our Caring Together strategy which identifies the ongoing development of clusters and supports them in federation and the establishment of Multi-Speciality Community Providers. 19

20 109/16 Public Questions Ms Crouch Follow up Question: We were assured the hospital would be safe, but we have now found out hospital bed funding will be cut and there will be a 40% budget cut to A&E for patients over 75. Mr Kapp Question: When are you going to revise your terms of reference to acknowledge the Clinical Commissioning Group is now responsible to the Health and Wellbeing Terms of Reference that were adopted by the CCG in May 2014? Response: This question has been asked and answered by the Health and Wellbeing Board. We have also written to you. The CCG is an autonomous organisation responsible to its regulators, NHS England. We will send another written reply to you. Ms Dickens Question: As the CCG will be aware, NHS Improvement is working with BSUH and SECamb regarding their special measures. How will these measures tie in with the STP, which has been delayed? Response: The CAO acknowledged that NHS Improvement is working with both organisations to work through the action plan. All organisations with CQC inspections receive a set of actions, however both organisations have more actions to embed and work on. We are the host commissioner for BSUH and we are responsible for the local system. The CAO sits with the Director of Quality and Patient Safety on the oversight on the quality and improvement to review the actions. We are not the host commissioner for SECamb and we are meeting with the Horsham and Mid Sussex CCG to understand our relationship with their actions. We are fully aware that a number of the acute trusts are experiencing performance issues. It would be remiss for us not to look at how these actions tie in to the STP. We are going to be meeting regarding the STP and ensuring the quality and improvement are sighted in that place and will be able to give a more complete answer after those meetings. Ms Dickens Follow up question: What does this mean for the timeline of the STP? Response: The STP document is owned and held by a number of organisations. A number of STPs have already been published and we are committed to having ours published as soon as possible. It will likely be in the new year, but we are not able to commit to a date today. Ms Dickens Final follow up question: How will this affect the 12 weeks of public consultation that are required? Will 20

21 this come into account after the STP is published? Response: Often with NHS planning, we start planning and we need to remain flexible in those plans as things change in services, for example special measures. We expect to be working to be clear about how the overall programme will look over the next three months. Public engagement will happen after we agree the draft plans. The CAO commits to engaging with the local community in Brighton and Hove. This is a national process and robust communication is challenging. We will ensure we communicate with you once the plans are published. 21

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23 Matters Arising/Action Matrix Template Date Agenda Item Title Item Action Required Member to action Action Due Action Status Jan 26th 16 11/16. 12/16. 13/16. Finance Quality and Report Patient Safety DS SJ The noted queried 5 year she plan if there could will are be bring place any further more based. detail updates We in have relation around been whether given to NHS access any England s patients not only were to SJ MS Verbal A Prior future to update next meeting meeting TBC On Complete May agenda Comments Mar-16 28/16 Clinical Strategy and Operating Plan Self Management Strategy to be put on a future GB agenda. CB Sep-16 On January Agenda Being completed by Public Health and Neil Francis for January Mar-16 28/16 Clinical Strategy and Operating Plan Primary Care Strategy Refresh to come back to a future meeting. CB Sep-16 In Progress To come to a future GB meeting 24th May 16 49/16 Capability and Capacity Plan An update on programmes of work and realigning staff to be presented CB Timescale tbc Complete CB updated at the meeting in July 16 May-16 50/16 OD Plan 360 o feedback to come back to a future Governing Body meeting as an agenda item. JC Dec-16 Closed Loraine Welch will be bringing this paper to the Governing Body Informal Seminar in December Nov /16 Corporate Risk Register LB to reflect on the BSUH risk register process and how it fits in to the Governing Body cycle, so the committee can be more up to date on their risks. LB Jan-16 Not Started Nov /16 Contract and Performance Report COO to pick up the point on the understaffing of the phlebotomy service and the provider letting GPs know if their patents are not able to be seen. JC Jan-16 Not Started 23

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25 Name of Meeting: Governing Body Date of meeting: Tuesday 24 th January 2017 Item Number: 7/16 Title of report: Clinical Chair s Report Recommendation: For information Summary: The Clinical Chair s report covers the key areas of focus since Monday 31 st October The areas covered include Clinical Strategy Communications Sustainability of General Practice and the Transformation of Primary Care Meetings with external stakeholders 25

26 Sponsor: David Supple, Clinical Chair Author: David Supple Clinical Chair Date of report: 13 th January 2017 Financial implications: Nil specific of note Legal or compliance implications: Nil specific of note Link to key objective and/or assurance framework risk: The content of this document pertains to all corporate objectives. 26

27 Clinical Chair s Report January Background information This Clinical Chair s report covers the key messages and activities of the Clinical Chair up to the 13 th January Introduction Let me begin my first Clinical Chair s report by saying thank you to the Governing Body for welcoming me into my new role at Brighton and Hove CCG. Whilst I have been a local GP for many years, I have been struck by how much our City s healthcare requires strong and clinical led commissioning to improve patient experience and out comes from our patients. We have a lot to do and our team is committed to improve the healthcare experience of our population. Alongside the Chief Accountable Officer, I am confident that collectively we can face these challenges head on and I look forward to working with each of you. I would like to take the opportunity to thank Dr. Xavier Nalletamby for his work and the time to he gave me to talk me through his insights into the City. I would like to welcome today to the Governing Body, Dr. Andy Hodson our new Chief of Clinical Leadership and Engagement. Andy brings with him a wealth of clinical experience and I am confident that he will be an excellent asset to the Chief Accountable Officer s senior team. I would also like to welcome Rob Persey, Executive Director for Health and Adult Social Care for Brighton and Hove City Council to our Governing Body. I know our Chief Operating Officer has already had a number of positive meetings with Rob and I look forward to seeing the work both their teams can create in relation to service and commissioning integration. As part of my induction, I have tried to go to as many internal meetings as possible to get a good understanding as to how the organisation operates and I am looking forward to the feedback from our governance review. 3. Clinical Strategy In the agenda today the Chief Operating Officer will be updating you on the actions taken to pull together a clear and credible clinical strategy. We have productive discussions with our Clinical Strategy Group in December and January regarding the future multi-specialty community provider model and we aim to give a clear position to our member practices at the City Wide membership meeting on 31 st January. As part of the refreshed clinical strategy, I am also looking at the appropriate clinical leadership structure that we now need within the organization. I will be working closely with the Chief of Clinical Leadership and Engagement on this and will update the Governing Body on this in due course. 4. Communications I am keen to work with our member practices in a way that ensures we have meaningful dialogue and as such I will be working with the Chief Accountable Officer in a way that ensures we foster a better dialogue with our member practices. 5. Sustainability of General Practice and the Transformation of Primary Care I feel that a key part of my role is to ensure the standard of General Practice within dour City improves. At a national and local level, a number of our primary care colleagues are experiencing challenges. We as a CCG have committed to working more closely with our 27

28 practices to pull together a real time sustainability plan. Our practices will however need to work together in a different way to deliver these changes and as mentioned will start that discussion with them next week. 6. Meetings with external stakeholders I have spent time meeting a vast array of people over my first few months and I will continue to meet my counterpart Chairs and colleagues over the next month or so. Date: 13 th January 2017 Sponsor: David Supple, Clinical Chair 28

29 Name of Meeting: Governing Body Date of meeting: Tuesday 24 January 2017 Item Number: 8/17 Title of report: Chief Accountable Officer s Report Recommendation: For information Summary: The Chief Accountable Officer s report covers the key areas of focus since the last update to the Governing Body. The areas covered include CCG legal directions Portfolio changes within the Director team New starters 2017/18 Corporate objectives 2017/18 operational planning 2017/18 contract negotiations Current operational performance Brighton and Sussex University Hospitals NHS Trust Sustainability and Transformation Plan National bids for funding 29

30 Sponsor: Adam Doyle, Chief Accountable Officer Author: Adam Doyle, Chief Accountable Officer Date of report: 13 January 2017 Financial implications: The risks related to the 2017/18 financial plan is mentioned within the body of the document. Legal or compliance implications: The section related to legal directions and the governance review covers the issues related to the CCGs being placed in legal direction by NHS England Link to key objective and/or assurance framework risk: The content of this document pertains to all of the current corporate objectives. 30

31 Chief Accountable Officer Report January Background information This Chief Accountable Officer s report covers the key messages and activities of the Chief Accountable Officer since the last update to the Governing Body. 2. CCG Legal Directions It updated the Governing Body at our last meeting that as part of our legal directions, we are conducting a review of the governance within the organisation. Capsticks LLP have been commissioned to do this piece of work and as the Governing Body is aware, their approach is as follows: To review of papers of the Governing Body and committees of the Governing Body Meeting with all Governing Body members Observing all meetings of the Governing Body It is aimed that the first draft of the report will be shared with the Clinical Chair, the Lay Member for Governance and I at the beginning of February. We aim to use the Governing Body seminar February to go through the feedback with Capsticks. Capsticks are attending our meeting today and are sitting in the public gallery observing this meeting. 3. Portfolio changes within Director team As the Governing Body is aware I have spent time with the Directors within the management team to clarify roles and responsibilities. This had led to a more streamlined approach to the management of contracting, performance, communications and organisational development. I do not expect any further significant changes to the management structure apart from any further recommendations that come as part of our governance review. 4. New starters I would like to welcome Dr. Andy Hodson to his first meeting of the Governing Body. Andy joined us on 9 January 2017 and will sit as part of the Senior Management Team within the organisation. Since my last update to the Governing Body we have recruited Gail Newmarch as our temporary Director of System Resilience. Gail has had a significant impact in her role and she has worked very closely with our wider system partners to improve capacity and flow within our urgent and emergency care pathway. As a result we have seen a significant reduction in delayed transfers of care out of the hospital. I have now asked Gail to focus on the good flow of patients through the Royal Sussex County Hospital and the Princess Royal Hospital sites. I would also like to welcome James Corrigan as our Project Manager for our Caring Together programme. James comes with a wealth of experience working as a programme manager for a number of different health and care systems and he will report to our Chief Operating Officer for this work. Martha Robinson, Head of Communications had her last working day with the CCG on 20 January Martha was pivotal in a number of national leading campaigns in her time with the CCG and I would like to thank her for her support. We have offered the post to an excellent candidate and are in the final stages of pre-employment checks. Until the new post- 31

32 holder starts we have secured some interim support from Sian Carter an experienced communications specialist to cover this short gap /18 Corporate Objectives As part of ensuring we set a culture of delivery into 2017/18, I am currently reviewing the organisation s vision, values and corporate aims. Having reviewed them and discussed them with the senior team, they do seem fit for purpose but are in need of relaunch to ensure that all staff, members, partners and patients see them as central to what we do. I have also drafted the corporate objectives which will need to be formally agreed by the Governing Body in March. Moving forward I will ensure that the objective setting of all staff within the organisation is aligned to delivering our corporate objectives /18 operational planning We submitted our operational plan on time and have received very positive feedback on it. The key issues that we know we still need to address are delivering a full savings plan, crystalizing the deliverables that can be achieved through our Better Care fund plan and ensuring we have robust demand and capacity plans across our services. The team, are working hard on this and will be able to provide further detail in today s meeting. The key risk that needs to be highlighted to the Governing Body is that at the time of writing this report the CCG still does not have a financial plan that balances to meet the NHS England business rules for 2017/18. As such I have taken the necessary steps to ensure that council and voluntary sector partners aware of this. Brighton and Hove CCG must set a credible and balanced budget for 2017/18 and the senior management team has been tasked with this aim. As a result this may mean that the Governing Body needs to take some difficult decisions. The Chief Finance Officer will be covering these later today with us /18 contract negotiations As the Governing Body will be aware, it was the national expectation that we sign two year contracts by 23 December 2016 and I am pleased to say that our contract for Brighton and Sussex University Hospitals NHS Trust was signed by that deadline. All other major contracts have now been signed and we are currently working through any long stop contractual issues in preparation for 1 April Current operational performance As previously mentioned, the CCG performance in the areas of the NHS Constitution, Improving Health Outcomes, the Improvement and Assurance Framework is under review. I continue to work closely with the senior team to ensure we have a robust integrated performance framework that reports internally to the senior management team. This has improved since the last Governing Body but still has significant work to do to ensure that provide internal assurance. Due to the cultural changes that are required to deliver this, I have given the team until the end of quarter four to ensure this is in place. Our system has not been immune to the wider pressures the NHS has been experiencing. Our team have been chairing three daily teleconference calls to ensure that the system response is appropriate and in place. I receive regular briefings throughout the day on how the system is performing and intervene as appropriate. I would like to thank the staff within our teams and the health and care professionals working in all of the services we commission from. 32

33 9. Brighton and Sussex University Hospitals NHS Trust Later today we are holding a Board to Board meeting with the Trust and we are aiming to focus on the key elements of changes since the previous CQC inspection, the internal governance arrangements for the organisation and the transitional arrangements as the Trust moves to a new leadership structure. 10. Sustainability and Transformation Plan (STP) We published our Sustainability and Transformation plan at the end of November and I have been asked to speak about it with a number of partners, the Health and Wellbeing Board and the Health Overview and Scrutiny Committee. A key piece of work that we now need to focus on is the acute service model across Sussex and we ae currently working across the STP to do this. Our place based plan, Caring Together now needs to gain significant momentum and a delivery plan is expected to be shared with the Governing Body in March. 11. National bids for funding Across our STP we have made applications for two bids for national funding: Diabetes NHS England announced a 40m national fund to improve diabetes services in four priority areas: Improving the uptake of structured education for people with diabetes Improving the achievement of the NICE recommended treatment targets New or expanded multi-disciplinary footcare teams (MDFTs) New or expanded diabetes inpatient specialist nursing services (DISNs) Due to the short timeline for submission we have submitted a bid across our STP. The Chief Operating Officer will be shared this with our Clinical Strategy Group next month. Cancer The National Cancer Transformation programme has asked for bids from STP s that covers Prevention Earlier diagnosis Treatment and Care Living With and Beyond Cancer (LWBC) I have worked closely with a number of CCGs in the Central Sussex and East Surrey Alliance to give feedback to the wider STP on what we need to see in these areas and at the time of writing the bid was planned to be submitted on 18 January 2017 to meet the national timeline. Date: 13 January 2017 Sponsor: Adam Doyle, Chief Accountable Officer 33

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35 Name of Meeting: Governing Body Meeting Date of meeting: 24 th January 2017 Item Number: 9/17 Title of report: CCG Clinical Strategy update Recommendation: For information and noting Reviewed at: Clinical Strategy Group December 2016 and January 2017 Summary: This paper provides the Brighton & Hove Clinical Commissioning Group s (B&HCCG) Governing Body with an update on the CCG s emerging clinical strategy and journey towards a Multi-Specialty Community Provider (MCP). This paper describes the relationship between the CCG s strategy Brighton & Hove Caring Together, the Central Sussex and East Surrey Alliance (CSESA) and the Sustainability & Transformation Plan (STP). The CCG s Operating Plan and the CCG s document Implementing the General Practice Five Year Forward View submitted to NHS England in December 2016 both set out an ambitious programme to commission a fully operational Multi Specialty Community Provider by 2020 in line with neighbouring CCGs. The CCG s Clinical Strategy Group has agreed the following: Brighton & Hove Caring Together is CCG s strategic programme which delivers the out of hospital strategy, greater integration of health and social care and the roadmap to an MCP Brighton & Hove Caring Together is the CCG s contribution to the CSESA and STP. 35

36 MCP is the preferred new model of care for Brighton & Hove which provides all out of hospital care, operates on a population basis with a capitated budget and is the overarching organisation with which the CCG contracts for all out of hospital care Significant rapid change is required to provide sustainability within primary care The cluster model provides the building blocks for Caring Together however some changes needs to be considered to maximise neighbourhood, community and geographical alignment A GP federation is an essential element for Caring Together and requires the support of the CCG Significant engagement with the wider CCG membership is required to enable greater understanding of the proposed model 36

37 Lead Director: John Child - Chief Operating Officer Clinical Lead: Dr David Supple - CCG Chair & Dr Andy Hodson - Chief of Clinical Leadership and Engagement Author: John Child - Chief Operating Officer Date of report: 24 th January 2017 Financial implications: Developing new models of care is crucial for the financial sustainability of the CCG and the wider health and social care economy over the next five years. Legal or compliance implications: The CCG will ensure that future models of care are subject to procurement processes which will comply with the relevant statutory requirement using the MCP contractual framework published in July Link to key objective and/or assurance framework risk: Development of the CCG clinical strategy aligns with all key objectives. Patient, carer and public engagement: The CCG remains committed to ensuring full public engagement and consultation around emerging new models of care. To the date the CCG has held several public events to discuss the CCG s strategy Caring Together. This has also been presented at the Brighton & Hove Health & Well Being Board. The journey towards new models of care in Brighton & Hove is a key component of the wider regional planning forming part of the Central Sussex & East Surrey Alliance and the Sussex & East Surrey Sustainability and Transformation Plan footprint. The CCG and partner organisations are committed to full public engagement on both of these plans. Equality Impact Assessment An EIA will be completed once plans are further developed and the CCG will ensure this is built into the overarching programme of work. 37

38 Brighton & Hove Clinical Commissioning Group s Clinical Strategy 1. Background information & strategic context Brighton & Hove CCG is part of the Sussex and East Surrey Sustainability and Transformation (STP) regional footprint. The STP has developed three individual placebased planning areas; Brighton & Hove CCG is part of the Central Sussex & East Surrey (CSESA) footprint. All the organisations within the CSESA footprint have a shared ambition to transform the current model of care in line with the direction set out in the NHS Five Year Forward View and the local STP. The CCG as a member of the CSESA shares a collective vision to develop a system of healthcare that is less reactive, less hospital based and with fewer bed based services. The proposed model of care will ensure integration of existing health and social care services is central to its development and services will be provided closer to patients homes and places of need. The CSESA alliance shares the following overarching strategic objectives: Care designed for the needs of local populations Meaningful integration of providers Sustainability of primary care Sustainability of acute care These high level strategic objectives include an ambition to develop MCPs with general practice at the centre of the model and to transfer significant levels of activity from acute to community settings. If successful this will support the long term sustainability of primary care, enable acute providers to meet and exceed NHS constitutional quality and performance thresholds and reduce total healthcare spending to enable long term financial sustainability of both the local and regional health and social care economy. The CCG s Operating Plan and the CCG s document Implementing the General Practice Five Year Forward View submitted to NHS England in December 2016 both set out an ambitious programme to commission a fully operational Multi Specialty Community Provider by 2020 in line with neighbouring CCGs. 2. Brighton & Hove Caring Together The CCG s strategic out of hospital transformation plan for the City is referred to as Brighton & Hove Caring Together. Caring Together is the CCG s contribution to and local interpretation of the wider regional planning footprints. Whilst the CCG is leading the Caring Together programme it is recognized as a City- wide transformation plan to include existing NHS health care providers, the City Council s social care and public health services, the community and voluntary sector and the independent social care providers. During 2015/16 the CCG invested to deliver care differently for the most complex patients in the City via the Proactive Care programme. As a result GP practices began the fundamental shift in culture from working as independent entities to a model which embraces collaboration and partnership. As a result practices in the City are networked into six clusters. Each cluster serves a community of thousand patients and works in partnership with the 38

39 wider community, namely pharmacists, NHS providers, the community and voluntary sectors and adult social care. It is proposed that via the Caring Together programme these clusters will be supported to evolve into an MCP. The Caring Together programme will provide the strategic vehicle for transformational change within Brighton & Hove. It will provide a publically identifiable programme of change pulling together the existing elements of primary care cluster development, Proactive Care and the integration work delivered to date by the CCG s and the Council s Better Care Plan. To date the Caring Together programme has articulated high level aims and outcomes for Brighton & Hove but further work on the detailed implementation plans is required with clear milestones throughout 2017/18. Therefore the CCG has secured a dedicated Programme Director resource to drive the programme forward and support the development of the MCP. The CCG has developed draft governance arrangements for the Caring Together programme which includes an executive led partnership group and an operational delivery group. It is proposed these governance arrangements incorporate the existing Better Care Board and the Integrated Provider Board to ensure the programme is shared equally by commissioners and providers. The executive group first met in November 2016 and the CCG is seeking to fully transition to new governance and programme structure by March Further work is required to ensure the Caring Together structure dovetails with the Brighton & Hove Health & Well Being Board and the STP governance structure. During October & November the CCG and the Council jointly hosted a series of Caring Together public engagement events to raise awareness of the proposed programme of work and seek views from the public as to how services should be developed. These events also included an explanation of both the STP and the CSESA plans and how these related to Caring Together. Brighton & Hove CCG membership voted in support of the creation of a Federation in 2016 to build a more resilient and sustainable model for primary care. Further development of the Federation is now required in order to support the journey to MCP. 3. Clinical Strategy Group In December and January the CCG s Clinical Strategy Group (CSG) has further considered the CCG s emerging clinical strategy and journey towards an MCP to ensure the proposed future model of care is clinically led and meets the requirements of the City s general practice. Over the course of two workshops the CSG agreed the following: Brighton & Hove Caring Together is CCG s strategic programme which delivers the out of hospital strategy, greater integration of health and social care and the roadmap to an MCP Brighton & Hove Caring Together is the CCG s contribution to the CSESA and STP. MCP is the preferred new model of care for Brighton & Hove which provides all out of hospital care, operates on a population basis with a capitated budget and is the overarching organisation with which the CCG contracts for all out of hospital care Significant rapid change is required to provide sustainability within primary care 39

40 The cluster model provides the building blocks for Caring Together however some changes needs to be considered to maximise neighbourhood, community and geographical alignment A GP federation is an essential element for Caring Together and requires the support of the CCG Significant engagement with the wider CCG membership is required to enable greater understanding of the proposed model 4. Timeline to MCP and next steps The CCG has secured Programme Director resource to lead on Caring Together from January The CCG proposes to have a written clinical strategy with a detailed project plan for implementation by the end of March 2017 setting out the roadmap towards an MCP. Central to the success of delivering Caring Together will be, in addition to a detailed implementation plan, the realignment of existing commissioning activity to ensure it fulfills the objectives of the clinical strategy and aligns to the overall vision. Other key timeframes include: Quarter /17 - develop federation implementation plan and develop new governance arrangements Quarter /18 - embed governance arrangements and develop capitation model Quarter /18 - federation in place Shadow MCP in place Quarter /19 with a fully functioning MCP from the following year. The CSG needs to further consider the clinical model for the proposed model of care, how current community services (both physical and mental health) are aligned with any proposed changes to the cluster arrangement and the key outcomes framework for any new provision. Date: 24 th January 2017 Lead Director: John Child, Chief Operating Officer 40

41 Name of Meeting: Governing Body Date of meeting: January 2017 Item Number: 10/17 Title of report: Brighton and Hove CCG Operating Plan Recommendation: Governing Body are asked to: Approve the Brighton and Hove Operating Plan (see appendix 1). Summary: CCGs are required to submit a two year operating plan for the period April 2017 to March The attached Brighton and Hove CCG Operating Plan describes how we will deliver years 2 and 3 of our place based plan and is aligned to the delivery of the Sustainability and Transformation Plan. It sets out the detailed plans including what we will deliver by when, how we will measure the impact and is underpinned by detailed financial and activity plans. The full narrative plan is contained in Appendix 1. A short summary of the plan will be produced and published on our website alongside the full plan, following approval by the Governing Body and NHS England. To allow detailed monitoring against delivery of the plan all of the key performances indicators will be included in the new Integrated Finance, Performance and Quality Report (see separate agenda item). The Performance and Governance Committee reviewed and approved the plan on 20 th December The plan was subsequently submitted to NHS England on 23 rd December NHS England will provide an assurance rating for the plan in January 2017 this will be shared with the Governing Body upon receipt. 41

42 Sponsor: Lola Banjoko, Director of Performance and Delivery Author: Ramona Booth, Head of Planning and Delivery Date of report: 15 th December 2016 Financial implications: N/a Legal or compliance implications: NHS Constitution Standards Link to key objective and/or assurance framework risk: Improvement and Assessment Framework NHS Outcomes Framework 42

43 Operating Plan December

44 Operating Plan Contents 1. Introduction Planning Landscape Sussex and East Surrey Sustainability and Transformation Plan Central Sussex and East Surrey Place Based Planning Brighton and Hove Caring Together Brighton and Hove Operating Plan Primary Care and Community Services (Out of hospital services) Urgent Care Elective Care Cancer Mental Health Transforming Care for people with Learning Disabilities and Autism Quality & Safety Technology, Research, Innovation & Growth Immunisation Prevention and screening Children s, Young people s and Maternity Services Medicines Management NHS Continuing Health Care Estates Plan Financial Plan Governance and Assurance Patient and public engagement Conclusion Glossary 71 Plan on a Page 74 44

45 1. Introduction Brighton and Hove CCG is a part of the Sussex and East Surrey Sustainability and Transformation Plan (STP). Our STP area is home to 1.7 million people and has a health and social care budget of 4 billion. We recognise that demand and cost are increasing and our budgets are not. To address this, the STP describes a model of care that supports citizens to improve and manage their own care and ensures that when help is needed it is provided in an integrated and efficient way. The STP has developed three place-based planning areas. Brighton and Hove CCG is part of the Central Sussex and East Surrey Alliance (CSESA) planning area. The organisations that form the CSESA area have a collective commitment to transform the model of care in line with the direction set out in the STP. We have set out an ambitious programme to realize fully operational, legal Multispecialty Community Provider (MCP) entities by This will be underpinned by realization of robust benefits of the new care models, delegated population-based budgets and reform of the commissioner landscape. This Operating Plan describes how we will deliver years 2 and 3 of our place-based plan and thus our contribution to the STP (plan on a page available in Appendix 1). This document sets out the detailed plans including what we will deliver by when and how we will measure the impact and is underpinned by detailed financial and activity plans. Throughout the plan we have articulated the key risks to delivery and the associated mitigations. The STP defines Years 1-2 as addressing the quality and performance gaps. As a challenged system we have much to improve. In the past two years the local health and care system has faced significant performance challenges. Access to emergency care services has been below the required standards, people have faced long waits for planned care services and there have been an increasing number of people whose transfer from hospital has been delayed. Improving the performance against key national and local targets is of paramount importance to the local system. As such, our plans focus on the dual themes of delivering short term recovery whilst laying the foundations for the longer term models of care. This will ensure sustainable delivery of high quality health and care services in the future. In line with the STP we will start transformation of services in 17/18 and in years 3-4 accelerate and embed the changes by year 5. The Operating Plan, whilst aligned to the STP, is structured around the Must Do s as set out in the Planning Guidance. In each section the place based objectives are outlined and the Brighton and Hove contribution to their delivery through system wide change and the delivery of local improvement is quantified. This document sets out a clear and quantified roadmap for the next two years for Brighton and Hove CCG. We recognise that to meet the challenges set out in the Five Year Forward View and presented by the local system, we need a credible plan and robust systems in place to ensure delivery. Under the direction of our new Accountable Officer we will move to a process of systematic review and delivery. This will be underpinned by the required changes in our organisation both culturally and structurally. Through the delivery of the place based plan and our Operating Plan we intend to meet our legal directions by the end of 2017/18 and deliver the sustained improvement in 2018/19. 45

46 This plan sets out our absolute commitment to delivering the STP aspirations and system control total as well as the NHS Constitution Standards. 2. Planning Landscape The health and care planning landscape is complex and multidimensional. Our plans have been developed at local, place and regional level. They have been developed sequentially and are mutually reinforcing. Figure 1 below illustrates how the plans fit together: Figure 1: Planning Landscape Sussex and East Surrey Sustainability and Transformation Plan We have a large and diverse STP footprint. Care is provided by 23 separate organisations, resulting in fragmentation and complexity in planning and delivering high quality services. At the heart of our STP is the commitment to work together to solve these issues and improve quality and outcomes. Our aspirations for longer term transformation and delivery of the NHS Five Year Forward View (FYFV) is through our three places as we feel this is the best way to be responsive to diverse local needs. Sussex and East Surrey footprint Coastal Care East Sussex Better Together Figure 2: Sussex and East Surrey Sustainability and Transformation Plan Footprint 46

47 In addition to the place based plans we feel there are further benefits to working together as an STP and have agreed to focus on three areas: frailty, urgent care and primary care transformation. These themes run through our place-based plan and this Operating Plan. 4. Central Sussex and East Surrey Place Based Planning The Central Sussex and East Surrey Alliance (CSESA) is the central of the three places which make up the STP. Crawley Horsham & Mid Sussex Brighton & Hove East Surrey High Weald Lewes Havens 1.2M people 1.6bn annual healthcare spend 117 general practices 5 CCGs 4 local authorities 7 district councils 3 acute trusts 5 acute hospitals 5 community hospitals 2 community health trusts 2 mental health trusts 1 ambulance trust Figure 3: Central Sussex and East Surrey Alliance The Central Sussex and East Surrey Alliance have a collective vision to develop a system of healthcare that is less reactive and less hospital bed-based. It will deliver a great start in life and continue to promote people s wellbeing, their ability to stay healthy, to self-care and be cared for at home. We will bring together a system which places integration at it s centre, providing more care and services closer to patients homes and places of need. Led by primary care, we will build on the good work already in progress, promoting collaboration between all organisations working across health and social care. Our aspirations are described in a set of overarching strategic objectives set out in table 1. Care designed for the needs of local populations Meaningful integration of providers Sustainability of primary care Sustainability of acute care Uses detailed, integrated health and social care datasets based on combined GP lists to determine the changing needs of local people as an ongoing evaluation, not a snapshot Applies risk stratification using real-time data and RightCare methodology to drive proactive interventions to keep people healthy Identifies demographic subsets based on factors such as isolation, dependency, deprivation Delivers real organisational and operational integration between primary and community services Enables effective integration of mental health, adults and children s social care and acute services into a team around the patient Weaves social care tightly with healthcare to address the needs of the Reduces people s dependence on the system and its services Empowers and supports front-line primary care to take a system leadership role Builds broader, resilient general practice at the heart of the MCP model Releases GP capacity through an increased use Enables acute providers to meet and exceed the constitutional quality & performance thresholds Transfers significant levels of activity from acute to community setting Reduces total healthcare spend to enable long-term sustainability Reduces pressure on the acute system to allow 47

48 Care designed for the needs of local populations Meaningful integration of providers Sustainability of primary care Sustainability of acute care to determine additional or focused services Applies the pay-it-forward principle to developing systems of care for children and families especially complex ones Identifies and supports carers, to protect the pivotal role they play Maintains equality of service access and is developed in partnership with the population Supports patient choice to ensure dignity and quality of life whole person and family Builds working at-scale and removes existing organisation boundaries Formalises significant third sector support Uses single data systems for a seamless patient experience and real-time handovers Links people to a range of support services via social prescribing of skill mix Enables GPs to focus on complex patients and planned care Increases capacity and capabilities in primary care to enable delivery of service currently in acute including direct cancer diagnosis and some levels of speciality current in secondary focus on specialist acute care Provides care closer to home and minimises the need for admissions Dovetails primary & community care closely with acute capability and capacity to balance supply with demand Enables the system-wide carbon management approach Table 1: Central Sussex and East Surrey Alliance Strategic Objectives 5. Brighton and Hove Caring Together Implementing the local changes required to deliver our place based plan is referred to locally as Brighton and Hove Caring Together and illustrated in Figure 4 below. Figure 4: Brighton and Hove Caring Together 48

49 The Caring Together model has been co-designed by local commissioners and providers. Our collective commitment to this approach is enshrined in a statement of intent signed by our respective Chief Executives in Establishing the required infrastructure to deliver the new model of care will take 3-5 years, however the improved health and wellbeing of the citizens of Brighton and Hove will be realized over a much longer period. The plan is therefore described in phases. The current phase ( ) describes a new approach to the commissioning of services combining health and care budgets and co-location of commissioning teams. The next phase ( ) describes a significantly changed provision of services through the vehicle of a multispecialty community provider (MCP) and the third phase ( ) outlines the long term improvement in health and wellbeing of the citizens of Brighton and Hove. 6. Brighton and Hove Operating Plan The Brighton and Hove Operating Plan is our roadmap for delivery for the next two years. We have used the RightCare Approach to identify the areas with greatest opportunity for improvement. These form the basis of our pathway redesign projects. In addition the plan focuses on the themes of addressing the performance and quality issues that we face currently and laying the foundations for the delivery of the new models of care. This document is structured around the Must Do s as set out in the Planning Guidance. In each section the STP and place based objectives are outlined and the Brighton and Hove contribution to their delivery through system wide change and the delivery of local improvement is quantified. In addition each section sets out how we will restore performance to the expected levels and the timescales for doing so. 6.1 Primary Care and Community Services (Out of hospital services) There is national recognition that transformational change in all areas of health and social care service models and delivery is necessary to address the increase in the demand and complexity of the population needs. Our Sustainable Transformation Plan describes the strategic changes required to meet these needs and general practice and community care is recognised as a cornerstone to this transformation. The Brighton and Hove CCG Primary and Community Care alignment and support for the regional STP plan is best articulated through it s fit with the Central Sussex and East Surrey Alliance Place Based Delivery Plan. This Plan provides the detail to support the STP ambitions. For Primary and Community Care this specifically addresses the drive to deliver a transformational model based on the development of Multispecialty Community Providers. This plan confirms the commitment the local system has to meeting the challenges set by the General Practice Five Year Forward View in particular the delivery to our population of improved access, the funding and transformation of new models of care and the development of a sustainable and skilled workforce to deliver these ambitions. The CCG approach to Primary and Community Care, which is outlined below, covers the challenges the local system has faced in terms of performance and models solutions to the attainment of a recovered and sustainable future model of primary care. Primary Care Investment Brighton and Hove CCG will be increasing investment into General Practice in 2017/18 and 2018/19 in line with the proposals set out in the General Practice Five Year Forward View (FYFV). 49

50 The following plans are in place: 900k will be invested in transformational support from national CCG allocations as a nonrecurrent spend of 3 per head of the CCG population. This investment will be utilised for implementation of the 10 High Impact Actions and ensuring future sustainability in line with national guidance 90k will be allocated for expenditure on online General Practice consultation software 60k will be assigned to the training of care navigators and medical assistants for all practices within the city 1,800k funding will be used to improve access to General Practice The CCG has made a bid for the Estates and Technology Transformation Fund and confirmation will be provided in due course regarding whether we have been successful. We are also committed to gaining funding for other aspects of General Practice and intend to ensure access to GP training funding from Health Education England, and to supporting national efforts for investment in GP IT systems. In addition, we will collaborate with Public Health locally to increase the section 7A funding for screening and immunisations. Care Re-design As part of our alignment to the General Practice Five Year Forward Plan, we will be re-designing services to improve outcomes and ensure sustainability going forward. We have already been working towards this through the introduction of Proactive Care in the 6 clusters across the City, and plan to develop Multispecialty Community Providers in by 2020 using levers contained in Co- Commissioning and the General Practice Five year Forward View. The Multispecialty Community Providers ambition is a specific vision which dissolves the historical boundaries between primary, community, mental health and social care and is better placed to support a quality driven, preventative agenda which frees restricted resources to target those most in need/complex cases. Working at scale in these communities will the bridge workforce and capacity gaps in our general practice community which is a major obstacle to care model transformation. Brighton and Hove CCG is mirroring the direction of the Place Based Plan ambitions with the formation of six city wide practice clusters. These clusters are working in partnership with wider community based providers and are being supported to focus care around their registered populations of thousand patients. Going forward, these Clusters will be supported to evolve into MCPs (as per the Care Model and Contractual Framework published in July 2016). As an enabler to this, the CCG is reviewing community sector contracts and re-scoping services to align with this vision. Moving forward, and with an eye to the evolution of a system of MCPs, the 5 component CCG s of the Central Sussex and East Surrey Alliance have agreed on shared methodology and primary care objectives and principles. To ensure consistency of approach and quality, these 5 CCGs will jointly commission the legal and contracting support necessary for these MCPs across the footprint. Integral to this plan for care re-design is the underpinning intention to continue empowering and supporting our citizens to self-care. This includes the roll-out of the High Impact Action signposting, the Social Prescribing project and supporting self-care through the local My Life website and Every Contact Counts in order to alleviate general practice capacity issues. 50

51 Improved Access and delivering high impact actions Using the additional funding outlined above, we plan to support practices in the timing of appointments and commissioning additional consultation capacity. In addition, there will be an increase in advertisements regarding services to patients including publicity of practice, pharmacy and dental service opening hours so that it is clear to patients when they are able to access these services. Practice receptionists will also be trained to signpost patients to services and new consultation types will be delivered, such as online consultations. Digital technology approaches will continue to be used to support new models of care and improvement in access, including the risk stratification tool to identify patients at risk of losing independence and hospital admission and the introduction of the shared care record to all practices by the end of 2016/17. In addition, the CCG will continue to develop a digital roadmap and the GP dashboard. Currently there are significant inequalities in patients experience of accessing general practice throughout the city. We have already supported the procurement of the Homeless Practice, and we will continue to address these through cluster-working i.e. partnership working (one of the ten High Impact Actions), roll-out of the Locally Commissioned Services for Primary Care, and through close collaboration with the NHS England regional team to support the dispersal of patients affected by the Practice Group contract withdrawal. To ensure access to wider whole system services, the CCG will be learning from the Access Fund and disseminating this to general practice and will utilise the additional 3 per head investment to improve access through released capacity, timing of appointments and aforementioned new consultation types. Additional General Practitioner capacity will be enabled through the application for and roll-out of the Time to Care programme which will help us to support practices to help staff increase the time they spend directly with patients. The CCG will develop and submit an application for the Time to Care programme and subsequently support practices to enrol in the programme with the help of an assigned Facilitator. This work will involve changing working environments and the way in which routine tasks are carried out through implementation of appropriate High Impact Actions, building on the workflow re-direction work that is already underway locally. Workforce and Workload To allow these changes to take place, the general practice workforce will need to be strengthened and made increasingly sustainable. The CCG will achieve this through re-directing workflow within practices, and supporting transformation through the adoption of the Releasing Time to Care programme. A programme of upskilling reception and clerical staff has commenced to develop greater skills in supporting the process of coding and identifying clinical streaming of information via the EPIC programme, and this will continue to be rolled out. We have a Primary Care Workforce Tutor in post funded by Health Education England, Kent, Surrey and Sussex (HEE-KSS), working with Universities and primary care to support the training and placement co-ordination of nurses and GP trainees into the area. We have had 27 practice nurses update or complete their mentorship qualification. This is an increase from 5 practice nurse mentors to 32 practice nurse mentors over the past 2 years. This has enabled 30 student nurses from Brighton University to have training placements within Brighton and Hove GP practices. The number of placements will be increased over the next year. The 2017 student nurse placement program has already been agreed with practices and 24 51

52 student placements have been planned so far. All 6 clusters are participating in a rolling programme to ensure no practice is overburdened. A hub and spoke model will allow smaller practices to support the program and gain from the value of having students. In January 2017 three more practice nurses will commence the mentorship course at the University of Brighton, increasing the number of placements available for student nurses. Three experienced mentors have completed further training to become sign off mentors in order to ensure a robust and quality training experience for third year student nurses who have undertaken their management placements within primary care, encouraging them to consider primary care as a career option. Mentors within the city are supported at a mentorship support group, which is delivered locally once a year so they can share ideas and experiences to support students. Brighton and Hove CCG recognise the need to work with practices to look at skill mix in practices and across multi-organisational community teams, and to develop career pathways to offer newly qualified staff real opportunities to achieve varied and structured development in the community from point of qualification. New practice nurses to Brighton and Hove are encouraged to undertake an introduction to practice nurse course at the University of Brighton. The course was originally commissioned by HEE-KSS to ensure the development of a well-trained practice nurse workforce with the skills and knowledge to meet the changing needs in primary care. This has been supported with a programme of training delivered across Sussex, providing knowledge and skills on long term conditions, childhood immunisation and wound management to ensure new nurses feel confident, competent and supported in their new role. The primary care workforce tutors have proposed an STP workforce initiative, for this course to be extended to new community nurses as well, so dual training can be introduced to enable closer working to support placed based care. Practice nurses within the city have been encouraged to also upskill and develop so they can take on extended roles. Brighton and Hove currently has five practice nurses undertaking MSc specialist practice pathway in general practice nursing, one nurse completing the BSc specialist practice pathway and one nurse completing modules on the MSc Advanced Practice (Health). They will gain extended skills in physical assessment, non-medical prescribing, chronic conditions and leadership. This will enable them once qualified, to increase their role within clusters to support GPs. Some of these nurses, when they have consolidated their learning, will be able to work as Advanced Nurse Practitioners. We are also supporting five nurses to undertake the Diabetes in Primary Care module delivered at the Brighton and Sussex Medical School. Practice nurses are also supported at a practice nurse forum where they can discuss best practice, to ensure quality and safe care for patients and to ensure they are meeting CQC regulations. Healthcare assistants (HCAs) have also been supported to upskill, with the development of a Band 1-4 skills, qualification and competency framework. This has encouraged six HCAs to start health and social care apprenticeships. Brighton and Hove is also supporting four HCAs to undertake the foundation degree at Brighton University, so they can expand their roles. It is anticipated that a new project to risk assess HCA skill delivery and assess if they can deliver some of the skills delivered by nurses will commence next year using the Calderdale risk assessment tool. The Primary Care Workforce Tutor is also in discussions with the University of Brighton about the new Nurse Associate role. We are additionally supporting the return to practice programme for nurses. Working with larger NHS providers, there is a Director of Nursing Group which identifies ways of supporting primary care and nursing home practitioners to access multi-organisational consistent high quality training and development through the use of skills labs across Sussex. Through joint 52

53 working encompassed in the STP workforce plan and with Skills for Health we are looking at ensuring consistency in the skills and competencies across staff groups, levels and organisations to enable more flexibility across working environments and organisational boundaries to be able to match workload and demand with capacity. Brighton and Hove are also working closely with HEE-KSS and the STP footprint to develop Community Education Provider Networks (CEPN). This will be an education delivery board consisting of groups of primary and community care organisations that will come together as a group of like-minded providers to collaborate on: workforce, education, training and placements, creating an integrated and multi- disciplinary approach in response to workforce planning. Brighton and Hove CCG has circulated a workforce directory to encourage practices and clusters to consider ways to contribute to the growth of the workforce, either by supporting an apprenticeship, hosting a student or investing in existing staff. The directory is broken down into four initiatives: Creating opportunities to attract people to the healthcare profession e.g. Work Experience Placements, Business and Administrative/Health Care Apprenticeships Creating opportunities to attract existing health professionals who may never have considered a career in Primary Care e.g. Pre-Registration Nursing Students, Medical Students, FY2 s, GP Trainees, Pharmacy students, Paramedic students Attracting people back to the profession e.g. Return to Nursing Campaign, Return to Medicine/General Practice/ Retainer Scheme, Physician Assistants Providing opportunities to up-skill present staff, so they can extend their sphere of practice and take on more responsibility e.g. Advanced Nurse Practitioner, BSc - General Practice Nurse, Foundation Degree - HCA Brighton and Sussex Medical School is designing the development and delivery of a Physician s Assistant (PA) curriculum and it is expected that placements will be required from One of the practices has signed up to support PAs, and is also currently employing paramedic practitioners to work alongside GPs. Our practices have supported the HEE workforce tool (WRaPT) to inform our knowledge regarding workforce capacity and skills gaps, using the opportunity that collaborating with partners across the STP and using the WRaPT tool will bring, allowing more specific workflow transformation impact analysis and planning. Improving our baseline data of numbers of GP, registered nurses, support staff, practice managers and administrators will be established in order to inform us on recruitment and retentions needs. This will also establish the education and development programmes required to build sustainability and succession planning. The CCG along with STP partners will determine strategies for reducing locum costs and invest in Clinical Champions to work with the Royal College of General Practitioners and HEE-KSS. We know that we have high numbers of GPs who work as locums in the city. Through informal discussion we recognise that there is a level of choice in working in this manner allowing a flexible career and a mixed career. We will be working with our clinical leads and GP tutors to explore what will support flexible work options whilst ensuring the population receives high quality and consistent medical services. The GP retainer scheme has been advertised within the city. Also, we will be taking part in initiatives to attract and retain GPs and other clinical staff, for example by submitting our interest to NHS England for the Career Plus Programme (for clinicians over 50 years of age) and funding practice-based mental health therapists. 53

54 The CCG recognise that pharmacists play an important role in helping GP practices and primary care providers fill their gaps quickly, practically and cost-effectively. We already have 4 pharmacists in a group of our surgeries which are part of phase one of the NHS England Pharmacists in GP surgeries pilot and we are encouraging and supporting practices to apply for more pharmacists via phase two. In addition we fund six Better Care pharmacists, one in each of our clusters who support practices in managing long term conditions, conducting medication reviews and running minor ailments clinics. We also have a Consultant cardiac pharmacist who is running Atrial Fibrillation and hypertension clinics on behalf of a cluster and who is training nurses and other pharmacists in the city in these skills. We have a pharmacist and technician who run a care/nursing home medication review service who are supported by a dietitian and a nurse who look after medication, nutrition and hydration issues for 2000 patients in the city. Practices are recognising the valuable role pharmacists play in healthcare and increasing numbers are seeking to directly employ their own practice pharmacy support. In addition to this our plans are to continue to integrate with community pharmacists to ensure a seamless delivery of care across the city. We are delivering the NHS England Pilot Urgent Repeat Medication Service which is another example of using the workforce of pharmacists to take the pressure off the urgent care system. We will continue to grow the workforce and use pharmacists in primary care to enable us to deliver the FYFV. We will continue to facilitate the development of Multispecialty Community Providers and outcomes-based cluster-working to provide greater integration across services and optimise primary care for patients. Also, we will be working to increase care navigator and medical assistant presence in General Practice. Deployment of funding for training of reception and clerical staff, and online consultation systems Upon receipt of any funds granted for this purpose, the CCG will consult with practices on staff training and determine monitoring arrangements. On completion of this work, practices and staff will be identified for training in active signposting or document management and training will be provided alongside the Releasing Time for Care programme and the wider workflow re-direction. To further support these efforts, the CCG will consult with member practices on their online consultation requirements in order to develop this appropriately once the 90k investment in online consultation system development has been made. We will identify a number of practices to run online consultations in order to test the system prior to roll-out across the city. Throughout this process, we will share learning with other organisations within the STP footprint and consider joint procurement of the online consultation tool. To promote sustainability in workload, we are working to empower citizens and increase patient self-management within our STP footprint. To achieve this we already provide the My Life website and Every Contact Counts in primary care, and we are planning to deliver a model of social prescribing spanning primary, community and secondary care in the city, after learning from the initial 16 practices. 54

55 Additionally, through the roll out of the Primary Care LCS, patients will be offered the opportunity to create a personalised self-management plan with the relevant health professionals, which could include access to medicines management support and use of telecare/telehealth. Practice infrastructure The CCG has developed a local digital roadmap (prioritising interoperability) and estates strategy to support new models of care. Further details can be found in chapter 6.8. Also, we will support the General Practice pilot of the Extraction Programme Invitation and will develop a database of all services (including building and contract needs) for use by practices. Improving outcomes for our patients To support the delivery of new models of care and mitigate the pressures on the system and workforce, the CCG has worked with Public Health colleagues to assess the needs of our local communities and map them against local community assets, including general practices and voluntary organisations. Further to this, the CCG has developed and invested in an outcomes based approach to locally commissioned services which will reduce inequalities, support people to stay physically and mentally well and identify and manage patients at high risk of acute and chronic diseases. The additional funding, and the contractual approach that underpins this LCS, will provide General Practice with the confidence and means to invest in capacity and new ways of working. The aim of the LCS is to invest in General Practice to enable them to deliver services that will provide enhanced access, management and coordination of care for patients with long term conditions and provide practices with the investment and opportunities to deliver investigations and interventions precluding the need for onward referrals. Federation Brighton and Hove CCG Membership voted in support of the creation of a Federation to build a more resilient and sustainable business model for primary care based on collaboration and providing an equitable voice on the direction and delivery of Primary Care. Co-commissioning The CCG has been endorsed by its membership to request delegated responsibility for the Cocommissioning of Primary Care. The forthcoming challenge of co-commissioning requires robust governance arrangements and some changes will be required as this progresses. The CCG Primary Care Operational Group will lead the overall development of a primary care strategy in Brighton and Hove with dual purposes covering, strategy and development and Transactional. The latter will have delegated decision making powers from Primary Care Commissioning Committee. This group will concentrate on the contractual execution of service development and strategy, monitoring contracts and performance in primary care and the management of individual working groups delivering the primary care strategy. The Committee will ensure that the transactional aspects of primary care commissioning are undertaken quickly, efficiently, clearly and in line with national regulation and local strategy and provide assurance to the Governing Body. Reducing demand by addressing variation We are working with clusters and individual practices to enhance their understanding of the impact of referral rates on patient experience by sharing the outputs from the referral navigation service. These bespoke reports are shared with practices and provide benchmarked activity by provider 55

56 and specialty. Through structured support provided by our three Locality Member Group Chairs we will actively seek to improve referral behaviours and reduce variation. Over time through the expansion of advice and guidance services and the realignment of primary care incentives we will further reduce demand for acute based services. This is covered additionally under Planned Care on pages 22 and 23. Community Services The commissioning and contracting approach with Sussex Community Foundation Trust for the period reflects the strategic direction outlined above. In summary the CCG s key requirements are as follows: Aligning community health services with the six geographic clusters of primary care services across the city - this will involve working with the CCG, general practice and other partners to develop a hub and spoke model whereby services are aligned to support an agreed optimum population Develop a more detailed understanding of the SCFT cost base and activity across all services and care pathways this will help to reshape services to MCP model in collaboration with CSESA Integrating a range of existing community health services within multi-disciplinary team working to support the needs of a particular cluster population, with specialist clinical expertise aggregated to work city-wide or across groups of clusters Creation of flexible multi-disciplinary teams, rather than very specific services that target narrow cohorts of patients Reviewing specialist nursing services to determine what aspects can be delivered by your generalist community nursing teams e.g. wound care and falls prevention Developing community based consultant led care Building a resilient model of care based around a single point of access with timely referral to the appropriate cluster or city-wide service Building a culture of personalised care across cluster and city-wide integrated delivery teams - this will include professionals facilitating personal care planning discussions with individuals regarding their choice of preferred care options Developing an agreed approach to introducing capitated budgets - this will include defining agreed outcomes for local services and determining shadow arrangements for resourcing sub-acute services Agreement of an outcomes framework encompassing community, primary, mental health and social care. In addition to the actions required to align community provision with the new model of care there are other specific areas of focus in 2017/18 and 2018/19. These are covered in the sections below. Diabetes NHS England published new ratings in October 2016 identifying six clinical priorities. Against the diabetes measures Brighton and Hove CCG is rated as performing well which reflects our strong performance against the national targets and additionally, Brighton and Hove has achieved 100% participation in the National Diabetes Audit 2015/16, ranking us amongst the top CCGs in the country. 56

57 A new consultant led Diabetes Care for You community service opened in July 2016 following specification to meet the national priorities for diabetes care. Diabetes Care for You offer local patients with Type 1 and Type 2 diabetes Consultant-led care for the first time with the choice of two community settings to improve accessibility and provide patients the opportunity to move seamlessly through their care pathway. The service includes Diabetes Specialist Nurses, Dieticians, Podiatrists and Psychologists all working together under the leadership of Consultant Diabetologists to offer care and support to help people manage their diabetes. The new Diabetes Community Service will continue to have close links with hospital based diabetes services to ensure that if needed, patients will have access to all of the services and further specialist clinicians their condition requires. Structured education will now be delivered by this service in groups and it is expected that as a result of this change, uptake will be improved. We know that previously, reporting for structured education has not been as good as it should have been. All letters now have READ codes, so once an individual has completed the programme (or did not attend or did not complete) a letter will be sent to the practice with the appropriate READ code to be entered into the patient record, which should significantly improve our reporting to achieve this target. In addition to the above, the CCG will bid for a portion of 80m central funding to promote access to evidence based interventions. Brighton and Hove CCG will be working with CCGs across the STP footprint to submit a single STP footprint bid. It has been agreed that the lead focus should be foot care and that the funding request should include some funding for the 3 other areas that can be covered in the bid (inpatient, 3 treatment targets and patient education) which could be developed based on local individual Sussex CCGs but will be included in the single bid. The Vascular Network (co-ordinated by BSUH) will provide the conduit to support the implementation of the foot care project should the funding be awarded. Brighton and Hove CCG have agreed to administrate monies if the bid is successful across CCG s based on the provision of a band 4 worker which is included as part of the bid. Dementia Since the publication of the six clinical priorities, which identified need for improvement in dementia services, the CCG has achieved the national standard for dementia diagnosis and has put plans in place to improve care planning. In September 2016 the CCG achieved the national dementia diagnosis target however we recognise maintaining and improving the position will be challenging in light of changes to the way the target is measured (by registered/not resident population) and because the contract with our current Memory Assessment Service provider ends in Through monthly performance and contract meetings the CCG is working with the current provider to continue to develop the service into the final year of contract. The provider is recruiting (at their own risk) additional substantive posts in order to build up a bank of staff to ensure ongoing service resilience and timely diagnosis, crucial to maintaining and improving diagnosis. Following an extensive review of service delivery, the provider is also exploring innovation pilots to improve quality and experience for patients and crucially to raise awareness of the value of diagnosis by working collaboratively with the new Dementia Action Alliance in the city. 57

58 In order to increase face-to-face care plan reviews, every person who has been newly diagnosed with dementia is offered a holistic care plan within 20 days as part of our Memory Assessment Service. This is a formal KPI, of which we achieve an average of 86% against the target 95%. The care plan is delivered by the multi-disciplinary team within the service and offers access to dementia medication to slow disease progression and sign-posting. Also, this involves provision of information on the wider community services available to support people who are newly diagnosed with dementia and their carers. To increase the number of people diagnosed with dementia starting treatment within 6 weeks, the CCG has recently invested and expanded the range of support available to people who are newly diagnosed with dementia. These services include music, gardening, cafés, cooking, physical activity and cognition stimulation, all of which can be accessed within 6 weeks of diagnosis. These services are also accessible for those with a mild cognitive impairment. The Memory Assessment Service will go to open procurement in 2017 with a new service in place in April Procurement offers an opportunity to put into practice the latest thinking and best practice from NHS England around memory assessment models and our local learning from four years of delivery. We plan to procure a primary care based model which has been demonstrated by NHS England to improve quality. Services following this model have achieved 100% against the dementia diagnosis target and are also one of the lowest cost models nationally, generating savings that can be reinvested into developing dementia services in a whole system re-design for community support for people with dementia to prevent unnecessary acute admissions. Community Equipment Store In 2015/16 The CCG and Local Authority jointly procured a new Community Equipment Service. The new service commenced in October Whilst the service has had many successes there is a forecast overspend in 2016/17. To address this, the Commissioners have produced a detailed action plan which has been agreed with the provider and approved by the Health and Wellbeing Board. Summary of Primary and Community Care Plan Deliverables 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Implementation of new LCS Contract Co-commissioning of primary care Determination of funding for online consultation software Support practices to access Time to Care/GP Resilience Programme Local roll-out of High Impact Changes Workforce development through gap analysis, staff training and recruitment Full roll out of 6 cluster proactive care Procurement of Memory Assessment Service Develop contract and capitation model for MCP Implementation of Memory Assessment Service Shadow monitoring of capitation model Roll-out of online consultation software Table 2: Table of Primary Care and Community Services deliverables 58

59 Target Trajectory 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Extended hours in general practice 36% 57% 77% 100% Table 3: Primary Care and Community Services trajectory 6.2 Urgent Care The demand for urgent care services has changed over time, with an increasing proportion of beddays accounted for by patients from outside of the city itself. In addition, changes to patient pathways within the local acute Trust have resulted in a significant increase in patients with very short length of stay. The issues have been further compounded by significant increases in delayed transfers of care (DTOCs). To improve urgent care performance the CCG has commissioned a number of schemes aimed at reducing hospital attendances/admissions and supporting patients to stay for less time in hospital. By working across the STP footprint we will commission and contract manage services to implement the programmes within the national A&E improvement plan and Carter Review. This will include the delivery of an urgent care network aligned to our cluster care teams. Also, we will be working within the STP footprint to enable the delivery of networked hospital care to deliver seven day services. By delivering system and local change we will deliver the NHS Constitution standards in Brighton and Hove by April Acute Services Collaboration Under the auspices of the STP there is agreement to build on existing acute networks to identify future models for networked District General Hospital provision, building on pathways of care that integrate with place-based plans. As the lead commissioner for a challenged acute trust, this work is essential to ensuring patients receive timely care and to ensure the future sustainability of the local trusts. As part of our collective commitment to drive this agenda we are collectively implementing the 15 recommendations of the Carter Review. Managing Frailty The STP highlights frailty as a clinical priority area. This has been the case in Brighton for some time and is the focus of our Better Care Programme. Early and effective assessment of frail and vulnerable adults can enable general practice to plan alternatives to hospital admissions or arrange for early specialist hospital review. Where specialist assessment is needed, early conveyance ensures that patients attend hospital early enough to avoid a default admission, which is typical where patients arrive after 2pm. The Proactive Care programme delivered through the 6 clusters of practice implemented proactive management of frail patients. We expect the full roll out and delivery of our Proactive Care schemes in 2017/18 to result in a reduction in A&E attendance and non-elective admissions at BSUH of 614 patient pathways in 2017/18. The Acute Frailty Network has been developed to work with frontline teams to understand what support they need to improve services for frail older people. The overall aim of the network is to support adoption and spread of best practice in line with the Silver Book standards for healthcare systems across NHS England. 59

60 The Silver Book describes the issues relating to older people accessing urgent care in the first 24 hours of presentation, irrespective of provider. It goes on to describe the competencies required within all settings and recommends urgent care standards for older people during their acute care episode. The Brighton and Hove CCG signed up for the 3rd cohort of the Acute Frailty Network (AFN) in August 2016 and have been working with local partners to review, refine and improve pathways for frail patients in Brighton and Hove. Local projects have looked specifically at each stage of the pathway to ensure compliance with best practice and to ensure all partners use a common language and approach to frailty. This includes the universal use of the Rockford Scale. Admission Avoidance and demand management The CCG has commissioned a number of proactive schemes aimed at reducing non-elective attendances. The schemes identify frequent attenders using risk stratification and deliver, via GP clusters, proactive management. Pharmacists work to optimise medicine management and reduce the risk of hospital attendance. This scheme covers care homes too. We expect the full roll out and delivery of our proactive care schemes in 2017/18 to result in a reduction in A&E attendance and non-elective admissions at BSUH of 614 patient pathways in 2017/18. The roll out of Proactive Care across the city means that those patients who are the most frail and vulnerable are identified early and therefore can be prioritised for home visits and conveyance to hospital where necessary. A pilot to upload Proactive Care plans onto Summary Care Record Additional Information (SCRAI) is currently underway to enable ambulance crews to make informed decisions about conveyance to hospital. The CCG is also working with GP practices and SECAmb on measures to reduce the peaks in ambulance conveyance activity through earlier identification of those patients who may need specialist assessment and to ensure that such conveyances are earlier in the day. Brighton and Hove CCG also commissions a number of admission avoidance schemes from Sussex Community Foundation Trust (SCFT) and has recently changed the service specification to ensure that the Trust provides a responsive service and a new Referral Management Hub (RMH). The CCG commissions a number of community schemes aimed at reducing hospital attendances such as heart failure, respiratory, anti-coagulation, pharmacy hypertension clinics and the Palliative care partnership and it is in the process of commissioning a Complex Symptomology Service and service provision at a dedicated homeless practice. Streaming to Ambulatory Care & Primary Care from A&E The Urgent Care Centre is located adjacent to the Emergency Department and supports the streaming of patients at the front door of the Royal Sussex County Hospital. The CCG continues to be committed to providing a primary care service, via a GP, in A&E between the hours of 11am and 12midnight. We are working with the Trust to implement a new model of care in the Urgent Care Centre including a more diverse skill mix to cover the busiest period between 8am and 3pm. The model of service delivery at the Urgent Care Centre, including hours of operation, skill mix etc., will be reviewed over the next 6 months in line with work to design and procure a clinical navigation hub, in order to deliver a streamlined urgent care pathway for Brighton & Hove. We are working with our Out of Hours provider to re-model the service in order to offer more support to the wider urgent care system from April

61 Increase the percentage of 111 calls transferred to a clinical advisor The CCG commissions IC24 to manage demand by delivering GP services and community nursing out of hours (OOH). Given the increasing demand for repeat medicines which IC24 had to deliver, and the constraints on a limited GP workforce, the CCG commissioned an Urgent Repeat Medicines Prescriptions Locally Commissioned Service with Brighton and Hove Pharmacies which started in August The NHS 111 service, provided by SECAmb/Care UK, currently transfers approximately 25% of all calls to a clinical advisor for further discussion/triage. In addition to this, clinical floor walkers provide clinical input to circa 2,500 calls per month (where a clinician listens into a call and supports the health advisor in pathway decision making to ensure an appropriate disposition/outcome). Whilst these transfers are not counted in contractual KPIs, the addition of these cases equates to close to 30% of calls receiving clinical support. Furthermore, many calls are passed to Speak to GP within the GP OOH service for further clinical input. Working with the regional and Sussex lead commissioners for the service (Swale CCG and Horsham Mid Sussex CCG respectively), the CCG will be looking to develop a regional wide action plan with trajectories for ensuring auditable processes are in place to record all clinical transfers/support, and to increase the percentage of calls that are transferred to a clinical advisor to 35% in 2017/18. As an STP we are commissioning a new integrated urgent care service including 111, out of hours service and a local clinical hub by 2018/19. This will ensure that patients are directed to the most appropriate service and reduce 999 calls. Improving Discharge Processes The CCG has been proactively engaged in supporting improved discharge from the acute and community setting working with local authorities across the footprint. The CCG has commissioned a number of schemes with a number of community providers including the voluntary sector. Work has included: An expanded discharge to assess model which now incorporates Community Rapid Response Services leading to increased access to rehabilitation, recovery and re-ablement The roll out of a successful pilot to implement a revised discharge process on Jowers Ward (care of the elderly) to 4 additional medical and 2 surgical wards over the next few months A workshop to develop an action plan around the trusted assessor model and taking CHC assessment out of the acute setting Working closely with the Local Authority and care homes on supporting timely discharge from hospitals Working with the Local Authority within the Better Care Fund to commission a number of schemes to support and enable timely discharge from hospital The CCG is currently undergoing an in-depth review of the systematic pressures and opportunities in the management of delays in discharge. The aim is to identify opportunities to improve discharge process linked to key performance indicators to underpin a system wide % target which is currently 3.5%. This work will be completed in January 2017 and the work plan will updated to reflect this. The Ambulance Response Programme We are working with SECAmb to implement a range of admission avoidance pathways in order to support both See & Treat and Hear & Treat rates. This includes access to information for both ambulance control centre staff and paramedic crews on alternative pathways/dispositions for 61

62 patients in need of medical treatment, but where a conveyance to hospital can potentially be avoided. This includes reviewing the role of our Roving GP service and the introduction of a senior clinical oversight role in our OOH Service. We are supporting SECAmb to improve performance locally through a variety of measures including the increased use of Community First Responders (including partnership working with the Fire & Rescue Service), working with clusters to reduce peaks in admissions for assessment and working as a system to manage peaks in demand at certain times of the year (major events; bank holidays, Christmas etc.). We will continue to work with SECAmb on their Unified Recovery Plan (URP). Summary of Urgent Care Plan Key Deliverables 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Implement Carter Review Recommendations Develop acute collaboration plan with STP Full roll out of SAFER System wide Improvement of discharge processes New community bed model Develop Clinical hub Recommission 111 and OOH Table 4. Table of Urgent Care deliverables Activity Impact of Plans The charts to the left show the impact of the CCG plans on urgent care hospital activity. The first bar (far left) shows the amount of activity in 15/16. The subsequent bars (Green and red) show the adjustments made as a result of our plans. In 17/18 A&E attendances are expected to increase by 1.4% and a further 2.1% in 18/19 In 17/18 Non elective admissions are expected to reduce by 2.4% and then increase by 1% in 18/19 Figures 5a and 5b. Activity impact of urgent care plans on A&E attendances and non-elective inpatients 62

63 Key Performance Indicators Target Date GP in A&E 11am -12midnight 90% rota fill Apr-17 Reduction in OOH contacts for repeat prescriptions 90% Apr-17 Clinical transfer of 111 calls 35% Mar-18 Table 5. Urgent Care Key Performance Indicators Recovery Trajectory Target Compliance Date A&E 4 hour standard 95% The CCG is working with BSUH in the remainder of 2016/17 to further improve the urgent care trajectory, quantifying the impact of schemes, both internal to BSUH and within the wider health and social care economy. Table 6 and Figure 6. Urgent Care recovery trajectory. (Please note, this trajectory will be renewed in April 2017). Risk Mitigation Re-procurement of NHS 111 will not be Timescales and milestones to be refreshed delivered on time across the 111 re-procurement footprint Procurement of the Clinical Navigation Hub will Timescales and milestones to be refreshed not be delivered on time across the CNH procurement footprint Hospital@Home will not be able to deliver BSUH to work with SCFT on strategy. planned capacity due to workforce issues and care capacity issues Table 7. Urgent Care risks and mitigation 6.3 Elective Care The NHS Constitution Referral to Treatment standards have not been met locally for the past two years. During this period the available capacity at our local acute trust has not been sufficient to meet demand and as a result a significant waiting list has developed. In addition data quality issues have hampered our ability to accurately quantify the issues. The development of the system wide recovery plan in 2016/17 marked a turning point in our approach to elective care. The plan is based on significantly improved data and focused on plurality of provision, patient choice and managing demand. Over the STP footprint we will work to ensure that acute planned care services are configured and delivered in a sustainable way. Through the delivery of local and STP plans we will achieve the nationally mandated referral to treatment standard by April

64 Increasing capacity by plurality of provision The local CCGs are maximising the utilisation of available capacity across the system and working with the market to further increase the available capacity particularly in specialties with high demand. We recognise that the strategic direction as described in 3Ts means that the available capacity at BSUH will increasingly be utilised by specialist services and therefore we (the CCGs) must maximise alternative provision for more generalist services. By working across the Central Sussex and East Surrey footprint, and with neighbouring CCGs, we have ensured that the additional activity commissioned does not detrimentally affect other areas. Brighton and Hove CCG have commissioned additional patient pathways in 2017/18 and 2018/19 to ensure we meet underlying demand and reduce the backlog of patients to a sustainable level. We recognise that there is a risk that whilst this additional capacity is commissioned it may not be fully utilised. We are therefore going to the market in Q1 to commission further capacity in the most pressured specialities under Any Qualified Provider arrangements. Increasing patient choice All of the local CCGs have made proactive and concerted efforts to ensure patients are aware of patient choice and the increased variety in provision as a result of the additional activity commissioned. Patient groups and the Referral Management Service (RMS) ensure that informed patient choice is available particularly in high pressured specialties. RMS is now actively offering patient choice upon receiving referrals by booking patients to providers with the shortest waiting times. Patient letters clearly state that the patient should call should they want to change their destination. Where this falls outside agreed parameters, for example in excess of 30 miles from a patient s home, the patient receives a call to discuss options. We have worked with BSUH in developing and communicating the revised Patient Access Policy. The policy ensures that patients are aware of their roles and responsibilities in adhering to appointments with the aim of reducing DNA, cancellations and lost capacity. GPs working with patients using Shared Decision Making (SDM) to ensure referrals are done at the right time, first time. Promotion of SDM including guidance to support SDM in primary care will be rolled out in 2017/18. The impact of increased plurality of provision and promotion of patient choice has already had a significant impact on patient flow. In October % of planned care referrals went to BSUH by October 2016 this had reduced to 60%. By working with our Referral Navigation Service (RNS) provider and local acute trust we plan to significantly increase utilisation of e-referral in line with national guidance. Our plan is to align practice incentives to ensure utilisation of e-referral and advice and guidance and to ensure our contracts with RNS and BSUH mandate the use of e-referral. This requirement has been included in the BSUH contract Service Development Improvement Plan (SDIP) with milestones to meet the April 2018 target. Reducing demand by addressing variation There are significant differences across the STP footprint in terms of referral rates and adherence to the local Low Priority Procedures Policy. The following describes the actions being taken to reduce variation: 64

65 Refresh of the current advice and guidance with key providers to GPs to access non-urgent advice before a referral decision is made. Final specification is out for review with the aim of sign off and dissemination by end of September 2016 Tightening up the current Brighton and Hove process for Low Priority Procedures (LPP) bringing it in line with the other 2 CCGs - October 2016 Expanding the LPPs to other pathways in line with other CCGs across the country November 2016 We are working with our member practices to understand and reduce variation in GP referral rates using activity dashboards see primary care section for further detail Redesigned pathways Using the RightCare approach we have developed plans to improve pathways in neurology and Cardiovascular Disease. Focusing initially on headache pathways and implementation of the associated NICE guidance, we will reduce demand for acute based services in these areas. Under the auspices of the Planned Care Board the local CCGs have developed further plans to redesign pathways and have enshrined these in the relevant contracts for 2017/18 and beyond. The list of pathway redesigns is contained in the table below. Aligned to our STP approach where the configuration of services will be based on long term sustainability we will also look at Ear, Nose and Throat, ophthalmology, gastroenterology and urology pathways. Addressing the backlog and 52 week waiters at BSUH Whilst ensuring there is a plurality of provision at the point of referral, the CCG has also worked with BSUH to ensure that those waiting the longest have access to alternative provision. The clinical lead for planned care has worked with the Trust to provide support, clinical review and contacting patients. Diagnostic Pathways Across the STP footprint providers have struggled to maintain compliance with the diagnostic waiting time standard. To ensure that sufficient capacity is available to meet the referral to treatment time standards and the increased demand as result of the NICE guidelines relating to cancer the CCG is commissioning additional endoscopy capacity. To meet future demand we are working as an STP to develop a diagnostic hub. Summary of Elective Care Plan Deliverables Expected impact (monthly) Start date New community Lower Urinary Tract Service (LUTS) commissioned 40 Oct-16 Implementing a direct to test DD pathway 140 Jan-17 Paediatric joint community clinic 20 Dec-16 Neurology headache pathway- working with community 10 Dec-16 Expansion of community ENT service 100 Apr-17 Procurement of an endoscopy service 200 Oct-17 CCGs to proceed with the procurement of a community IBS service 60 Mar-17 Working with BSUH on direct to test for a number of pathways e.g. head /18 MRI and sinus CT Table 8. Table of Elective Care deliverables 65

66 Activity Impact of Plans The charts to the left show the impact of the CCG plans on planned care hospital activity. The first bar (far left) shows the amount of activity in 15/16. The subsequent bars (Green and red) show the adjustments made as a result of our plans. In 17/18 elective care activity is expected to increase to address the waiting list backlog. In 18/19 elective care activity is expected to reduce this is in part due to less activity being required as the waiting list backlog will have been addresses and also the impact of CCG demand management plans. Figures 7a, 7b and 7c. Impact of Elective Care plan on planned care hospital activity 66

67 Recovery Trajectory Target Compliance Date Referral to Treatment Time 92% April 2018 Diagnostic Waiting Time 1% April % 90% RTT Incomplete (% <18 weeks) 85% 80% 75% 70% 65% 2015/ / /18 Plan 2018/19 Plan 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% Diagnostic Waiting Times (% > 6 weeks) 2015/ / /18 Plan 2018/19 Plan Table 9 and Figures 8a and 8b. Elective Care recovery trajectory New Targets Target Compliance Date E-referral coverage 17/18 = 80% 18/19 = 100% October 2017 April 2018 Wheelchair Access - Children 17/18 = 92% Quarter waiting less than 18 weeks for a 18/18 = 100% Quarter wheelchair Table 10. New targets for Elective Care Risk Lack of enough provision of additional RTT activity from IS providers to meet demand Mitigation Scoping out of options to utilise additional activity commissioned by a neighbouring CCG AQP Procurement in train Clinical sign up to refreshed pathways and Robust comms and engagement actions to be demand management initiatives developed Lack of internal resource to deliver IBS pathway Re-prioritisation of projects Table 11. Risks and mitigation for Elective Care 67

68 6.4 Cancer The Sussex and East Surrey STP identifies cancer as a clinical priority area to improve the quality of services and associated health outcomes. Brighton and Hove CCG will work on this strategy through the STP and Cancer Alliances. NHS England published new ratings in October 2016 providing a snapshot of how well different areas of the country are diagnosing and treating cancer and supporting patients. This is based on data published over the last two years and the CCG improvement and assessment framework provides an initial baseline rating for six clinical priority areas which includes cancer. Table 12 shows the indicator ratings for Brighton and Hove CCG. Brighton and Hove CCG - Indicator Rating Overall rating 47.3% 82.1% 68.9% 86.2% Best performing 61.0% 94.9% 74.5% 9.0 Needs Improvement New of cases of cancer diagnosed at stage 1 and 2 as a proportion of all new cases of cancer diagnosed Of people with an urgent GP referral having first definitive treatment for cancer within 62 days of referral Of adults diagnosed with any type of cancer in a year who are still alive one year after diagnosis. Table 12. Brighton and Hove CCG Indicator Ratings Of responses, which were positive to the question "Overall, how would you rate your care?" A Cancer Strategy has been developed for Brighton and Hove in collaboration with partners, to respond to the national Independent Cancer Taskforce Review (2015) 1. This Strategy provides a transformational framework for the diagnosis, treatment and care for people affected by cancer in the city and works towards delivering a gold standard service in the city. It is anticipated that through the work being carried out and through early diagnosis we will significantly improve oneyear survival to achieve 75% by 2020 for all cancers, compared to the current survivorship rate of 69% for Brighton and Hove. A number of specific projects have been developed and implemented to support the local and national strategy ambitions. These include: 1. Commissioning with Public Health and Early Awareness Service which commenced on 1 September Provision of an enhanced stop smoking service in the city to target hard to reach populations which commenced on 1 October The service will increase quit rates, improve smoking cessation awareness and early detection targets through targeted outreach and communications and smoking cessation innovations through behaviour change in key communities and groups. This service will ensure there is a quit rate between 40% - 70%, with at least 85% of quits to be CO validated and 70% of quits to be achieved from any of the target groups identified above. 3. Extension of the physical activity programme for people living with and beyond cancer from 1 September 2016 to 31 August This programme aims to strengthen interventions along cancer care pathways by improving awareness of the health benefits of physical activity to patients and healthcare professionals. For those living with and beyond cancer, the service will increase the amount of people participating in physical activity (by 500 people per quarter), improve health outcomes and deliver activities and information to 1 Achieving world-class cancer outcomes: a strategy for England (2015) 68

69 people in a way that is meaningful and relevant to them. During the 10 month pilot (August 2015 to May 2016), 192 clients registered with the programme, 172 initial 1-2-1s were completed and there were 606 attendances at the 14 group classes provided. 4. The development of a Locally Commissioned Service (LCS) for cancer which will be piloted in January 2017 and rolled out fully on 1 April This service will include: Nomination of a clinical and non-clinical lead for cancer to support implementation of LCS Contact with non-responders for screening and encouraging them to attend Improvement of 2WW referrals and processes Provision of safety netting processes Improvement in cancer diagnosis recording Significant event analysis for delays and emergency presentations Contact with patients after a cancer diagnosis Cancer care reviews within 6 months of a cancer diagnosis for each patient This service will not only reduce variation in primary care, but will also improve the quality of service and proactively target patients to ensure early diagnosis and improve patient experience. As part of the development of the locally commissioned service the CCG has developed a comprehensive training package for General Practice staff to upskill the workforce around cancer. This will help to improve patient experience and outcomes. 5. Provision of Luteinising Hormone-Releasing Hormone (LHRH) Agonist Therapy for prostate cancer within primary care to provide care closer to home to improve patient experience. LHRH slows down the growth of cancer cells in the prostate. 6. Collaborative working with STP commissioners and providers to implement NICE Guidance for Suspected Cancer (NG12, 2015). 7. Participation in the Cancer Research National Cancer Diagnostic Audit which aims to improve patient care by driving up quality. 8. The MacMillan Horizon Centre (opened November 2016) will offer a range of support for people affected by cancer from information and advice to complementary therapies and psychological support. The projects outlined previously will continue. Brighton and Hove CCG has contractual and monitoring processes in place with providers to monitor the quality of services, activity and patient experiences. Impact will continue to be measured through national and local KPIs and outcomes measures. It is anticipated that through the proactive work being carried out to improve awareness of cancer signs and symptoms and lifestyle factors, the proportion of cancers being recorded at stage 1 and 2 will increase and those diagnosed at a later stage will decrease. It is expected that this will improve outcomes for patients and survivorship. Work which will be untaken in that has not been outlined already in the previous section includes: Cancer Access meeting the NHS constitutional standards. Historically the CCG performs well on cancer access targets for two-week wait to see a specialist for an urgent GP referral for suspected cancer and 31 days wait from the date a decision to treat (DTT). However, improvements are required on the 62 day wait from an urgent referral for suspected cancer to the first definitive treatment for all cancers. 69

70 The CCG is expected to support our patients and providers and will continue to work with BSUH to meet the NHS Constitutional 62 day cancer standard through work which will include securing adequate diagnostic capacity and the CCG has already increased endoscopy capacity for diagnosis. We are working with the Trust on the development of direct access and straight to test pathways for lung/chest X-rays and colonoscopies for 2 week wait referrals. As part of the STP, Brighton and Hove CCG will work with partners to develop a diagnostic hub. These measures will support waiting time and referral targets by increasing capacity, improving efficiency of diagnostic access and providing clear guidance when cancer is suspected The number of two week referrals continues to increase each year. Between 2014/15 and 2014/16, referrals increased by 5% and it is expected that there will be up to a 20% increase with the implementation of NICE guidance for suspected cancer (NG12). The guidance lowers the suspicion of cancer to a 3% positive predictive value (PPV) threshold (from an average of 5%) and aims to improve the early diagnosis of cancer and subsequent survival and outcomes. Collaborative working across Sussex CCGs and with providers has been established to develop and agree a joint implementation plan and work will be undertaken to review clinical pathways and ensure sufficient capacity within the system. Following the outcomes of the vanguard sites being piloted, the CCG will work with BSUH to ensure patients are given a definitive cancer diagnosis or the all clear within 28 days of being referred by a GP. Transforming Cancer Care living with and beyond cancer Enhanced survival and improved life experience of those who have been treated for cancer is also crucial. This approach provides support for those experiencing cancer to aid recovery and improve their experience of living with the condition. The CCG will work with BSUH, primary care and partners to develop the recovery package by ensuring that: All patients have a holistic needs assessment and care plan at the point of diagnosis A treatment summary (standardised across tumour site groups) is sent to the patient s GP at the end of treatment A cancer care review is completed by the GP within six months of a cancer diagnosis (through the cancer LCS) and upon completion of treatment. The review template will be used as a prompt to facilitate a holistic patient-led review, including agreement about further follow-up, and carers will be signposted to appropriate support Health and Wellbeing Clinics to provide education and support The CCG will ensure stratified follow up pathways for breast cancer patients are rolled out and will prepare to roll this out initially to prostate and lung and then to other tumour group sites. Risk stratification will take place so that patients will be assessed post-treatment for their risk of developing further disease in order to identify patients who can safely self-manage without the need to attend hospital-based follow up appointments. It is expected that this will reduce the amount of unmet need, reduce the demand on services and reduce financial costs by removing a number of follow up outpatient appointments. BSUH have participated in a pilot implementation of a secure web space where patients can bring together the people and information they need to help manage their care. The tool has been developed by Cancer Research UK and Patients Know Best (PKB) and promotes integrated care 70

71 and patient empowerment. This reflects the key recommendation of the Independent Cancer Taskforce Review (2015) for people to have online access to their own records. BSUH have offered it to patients who are participating in the Late effects of Pelvic Radiotherapy project. Although this has been piloted with a small number of patients, it has enabled clinical nurse specialists and patients to communicate and assess conditions remotely which has been beneficial to this group. Patients are able to track many symptoms and specific consultations can be sent to provide more detail. Enhanced remote follow up support has also been offered through PKB for patients with colorectal/anal cancer. Brighton and Hove CCG will continue to build upon the work carried out in 2016 to understand and improve people s experience of care after cancer treatment ended. The CCG previously worked with NHS England and Macmillan in a pilot project to recruit peer researchers who carried out face to face interviews about experiences of care during and after cancer treatment. Alongside the recruitment, an online questionnaire was completed by patients and a workshop event was held. The focus for Brighton and Hove CCG during the pilot project was improving patient experience of the cancer recovery package by seeking to understand the service user and carer experience of the cancer recovery package with a view to building a useful suite of tools to monitor and continue to improve services. There was an emphasis on engaging diverse groups of patients and a key focus on: Engaging people (both staff in the system and service users/carers) in improving the recovery experience and in planning how to monitor and improve recovery experience on an on-going basis Developing a model for designing/commissioning a service based on best possible evidence from patients and families Developing a standard of what the best possible experience would look like in terms of the recovery package for this group of patients The workshop led to several solutions to improve care, and a subsequent workshop in October 2016 reviewed progress against these solutions and actions. In future, the CCG will build on this work when reviewing cancer pathways and models of care. Going forward, the CCG will continue to work to meet the Independent Cancer Taskforce Review recommendations which focus on prevention, early diagnosis, patient experience, living with and beyond cancer, modernising cancer services and ensure that we develop and commission models of care to improve patient outcomes. Part of the longer term strategy will be to shift appropriate follow ups from secondary care into the community settings utilizing multidisciplinary and multispecialty clinics as outlined in NHS England 5 year Forward View. Summary of Cancer Plan Deliverables 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Roll out cancer LCS Evaluation of NG 12 impact Roll-out of stratified follow-up pathways for breast cancer patients Roll-out of stratified follow-up pathways for prostate and lung cancer patients Roll-out of stratified follow-up pathways for other tumour site patients Table 13. Table of Cancer plan deliverables 71

72 Finance ( 000s) 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Early Awareness Service Enhanced Stop Smoking Service Physical Activity Programme for Living with and Beyond Cancer Locally Commissioned Service for Cancer Table 14. Cancer finance Recovery Trajectory Target Compliance Date 62 day cancer target 92% April 2017 Cancer wait time- 2 week wait target 93% May 2016 Cancer wait time 31 days to first treatment 96% February 2016 Cancer wait time 31 days to surgery 94% August 2016 Cancer wait 31 days to radiotherapy 94% May 2016 Cancer wait 31 day to drug administration 98% July % All Cancer Waiting Times (% <2 weeks) 95% 90% 85% 80% 75% 70% 2015/ / /18 Plan 2018/19 Plan 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Cancer Surgery Waiting Times (% <31 days) 2015/ / /18 Plan 2018/19 Plan 72

73 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cancer Waiting Times GP Referrals (% <62 days) 2015/ / /18 Plan 2018/19 Plan Table 15 and Figures 9a, 9b and 9c. Cancer recovery trajectory. Key Performance Indicators Target Two-week wait to see a specialist for an urgent GP referral for suspected cancer 95% 31 days wait from the date a decision to treat (DTT) 95% New of cases of cancer diagnosed at stage 1 and 2 as a proportion of all new cases of cancer diagnosed Of adults diagnosed with any type of cancer in a year who are still alive one year after 75% diagnosis. Of responses, which were positive to the question Overall, how would you rate your 90% care? Number of Cancer Care Reviews completed within 6 months 100% Number of people completing physical activity programme 500 Number of successful quits (70% target) through the enhanced stop smoking service. 70% Table 16. Cancer Key Performance Indicators Risk Delay in implementation of NICE Guidelines for suspected cancer Capacity within BSUH to meet demand within diagnostics Capacity within BSUH to meet 62 urgent referral to treatment Mitigation Joint plan agreed by BSUH and Commissioners which is to be monitored through PMO at planned care board Review alternative referral pathways for routine referrals Review alternative referral pathways for routine referrals Table 17. Cancer risks and mitigation 6.5 Mental Health Improving mental health is a fundamental part of the CCG clinical strategy. The Five Year Forward View for Mental Health (2016) sets out a clear direction for the NHS to improve mental health and wellbeing, showing why change is needed and what it will look like. Some of what is needed can be brought about by the NHS itself. Other actions require partnerships with local organisations including local government, housing, education, employment and the voluntary sector. The evidence is clear that improving outcomes for people with mental health problems supports them to achieve greater wellbeing, build resilience and independence and optimise life chances, as well as reducing premature mortality. 73

74 The evidence is equally clear on the potential gain for the NHS and wider public sector from intervening earlier, investing in effective evidence-based care and integrating the care of people s mental and physical health. The CCG s ambition is to deliver parity of esteem for mental health with physical health and our strategic approach is to: Provide early intervention Provide services in community settings wherever possible Integrate mental health care into the whole system The Happiness: Brighton and Hove and Wellbeing Strategy (2014) provides the framework for a whole system approach to mental health and wellbeing in Brighton and Hove. In addition to specific improvements with the mental health system it provides a framework to embed mental health in all aspects of life in line with the principles of the 5 Year Forward View for Mental Health. The CCG recognises that the successful local implementation of the Five Year Forward View for Mental Health is dependent upon establishing services which are sustainable for the long-term. The principles on which we have based our Implementation Plan include: The co-production with people with lived experience of services, their families and carers Working in partnership with local public, private and voluntary sector organisations, recognising the contributions of each to improving mental health and wellbeing Identifying needs and intervening at the earliest appropriate opportunity to reduce the likelihood of escalation and distress and support recovery Designing and delivering person-centred care, underpinned by evidence, which supports people to lead fuller, happier lives Underpinning the commitments through outcome-focused, intelligent and data-driven commissioning In the Brighton and Hove planned expenditure on mental health related care is 70,547,000. The CCG plans to increase this expenditure in by at least 2% in order to meet our obligations under the Mental Health Investment Standard. The mental health related expenditure in is planned to be at least 71,957,190. Children and Young People Transformation Plan The Local Transformation Plan has been developed collaboratively and co-produced with local stakeholders including children and young people and outlining the need to transform care and support on a whole system basis. Our aim is to build infrastructure to ensure children and young people have resilience and are able to thrive to markedly improve their lives. This will happen alongside the development of a system of prevention enabling services to respond quickly to need, with specific, targeted support to vulnerable children. Considerable progress has been made during 2016 towards implementing whole system transformation for children and young people s mental health. The CCG has refreshed its Local Transformation Plan in 2016 which is based around three inter-related programmes of work: Building the infrastructure, including skilling up the workforce to respond to young people s mental health and promoting anti-stigma 74

75 Shifting the balance of resources towards prevention, early intervention, resilience and promoting mental health and wellbeing Targeting resources to those most at risk, for example those in crisis, Looked After Children and those known to youth offending services. Local Priorities In addition to implementing the requirements under the 5 Year Forward View the CCG have identified the following local priorities: Development of a community rehabilitation service to provide increased support in the community to reduce avoidable hospital based care. The new service will be in place from April Increased development of primary care based mental health services under the Innovation funding arrangements (cross reference primary care section) to provide early intervention and prevent problems escalating. Maximising the investment opportunities associated with shifting providers of care. Developing improved pathways between the Community and Voluntary Sector (C&V) and SPFT is a key priority. During the CCG will re-commission its C&V mental health support to ensure that the skills and experience of the community and voluntary sector are utilised within mental health pathways of care. Mental Health Plan Summary Deliverables 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 New IAPT contract in place (to achieve coverage trajectory) Enhance Crisis Resolution Home Treatment Team as alternative to acute admission Serious Mental Illness Locally Commissioned Service available to 100% of Brighton and Hove Population New Children and Young People services commence (to achieve access target) Increase access to Individual Placement Support for people with severe mental illness Table 18. Table of Mental Health plan deliverables Deliverable CCG Plan Increase access to high The CCG has refreshed and published its CYP Transformation Plan quality mental health during 2016 which includes plans for a sustainable workforce. The services for an additional CCG s Plan is for a large expansion of capacity to enable intervention 70,000 children and young at the earliest possible opportunity. A new Community Wellbeing people per year, nationally. Service has been designed and is currently being procured. It will be in place from June There will be an expansion of an equivalent Wellbeing Service in schools and colleges and this will provide capacity for an additional 2,305 interventions per year. Community eating disorder teams for children and young people to meet The Plan can be viewed here: A new Sussex-wide Community eating disorder service for children, young people and their families has been commissioned and the service started on 1 October The service is part of the Quality 75

76 Deliverable access and waiting time standards. Increase access to evidence-based specialist perinatal mental health care. Commission additional psychological therapies for people with anxiety and depression, with the majority of the increase integrated with physical healthcare. Expand capacity so that more than 50% of people experiencing a first episode of psychosis start treatment within two weeks of referral with a NICE-recommended package of care. Reduce suicides by 10%, with local government and other partners. Commission effective 24/7 Crisis Response and Home Treatment Teams as an alternative to acute admissions. CCG Plan Network for Community CAMHS (CNCC) eating disorder assurance network. Additional capacity is in place to meet the two as access and waiting time standards by Q CYP ED 4 week wait CYP ED urgent referrals 1 week wait The CCG in collaboration with other commissioners and our local providers of mental health services in the STP footprint submitted a successful bid to the Perinatal Community Development Fund in September 2016, to enable increased access to evidence-based care with appropriately skilled multi-professional workforce. Mobilisation plans are being developed for an enhanced service to be in place during 2017 which includes a sustainable workforce plan. The CCG is in the process of re-commissioning the IAPT service which includes capacity to meet the increased coverage targets as well as the requirement to integrate with physical health care. The contract is for an initial 3 year period from 1 June 17 to 30 May It will achieve a coverage of 22% by the end of the contract period and the targets are as follows: % % % Additional capacity has been commissioned from the Early Intervention in Psychosis Service during The access and waiting time targets have been consistently achieved since Q There has been a downward trend in suicide rates within Brighton and Hove since 2001 due to strong cross-sector partnership arrangements jointly owning and implementing the suicide prevention action plan. Rates though still remain higher than the England average. Additional resources have been identified to support the refreshed action plan as part of our commitment to meet the mental health investment standard. The CCG commission a Crisis Resolution Home Treatment (CRHT) Service which is currently available for home visiting between 8.00am to 10.00pm 7 days a week. Overnight mental health support is provided by a dedicated rapid response phone line as well as a face to face service provided Mental Health Liaison Team at the Royal Sussex County Hospital. The CCG is in the process of bench-marking the CRHT which will inform the development of a plan to increase the effectiveness of the team. Initial priorities for improvement include: Ensuring a home visiting service is provided to meet local patterns of demand Increasing capacity to enable greater intensity of visiting and proactive support to inpatients Further integration of social crisis support function alongside the clinical model Developing a more bespoke service offer for older people 76

77 Deliverable Eliminate of out of area placements for nonspecialist acute care by Deliver integrated physical and mental health provision to people with severe mental illness. Ensure that 50% of acute hospitals meet the core 24 standard for mental health liaison as a minimum, with the remainder aiming for this level. CCG Plan The CCG plans for an enhanced CRHT service to be available by Q Out of area placements (OAPs) are currently used for non-specialist acute care are used at time of peak demand. There has been a significant reduction in activity in compared with Analysis of data for Q1 and Q shows that there was a total of 27 B&H placed out of area. Analysis of a weekly basis shows that in half of the time there are no OAPs. Plans to reduce OAP s have two key elements: Systematic work to reduce longer than necessary length of stay in order to free local bed capacity. The CCG has agreed the patient care and flow CQIN with SPFT in which provides a structured process to improve flow and reduce length of stay Enhancement of the CRHT to capacity to facilitate earlier discharge from hospital The CCG commission a LCS for Serious Mental Illness. Currently 1/3 of our population is covered by the scheme but additional investment has been made during to roll-out the scheme to the whole city. Whole city coverage will be secured during The CCG commission a 24/7 Mental Health Liaison Service for adults at the Royal County Hospital and is a successful example of multiagency partnership working and integration of physical and mental health. The service is commissioned to provide a 1 hour response time in A&E but there is insufficient capacity to fully meet the needs of the hospital and in particular provide a fully comprehensive service to the hospital wards. There is therefore scope to further support whole system working particularly in terms of reducing acute length of stay and re-admission rates. The CCG, Sussex Partnership Foundation Trust (SPFT) & Brighton and Sussex University Hospitals Trust (BSUH) are planning to submit a bid as part of Wave 1 to enhance the service in order that the Core 24 standard can be met. Increase access to Individual Placement Support (IPS) for people with severe mental illness (SMI). There is also a 7 day a week service for children located at the Royal Alexandra Children s Hospital. The CCG currently commission a community and voluntary sector organisation to provide IPS for people with SMI. This service is embedded and works as an integral part of SPFT services. The CCG is planning to re-commission the service in with a new contract to start on 1 April The re-commissioning plan will include additional capacity to increase access by at least 25%. Table 19. Table of CCG Mental Health plan against national deliverables 77

78 Trajectory Target Compliance Date Dementia-estimated diagnosis 66.70% September 2016 rate for people aged 65 and over IAPT coverage 2017/18 = 4.20% 2018/19 = 4.75% Q4 2017/18 Q4 2018/19 IAPT recovery rate 50.00% Q1 2017/18 IAPT waiting times 6 weeks 75.00% Q1 2017/18 IAPT waiting times 18 weeks 95.00% Q1 2016/17 Early Intervention in Psychosis Psychosis treated with a NICE approved care package within two weeks of a referral 2017/18 = 50.00% 2018/19 = 53.00% Q1 2016/17 Q1 2016/17 Improve access rate to Children and Young People s Mental Health services Waiting Times for Routine Referrals to CYP Eating Disorder Services - Within 4 Weeks 2017/18 = 30.00% 2018/19 = 32.00% 2017/ /19 By 2020: 95% Q1 2017/18 Waiting Times for Urgent Referrals to CYP Eating Disorder Services - Within 1 Week By 2020: 95% Q1 2017/18 Table 20. Mental Health trajectory Risk Mitigation The key risk to the plan is recruitment of staff to Plans to mitigate the risk include: deliver the increased capacity. Whilst it is introduction of skill mix including utilising positive that Brighton and Hove has the lowest levels of vacancies across SPFT it is not always the skills of community and voluntary sector and primary care possible to recruit successfully the first time. development of a whole-system workforce strategy for CYP Table 21. Mental Health plan risks and mitigation 6.6 Transforming Care for people with Learning Disabilities and Autism There are an estimated 4,746 adults aged years with a learning disability living in Brighton & Hove in 2015, with around 6% with a severe learning disability. Brighton and Hove CCG and Brighton and Hove City Council are working together to improve and transform the access to, provision of and quality of health, social care and community services for this cohort of our population. Through the delivery of The Brighton & Hove Joint Strategic Plan: Transforming Care, our organisations are committed to improving the health and wellbeing of this community. This will be achieved by ensuring they have equitable access to the same level of health, social and community services as others, that they are proactively supported when they are in crisis and ensuring they are cared for in the most appropriate place with high quality care when required. Further to this the joint plan will deliver improved access to health care to reduce the higher rate of premature mortality in this group and to ensure the quality of this care through the education and training of staff and ensuring access and equipment are matched to their needs. These deliverables are articulated in the Brighton & Hove Joint Strategic Plan. This plan shares Sussex Transforming Care Partnership Plan priorities to support improvements in workforce development, training and education, developing Proactive Community Support and Crisis 78

79 Prevention, Inpatient and specialist treatment, improving proactive planning of transition and delivering the Personalisation and Personal Health Budgets. Further to the above the Brighton & Hove Joint Strategic Plan: Transforming Care, has 4 strategic objectives: Ensure all hospital placements are good quality, appropriate and reviewed regularly, with a focus on effective intervention & timely discharge Review & enhance the local resources in place for crisis intervention and prevention of admission Ensure all local services provide good quality, safe services for people in the defined group Review and improve how children and young people considered to be in the at risk group are identified, assessed and planned for. The Brighton & Hove Learning Disability Strategy: A good, healthy and happy life, , identifies additional factors necessary to progress the required improved health outcomes for those with learning disabilities and autism. These include equitable access to health and mental health services and supporting equal access to healthcare with specialist learning disability support where needed. Health and Wellbeing promotion for this community can be enhanced further with health and mental health training opportunities for support staff and families. Less direct measures include good health education information and supporting access to community and leisure activities which improve/engender better health. These measures will support the delivery of improved health outcomes through encouraging engagement with the prevention agenda, increases in physical activity and activities that support wellbeing and improvements to quality of life. There is further work to progress the ambitions for health improvements identified above and the contribution to reducing premature mortality and the attainment of the 75% annual health check target and these are briefly outlined below: To support the achievement of a 75% annual health check target, more specific analysis is required to improve information on why some of this cohort are not receiving an annual health check and the reasons for this in order to develop a targeted approach. In addition, we will work collaboratively with NHS England public health commissioners to increase uptake of other types of screening and immunisation in this cohort of the population to improve health outcomes and reduce inequalities. To support the reduction in premature mortality, the city has a dedicated health facilitator who leads on a large part of the work taking place to improve health outcomes for people with a learning disability and in the future this post may be supported by a clinical lead to support this work. This will support the progress in improving access to health services, education and training of staff and by making necessary reasonable adjustments for people with a learning disability and/or autism. The CCG is working in collaboration to refresh the Autism Strategy for

80 Summary of Transforming Care Plan Deliverables 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Reduce the number of inpatient beds for people with learning disabilities Fully implement the New Service Model by March 2019 Improve access to healthcare for people with learning disabilities so by 2020, 75% of people on a GP register are receiving annual health checks Table 22. Transforming Care Plan deliverables Trajectory Target Target achievement date Uptake of annual health 75% Q4 2018/19 checks in patients with learning disabilities and autism Risk Table 23. Transforming Care Plan measurable trajectory Identification of service gaps in community provision to meet assessed need Capacity of the Enhanced Crisis Response Service to continue to deliver a wraparound service Table 24. Transforming Care Plan risks 6.7 Quality & Safety The CCG Clinical Quality and Patient Safety team holds commissioned service providers to account for the quality of services they provide. They do this by planned care monitoring and analysis of: A wide range of quality measures including information and data that is contractually agreed between providers and the CCG A range of other measures such as Safeguarding alerts, Section 42 enquiries undertaken, Coroner Regulation 28 letters issues and responses, mortality reviews, serious incidents, soft intelligence received by the CCG s dedicated feedback . Also, they appropriately share intelligence and information with other key stakeholders such as Healthwatch, the Local Authority (including Public Health) and CQC. Workforce planning Brighton & Hove CCG will be directly engaged in Workforce Planning at a strategic level within its STP area (see also pages 9-12 within the Primary Care and Community Services chapter). The Director of Clinical Quality and Patient Safety is a member of the STP Workforce workstream and a member of the Local Workforce Action Board (LWAB) and will therefore have oversight of workforce development needs across the whole health and social care economy. We have been working on the overarching Workforce Strategy plan with the STP, and will be developing our local workforce strategy further ensuring it maximises the funding and support opportunities available and aligns with local, CSESA and STP strategies. In addition, the CCG s Primary Care Workforce Tutor represents the CCG at the STP-wide Community Education Providers Network (CEPN), as part of their role to ensure sustainable workforce development within Primary Care. Workforce data will be monitored via quality review meetings with key service providers with a focus on recruitment and retention, vacancy rates and staffing templates. Also, staff wellbeing 80

81 measures such as appraisal and training rates, sickness absence levels, and staff survey results will be reviewed in order to provide a temperature check of how well providers are managing their workforce. The CCG is supporting the implementation of the Workforce Repository and Planning Tool (WRaPT) which will pull data from existing systems in health and social care across the STP footprint to enable large scale workforce transformation planning. The Quality team will work closely with commissioning managers to ensure that during contract and performance review there is robust monitoring of plans to ensure workforce succession planning, development of shared training opportunities across providers and including supporting small providers (for example, care homes) and that any service re-designs and procurements undertaken will have service specifications and contracts that include safe and sustainable workforce solutions. The CCG has led on a significant piece of work during 2016/17 to develop an educational tool for domiciliary care providers and carers within the Care Home sector. The Stop Look Care booklet has been agreed for publication following extensive engagement with health and social care providers. It will enable unregistered carers to manage the care of individuals within their sphere of competence, and crucially to recognise signs and symptoms that require escalation to a healthcare professional. This educational booklet has been designed to enhance the existing Care Certificate and will be published and made available to all care service providers in 2017/18. A review of its implementation will be undertaken in March The Mental Health Children and Young People Transformation plan is also under way, developing the workforce as necessary for such a large-scale transformational change. Safeguarding Adults and Children Safeguarding of vulnerable members of our population (adults and children) is a priority for the CCG. Services are monitored against agreed Safeguarding standards and against the CCG s Safeguarding Assurance Framework. The Director of Clinical Quality and Patient Safety is the executive lead for Safeguarding in the CCG, and represents the CCG as a statutory partner on the local Safeguarding Boards. There is dedicated support to this role from a Designated Nurse for Adults and Designated Nurse for Children, as well as a Designated Doctor and Named Doctor for Children. The Designated Nurse for Adults is the named Prevent lead for the CCG and provides all of the required training for staff, as well as ensuring service providers fulfil their statutory requirements. The Designated Nurse for Adults also provides local training for Primary Care, including targeted support to providers where improvements to Safeguarding procedures may have been identified in CQC inspections. Brighton and Hove has a robust system of reviewing outcomes and recommendations from national and local reports of Mental Health and Domestic Homicides and Serious Case Reviews through the CCG Safeguarding Committee (which involves commissioners and Public Health representatives), as well as Chairing the LSCB Serious Care Review Panel. The Director of Quality also sits on the SPFT Mortality review group. All commissioned organisations are requested to respond to any findings and recommendations through the quality monitoring processes and Quarterly Review Meetings, where safeguarding is a dedicated agenda item. Clinical Quality Managers within the CCG also provide additional support to CCG Safeguarding leads and Safeguarding colleagues in the Local Authority in conducting Section 42 enquiries with 81

82 local health and social care providers. One of the key aims in 2017/18 is to ensure the CCG receives all key information concerning Section 42 enquiries relating to services commissioned by the CCG, to enable its triangulation of other quality information and data. The Director of Clinical Quality and Patient Safety has led on the Sussex-wide development of Mental Capacity Act (2005) Deprivation of Liberty Safeguard Best interest Assessors (BIAs). As a result, health professionals have been developed across NHS providers and CCG Continuing Care teams. This is to improve capacity to enact the Mental Capacity Act and to prepare for any changes required by health providers when the Law Commission review on the Law of Mental Capacity and Deprivation of Liberty publishes its recommendation (due December 2016). The Director of Quality is also the Senior Responsible Officer for the Sussex Transforming Care programme and over the coming months will be working with NHSE leads to implement the programme to support a mortality review for people with learning disabilities. Learning from complaints, incidents and serious incidents Complaints The monthly Quality team meeting agenda includes a standing item on complaints and therefore the CCG Complaints Manager attends every meeting to discuss the complaints that have been received by the CCG in the previous month. This way, any issues and themes in complaints about providers commissioned by the CCG can be triangulated with other data/information linked to Quality and raised via the monthly quality review meetings with providers. For complaints about non-commissioned services (for instance General Practice), the information is collated via a CCG quality and risk database for all practices, in preparation for when the CCG becomes a co-commissioning CCG and has more delegated functions for quality and patient safety in primary care. For complaints received about specific CCG issues, a quarterly report is written by the Complaints manager for discussion and identification of actions to be taken. This is presented to the CCG Senior Management Team (SMT) and to the Quality Assurance Committee (a sub-committee of the Governing Body). Serious incidents The CCG Clinical Quality team conducted a comprehensive serious incident investigation in 2016, following the unexpected death of a person in receipt of a CHC package of care. The CCG carried this out because the case was very complex and involved a number of health and social care agencies. Subsequent meetings with the providers concerned took place after the investigation was completed, in order to monitor progress and implementation of agreed actions. The CCG was able to conduct this investigation because the Clinical Quality Lead and Managers within the team have all had experience and training in root cause analysis investigation and human factors training. In addition, Brighton & Hove CCG continues to host a pan-sussex Patient Safety team that oversees the management of serious incidents on behalf of the Sussex CCGs. As part of this service there is a fortnightly serious incident scrutiny panel, where the panel reviews all serious investigation reports and can identify themes for individual providers, as well as across the county. When common themes are identified, specific support and training is provided for organisations to address the issues and support improvement. For the past two years Brighton and Hove CCG has hosted an annual Patient Safety Conference. The last conference was attended by nearly 200 people and presented learning from cases involving a death from sepsis, and a joint investigation 82

83 of the local Brighton & Hove acute trust and mental health trust into the suicide of a person who left an A&E department. The Patient Safety team has successfully addressed unwanted variation across providers in the way that falls and pressure damage are investigated by introducing standardised templates that capture all required elements of a robust investigation. In 2017/18 the team will continue to host twice yearly meetings with Patient Safety managers and leads from all local organisations. These meetings enable providers to come together to share good practice and for the CCG to raise any themes and issues observed by the serious incident panel that can be addressed collectively with all providers in the room. Patient experience The CCG continues to monitor patient experience measures and hold commissioned service providers to account via Quality Review meetings. These measures include: Complaints looking at numbers, types of complaints and trends in reporting Friends and Family Test (FFT) looking at response rates and focusing on qualitative feedback to FFT (for complaints) Feedback from providers internal Patient Experience and Patient Engagement meetings and ensure providers have robust methods of receiving patient feedback Themes and trends from soft intelligence received by the CCG via the Feedback on Providers These measures are monitored with assurance that providers make changes to services based in complaints and feedback received. In 2017/18 the team will continue to host twice yearly meetings with Patient Safety managers and leads from all local organisations. These meetings enable providers to come together to share good practice and for the CCG to raise any themes and issues observed by the serious incident panel that can be addressed collectively with all providers in the room. Quality Impact Assessments In 2016, a Quality Impact Assessment tool was created by the Clinical Quality team to support commissioners and the Programme Management Office (PMO) in any service redesigns or procurements. This tool was approved by the CCG s Senior Management Team and is included in the PMO handbook for commissioners. In 2017/18 the CCG will be able to demonstrate evidence that these are completed routinely. Quality Impact Assessments are carried out for all contracts and pathway redesigns. They follow the three key pillars: patient experience, clinical effectiveness and patient safety and are then further supported by using the five domains (same as CQC) Safe, Effective, Caring, Responsive and Well-led. The quality and patient safety team have produced a quality assurance document that is embedded into all commissioning contracts. The Quality team will ensure the plans will be delivered and risks mitigated via the following means: Monthly Quality Review meetings with organisations for which B&H CCG is the coordinating CCG and also for key providers where the CCG is an associate commissioner. Any issues that are not resolved at the Quality Review Meeting will be escalated to the provider s Contract Management Group and/or Quality Oversight Group 83

84 Locally, the CCG Quality team undertakes a timetable of quality assurance visits, both planned and unannounced. These may be actioned following any themes/issues identified from serious incidents or from triangulation with other sources of quality-related information. Visits may be undertaken where it is felt additional scrutiny and/or assurance for the CCG and external stakeholders is needed. All assurance visits will have a written report, with any recommendations for action, shared with the provider and reported to the CCG Senior Management Team and Quality Assurance Committee Quarterly meetings with CQC and Healthwatch Monitoring returns and ensuring plans are in place to address any gaps from providers self-assessment against the CCG s Safeguarding Assurance Framework Significant quality risks will be made visible to the CCG by logging on the organisation s risk register The Quality Team is working with BSUH (an organisation in special measures) as host commissioner to monitor and test the implementation of the improvement requirements. We are working collaboratively with local CCGs, NHS Improvement and NHSE Quality leads to ensure a robust and coordinated approach. We are working with other provider organisations (SCFT and SPFT) directly and through the host commissioners to support a robust approach to early identification and monitoring of actions to mitigate any quality and safety issues. Deliverables 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Ensure Quality Impact Assessments are completed routinely during service redesigns and procurements Host twice-yearly meetings with Patient Safety managers/leads from all local organisations Publish Stop, Look, Care booklet and make available to all local care providers Ensure CCG receives all key information concerning section 42 enquiries relating to services commissioner by the CCG to enable triangulation of other quality information or data Table 25. Quality deliverables 6.8 Technology, Research, Innovation & Growth The NHS Five Year Forward View identifies three key challenges for health and social care as being exacerbated by the lack of integration across health and social care services. It looks to digitally enable transformation to address the three national challenges of closing the gaps in health and wellbeing, care and quality, and finance and efficiency. To address the data and technology issues identified, the National Information Board published Personalised Health and Care 2020 Using Data and Technology to Transform Outcomes for Patients and Citizens A Framework for Action in November The ambition of this is that health and care should be paper free at the point of delivery by The mechanism for delivery of this framework was the establishment of CCG led Local Digital Roadmap footprints leading to the development of Local Digital Roadmaps (LDR) as part of the development of the Sustainability and Transformation Plans (STP). 84

85 Digital technology is a key enabler of the East Surrey and Sussex Sustainability and Transformation Plan. The East Surrey and Sussex Local Digital Roadmap aims to: Ensure there is a digital component to all appropriate transformation initiatives Take advantage of technology to support new care delivery models Take advantage of existing national and local investments in technology to maximise the benefit from those investments Support local strategic decisions, prioritisation and investment, and exploitation of funding opportunities Exploit potential for common approaches to deliver underpinning infrastructure and solution architecture Develop programme plans, deployment schedules and a design and procurement process that identify economies of scale opportunities within the footprint Facilitate national investment prioritisation and supplier product roadmap development Ensure robust governance of delivery The LDR identifies key digital programmes to underpin delivery of the STP including a shared digital care record, system-wide Citizen Relationship Management, citizen portal, urgent care technology stack (as part of the 111 procurement) and shared infrastructure. Project mandates included in the October submission of the LDR will be developed into investment-ready plans by 31 March The CCG is expected to make early progress with clear momentum by March 2017 and substantive delivery by March 2018 towards delivering the ten nationally defined universal capabilities. These capabilities are detailed in the CCG s Informatics Oversight Committee Programme Plan and underpinning Clinical Informatics Delivery Plan. Health and Care professionals who will need to access and share information, alert, task and notify other relevant professionals across care settings. Investment in infrastructure will facilitate a more effective uptake of digital technology. The CCG s Informatics Delivery Plan focuses on delivering the following: The requirements of the GP IT Service Operating Model Mobile technology Wireless connectivity for primary care professionals and service users Ubiquitous network access giving primary care professionals access to the digital solutions they need, regardless of where they are providing care. Summary of Informatics Plan Deliverables 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 East Surrey and Sussex STP Footprint STP Exec and NHSE agree 3 year plans and source funding Summary Care Record GP Viewing Record Sharing IDCR Summary Care Record Additional Information (Care Plans) 85

86 Deliverables 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Information Sharing Standards Information for Patients CRM Patient Access to Online Services Universal Capabilities (not included above) E-Referrals Discharge Summaries NHS England & NHS Improvement Guidance Domain Server Refresh PC Refresh Wireless in GP Practices Provision of Remote Hosting / Cloud Solutions for GP IT Servers Coin in GP Practices GP IT Modelling Structure PC Refresh Programme for 17/18 Window XP and other rogue devices identify and deal with unknown devices which could be causing poor performance Mobile Working Develop mobile working strategy, providing ability to use technology in any place and access data networks and information on supported mobile devices Mobile Device Management Options appraisal of MDM solutions and deployment approaches Wireless Network Installs and / or Upgrades CCGs with wireless networks already fully in place will bid for refresh of the infrastructure. CCGs will bid for installation of new wireless networking equipment where required Provision of a remote hosting / cloud solution for GPIT servers includes removal of local admin rights Single domain for practices move all GP practices from a local domain structure to the central SUSSEX domain. To further improve roaming users, SSO with other systems and central data storage Local GP server replacements Windows 10 deployment and licence implications for CSU to create WIN 10 image for PCs and mobile devices Table 26. Technology, Research, Innovation and Growth deliverables Activity 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Summary Care Record Additional Information 86

87 Working with Commissioners prepare and implement a Footprint wide CQUIN to incentivise providers to view the SCR in an Urgent & Emergency Care setting Using SCR AI to support palliative care coordination and other end of life information from GP records Information Sharing Standards Primary Care SNOWMED CT Patient Access to Online Services 10% patients accessing primary care services online or via apps EPS Phase 4 add the ability for patients that have not chosen (nominated) a pharmacy to utilise the service through the use of paper or electronic tokens for the patient to use to collect the prescription form the pharmacy of their choice Universal Capabilities (not included above) Build an action plan with those partners not achieving the targets and monitor via Governance Implement plan and monitor Carry out further analysis of status and noncompliant partners and consider action Discharge Summaries To ensure all discharge summaries from A&E departments are sent electronically to GPs and that the structure is aligned with Academy of Medical Royal Colleges headings End point look-up via MESH to allow nationwide delivery Structured messaging (ITK CDA). Capability to carry coded procedures, diagnosis, allergies, adverse reactions and medications NHS England & NHS Improvement Guidance Mandated use of the e-referral system (ERS) Compliance with new interoperability requirements for clinical IT systems By October 2018 all clinical letters to be transmitted electronically as structured messages using standardised clinical headings. Table 27. Technology, Research, Innovation and Growth activity Risk L I Mitigation Proactive Care Statutory requirement of practice to L L Advice has been sought from the IC experts in maintain confidentiality could be breached. At the same time if excluded unnecessarily the patients could be withheld from a programme that is much needed order to understand whether there is a need for the code to be excluded. Current guidance is that there is no statutory reason for exclusion however locally there may be a need if in the expectation of the patient is to exclude Practices data is key to maintain validity of the tool and to maintain equality across the city M M CCG will not access the tool until clarity has been provided to practices about the extent of CCG use of the tool Table 28. Technology, Research, Innovation and Growth risks and mitigation 87

88 6.9 Immunisation Brighton and Hove CCG and Brighton and Hove City Council hold a Memorandum of Understanding which details our shared working towards improving the health of the local population. Brighton & Hove CCG holds a twice yearly flu immunisation steering group meeting to review the local data from the previous year, develop plans to increase uptake and support NHSE with their winter flu programme. This includes facilitating the immunisation of local social care and school staff, supporting national flu immunisation campaigns and supporting pharmacies with their immunisation plans. Childhood immunisations are reviewed regularly and included in the Director of Public Health s annual Health Protection Report. When outbreaks of vaccine-preventable diseases occur, Brighton & Hove Public Health work closely with Public Health England to communicate widely with stakeholders to improve local uptake and where appropriate, the media can be utilised to help raise public awareness. NHS England reports to the Brighton & Hove Health Protection Forum annually on all local immunisation and screening programmes to assure Public Health England. We plan to build on the advice received from our Local Authority public health team and work with NHSE public health commissioners to increase the uptake of immunisations in the context of local resilience planning, for example influenza vaccinations in the eligible population Prevention and screening The prevention of ill health in all forms is central to the principles of the CCG and Brighton and Hove City Council Public Health team commissioning, underpins the concept of the empowered citizen at the centre of the CCG Caring Together Strategy and plays a crucial role in the delivery of a sustainable transformed health and social care system. The most effective mechanism to prevent most chronic conditions is to promote a healthy lifestyle, particularly through maintenance of a healthy diet and physical activity uptake. These factors support the prevention of a number of long term conditions such as diabetes and cardiovascular disease and therefore improve quality of life. This in turn reduces the burden on health services. Brighton and Hove City Public Health team commissions a number of services which promote and deliver a preventative approach to health. These include: Brighton and Hove food partnership a free healthy lifestyle service helping children, adults and families establish a healthier weight Active for Life encourages participation in physical activity in areas of high deprivation and health inequalities Healthwalks a service providing free walks across the City, making exercise accessible to a wide range of people within the local population Health Trainers service free support to adults to increase physical activity and improve nutrition, and when appropriate also provides stop smoking and alcohol advice. This service is jointly funded by the CCG Prevention is also integral to healthy ageing. Approximately 30% of people aged 65 and 50% of those aged 80 and above experience a fall per annum with an estimated annual cost to the NHS of 88

89 more than 2.3bn. In light of this, Brighton and Hove delivers the following falls prevention initiatives: Standing Tall: Extra Time a service which provides post-nhs support for older people who have previously suffered falls through an exercise programme to improve muscle strength and balance, reducing the risk of further falls. This initiative also has the additional benefit of a reduction in social isolation Better Care Fund Falls Prevention project this project aims to prevent falls and resulting injuries and loss of independence Social isolation is a known risk factor for loss of independence and premature death. Standing Tall: Extra Time works to prevent isolation, and Lifesavers also helps to reduce this. Lifesavers is a project aimed at residents of East Brighton (a high deprivation area with health inequalities) who are older than 50 years old and aims to improve health and wellbeing through the avoidance of social isolation in vulnerable older people. Physical and mental health are associated and in response to this Public Health team commissions the charity, Right Here, to provide a service that builds mental resilience in young people aged through a range of activities. Additionally, the Men in sheds initiative is offered to retired and unemployed men who do not wish to access conventional mental health services to improve their wellbeing and prevent a decline in mental health. Grass Roots Suicide Prevention is also available to support the local communities in prevention of suicide. Brighton and Hove has a high proportion of young residents and free chlamydia and gonorrhoea screening is provided to people under 25 to prevent the spread of sexually transmitted infections and associated longer term complications such as Pelvic Inflammatory Disease. The Sexual Health Promotion partnership also prevents sexually transmitted infections and promotes sexual health in the local population through provision of free advice and contraceptives. The provision of Health Checks to residents aged between 40 and 70 years old also support the prevention agenda and early detection of risks to conditions. Within these appointments, blood pressure, BMI and cholesterol are measured, and risks of heart disease or diabetes are assessed. Through this, advice and support can be given to prevent development of these diseases or early support offered if either is indicated. These Health Checks are commissioned by the Local Authority. We actively encourage General Practitioners to offer these to patients and we receive public health guidance on how we can commission services to maximise screening uptake and minimise inequalities. Obesity and diabetes By 2020, the Public Health Mandate 4.1 requires a measurable reduction in child obesity. Locally, one in four children (26%) in the city are leaving primary school already overweight or obese. These children are at increased risk of becoming overweight or obese adults, and have an increased risk of developing type 2 diabetes, cardiovascular disease, musculoskeletal disease and some cancers. The Public Health Team and CCG commission the following services to reduce childhood obesity, and intend to explore the possibility of expanding some as appropriate: Family Shape Up - a child weight management service within the Active for Life community weight management service. 89

90 Free swimming for children across the city A menu of free Active for life and sports development opportunities within the City Park run a free family event held every Saturday in parks across the City to encourage families to be active in open spaces A wide variety of free active events including Dance Active, TAKEPART sport and physical activity festival and Soup and Stomp. This work is supported by liaising with food outlets across the city through regulatory services to provide a healthier choice for city residents. We also continue to work with public health to deliver the schools programme with a focus on food (including Sugar Smart) and increasing physical activity and active travel to school. This work is supported by: Change for Life Clubs delivered in-house by teachers and supported by the Local Authority Sports Development team School Games available to all registered schools to organise and support competitions and support them to achieve the School Games Mark Daily Mile a concept to incorporate a whole school approach to be active during the school day Kitchen Garden a cookery/nutrition curriculum resource for teachers which also offers workshops Bike It two Bike It offices work across primary schools in the City offering parent rides, bike workshops and training for pupils on learning to bike ride safely Healthy Choice Award support for school to improve breakfast food provision and achieve the Award MAC/Zip Zap Curriculum/after school physical activity and good nutrition clubs run in primary schools by Albion in the Community School travel team works with schools to promote and improve active travel through provision of school assemblies, events, support for staff and a scooting course. To complement the work of the Local Authority Public Health team with regards to obesity, the CCG will continue to encourage the identification and referral of overweight/obese patients to appropriate services, and provide data to the Public Health team on weight reduction activity within commissioned services. Additionally, we will continue to encourage Primary Care practitioners to identify and refer patients with inactive lifestyles to available services (such as the Health Trainer service), and provide information to Public Health on physical activity referrals within commissioned services. Drug and Alcohol Misuse There are currently 2424 individuals receiving support from substance misuse treatment services in Brighton and Hove. The majority of these are receiving support for their opiate addiction (1224), with smaller numbers supported for non-opiate addiction (295), alcohol (627) and alcohol and nonopiate together (278). Treatment options for local residents with substance issues are commissioned by the Public Health team within Brighton and Hove City Council. Meeting the needs of local residents with substance misuse issues is a priority for the city. GP practices can help support patients to identify their substance issue and refer onto treatment services. Local residents can also self-refer into treatment services. The number of people accessing support for their alcohol issues has increased in the last year. The aim is to also increase the number of people with drug issues who access treatment services. Providers are looking at how best to engage more individuals, with a specific focus on both the BME and LGBT communities. 90

91 A priority for providers is to support higher numbers of people to recover from their addiction issues, and successfully re-integrate within the community. This is measured by looking at the percentage of people who successfully complete treatment services. Performance figures for quarter two of 2016/17 show a considerable increase compared with the same period in 2015/16. KPI : Increase the number of successful completions (as a proportion of all treatments) Target Q2 Opiates 6.8% 9.7% Non-opiates 33% 39.1% Alcohol 38% 45.4% Alcohol and Non-opiates 34% 39.7% Table 29. Public Health Drug and Alcohol Misuse Service KPI progress for 2016/17 KPI : Increase the number of those who successfully complete treatment and do not re-present within 6 months (as a proportion of all treatment) PHOF 2.15 Target Q2 Opiates 6.8% 5.9% Non-opiates (includes Alcohol and Non-opiates) 37.3% 29.7% Alcohol 38.6% 34% Table 30. Public Health Drug and Alcohol Misuse Service KPI progress for 2016/17 The Public Health team are making considerable budget reductions across all service areas. The resource within the substance misuse service is likely to reduce as a consequence of this, and could have an impact on service outcomes in the future. Commissioners and providers will work together to reduce this impact where possible. Deliverables 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Drug and alcohol misuse: increase the number of people with drug issues who access treatment services Smoking cessation in maternity: work with the Local Authority and BSUH to review maternal smoking cessation practices against NICE guidance PH26 and PH48 Table 31. Prevention deliverables 6.11 Children s, Young people s and Maternity Services Maternity Services Maternity Services in Brighton and Hove are provided by Brighton and Sussex University Hospitals Trust (BSUH). Brighton and Hove CCG commissions BSUH to provide the three pathways for maternity care antenatal, delivery and postnatal, as described by the maternity pathways payment tariff (MPP) introduced in Antenatal and postnatal care are largely community based services provided by the community midwifery team including a Home Birth Team. Hospital care is provided across 2 sites in Obstetric Led Units (OLU): The Royal Sussex County Hospital in Brighton and the Princess Royal Hospital in Haywards Heath. Most women in Brighton and Hove give birth in an OLU and whilst plans for a co-located Midwife Led Unit (MLU) have been agreed there has been considerable delay in developing this. There is however a very strong homebirth team and around 6% of women locally give birth at home. This is significantly higher than the national average (around 3%). 91

92 Improving outcomes in maternity care has been an ongoing priority for successive Governments. This Government has made reducing stillbirths an objective and reducing deaths in babies and young children is a key indicator in the NHS Outcomes Framework. A range of national documents have been published to support this, with the following key themes focused on improving safety and quality in maternity services: Leadership for a safety culture within and across organisations Sharing progress and lessons learnt across the system Early detection of the risks associated with perinatal mental illness Reducing still birth and early neonatal death The CCG has regular Quality Review Meetings with BSUH to focus on these themes and monitor progress. One of the persistent challenges is around work force issues, particularly around sonographers and their role in supporting early detection and monitoring of foetal growth restriction problems. This is a national problem and will be a priority for the STP Local Maternity Systems. Sustainable solutions are more likely to be found across the wider geography and with collaborative working across providers. This will be a priority area for The National Maternity Review report (Better Births A five year forward view for maternity care) was published by NHS England in This report highlighted seven key priorities to drive improvement and ensure women and babies receive excellent care nationally. Personalised care The Brighton and Hove CCG and BSUH continue to work with MSLCs to gain local feedback on personalised care and review National Maternity Survey results. Continuity of carer - The CCG will evaluate the new midwifery hub in 2017 to assess if this model could be used to deliver small teams in community hubs and continuity of carer, taking learning from the Early Adopter sites into account. Better postnatal and perinatal mental health care The CCG has already made significant investment in perinatal mental health and with the additional funding from the STP bid we will continue to monitor the service to ensure it meets the needs of the population. Postnatal care has been identified as a priority and we are committed to progressing work with BSUH to improve this. A new and more personalised payment system. Safer care BSUH is developing a Safety Improvement Plan and the CCG is part of the Strategic Clinical Network which provides valuable benchmarking information across providers in the South East. Multi-professional working BSUH provides multidisciplinary training within maternity services on a regular basis. Working across boundaries within the STP footprint. Better Births provides a framework for longer term structural and transformational change in maternity services with actions for NHS England, Commissioners and Providers. One of the key recommendations is that going forward, planning and delivery for maternity services will be across larger Local Maternity Systems (LMS) covering populations of between million. STP Boards with Clinical Networks will provide leadership and infra structure for these changes. The local LMS area is in the process of being agreed, and once this has happened we expect to develop joint plans with neighbouring CCGs during 2017 to deliver the 5 year forward view for maternity. 92

93 Brighton & Hove CCG has already begun to make progress against some of the key recommendations. We are working with BSUH on developing small teams of midwives to deliver continuity of care and piloting the development of community hubs which will be evaluated in The city has an established perinatal mental health team comprised of midwifery and mental health staff. Recently, we were successful in a STP-wide bid to increase the capacity of the team to enable it to meet the needs of a greater number of women with perinatal mental health needs. The enhancement to the service will be introduced in 2017 and will include a named midwife for mental health. We have also identified two clear priority areas for future improvement and for work across the larger STP footprint postnatal care and the workforce issues relating to Sonography. Brighton and Hove CCG supports a very vibrant and long-standing parent led Maternity Services Liaison committee (MSLC). They have a key role in providing regular feedback on patient experience and challenge to both providers and commissioners. The MSLC will be firmly engaged with our plans and reviews as part of our collective work on Better Births over the coming years. The CCG improvement and assessment framework (CCG IAF) baseline. The baseline maternity assessment has been designed to align with a number of the key themes from Better Births. Four indicators have been selected which provide a broad representation of the various aspects of the maternity pathway: Patient Experience Patient Choice Maternal smoking at time of delivery Stillbirth and neonatal mortality This assessment is intended to provide an initial baseline of how CCGs are performing in the areas measured by the indicators. However, it is important to note the assessment is limited by the small number of metrics selected and is not intended to provide an overall picture of the quality of maternity services within the CCG area. Current Performance in Brighton and Hove CCG Patient Experience % This is a composite of a range of areas and is in line with the average for most Trusts. Areas where Brighton and Hove is performing better include: Skin to skin contact in labour Partner involvement in labour The indicators that show the most scope for improvement are: Length of hospital stay being about the right amount of time Reasonable response time after birth Partner length of stay The sample size of 219 patients is relatively small and the CCG is working with BSUH and MSLC to obtain further local feedback to inform an improvement plan. 93

94 Patient Choice 66% This score is similar to the average score for England. Across the BSUH footprint, women are currently provided with choice of hospital or home birth but there is no option for a midwifery led unit locally which limits the availability of choice. The CCG is working across the STP footprint to review choice of birth place and also with providers and MSLC to understand pathways for informed choices. Maternal Smoking Cessation In 2015/2016, 6.3% of mothers (185 maternities) were smoking at time of delivery (SATOD) compared to 10.6% nationally. When this is compared to 15 of our nearest CIPFA neighbours Brighton and Hove has the lowest rate. The trend shows that Brighton and Hove rates have been below the national and south east average for the past six years and we have had a 1.4% decrease in women smoking at time of delivery over that time. All pregnant women that smoke are identified at time of booking and referred to the RSCH smoking cessation lead, and reduction is measured at time of delivery. The majority of women and their partners are treated by the hospital service and only small numbers are seen by other locally commissioned services (GP and pharmacy). Women setting a quit date in 2015/16 has increased threefold on the previous year with 89 women setting a quit date and 79 (89%) reporting they stopped smoking. In order to reduce the harmful effect of smoking on infants born to mothers that smoke, break the cycle of smoking in families and ultimately reduce inequalities smoking cessation in maternity must be a priority. The Brighton and Hove Tobacco Control action plan calls for a review of maternal smoking cessation practices in Brighton and Hove against the NICE guidance PH26 and PH48 and there are plans to work with the CCG and RSCH partners to commence this work in 2017/18. This will ensure that best practice is identified as well as areas for continued improvement to inform the work of commissioners, BSUH management, midwives and smoking cessation services. Still Birth Rate The still birth rate of 6 per 1,000 live births is slightly lower than the England average (7.3) but there is scope to improve to the levels of the best performing Trusts (the top 5 Trusts in the country have an aggregate score of 5.6). Still birth rates are affected by smoking and detection of foetal growth rates, raising awareness of reduced foetal movement as well as foetal monitoring in labour. Given the very positive local work on smoking cessation, the main focus of our improvement plans are to enhance detection of foetal growth restriction. Workforce issues are a key priority area to address via the Local Maternity Systems 2017 work plan. Summary of Maternity plan Deliverables 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Analysis of National Maternity Survey to inform SDIP with provider Establish Local Maternity System (to cover population size 0.5 to 1.5million) as part of wider 94

95 Deliverables 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 plan across the STP footprint Enhanced Perinatal Team in place Evaluation of Community Hubs Pilot Agree Plan for personal maternity budgets Table 32. Maternity deliverables Risk L I Mitigation Lack of workforce to deliver maternity care 4 4 To be addressed as part of STP Plans. Insufficient community estate to deliver Community Hubs Table 33. Maternity risks and mitigation 4 2 To be addressed as part of Estates Plan Children and Young Peoples Services The Brighton and Hove Joint Children and Young People s Health and Wellbeing Strategy developed in 2015 set out the shared ambition of the CCG and Brighton and Hove City Council for the children and young people of the city for the next 5 years. It supports the planning and delivery of more integrated, proactive and preventive services across education, health and care in order to deliver positive outcomes for children and young people. The vision described in our strategy is for a path to lifelong good health and wellbeing beginning with ensuring that our children have the best start in life. Children can also feedback into family/support units influencing behaviours that impact on health outcomes for the whole family. Having happy, healthy children in our city will lead to happy, healthy adults and contribute to reduced reliance on the health and social care system. We have much to celebrate in the City in terms of high quality children s services as evidenced by: The recent CQC inspection at the Royal Alexandra Children s hospital which was rated as outstanding The joint CQC/OFSTED inspection of services for children and young people with special education needs and disabilities (SEND) which identified a significant number of strengths across health, education, social care and the voluntary sector in terms of how Brighton and Hove identifies and meets the needs of children and young people with SEND The majority of health care for children and young people is provided by GPs in primary care and is in the context of looking after the family unit. The CCG aims to ensure that primary care services in the city have the capacity and capability to offer high quality and holistic health care to children and young people. We will do this through the Locally Commissioned Service (LCS) outcomes contract, building on the work started in 2015 /16. The future vision is to develop children s health hubs around GP clusters providing more integrated and multi-disciplinary approaches. In particular, by looking at more joined up care and sharing of skills across secondary and primary care The CCG has three new developments in 2017 that will support these aims: 95

96 1. Piloting Joint Paediatric Clinics and Multi Professional Case Learning in Primary Care Clusters: A hospital paediatrician will work with GPs in a cluster to provide joint clinics, enabling more care to be provided in primary care and therefore avoiding the need for hospital attendances. This will rotate between surgeries each month and be followed by multi professional case discussions, allowing children s professionals to bring cases for wider discussion and learning. 2. Expanding and transforming the Children s Community Nursing Service to support care closer to home: Significant investment is being made to expand the existing team that currently provide a hospital at home service to increase working hours to 8pm and across weekends. Nurses will also work with children and families to prevent admissions and build relationships with GP Clusters to support improved skills and liaison with the primary care workforce and identify further opportunities to support children out of hospital. 3. Piloting integrated therapy teams at the Children s Hospital to improve outcomes for children and young people with complex symptomology: The integrated therapies team will work closely with paediatricians to identify children and families who could be better supported to manage their symptoms in a more holistic approach reducing unnecessary hospital appointments and investigations. The CCG is committed to bringing care for children and young people, particularly those with the most complex needs, closer to home and away from hospital based settings. This is also reflected in the work we do with our commissioning colleagues in the Local Authority to support services in schools and to jointly commission a range of services promoting positive mental health. Summary of Children and Young People plan Deliverables 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Full City Roll Out of Joint Paediatric Clinics Expansion of Children s Community Nursing Team to prevent unnecessary hospital attendances and admissions. Medically Unexplained Symptom Pilot Evaluated RTT cross reference planned care section Table 34. Children and Young People s Plan deliverables Risk L I Mitigation Lack of workforce to deliver maternity care 4 4 Needs to be part of STP Plans. Insufficient community estate to deliver 4 2 To be addressed as part of Estates Plan Community Hubs Table 35. Children and Young People s Plan risks and mitigation 6.12 Medicines Management Moving into , we will continue to work with partner commissioners, providers and other organisations to optimise medicines use in all care settings for our population, to ensure that 96

97 patients get the best possible health outcomes from the investment that we make in medicines and other prescribed items. We will continue with the managed entry of new drugs via the Brighton Area Prescribing Committee as a governance structure to reflect the needs of the local health economy. We will engage with neighbouring CCGs and providers to ensure that medicines which are evidence based and affordable are made available to the general public whilst delivering value for money when committing the use of public funds. We will also focus on the implementation of NICE Guidance and on prescribing in key therapeutic areas such as for those with long-term conditions. As the Coordinating Commissioner for BSUH and Associate Commissioners, with regards to high cost drugs, we will ensure: a. Adherence to all medicines management specification documents, i.e. The Interface Prescribing Policy (IPP) and the CCG 2017/18 Payment by Results (PbRe) excluded drugs Commissioning Intentions for PbRe Drugs document. b. All existing, and new drugs and technologies should be provided within the scope of National Tariff guidance unless: Explicitly excluded through the National Tariff 2017/18 and funding agreed with commissioners They are part of excluded services They are approved through local arrangement agreed with the commissioners The 2017/18 Payment by Results excluded drugs Commissioning Intentions document will contain all drugs and indications that are expected to be prescribed in 2017/18 in line with the scoping horizon work undertaken between October and December A full data set will be submitted for all drug charges and any subsequent challenges. We will continue to monitor prescribing spend against budgets set for GP practices and other providers. We will use our prescribing monitoring dashboards to identify outliers with prescribing, and work with partners to address any problems or learning needs. We will look at the following specific areas/projects as part of our work plan: Poly-prescribing and De-prescribing Care of the frail and elderly Continence Antimicrobial Stewardship (AMS) Atrial Fibrillation and Hypertension Diabetes Pain and Substance Misuse Benzodiazepines Medicines Safety Medicines Waste Using pharmacists in the community more widely to help with GP workload, out of hours and A & E attendances related to medicines We have set KPIs for all our projects and will be monitoring performance against KPIs on a regular basis. 97

98 Summary of Medicines Management Plan Deliverables ( 000s) 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Meds Optimisation OptimizeRx Care Homes Med Review Bettercare Med Review Rebates Biosimilars saving Table 36. Medicines management deliverables Finance ( 000s) 2017/ /19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Prescribing Commissioned clinical services Pbr Excluded Medicines Table 37. Medicines management finance Risk L I Mitigation L I Failure to deliver Prescribing QIPP 3 4 Robust clinical engagement plan, 1 4 adequately staffed field team (business case submitted) Failure to deliver biosimilars QIPP 4 4 Risk shared capacity investment 2 2 Table 38. Medicines Management risks and mitigation 6.13 NHS Continuing Health Care The NHS Continuing Healthcare National Framework provision can be delivered through a care home placement or a package of care in the client s own home. Support plans are individualised to meet the client s healthcare needs. Care is commissioned using clinical expertise and local social care networking, empowering clients to take control of their own health needs. NHS Regulations (2013) and the NHS Mandate commitment is for all adults and children in receipt of Continuing Healthcare/Continuing Care to have a right to have a personal health budget (PHB) if they request one. NHS Operation Planning and Contractual Guidance Annex 2 sets a national target of improving patient experience through provision of personal health budgets or integrated personal budgets to 50, ,000 people by Key items Brighton and Hove committed to take action to ensure all individuals who are entitled to Progress We have fully embedded the Personal Healthcare Budget (PHB) policy and ensured this has remained a high focus within the CCG over the duration of the year. We have increased the level of collaborative working across East Sussex /HWLH and HMSx CCGs The CCG completed the PuPoc workstream within the timeframe 98

99 continuing healthcare support have access to timely high quality services and support. identified (September 2016) The CCG has prioritised all fast track referrals for CHC and has sought to ensure that all care packages and/or placements are sourced as expediently as possible, in order that patients can receive safe and effective care within a setting of their choice. The CCG is seeking to ensure that more than 80% of all full NHS CHC assessments are completed within 28 days. The CCG is seeking to ensure that less than 15% of all full NHS CHC assessments take place in an acute hospital setting We are developing a trusted assessor model with our neighbouring CCGs - East Sussex /HWLH and HMSx CCGs We are implementing a monthly integrated care meeting, jointly chaired between Brighton and Hove CCG and Brighton and Hove City Adult Social Care team. To promote joint working and to seek to reduce delay across the wider systems of health and social care. The CCG is committed to ensuring that organisational boundaries and perverse financial incentives do not impede integrated working. The CCG is committed to expanding partnership working in alignment with the NHS Operational Planning and Contracting Guidance and in alignment with the STP The CCG has committed to a full review of internal processes within the CHC referral pathway, the recommendations of this review are expected in quarter /17 for implementation in 2017/18 Brighton and Hove CCG is committed to establishing and chairing a multi-stakeholder forum which will meet monthly to develop and implement locally 1. A trusted assessor model. 2. A discharge to assess model - both of which will be modelled utilising national areas of excellence with lessons learnt Table 39: Progress on the 2016/17 Operating Plan Our progress against the 2016/17 operating plan is described in table 37. In order to ensure that more than 80% of all full NHS CHC assessments are completed within 28 days, a workforce review will begin by the end of 2016/17. The aim of this review is to enable the achievement of this target through re-prioritisation of working behaviours and patterns. A detailed action plan is being developed which will have a clear improvement trajectory over the duration of 2017/18 and the first 3 quarters of 2018/19. To achieve the target of less than 15% of all full time CHC assessments taking place in an acute hospital setting, we are leading a significant workstream across the 3 local CCGs and Local Authorities. This is currently scoping options of how it can be most effectively achieved and a strategic steering group intends to meet in order to progress this key work. In addition to this significant work, we have a well-established Personal Health Budgets (PHB) policy which has seen year on year growth in numbers. We intend to remain committed to this success and plan to expand and increase the numbers of those in receipt of a PHB to a minimum of 190 recipients in 2018/19. We will work towards this in 2017/18 by collaborating with the Local Authority to strategically develop the self-directed support agenda alongside our own plans to increase self-management and social prescribing as part of Brighton and Hove Caring 99

100 Together. 7. Estates Plan Currently, the clinical estate is comprised of the estate portfolios held by BSUH, SCFT, SPFT and GP practices. Generally services are provided within these estates although some services are commissioned to operate in other providers estates in order to facilitate increased integration (for example Better Care workstreams). Over the forthcoming years, integrated working will increase with improved space utilisation and co-location of services to deliver joint health and social care outcomes in clinical estates. As a result, there will be more joint strategic working across health and social care and all General Practice premises will be of a high quality standard, enabled by the Primary Care Transformation Fund. In addition, hub and spoke models will be used more for improved service delivery, and out of hours working will become more frequent to better utilise assets and meet the needs of the population. In terms of the administration estate, the CCG has recently re-located to Hove Town Hall to be co-located with the Local Authority. Providers are seeking to rationalise administrative accommodation by making greater use of flexible desks and ICT for a reduced footprint in nonclinical buildings, in response to The Carter Review. We will provide ongoing support for reducing estates footprints by supporting integrated approaches to commissioning services across local CCGS and Local Authorities, including greater use of ICT interoperability and collaborative agreements. Previously, organisations have been responsible for managing their own footprint and estates operational costs which led to a fragmented approach to the management of void space. There have been advances on sustainability measures, but metrics on shared space and indirect measures (such as impact on staff health and wellbeing) are at an embryonic stage. In , costs will need to be rationalised through rationalisation of estate that is poor value for money or under-utilised and savings may be required to invest in other estate elsewhere. Flexible deployment and cultural change aligned to communities of practice will enable more intensive use of a higher quality yet reduced footprint. An audit will be undertaken to review environmental performance and impact on staff wellbeing. 8. Financial Plan 2016/2017 Position Our control total for 2016/17 is 9,685k and includes our previously earned surpluses of 12,685k and our approved access to 3,000k of this surplus to be used to support RTT and Proactive Care. This use of surpluses is referred to as drawdown and requires business case approval from NHS England. We remain on target to deliver against this but there are risks within the system that need to be managed between now and the end of March Within this position are some significant recurrent cost pressures which are detailed in the month 8 report and include: mental health specialist placements 1.3m for funded nursing care increases agreed nationally 1m for equipment stores within the Better Care Fund unidentified savings in year 100

101 The major non-recurrent issue is around the Patient Transport Service (PTS) contract and supporting the change process and there are two further risks still to be quantified /mitigated which relate to our MSK contract and our settlement of a contract dispute around 2015/16 with BSUH. The latter is subject to mediation on 22 December with NHS England and NHS Improvement. The required 0.5% contingency reserve of 1,893k has been identified to support these issues but savings/underspends of about 1,000k are still required to ensure we deliver. Within the Business Rules that govern our operation a 1% non-recurrent reserve was created, and this remains unspent per NHS England instructions. An analysis of the savings target for this year is being updated constantly to identify and confirm what amounts have been found by slippage in this year, which will lead to the need for further recurrent plans in 2017/18. Currently, this figure is nearing 4,000k Financial Plan There are three NHS business rules which have a material impact upon the plan: The first is maintenance of the 0.5% contingency which can be used to support unplanned variances in year. The second rule recreates the 1% non-recurrent reserve. Per NHS England instructions for 2017/18 and 2018/19 half of this reserve is available for allocation and will be used to fund the increase in primary care, which has been calculated at 3 per head over the next two years (circa 900k in total), and a reserve for RTT activity of 1,000k The last rule is that of adhering to our control total. As previously mentioned the CCG was allowed 3,000k drawdown in 2016/17, and it had been planned to replicate this for the next years, which would have left a cumulative surplus of 1% - the required target for all commissioners. However, NHS England have now informed the system that these amounts will be halved for 2017/18 and 2018/19, leading to a requirement for further savings plans to ensure the control total is achieved. A summary of our financial plan is contained in the tables below. Activity Growth The activity growth percentages used in the plan were calculated for the STP submission, before allowing for any pathway changes or different forms of provision, and for our CCG the following figures were applied: 101

102 2016/17 Forecast 2017/18 Forecast 2018/19 Forecast 2019/20 Forecast 2020/21 Forecast Secondary Care Acute - NHS 2.77% 2.78% 2.79% 2.80% Acute - Non-NHS 2.77% 2.78% 2.79% 2.80% Mental Health - NHS 1.9% 1.9% 1.9% 1.9% 1.8% Mental Health - Non NHS 1.9% 1.9% 1.9% 1.9% 1.8% Community Health Services - NHS 3.3% 3.4% 3.4% 3.4% 3.3% Community Health Services - Non NHS 3.3% 3.4% 3.4% 3.4% 3.3% Other NHS 2.0% 2.2% 2.2% 2.2% 2.3% Continuing Care 6.5% 5.8% 5.5% 5.7% 6.6% Prescriptions 3.7% 5.4% 4.4% 4.2% 4.2% Other Primary Care 6.1% 4.9% 5.3% 5.2% 5.2% Admin 1.7% 1.8% 2.1% 1.9% 2.0% CCG Other 6.1% 4.9% 5.3% 5.2% 5.2% Social Care Expenditure 1.7% 1.8% 1.9% 2.1% 2.2% Table 40. Activity Growth Tariff and inflation The figures issued nationally have been used in the STP and are as follows: Inflation 2016/17 Forecast 2017/18 Forecast 2018/19 Forecast 2019/20 Forecast 2020/21 Forecast Secondary Care Acute - NHS 3.1% 2.3% 2.0% 2.0% 2.9% Acute - Non-NHS 3.1% 2.3% 2.0% 2.0% 2.9% Mental Health - NHS 3.1% 2.1% 2.0% 2.0% 2.9% Mental Health - Non NHS 3.1% 2.1% 2.0% 2.0% 2.9% Community Health Services - NHS 3.1% 2.1% 2.0% 2.0% 2.9% Community Health Services - Non NHS 3.1% 2.1% 2.0% 2.0% 2.9% Deflator 2016/17 Forecast 2017/18 Forecast 2018/19 Forecast 2019/20 Forecast 2020/21 Forecast Secondary Care Acute - NHS -2.0% -2.0% -2.0% -2.0% -2.0% Acute - Non-NHS -2.0% -2.0% -2.0% -2.0% -2.0% Mental Health - NHS -2.0% -2.0% -2.0% -2.0% -2.0% Mental Health - Non NHS -2.0% -2.0% -2.0% -2.0% -2.0% Community Health Services - NHS -2.0% -2.0% -2.0% -2.0% -2.0% Community Health Services - Non NHS -2.0% -2.0% -2.0% -2.0% -2.0% Tables 41 and 42. Inflation and Deflator forecasts Savings Planning for the savings required over the next two years is well under way as a lot of work has been done already for the STP. The impact of these suggestions on our CCG has been calculated and plans are being worked up to support these changes where appropriate. Not all of them will be deliverable in the next two years and may well require investment to deliver future savings. Meanwhile, each directorate is looking at all areas of expenditure to ensure that opportunities to maximise efficiencies are explored. Savings within mental health provision are being sought to absorb the pressure on specialist placements of 700k in 2016/

103 The increase in funded nurse care of 1.3m is being delivered in part by savings within CHC budgets. The pressures on the Better Care Fund (due to overspends and under-budgeting on the equipment stores), are being funded by redirecting spend within the 20m budget. In the light of the development of clusters within primary care, the commissioning of LCS is being reviewed to ensure that provision, and therefore cost, is not being duplicated across the city Plan Forecast Plan Plan Description '000 '000 '000 '000 Initial Resource Limit 349, , , ,629 Growth 9,484 9,484 7,198 7,283 Recurrent Adjustments Published Allocations 359, , , ,912 Running Costs 6,386 6,301 6,385 6,384 Primary Care Allocation Non-recurrent adjustments - HRG4+IR Rules 0 0 (2,372) (2,410) Non-recurrent adjustments - Drawdown 3,000 3,000 1,505 1,505 Non-recurrent adjustments - Other (304) Revenue Resource Limit 368, , , ,391 Programme Costs Acute Care 178, , , ,231 Mental Health 50,599 50,857 51,325 53,239 Community 40,528 39,514 39,008 40,075 Continuing Healthcare 29,093 28,732 30,875 31,829 Primary Care 45,749 45,754 45,276 45,570 Other Programmes (incl Running Costs) 19,126 21,592 17,506 18,443 Total Programme Costs 363, , , ,387 Reserves General Reserve 721 1,365 RTT Reserve 1,000 1, % Contingency 1,893 1,862 1,900 1% Non-Recurrent Reserve 3,594 3,594 3,666 3,739 Total Reserves 5,487 3,594 7,249 8,004 Surplus - after drawdown /17 Forecast ' /18 Forecast ' /19 Forecast ' /20 Forecast ' /21 Forecast '000 Surplus b/fwd 12,685 9,685 8,180 6,675 5,170 Drawdown (3,000) (1,505) (1,505) (1,505) (1,505) Surplus c/fwd 9,685 8,180 6,675 5,170 3,665 Figure 10. Savings plan 103

104 Commissioner Summary 2016/17 Forecast ' /17 Normalised ' /18 Forecast ' /19 Forecast ' /20 Forecast ' /21 Forecast '000 CCG Programme 372, , , , , ,114 CCG Admin 6,386 6,386 6,385 6,384 6,381 6,376 CCG Income, total 378, , , , , ,490 Secondary Care Acute - NHS 153, , , , , ,407 Acute - Non-NHS 25,128 24,278 24,975 25,620 26,285 27,216 Mental Health - NHS 31,683 31,683 33,427 34,524 35,620 37,010 Mental Health - Non NHS 18,350 18,350 18,724 19,043 19,364 19,859 Community Health Services - NHS 28,566 28,566 30,738 32,897 35,129 37,799 Community Health Services - Non NHS 11,954 11,954 12,371 12,765 13,169 13,706 Other NHS Continuing Care 28,729 29,329 30,956 32,602 34,388 36,612 Prescriptions 39,452 39,452 40,255 40,703 41,092 41,502 Other Primary Care 6,389 5,899 6,179 6,492 6,820 7,163 Admin 6,301 6,386 6,488 6,611 6,724 6,845 CCG Other 10,422 13,585 14,228 14,949 15,705 16,495 Social Care Expenditure 7,980 7,980 8,107 8,245 8,402 8,571 CCG Expenditure, total 368, , , , , ,187 Surplus b/fwd 12, Commissioner Income 365, , , , , ,490 Commissioner Expenditure 368, , , , , ,187 Commissioner Surplus / (Deficit) in year (3,000) (6,207) (8,293) (7,413) (6,135) (1,697) Commissioner Control Total (3,000) (1,505) (1,505) (1,505) (1,505) Risks Table 43. Finance STP submission 2016/17 out turn. The main risk for this year remains the need to deliver additional savings plans or further underspends by 31 March With this in mind, an has gone out to all Executive Directors of partnership organisations informing them that no uncommitted/new expenditure will be permitted without a direct request from the relevant Director to the CCG Chief Finance Officer and the Chief Accountable Officer. 2017/18 Savings Plans. Plans of approximately 13,000k are required for 2017/18, of which 2,000k can be found non-recurrently. This will subsequently require plans of 9,000k in 2018/19. Currently these plans are not of a satisfactory level of detail but weekly meetings are identifying more and improving the quality of those already suggested. At this time, there are plans for approximately 7,500k which are rated green, and a further 1,700k rated amber. This leaves a further 3,800k to be found, including the new requirement of 1,505k due to the reduction in drawdown in each year. NHS Contracts. The agreement of contracts between the CCG and its main suppliers remains a risk. As lead commissioner for BSUH we have reached a contract settlement for both years, but there is risk in this for both sides around the delivery of QIPP. Co-commissioning. The CCG submitted its application for delegated co-commissioning on 5 December 2016, in line with the national timetable. Work is ongoing with NHS England to identify any potential financial risks due to outstanding revaluations of rental amounts which will be resolved before 1 April

105 QIPP Savings The CCG has a 13m QIPP target for each of the next two years. The table below summarises our QIPP: Start Date 17/18 RAG 18/19 RAG Medicines Management Core GP Presc Apr-17 1,668 G 1,500 A Medicines Management PbR Exc & MSK (Bio-similars) Apr-17 1,596 G 1,596 A Mental Health Specialist Placements Apr A 400 A Mental Health Out of area treatments Ongoing 5 G 5 G Mental Health Voluntary sector contracts 70 A Childrens Services Children s community nursing Apr G 125 A Urgent / Planned Care LUTS (Reduction in OPN & FU) 155 G Urgent / Planned Care Direct to Test (Reduction in OPN & FU) Apr G Urgent / Planned Care CVD (Right Care) not starting till 18/ R Urgent / Planned Care LPP Phase 1 Apr G Urgent / Planned Care LPP Phase 2 not starting till 18/ A Urgent / Planned Care Headache Pathway Apr G Urgent / Planned Care Low vision services - Stop Investment Apr G Urgent / Planned Care Advice and Guidance (OPN) Apr G 10 A Urgent / Planned Care SAU Apr R Urgent / Planned Care Reduction in over committed RTT contracting 1,000 G CHC Efficiencies 250 G 750 A Community CSTS Beds Reprocurement (reduced to show 17 week delay) Jul R Community Review of LCS Community SCFT Service Line Review - Offset Growth Apr G 1,285 A Community Proactive Care - Savings Ongoing 1,214 A Community Proactive Care - Reduced Investments Apr-17 1,000 G Transforming Care LD / Autism Review of other Funding 1,000 R Internal Budget Review 300 G Better Care Budget Review 500 R Balance Needed 1,635 R 4,153 R Total 13,076 10,535 Table 44: QIPP savings 7,536 G 5 G 1,714 A 5,986 A 3,826 R 4,544 R 13,076 10, Governance and Assurance In an increasingly integrated and by definition more complex, commissioning and service delivery landscape the robustness of governance and assurance models is of upmost importance. The new ways of working and models of service operation are cutting across geographical, sectorial, organisational and political boundaries and as such governance arrangements need to be adjusted to suit the needs of these new organisational/ operational structures, be they physical or virtual entities. Well thought out Governance is required to ensure that decisions are made by groups with the correct legal authority and to provide frameworks of accountability and assurance. 105

106 Governance models for the system-wide Sustainable Transformation Plan are strategic in context and operation with oversight by a STP Programme Board with the Executive being led by the leaders of the three-place based plans. In these terms it is more relevant to outline the Governance of the Place-Based Plan which will be more pertinent in its detail and model of operation to the Brighton and Hove CCG Operating Plan. The Central Surrey and East Sussex Alliance governance model is complex, covering 5 CCGs and 6 Local Authorities spanning health and social care domains, and will be based on the Principles of Governance detailed below and these translate into the model presented in figure 11. Shared leadership Parity between board members Representation of all major providers Shared ownership of the board and accountability to communities Openness, transparency, inclusiveness Joined up governance to avoid repetition Programme board independent chair Democratic representation to provide public accountability The public will be engaged throughout and consulted appropriately Place-based programme aligns strategic direction across place Seeks integration, sharing and efficiencies across place-based themes Works with the leadership of the other two places to align across borders and avoid repetition or competition Delivers consistent messages to STP Programme Board & individual organisations sovereign governance arrangements Delivers place-based messages alongside local strategy to the 4 HWB s to enable an aligned strategic view across the whole of the local health and care economy Local HOSCs continue to review proposals for substantial change in context of place based plans Single financial statements Single published view of estates Figure 11. The Central Surrey and East Sussex Alliance governance model. 106

107 Brighton and Hove CCG Governance The CCG has a clear and systematic governance and decision making process which is articulated in detail in the CCG Constitution. The CCG continues to update and amend its governance in accordance with internal and external demands and changes. The TIAA undertakes an annual programme of review all of the pertinent CCG work areas whose reported feedback feeds into the cycle of improvement. In 2015/16 of the CCG commissioned a Capability and Capacity Review from an external consultancy with the specific remit to consider the leadership and committee structure of the CCG. This was received in early 2016 and a series of actions were planned to address the issues identified. Progress against this plan is monitored by the CCG s Governing Body. NHS England advised the CCG that the position of not assured had not sufficiently improved and on 1st September NHS England published legal directions with which the CCG is obliged to comply. These directions consider the CCG s leadership capacity, developing the actions identified at the Capability and Capacity Review, a review of the CCG s governance, developing commissioning plans and plans to address shortfalls against referral to treatment targets and A&E waiting times. Drafts of these plans were submitted to NHS England on These plans are being agreed with NHS England and will be monitored by the Governing Body and at the quarterly assurance meetings with NHS England. During 2016/2017 the CCG made a number of changes to committees, policies and governance to further strengthen our governance and assurance processes. This has included the introduction of a biweekly CCG Senior Management Team (SMT) meeting to address operational issues. To support the focus and efficacy of the SMT meeting the CCG is introducing a Commissioning Operations Meeting to undertake detailed reviews of the CCG commissioning plans and to escalate identified issues to either the Senior Management Team or NHS England as appropriate. This forum is chaired by the CCG Operational Officer and membership consists of their direct reports, including the Heads of the CCG teams and the Head of Finance. The CCG is currently undergoing a governance review which will be completed at the end of January The outputs from this will be translated into an action plan to be monitored through the governance structure. To facilitate and support the delivery of the Primary Care Strategy, and the in turn the Multispecialty Community Provider model outlined in the Place-Based Plan the CCG has formed a Primary Care Commissioning Committee to support the delivery of Co-Commissioning and MCPs. To strengthen the audit and accuracy of the CCG Membership voting processes a paper vote submission system has been agreed. CCG Performance Management Successful organisations are typically the ones that invest time and resources in the acquisition and delivery of good information in order to become an 'intelligent organisation'. To enable this, the CCG will embed performance, contracting, finance and quality into one reporting framework. This integrated report will act as the intelligent tool that drives through the way we commission, contract and drive through delivery and improve and sustain performance. It would also enable us to transform services. The CCG will ensure that timely, accurate and appropriate information is available to relevant staff that will: 107

108 provide information on how the CCG commission's and delivers services by understanding the health and social care needs and wants of patients and their experience of the services they use ensure the existence of an appropriate assurance framework to serve internal and external performance management regimes These correlate to the requirements for CCGs functions to: act with a view of securing continuous improvement in the quality of services, and in the outcomes have regard to the need to reduce inequalities between patients access to and outcomes from health services promote the involvement of patients, their carers and representatives in decisions about the provision of health services to them promote transformation and innovation in the provision of health services (new models of care) act with a view of securing integration in the provision of health services and the provision of health and social care services in situations where the CCG considers that this would improve the quality of the services or reduce inequalities between patients in outcomes and access to services. The report will be used to: inform the operating plan inform and improve prioritisation and commissioning; including how we Commission for Quality and Innovation (CQUIN) ensure clinicians and managers have the information they need at the time they need it ensure that internal performance management of the CCG achieves continuous improvement and transformation support the CCG to meet the NHS constitutional standards, Improvement and Assessment Framework and the NHS Outcome framework provide assurance that the CCG is meeting and surpassing contractual standards of service delivery, patient quality, performance within a sustainable financial envelope i.e. value for money inform and enable decommissioning decisions CCG Information Governance The CCG has robust systems in place around Information Governance (IG), and assurance around this comes from the annual submission of the IG Toolkit. The CCG consistently achieves above Level 2 (66%) in its toolkit submission. In the overall result was 73%. The toolkit submission is audited by TIAA. All staff complete two modules of mandatory e-learning relating to IG annually, for which they must pass an assessment, training completion is monitored by the IG Manager. The CCG has an IG Committee, chaired by the Caldicott Guardian and attended by the SIRO and other relevant heads of department. This committee meets quarterly and its remit includes providing oversight of IG within the CCG, monitoring progress against the IG action plan, promoting and facilitating good IG practice across the CCG, planning the implementation of new legislation, guidelines and regulations and ensuring initiatives and policies are communicated across the CCG. 108

109 Conflicts of Interest Brighton and Hove CCG has developed a robust policy on the management of conflicts of interest. This policy meets the requirements of the latest statutory guidance on handling Conflicts of Interest published by NHS England. NHS Protect Audit NHS Protect carried out an audit of the CCG during the year, looking at an array of governance matters including risk management, gifts hospitality and sponsorship, the management of conflicts of interest and counter fraud measures. Only two matters of concern were noted during the audit. Action plans have been put in place against these issues which have been agreed with NHS Protect and are monitored at the CCG s Audit Committee. Board Assurance Framework and Risk Management Risk management is a fundamental part of quality and safety assurance and the CCG has an integrated Risk Management Framework covering clinical, financial and corporate risks. The CCG Risk Assurance approach is described in detail in the Board Assurance Framework Guidance. The Governing Body review and update the CCG Strategic Objectives and the principal risks to these on an annual basis. This process is described in our Assurance Framework. The organisation has an established risk management system which identifies and tracks corporate, team and project level risks. These are reviewed monthly and are recorded and reported on dedicated Ulysses Safeguard Risk Management Software. The Corporate Risk Register and Report are reviewed and discussed monthly at the Senior Management Team and Performance and Governance Committee, prior to presentation to the Governing Body. Clinical Risks are also reviewed at the Quality Assurance Committee and there are clear mechanisms through which quality and patient safety risks are escalated and resolved. The CCG risk management and recording process is assured through review at the monthly Audit Committee and the Annual Internal Annual Audit. The CCG Corporate Risk Register brings together the risks collected from team and project risk registers and maps them to the principal organisational risks identified by the Governing Body and partners across the city. These in turn are mapped to our strategic objectives. 10. Patient and public engagement The CCG s Patient and Public Participation Strategy outlines how we will work to ensure patients and carers are at the heart of everything we do. Over the past year, the CCG has built on existing work to ensure that we continue to engage with patients, carers and the public to achieve this objective. The Participation and Communications Assurance Committee (PARC), a sub-committee of the Governing Body, oversees the delivery of the Patient and Public Participation Strategy, and has a role in assuring the Governing Body that we hear and act on the voice and experience of local patients and their carers. The PARC is chaired by the Governing Body s Lay Member for Patient and Public Participation, and membership includes Brighton and Hove Healthwatch, the Community and Voluntary Sector (CVS), Public Health and an elected member from the Patient Participation Group (PPG) Network, whose role includes bringing issues from the PPG Network to PARC. 109

110 We have over the past year continued to build our PPGs in each GP practice, supported by local Community Development workers and Community Works, our local CVS infrastructure organisation. This expertise has benefitted PPGs and GP practices and there are now active PPGs in the majority of the city s GP practices. We have awarded 15 small grants to PPGs this year, against criteria related to increasing PPG membership, linking with wider communities and supporting health and wellbeing. We have continued to support the development of the Hangleton and Knoll Health Forum, which incorporates membership from 5 PPGs and GP practice leads, local pharmacy, community groups and locally elected members. The group is co-led by Health Champions, and is taking a holistic and focused approach to health issues in the Hangleton and Knoll area. We have begun work to involve local people and the CVS in supporting cluster based working, taking an asset based approach to co-developing solutions related to identified cluster priorities. The CCG has continued to commission 10 CVS organisations to help us reach and hear from some of the most marginalised communities in the city, resulting in actions to help improve access to, and experience of, local NHS services. We will recommission this work jointly with the Local Authority from April 2017, in order to maximise the impact of engagement work and further develop a solution-focused approach. We have continued to carry out engagement related to our clinical work streams, including work to inform the re-procurement of our Increasing Access to Psychological Therapies (IAPT) and Wellbeing services, our Transformation Plan for Children and Young People and our recommission of Community Short Term Services, and will continue to ensure that the engagement of patients and carers is included in all of our clinical pathway workstreams. We have carried out targeted local engagement with patients who were likely to be affected by the changes resulting from contracts for the management of 5 local GP practices ending. This feedback was facilitated by Community Development organisations, and fed back to NHS England for consideration in making a decision about the future of these practices. This work continues to inform how patients of these practices are supported as changes take place. Throughout the year, we have run several open sessions at our Governing Body meetings, where local people can engage with our senior leaders on our plans and key issues. In addition, we have run several public events to outline our plans for integrated services in the city, and to take feedback on these plans and further development. We will continue to run public events as one way of hearing from local people. We will also further develop how we hear from people digitally, using the CCG website and expanding the use of social media as an engagement tool. We will continue to engage with local people as we develop plans with other NHS organisations and local authorities beyond Brighton and Hove, ensuring that we engage appropriately and the views and experiences of our local community influence planning and service design. 11. Conclusion The CCG Operating Plan confirms the commitment the Brighton and Hove CCG has to meeting the challenges set by the NHS Five Year Forward View and the NHS Mandate. While acknowledging the challenges the CCG has faced in terms of the performance the plan provides solutions to the attainment of a recovered and a sustainable future model of care which is set in the context of the Sustainability and Transformation Plan. 110

111 Glossary Acronym 2WW A&E AMS AQP B&H BHCC BIA BSUH CCG CCG IAF CEPN CHC CO validation CQC CQUIN CRHT CSESA CSTS CSU CT CVD CVS CYP CYP ED DD DNA DToC DTT ENT EPS FFT GP GPwSI HMSx CCG HOSC HRG4+IR HWLH CCG IAPT IBS IG IPP Definition Two week wait Accident and Emergency Antimicrobial Stewardship Any Qualified Provider Brighton and Hove Brighton and Hove City Council Best Interest Assessor Brighton and Sussex University Hospital Trust Clinical Commissioning Group Clinical Commissioning Group Improvement and Assessment Framework Community Education Providers Network Continuing Health Care Carbon Monoxide validation Care Quality Commission Commissioning for Quality and Innovation payments framework Crisis Resolution Home Treatment service Central Sussex and East Surrey Alliance Community Short Term Service Commissioning Support Unit Computed tomography (scan) Cardiovascular disease Community and Voluntary Sector Children and Young People Children and Young People Eating Disorder service Digestive Diseases Did Not Attend Delayed Transfer of Care Decision to Treat Ear, Nose and Throat Electronic Prescription Service Friends and Family Test General Practitioner General Practitioner with Special Interest Horsham and Mid Sussex Clinical Commissioning Group Health Overview and Scrutiny Committee Healthcare Resource Groups (costing and payment currency) High Weald, Lewes and Havens Clinical Commissioning Group Improving Access to Psychological Therapies Irritable Bowel Syndrome Information Governance Interface Prescribing Policy 111

112 Acronym IS IT IVF KPI LCS LDR LDR LHRH LoS LPP LUTS LWAB MCP MDM MESH MPP MRI MSK MSLC NG12 NHS NHSE NHSI NICE OAP OLU OOH PARC PbR PH 28 PH26 PHB PKB PMO PPG PPV PTS PuPoc QIPP READ codes RMH RMS RSCH Definition Independent Sector Information Technology In-vitro fertilisation Key Performance Indicator Locally Commissioner Services Local Digital Roadmap Learning Disability Luteinising Hormone-Releasing Hormone Length of Stay Low Priority Procedure Lower Urinary Tract Symptoms Local Workforce Action Board Multispecialty Community Provider Mobile Device Management Messaging Exchange for Social Care and Health Maternity Pathways Payments tariff Magnetic resonance imaging Musculoskeletal Maternity Services Liaison Committee NICE guidance: Suspected cancer recognition and referral National Health Service National Health Service England National Health Service Improvement National Institute for Health and Care Excellence Out of Area Placements Obstetric-led unit Out of Hours Participation and Communications Assurance Committee Payment by Results Public Health guidance: Looked-after children and young people Public Health guidance: Smoking cessation in routine antenatal care Personal Health Budgets Patients Know Best Programme Management Office Patient Participation Group Positive Predictive Value Patient Transport Service Previously Unassessed Periods Of Care Quality, Innovation, Productivity and Performance programme Clinical terminology system used in General Practice Referral Management Hub Referral Management Service Royal Sussex County Hospital 112

113 Acronym RTT SAFER SATOD SAU SCFT SCR SCRAI SDM SECAmb SMI SMT SNOMED CT SPFT SRC SSO STP TIAA URP WRaPT Definition Referral to Treatment Patient flow bundle Smoking At Time Of Delivery Surgical Assessment Unit Sussex Community Foundation Trust Summary Care Record Summary Care Record Additional Information Shared Decision Making South East Coast Ambulance service Severe Mental Illness Senior Management Team An organised collection of medical terminology providing codes for use in clinical reporting Sussex Partnership Foundation Trust Sussex Rehabilitation Centre Single Sign On Sustainability and Transformation Plan Business assurance specialists Unified Recovery Plan Workforce Repository and Planning Tool 113

114 Must Do 7: Mental Health Implementation of the 5 Year Forward View including increased access to additional psychological therapies (e.g. in Primary Care through Innovation funding), and increased high-quality mental health services for children and young people (e.g. CYP IAPT). Delivery of mental health access and quality standards e.g. through 7 day access to the commissioned Crisis Resolution Home Treatment (CRHT) Service Maintenance of the dementia diagnosis rate Elimination of Out of Area Placements for non-specialist acute care by 2020/21 by working systematically to reduce length of stays and enhancement of the CRHT service capacity to facilitate earlier discharge Must Do 6: Cancer Implementation of the Cancer Taskforce recommendations in conjunction with Cancer Alliances e.g. the introduction of a secure patient portal to allow colorectal patients online access to their own records Delivery of the NHS Constitution 62 day cancer standard by April 2017 utilizing adequate diagnostic capacity Improvement of one-year survival rates through commissioning an Early Awareness Service and Cancer LCS Roll-out of stratified follow-up pathways for breast, prostate and lung cancer patients prior to roll-out for other tumour group sites Implementation of a Recovery Package comprised of holistic needs assessments, treatment summaries and cancer care reviews Must Do 8: People with learning disabilities Delivery of Transforming Care Partnership plans in collaboration with the City Council Delivery of reduction of inpatient bed capacity by March 2019 Analysis of annual health check uptake to develop a targeted approach to increasing participation to 75% amongst this cohort Reduction of premature mortality supported by a dedicated health facilitator Appendix 1 Brighton and Hove Operational Plan : Alignment to national Must Achievement Dos of local STP targets for activity Must Do 5: Referral to treatment times and elective care Delivery of the NHS Constitution standard that more than 92% of patients on elective pathways wait no more than 18 weeks from referral to treatment by August 2018 Delivery of patient choice through the Patient Access Policy and Referral Management Service (RMS) Achievement of 100% e-referral coverage by April 2018 Achievement of service redesign to streamline pathways, e.g. the development of a community neurology headache pathway Implementation of Better Births recommendations through local maternity systems e.g. development of small midwife teams to deliver continuity of care Must Do 9: Improving quality in organisations Implementation of plans for quality improvement, particularly through the Urgent Care Improvement Programme for BSUH Workforce measurement and improvement throughout the CCG and Primary Care to ensure safe, productive and sustainable services Delivery of annual Patient Safety Conference to learn from and reduce deaths related to healthcare Must Do 1: STPs Implementation of agreed milestones, working towards 2020/2021 Setting trajectories against the core metrics set and achieving these by 2019 Must Do 2: Finance Delivery of CCG control total Achievement of local STP targets for activity growth Elective care redesign to manage demand Development of Multispecialty Community Providers (MCPs) to drive the preventative agenda Medicines optimisation Must Do 3: Primary Care Ensuring sustainability of General Practice through the introduction of the Releasing Time to Care programme and Better Care Pharmacists Investment in General Practice through the Primary Care Locally Commissioned Services (LCS) Mitigation of workforce issues through relationships with Health Education Kent, Surrey and Sussex, Practice Learning Sets and practice nurse forums Support for General Practice at scale through development of MCPs and LCS Must Do 4: Urgent Care Delivery of the 4 hour A&E standard through implementation of the A&E Improvement Plan and initiatives such as commissioned community schemes to reduce hospital attendances (e.g. for hypertension), a Complex Symptomology Service and the Urgent Care Centre GP service Delivery of ambulance response standards through implementation of the A&E Improvement Plan Delivery of a reduction in the proportion of ambulance 999 calls that result in avoidable transportation to A&E through the Ambulance Response Programme Initiation of a cross-system approach the waiting time standard for urgent care for those in mental health crisis through the Streaming to Ambulatory Care and Primary Care from A&E Programme Implementation of the Urgent and Emergency Care Review, e.g. 114 through the development of the Clinical Hub to support NHS 111

115 Name of Meeting: Governing Body Date of meeting: 24 th January 2017 Item Number: 11/16 Title of report: Ratification of Decision to Terminate Patient Transport Service Contract Recommendation: For Ratification Reviewed at: Decision made by CCG Governing Body as a written resolution in accordance with CCG Standing Orders Annex 1 Paragraph Summary: Brighton and Hove CCG, following a joint procurement with the seven CCGs Sussex, entered into a contract with Coperforma Ltd to provide patient transport services commencing 1 st April Since commencement the service has fallen short of the anticipated service levels. Despite robust performance management and use of the available contractual levers, Coperforma s contractual performance has not improved to the required levels. It is not anticipated that the provider s service model will ever be capable of meeting its performance targets in the contract. In October 2016 the CCG parties to the contract discussed the ongoing poor performance of the service and sought advice as to the potential options for the service going forward. It was recommended that the CCG agreed to terminate the contract with Coperforma Ltd and seek to enter a new contract with South Central Ambulance Service NHS Foundation Trust. The service would transition over a period of several months and would commence fully on 1 st April Each CCG Party to the contract was required to seek agreement from its Governing Body to accept the proposal to terminate the existing service and commence mobilisation of a new service on 1 st April Unfortunately there was very limited time available for the CCGs to make this decision and it was not possible for Brighton & Hove CCG to convene a quorate meeting within the required timescale. The Governing Body therefore agreed by written resolution dated 28 th October to commence the termination of the existing contract with Coperforma Ltd. This paper requests that the Governing Body formally and publicly ratifies the written resolution made by the Governing Body on 28 th October

116 Lead Director: John Child Chief Operating Officer Author: Owen Floodgate Head of Corporate Affairs Date of report: 5 th January 2017 Financial implications: No termination penalties will arise as a result of contract termination. Legal or compliance implications: The Governing Body has agreed to enter into a contract with South Central Ambulance Service NHS Foundation Trust without following a competitive procurement process. This is a matter of necessity to ensure consistency in service provision and all appropriate steps have been taken to mitigate any potential risk of challenge. Link to key objective and/or assurance framework risk: The decision to terminate the contract and establish a new service significantly reduces the risk of service failure and will enable eligible patients to continue to access service across Sussex. Patient, carer and public engagement: There has been no formal engagement in regards to the making this decision. However there has been significant engagement regarding the performance of the existing service and service improvement across Sussex. This will continue as the service transitions to the new provider and beyond commencement of the new contract. Equality Impact Assessment Specific equality analysis was not conducted in respect of this specific decision. However equality analysis will be conducted as part of the development of the new service. 116

117 Ratification of Decision to Terminate Patient Transport Service Contract Written Resolution The CCG members of the Patient Transport Service Program Board received advice at a meeting of 19 th October 2016 that it would possible to terminate the existing contract and that SCAS would be willing to provide the service going forward. The members of the Program Board were asked to seek agreement from their respective Governing Bodies to commence termination of the existing contract and transfer of the service to SCAS. On 25 th October 2016 the Governing Body of Brighton & Hove CCG held its regular bimonthly seminar. The meeting was not held in public and is not a decision making meeting of the Governing Body. Christa Beesley, the CCG s Clinical Accountable Officer and representative on the Program Board, informed those present of the information presented at the Board, the advice received, and the action requested. Those present discussed the proposal. Unfortunately there was very limited time available for the CCGs to make this decision and it was not possible for the CCG to convene a quorate meeting within the required timescale. The Governing Body therefore agreed by written resolution dated 28 th October to commence the termination of the existing contract with Coperforma Ltd. The process for making a decision by written resolution is contained within CCG s constitution and standing orders at Annex 1 Paragraph Each member of the governing body was sent the resolution and required to respond in writing stating whether or not they agreed with the resolution. The members agreed unanimously to accept the resolution. It is now required that the resolution is ratified at a public meeting of the CCGs Governing Body. Request for Ratification The Governing Body is requested to formally ratify the written resolution made on 28 th October Date: 5 th January 2017 Lead Director: John Child Chief Operating Officer 117

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119 Name of Meeting: Governing Body Date of meeting: 24/01/2017 Item Number: 12/17 Title of report: Corporate Risk Register Month 8 Recommendation: This paper was reviewed and agreed by the Performance and Governance Committee on 20 December 2016 and any amendments/additions requested by the committee have been included in this paper. The Chief Accountable Officer requested that prior to submission to future meetings, the Risk Register should be reviewed by the Senior Management Team. This was also submitted to the CCG Audit Committee on 10 January The Performance and Governance Committee were recommended to review and approve the contents of the CCG Corporate Risk Register and note the mitigations against existing risks contained in the corporate risk register review and note the Corporate Risk held on the separate confidential risk register The Director of Performance and Delivery and the Business Support Manager met with the TIAA to agree the scope and timetable for the Annual Risk Audit. The Business Support Manager is following up on the BSUH Risk Register. Summary: There are currently 23 risks reported on the CCG Corporate Risk register broken down as follows: 7 quality; 7 financial and 9 performance and delivery. One new risk regarding delivery of the Clinical Navigation Hub has been added (183). 119

120 Sponsor: Lola Banjoko, Director of Performance and Delivery Author: Ramona Booth (Head of Performance and Delivery) Date of report: 14/12/16 Financial implications: Specific risks relating to CCG Financial Balance Individual risks and associated controls and or mitigating actions may have financial implications. Legal or compliance implications: Risk management required to meet NHS England Assurance requirements Risk management required to support Annual Governance Statement and statutory/mandatory return Risk management assurance for Statement of Internal Control Link to key objective and/or assurance framework risk: Corporate Risks are fundamentally linked to the organisation s strategic objectives and the National Assurance Frameworks. 120

121 Senior Management Team Review of Corporate and Team Risks The CCG Governing Body requested that, to provide assurance for all risks held by the CCG, the Senior Management Team should complete regular reviews of all team risks, as required by the CCG Risk Management Policy and Strategy. Further to the above, the CCG Chief Finance Officer has requested that the CCG Heads of Teams need to review their team risk registers prior to the SMT meeting in order to raise /escalate concerns and advise of weaknesses in their team risk reports. 3. Corporate Risk Register Report Month 8 There are currently 23 risks reported at corporate level. One new risk has been added (risk 183). Full details and progress updates for all risks are in the full Corporate Risk Register Report attached Delivery of the Clinical Navigation Hub (CNH) Risk Description: Consequence of Risk: Risk Level: Delivery of the Clinical Navigation Hub across 5 CCG's is complex. There are multiple dependencies with the potential to significantly impact upon the key design/development stages and ultimate delivery of the service. These include (but not limited to): _Progress of and alignment to the NHS 111 reprocurement _Effective governance of the NHS 111 re-procurement _Development of supporting IM&T architecture _Access to and quality of data to support activity and financial modelling _Dedicated commissioner/clinical resource. If these key areas are not effectively managed/supported then there is a significant risk that the Clinical Navigation Hub will not be delivered by March This will negatively impact on the Urgent Care system and the wider healthcare economy. This may result in the following -poor patient experience -quality impact on standards and delivery of care -reputational damage to CCGs and associated providers -increase in A&E referrals -underutilisation of community services. Score 12-High Date: 14/12/16 Sponsor: Lola Banjoko, Director of Performance and Delivery 121

122 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 53 Ver /04/2014 BSUH - Emergency Department The Emergency Department is frequently assessed as being on high escalation status, indicating significant pressure on the department, which impacts on the hospitals (in particular RSCH) and the local health economy, including significant ambulance handover delays. See also: Risk 63-National Targets and Standards Consequence of Risk: There is a risk of patient safety being compromised, and a risk of poor patient experience particularly in ED. There is also a risk of reputational damage to the Trust and the CCG. Ian Wilson Soline Jerram 4 x 3 = 12 Clinical Quality And Patient Safety / / 4 x 5 = 20 4 x 2 = 8 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Risk Control Risk Assurance Control/Assurance Gaps A&E Delivery Board has been created to replace the pre-existing System Resilience Group, to monitor compliance and progress against A&E quality and performance indicators. Attended by senior representatives from BSUH, the CCG, NHSI, NHSE and other key stakeholders/providers from the local health economy. The new A&E dashboard may not capture all of the information that was captured in the previous dashboard. Monitoring of quality and performance via Sitrep data, serious incident reporting and feedback mechanisms to the CCG, including complaints, Healthwatch, Feedback on Providers (FOP) Quality Oversight Group in place to oversee implementation of the Trust's CQC improvement plan Daily systems-wide calls with key stakeholder organisations in place, using SHREWD to assess level of systems pressures Bi weekly Executive Level PMO (with BSUH) commenced June Action Plans and impacts reviewed internally by CCG Executive Team Proactive communications campaign advising of the most appropriate setting to seek treatment when ill. BSUH has an improvement plan in response to the CQC inspection in April Systems in place to share and escalate information received by the CCG, including via monthly quality report to the Quality Assurance Committee Senior/executive representation from CQC, NHSI, NHSE, CCG and BSUH NHS England also included to provide a regional oversight Representation from other CCGs present Reported to Performance and Governance Committee Monitoring A&E attendance and CCG delivery of QIPP aimed at reducing demand. Monthly highlight report updates of the plan are shared with the CCG and other members of the Quality Oversight Group. QRM will continue to focus on finer details of the plan. Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Hospital at Home initiative to reduce pressure Plan to go live on 3rd October Renee Padfield 15/03/2016 Hospital at Home was implemented on 3rd October. There is a plan to scale this up to 20 patients by the end of November, and will be 30/11/2016 / / Page 1 of 40 14/12/

123 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Review new A&E dashboard to establish if any quality measures are not captured, for example staffing establishment, incidents, patient experience etc. evaluated by UC-ORG fortnightly. This action will be taken forward via the monthly QRM. Renee Padfield 09/11/ /12/2016 Ensuring alignment of escalation triggers, actions and responses across the local health economy. Working towards target date completion of Further work to align triggers with SHREWD (Single Health Resilience Early Warning Database) will take place. Renee Padfield / / 11/07/ /12/2016 / / Page 2 of 40 14/12/

124 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 146 Ver /05/2016 National Targets and Standards Performance against targets were not met in , including -A&E -Access targets for Referal to Treatment Times, Improving Access to Psychological Therepies, Health Care Acquired Infections, 62 Cancer Waits Consequence of Risk: This has a negative impact on patient experience, clinical outcomes and negative impact on organisational reputation. It may also have financial impact for the trust and CCG. Renee Padfield John Child 4 x 5 = 20 Performance And Delivery / / 4 x 5 = 20 4 x 3 = 12 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Risk Control Risk Assurance Control/Assurance Gaps There is a system-wide recovery plan for A&E in place which includes the national A&E improvement plan aimed at reducing attendances, managing demand, improving patient flow and reducing delayed transfers of care. A&E Delivery Board-agreed trajectories with the Trust Monthly review of national targets at the Performance and Governance Committee. This committee approves additional capacity and resources. Operational Resilience Plan overseen by the A&E Delivery Board CCG Wellbeing Contract Performance and Quality Review meeting with focus on Improving Access to Psychological Therepies targets There is a CCG 18 week Referral to Treatment plan in place to manage demand and secure/commission capacity at alternative providers and contract manage providers. Issues reported to Performance and Governance Committee Reviewed monthly by the Planned Care Programme Board (as part of the PMO process to review all milestones against delivery by the CCG with the provider) and is also overseen by the Planned Care and Cancer Board (formerly part of System Resilience Group). The CCG is working with BSUH on a recovery plan for the cancer 62 day target. The CCG have issued a contract performance notice for IAPT and are working with HERE to develop a recovery plan. Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Page 3 of 40 14/12/

125 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Contract Performance Notices (CPNs) were raised on 20th July 2015 and covered the four performance breach areas: -RTT -A&E Waiting times -Ambulance Handovers -Cancer 62d RTT Report to CCG Senior Management Team ( ) raising exception notices due to breach of remedial plans These CPNs will be closed when the agreed Remedial Action Plans deliver the national standards. To date, the standards remain in breach and therefore none of the CPNs have been closed. Stephen Allen 20/05/ /03/2017 / / Page 4 of 40 14/12/

126 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 181 Ver. 5 05/10/2016 South East Coast Ambulance Service Placed in Special Measures Following Care Quality Commission inspection in May 2016 SECamb was reported as inadequate and has been placed in special measures with particular focus in relation to the Safe and Well Led domains. CQC report covers many areas to be addressed-these include leadership and quality and safety of systems and processes. Consequence of Risk: The adequacy of the service has already has impacted on quality, reputation and efficiency of the service and its operation. Renee Padfield Lola Banjoko 4 x 5 = 20 Clinical Quality And Patient Safety / / 4 x 5 = 20 4 x 2 = 8 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. The imposition of special measures may exacerbate the above and may further result in the following- -reputational damage for the SECamb and Commissioning CCGs -poor patient experience and quality of care -further risk of on-going poor performance Risk Control Risk Assurance Control/Assurance Gaps Contract Management Meetings-lead by Horsham Mid Sussex CCG Service Specification held by Horsham Mid Sussex CCG Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Many of the CQC recommendations are included in the Unified Recovery Plan (URP) developed by the 3 Commissioning CCGs. This plan is jointly monitored by the Kent, Sussex and Surrey CCG contract, quality and commissioning leads. SECAmb has responded to areas of concern regarding the relationships with the CCGs. This engagement now includes a wider range of executives, clinical and operational staff linking in with CCG quality and safety leads.the CCG is working closely with SECAmb on non-conveyance pathways and BSUH on ambulance handover trajectories. Lola Banjoko Lola Banjoko 05/10/ /03/2017 / / 05/10/ /03/2017 / / Page 5 of 40 14/12/

127 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 170 Ver. 8 12/07/2016 Budget for Specialist Mental Health Provision Expenditure against the specialist hospital budget icreased significantly in 2015/16. There is a potential cost pressure on the budget of around 1m during 2016/17 Consequence of Risk: This leaves the Mental Health, Maternity and Children's team open to the risk of an overspend of 1m for Anna McDevitt Anne Foster 4 x 4 = 16 Financial 10/11/ x 4 = 16 4 x 1 = 4 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Risk Control Risk Assurance Control/Assurance Gaps Monthly budget reporting to Head of Commissioning Detailed reports to the CCG Performance and Governance Committee-next one due November 2016 Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date A review of current placements is being carried out to identify whether any placements could be funded from the community care budget given the additional resources the CCG recently allocated to the community care budget Commissioner has met with BHCC to discuss protocol and funding for nursing home placements. BHCC has been requested to feedback on draft protocol and on funding decisions by the end of November Follow up meeting scheduled for 27 October to agree protocol for new S117 cases. Agreement from BHCC sought on whether Community Care budget can be used to fund 3 historic nursing home placements currently funded by specialist placement budget Anne Foster and Carolyn Woods (BHCC) have spoken. The team managing the community care budget have agreed to consider taking on funding responsbility for patients in nursing homes who are funded through the specialist hospital budget. A protocol is going to be devloped around ensuring that all new cases for S117 aftercare funding are met from the Community Care budget. The development of this protocol will be discussed at the S75 meeting on Monday19 September Anna McDevitt 11/07/ /11/2016 / / Page 6 of 40 14/12/

128 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date The CCG are reviewing the dementia pathway with a particular focus on ensuring we have sufficient community support to prevent unnecessary hospital admissions The scope will include people who have the have complex mental health and dementia and who are currently being funded in specialist hospitals. The CCG are developing a new community rehabilitation team, due to start in April Meeting with SPFT and Adult Social Care scheduled for November Scoping work underway which will infrom pathway development Service specification in development. Gemma Dawson Anne Foster 29/07/ /11/2016 / / 12/07/2016 The CCG anticipate that this service will help prevent unnecessary admissions to specialist placements and also facilitate timely discharges by providing a service for people to be stepped down to Meeting has taken place and agreed there would be a pan Sussex commissioners meeting to discuss trust wide work on the rehab pathway and opportunities for joint working/sharing best practice etc. Meeting to be scheduled by mid October. 30/03/2017 / / Review the service specification with SPFT to ensure that there are robust arrangements in place for reviewing patients in specialist placements with a view to securing more timely discharges Anna McDevitt 05/10/ /03/2017 Consider whether it is more cost effective to commission Crawley Road beds (run by SPFT) as a block rather than spot purchasing Anna McDevitt / / 05/10/ /03/2017 Review specialist panel commissioning arrangements and update current service specification for the management of the specialist funding panel provided by SPFT. This will be discussed further at a pan Sussex commissioners meeting which will take place by end October Anna McDevitt / / 05/10/ /03/2017 / / Page 7 of 40 14/12/

129 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 165 Ver. 3 08/07/2016 Better Care and Operational Risk- Delayed Transfers of Care (DTOCs) Risk of deteriorating performance at acute and community provider level due to DTOCs. Consequence of Risk: There is a risk of negative impact to system-wide patient flows and the delivery of national 4 hour A&E targets. Also, this may lead to unsatisfactory patient experience. Michelle Elston John Child 4 x 4 = 16 Clinical Quality And Patient Safety 11/11/ x 4 = 16 4 x 3 = 12 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Monitoring implementation of Urgent Care initiatives developed to reduce acute delays including; Home 1st- Discharge to assess Process improvement across all bed unit including managing patients and family expectations not to stay longer in hospital- and SAFER. Choice- workshops October for front line staff Roll out of Discharge Improvement - successful Pilot on Jowers Ward Increase care capacity Support to SCFT to address DTOC and increased LOS - scheduled weekly meetings with respective LAs and CCGs Move CHC assessment out of the acute into the community Robust performance monitoring of DTOC by CCG, local authority and reason to ensure focus new model for Community Short Term Services - Discharge to Assess approach of assessing people's care/support needs in their own home environment - New system of CCG capacity management and support (Shrewd) - Evaluation of the Better Care Schemes Providers submit monthly update reports against the plans, for example on Discharge to Assess and Hospital at Home.Projects that have slipped are reported through the A&E Delivery Board. The Better Care Board (chaired by John Child) also has oversight of KPIs. Lola Banjoko 08/07/ /03/2017 / / Page 8 of 40 14/12/

130 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 194 Ver. 5 04/11/2016 Transfer of Patient Transport Services from Coperforma to South Coast There is risk that following the removal of the contract for Patient Transfer Services from Coperforma, and the subsequent transition of the service to South Coast Ambulance Service there may be significant impacts on the continuity of the service provision. Consequence of Risk: This may result in the following- -impact on patient safety with particular regards to high risk groups-eg renal, radiology and chemotherapy. -impacting on the day discharges and transfers between providers -negative impact on the quality of patient care and experience -reputational damage for the CCG -Political risk with potential for national news coverage and ministerial challenge -financial risk that the CCG will not have sufficient fiscal resources to cover the cost of the transfer -threat of industrial /legal action by staff affected by any transfer TJ Alexander John Child 4 x 4 = 16 Clinical Quality And Patient Safety 04/11/ x 4 = 16 4 x 2 = 8 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Risk Control Risk Assurance Control/Assurance Gaps Additional controls to be worked through once assurance has been received by High Weald Lewes and Havens CCG PTS Programme Governance Structure including: Programme Board oversight & scrutiny Weekly CCG / Coperforma mangement meeting Monthly meetings with Coperforma / acute trusts/commununity providers Contract management meeting Implementation of Remedial Action Plan (RAP) improvement targets Additional Programme Management capacity sourced to oversee the transition of PTS from Coperforma to SCAS PTS specialist advisor appointed. Increased overlay team and capacity at booking hub Increased number of Service Delivery Specialists to support hospital providers Complaints and Incidents process in place Action plan for each trust with provider Independent investigation Trusts have own bespoke vehicles Coperforma remedial action plan Business Continuity Plan Sharing of weekly data set and trajectory for improvement Increased number of transport providers CCG supporting coperforma to source increased clinical governance expertise Transition and mobilisation project plan detailing actions, milestones for PTS transition. Action Progress Mitigating Actions Person Responsible Start Date Target Date Comp Date Page 9 of 40 14/12/

131 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Actions to be worked through Meeting with Programme Board at Friars Walk on 16/11/2016 Managed phased transition between now and April between Coperforma and SCAS. PTS Director level programme board. Dedicated WTE staff at HWLH to manage the transition. CCGs requested clarity for managing CCG specific issues and areas for escalation. Clair Harris 04/11/ /11/2016 / / Page 10 of 40 14/12/

132 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 131 Ver /04/2016 Transitioning New large scale service contracts to new providers There is a risk that during the transitioning of service assets, including workforce, data and patients to a new provider of a remodelled service there may be there may be disruption of continuity of service. Consequence of Risk: This may impact on -clinical outcomes -poor patient experience -reputational damage to organisations concerned -and potentially give rise to unintended provider and commissioner costs. Lola Banjoko John Child 4 x 4 = 16 Performance And Delivery / / 4 x 4 = 16 3 x 2 = 6 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Risk Control Risk Assurance Control/Assurance Gaps Standard Monthly Highlight Reports from the new provider to the Lead Commissioner and all CCGs involved. On award of contract new provider submits the mobilisation plan which details staged movement to service launch for oversight by the commissioning organisations and should include details of the escalation processes in the event of delays/barriers arising. Robust service specifications aligned to system needs and clearly defined outcomes Monthly meetings between provider and lead commissioners to assess the key elements of the bid delivery and to identify and assess the key risks to the delivery of these-including validation services from Commissioning Support Units. These meetings/reports may become more frequent as the service commencement date approaches. The control and assurance is a reporting a proceedure and does not provide effective assurance with regard to effective control of risk Monthly highlight reports derived from the mobilisation plan are submitted on a monthly basis Impaired cooperation between old and new to the Lead CCG and relevant commissioning managers. The regularity of these may increase provider hinders smooth service transition. in line with the proximity of implementation. Inaccurate/out of date patient data Regular briefing, asset and data transfer meetings occur Potential inadequacy of systems testing prior to go live Potential issues with workforce recruitment/training Transition goes through the CCG's governance process for sign off before contract is awarded Transition key performance indicators agreed and a number of check points during the mobilisation. and monitored Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date CCG NHS Commissioning Assurance Framework tick list must be applied prior to procurement A Procurement Checklist has been developed under the direction of the John Child 27/04/2016 activity. Framework to include: Clarification of the role of the Procurement Governance Committee in the oversight and escalation CCG Procurement Governance Committee, along with a revised -Development of a Programme Board identification of due dilligence standards and the evidence for this functions Procurement Policy for the CCG. This includes/covers- -NHS Commissioning Framework checklist 31/12/2016 / / mobilisation plan, transfer of data from old and new provider to be done minimum of 6 weeks prior to start of service and signed off by the executive lead from the previous service as quality assured and validated; -Assessment/Development of robust mobilisation and service plans Robust Risk Assessment Framework - HR due diligence from old to new service including TUPE arrangements. Page 11 of 40 14/12/

133 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Page 12 of 40 14/12/

134 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 173 Ver. 6 12/08/2016 Impact of Brighton and Hove City Council Budget Reductions There is risk that the ongoing reduction to BHCC finances will increase demand for health care services and limit our to ability to meet the growing demand. Consequence of Risk: The BHCC budget reductions impacts on care capacity resulting in patients staying longer in hospital or patients attending hospital when they might have attended social care/community settings. Increase waiting times, delayed transfers of care, primary care demand, hospital services. Less opportunity for proactive preventative work. Ramona Booth John Child 4 x 4 = 16 Performance And Delivery / / 4 x 4 = 16 3 x 4 = 12 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Risk Control Risk Assurance Control/Assurance Gaps Health and Care Partnership inaugural meeting due in November 2016 Review of budgets and mechanism for integration and pooled budgets Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Clearly defined criteria and thresholds for services. Ramona Booth 30/09/ /03/2016 Assessment of impact in CCG strategic planning. Alignment of plans and joint working. Greater collaboration across the wider STP footprint and the development of a Multispecialty Community Provider model. Development of the ambition for integrated commissioning across CCG and BHCC. Scope for single budget and integration of both provision and commissioning. The CCG has secured additional resource to support the delivery of Caring Together and to ensure the joint objectives of the city council and the CCG are implemented. Start date: Jan Ramona Booth Ramona Booth / / 12/08/ /12/2016 / / 12/08/ /12/ / / Under the auspices of Brighton and Hove Caring Together Plan Page 13 of 40 14/12/

135 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date The development and implementation of the Brighton and Hove Caring Together Plan will have a positive impact on demand for social care. See attached plan. Caring Together plan submitted to NHS England 30th September. Further John Child review at the November Health and Wellbeing Board. 30/09/ /03/2017 The CCG will have strategic involvement in the 17/18 City Council budget setting process CCG and Council working closely on budget setting 17/18 John Child / / 30/09/ /03/2017 / / Page 14 of 40 14/12/

136 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 143 Ver. 8 17/05/2016 Additional Capacity to support delivery of Referral To Treatment The CCG may not be able to commission sufficient capacity to deliver Referral To Treatment compliance. Consequence of Risk: Failure to meet referral to treatment (18) targets have resulted in * adverse publicity associated reputational damage *increase complaints to the CCG *failure to deliver against required NHS Constitutional Standards *poor patient experience *potential for clinical risk as a result of treatment delays Ian Thompson Renee Padfield 4 x 3 = 12 Clinical Quality And Patient Safety 03/11/ x 5 = 15 3 x 2 = 6 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Risk Control Risk Assurance Control/Assurance Gaps Regular review of performance, ongoing engagement with providers to improve available capacity. Business case to P and G requesting funding to purchase additional capacity. Senior Management team scrutiny of monthly reporting. Reviewed at Planned Care and Cancer Board (replaced System Resilience Group) Existing contracts with Spire Montefiore and Nuffield Woodingdean have been extended to provide additional capacity. Potential availability of new capacity limited. Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Most recent trajectory received from BSUH show RTT compliance improving from 74% to 84% by March 2017 with 92% standard forecast to be achieved November Contract performance notices being sent by to BSUH regarding A&E compliance, Cancer 62 day target and 52+ week wait patients- Renee Padfield 12/10/ /11/2018 / / Any Qualified Provider to commence to commission additional Endoscopy and additional surgical procedures for DD. Business case sign off which has secured funding for GPwSI for Headaches and a primary care led Gynae clinic. Associate to High Weald Lewes Havens CCG for new non obstetric ultrasound contract. Associate to High Weald Lewes Havens CCG for East Sussex Outpatient Services for Digestive Diseases. Ian Thompson 03/11/ /03/2017 / / Page 15 of 40 14/12/

137 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Increased utilisation of independent sector providers through contractual arrangements and referral management service. Updated advice and guidance and improved BSUH bookings hub service. Pathway redesign in most challenged specialities (digestive diseases, neurology, ear nose and throat, ophthalmology and gynaecology. Page 16 of 40 14/12/

138 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 179 Ver. 6 04/10/2016 Overspend of Community Equipment Budget (Section 75 The service is delivered by NRS (independent provider) which reports to BHCC who are responsible for the contract management and monitoring and reporting against it. The majority of the spend on this service is for health needs not social care. This arrangement doesn't provide enough risk control for the CCG.-see mitigations below. The budget for this service is projected to overspend by 1.2 million in 16/17. Michelle Elston Michelle Elston 4 x 5 = 20 Financial 10/11/ x 5 = 15 3 x 3 = 9 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Overspend on this budget is subject to agreed split between BHCC and the CCG. Drivers contributing to this overspend are- -insufficient budget setting as result of inaccurate estimation of type of activity and equipment required by Brighton and Hove -prescriber behaviour-with a very high use of same day delivery requests, failed deliveries (eg prescriber not confirming customer presence for receipt of goods and subsequent need for redelivery) -original budget did not factor in growth or increase demand to support timely hospital discharge and the drive to support and treat people at home -low rate of collections due to prescribers not regularly reviewing equipment need and therefore not triggering collection for recycling Consequence of Risk: This overspend may result in -impact on the finances/delivery of the Better Care Plan-see new risk??? -reputational damage for the CCG and the service Page 17 of 40 14/12/

139 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review -financial impact on the delivery of required financial efficiencies -potential impacts on other budgets to finance the projected overspend -rationalisation of community equipment provision which will impact on patients' health and quality of life. Risk Control Risk Assurance Control/Assurance Gaps Brighton and Hove City Council hold the contract for this service and are responsible for monitoring and reporting spend against it. The CCG oversight of this via the Better Care Board-monthy The majority of the spend on this service is for health not social needs-see above. The management and contractual arrangements for this service mean that the CCG do not have sufficient control over the management of the overspend risk for this service. 1.1 million overspend in expected. Community Service Equipment Board meeting 6 weekly to oversee the delivery of the remedial action plan-see attached The CSEB reports to Better Care Board Arrangements insufficient to turn around budget position. Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date High level action plan to address and change prescriber behaviour (health and social) through- -appropriate use of same day delivery requests -lower rate of failed deliveries through IT functionality enforcing confirmation of customer presence for delivery -SCFT senior manager identified to join membership of the Community Equipment Service Board to drive through required changes to prescriber behaviour, supporting reduction in unnecessary same day requests and review and collection of equipment. Chief Executive of SCFT agreed to nominate senior member of nursing team at Associate Director level to support creation a framework document for prescribers of community equipment. Michelle Elston 18/10/ /12/2016 / / Page 18 of 40 14/12/

140 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date External Review by external, independent body to develop framework and protocols for prescribing equipment consistently across Brighton and Hove. To be agreed and signed off by Commissioners and the Better Care Board Review is underway. ICES Board meeting held w/c Meeting held with interim Head of Social Care (BHCC). Report submitted to the Health and Wellbeing Board highlighting position and share the action plan. Michelle Elston 18/10/ /11/2016 / / CCG Head of Primary and Community Care has created a detailed action plan jointly with the Local Authority to recover the financial position and improve quality and equity of provision from service-see attached. Recommendations for a time limited task and finish group to address financial, quality and equity issues. High level action plan to address and change prescriber behaviour (health and social) through- -appropriate use of same day delivery requests -lower rate of failed deliveries through IT functionality enforcing confirmation of customer presence for delivery -SCFT senior manager identified to join membership of the Community Equipment Service Board to drive through required changes to prescriber behaviour, supporting reduction in unnecessary same day requests and review and collection of equipment. Michelle Elston Michelle Elston 08/11/ /03/2017 / / 18/10/ /12/2016 / / Page 19 of 40 14/12/

141 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 199 Ver. 3 16/11/2016 Procure an integrated urgent care 111 provider. There is a risk to patient safety and quality in the failing re procure and mobilise a new model of service for NHS 111 by April This 111 re-procurement is a Sussex wide Programme, requiring collaboration with 8 CCGs which will reflect the local requirements that centre around the clinical model at the front door of A&E, Urgent Care and other services that require access on the same day. Consequence of Risk: Significant disruption to patient access to urgent care services resulting in major patient quality and safety consequences. Clair Harris John Child 4 x 3 = 12 Clinical Quality And Patient Safety / / 5 x 3 = 15 3 x 3 = 9 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Risk Control Risk Assurance Control/Assurance Gaps Procurement Process [Approach and Timescales]: (i) Development of service specification and other procurement documentation is well behind time leaving a very compressed timescale to deliver these key documents. (ii) Decision has yet to be made around procurement approach (will a PQQ be used etc). Delay to going out to procurement - may lead to delayed contract award / contract start date [links to Provider risk PR4] or compression of mobilisation period generating risks to effective transition to new service. Resourcing: (i) Overall project / programme resourcing has significant gaps / resource still to be secured. These areas include project management across the CCGs, Legal, HR, Procurement and IT&M. (ii) Specific concerns around IT&M resource as programme is highly dependent on technical solution to deliver - unclear at present whether Technology Solution will be procured with Service as a single entity or as a separate entity. (i) Delay in development of key information / documents - programme may slip further (ii) Quality of outputs may not be sufficient as required expertise has not been available to develop outputs (iii) Lack of quality / timely delivery may impact reputation of organisations (iv) Lack of quality / timely delivery may impact final product / service Unclear what conversations have taken place with current provider so position of current provider with regard to (i) Potential requirement / need for short term extension to existing contract (ii) Position with regard to mobilisation to new contract Page 20 of 40 14/12/

142 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review is currently unknown. (i) Existing provider may not be willing to undertake a short term extension to existing contract should that become a desired approach from the programme (ii) Existing provider may have commenced pre-contract end activity with their staff team (TUPE / Redundancy activity) that doesn't match with programmes required timescales (iii) Provider may financially penalise commissioners for late notice of any potential short term extension to contract Governance and Programme Management: Unclear lines of reporting across the programme - escalation routes for issues and decisions to be confirmed. Multiple organisations with a multiple approval mechanisms involved in the programme. (i) Delays as approval / decisions make their way through the multiple forums (ii) Conflict if different bodies arrive at different positions with regard to decisions / issues (iii) Lack of confirmed ownership / shared view of overarching owner of decisions may result in reversal of key decisions 151 Ver. 4 10/06/2016 NHS Workforce Capacity There is local and national recognition that there are significant issues relating to the availability and capacity of the NHS workforce; this includes the General Practitioners, nurses, certain specialities and allied health professionals. Changes to the allocation and distribution to Primary care training and development monies come in to place April Although initially through STP additional monies may be available for training and development all monies received via Health Education England allocation and or bids will be overseen by place based Community Education Practice Networks (CEPN)and not allocated by CCG. Soline Jerram John Child 3 x 4 = 12 Performance And Delivery 11/10/ x 4 = 12 3 x 3 = 9 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. The formation of a CEPN Board cross CCG areas is required. Brighton and Hove CCG will be a member of the A23 South CEPN Board (with High Weald Lewes Have CCG and Horsham Mid Sussex) This risk replaces previous workforce risk-69-primary Care Workforce Page 21 of 40 14/12/

143 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review and Capacity and 133-Sussex Community Workforce and Capacity-these specific risks are now held at team level. Consequence of Risk: This workforce capacity and resource shortage will impact on the CCG's and partner organisations ability to deliver the transformational change described our Operating Plan, Transformational Care Plan, Better Care plan and the integrated models of care required to deliver our strategic objectives and national outcomes/nhs Constitutional standards/nhs Mandate and NHS England Operational Plan Guidance. Reduced funding overall and requirement to allocate / prioritise funding across 3 CCGs may have an impact on local development. Risk Control Risk Assurance Control/Assurance Gaps Primary Care Transformation Board is overseeing transformation programmes and investments. Ongoing regular meetings which report into Primary Care Committee and the Primary Care Transformation Committee. Both Subcommittees of the Governing Body Staffing issues reviewed at monthly Sussex Community Trust perfromance meetings Head of Commissing chairs these meetings with actions captured and monitored monthly Recruitment to NHS roles is a local, regional and national problem which impacts on the supply of suitably trained staff. Staffing vacancy reports are discussed at Contract Performance and Quality Review meetings Staffing levels are reported alongside monthly KPIs and is a standing agenda item at Single Performance Conversations. CCG have agreed to source additional CSU Support for workforce assurance -to be secured by Brighton and Hove CCG has established -with HWLH/HMS (A23 South)- the Community Education Partnership Network Board The A23S and A23 N Community Education Partnership Network Board -Crawly and East Surrey partners- are further developing an overarching Board to ensure consistency and transformation across the A23 Corridor in the Sustainable Transformation Plan.. BHCCG Exec leadership in place and a member of the Regional CEPN Board and the STP workforce group MOU between HWLH Horsham Mid Sx and BHCCGs signed Date for initial meeting of partners in the A23S place identified Discussion with the leads in the A23N Place commenced Each CEPN Board area are at different rates of progress Each CCG is at a different place with governance and oversight of local education and training needs There is a need to grow and understanding across CCG/Primary care of the impact of the change Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Page 22 of 40 14/12/

144 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Organisations continue to review skill mix and new ways of working as well as recriutment drives John Child 15/04/ /03/2017 The Sustainable Transformation Plan is looking at addressing the issues of workforce development, both to enable new roles within integrated services, and to address sector-specific shortages. Workforce issues are identified as a key priority in the STP. A workforce development subgroup has been established and the CCG will utilise this group to ensure strategic workforce planning is integrated into commissioning plans. All new contracts and development specifications should include workforce development plans and engagement in providing system capacity e.g- offering placements and development experience. And meet with CCG and STP Operational and development plans. The Sussex/Surrey STP CCGs are working with NHS England and Health Education Kent Surrey and Sussex to look at consistency of application of workforce assurance tools, capacity mapping and competence alignment All CCG providers subject to the National CQUIN for 16/17 which includes the Introduction of staff health and wellbeing initiatives. Achievements against the agreed Contractual Performance monitored and signed off at level of achievement at CCG Quality Review Meetings Developing joint rotational roles with other providers-the STP are looking at more flexible working provision across services, providers and geographical areas where clinically appropriate. Aligning staff to better meet demand in different areas to support flexibility. John Child John Child John Child John Child John Child John Child / / 20/05/ /03/2017 / / 10/06/ /03/2017 / / 01/04/ /03/2017 / / 20/05/ /03/2017 / / 15/04/ /03/2017 / / 10/06/2016 CCG Heads of Commissioning should have sight of provider workforce strategies and commissioning 30/03/2017 of education and training to request oversight of these plans to ensure these fit with the CCG Commissioning plans. Also to evidence that provider use of the Apprenticeship levy and assurance of / / Page 23 of 40 14/12/

145 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date supporting training placements to provide assurance that they have capacity to support the these positions once training is complete. Page 24 of 40 14/12/

146 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 184 Ver. 3 13/10/2016 Achievement of 16/17 Planned Surplus (Control Total). There is a risk that CCG will fail to achieve its planned surplus due to Service Level Agreement activity levels being significantly above plan and costs exceeding other CCG budgets.. Consequence of Risk: This additional activity and associated cost pressures may impact on the achievement of planned surplus as required by NHS England (Control Total). Debra Crisp Pippa Ross Smith 4 x 3 = 12 Financial 09/11/ x 3 = 12 4 x 2 = 8 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. These may also impact on the opening financial position. Risk Control Risk Assurance Control/Assurance Gaps Budget Holders have monthly reports to update on financial position and have regular meetings with Regular reports by Head of Finance to Senior Management Team meetings. the CCG Finance team to discuss performance against budgets and whether any corrective action is required. Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Closely monitoring SLA performance - position regularly reported to Senior Management Team to enable any necessary actions to be taken, such as corrective action options or identification of alternative savings Close monitoring of expenditure against all budgets - with monthly reports provided to budget holders and any deviation from budget reviewed, in order that plans can be put in place to recover the position. Debra Crisp Debra Crisp 13/10/ /03/2017 / / 13/10/ /03/2017 On-going identification of additional QIPP savings to cover any remaining overspends. Debra Crisp / / 13/10/ /03/2017 / / Page 25 of 40 14/12/

147 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 185 Ver. 3 13/10/2016 Achievement of 16/17 QIPP Savings The CCG Operational Plan 16/17 included unidentified QIPP of 4.5m, there is a risk that all savings required will not be found, or that non-recurrent savings are identified Consequence of Risk: This may have a negative impact on the opening 17/18 position and increase the risk of the CCG failing to achieve the NHS England Control Total -see Risk 184 The CCG may fail to deliver against mandated surplus and financial balance which are statutory requirements. Debra Crisp Pippa Ross Smith 4 x 3 = 12 Financial 09/11/ x 3 = 12 4 x 2 = 8 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Risk Control Risk Assurance Control/Assurance Gaps Need controls Regular monitoring against QIPP delivery by CCG Senior Management Teams and the Programme With escalation to Executive Team as necessary. Review meetings. Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Regular monitoring and reporting of QIPP, in order that the position can be fully understood to enable the necessary corrective actions to be taken Further progress has been made towards identifying non-recurrent savings but this remains an issue due to the impact on the plans for next year. Pippa Ross Smith 13/10/ /03/2017 / / Date Entered: 10/11/16 Entered By: Lara Kiziltuna following discussion with Debra Crisp Close monitoring of savings achieved to ensure that any recurrent shortfall is reflected in longer term planning / QIPP plans. Debra Crisp 13/10/ /03/2017 / / Page 26 of 40 14/12/

148 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 186 Ver. 3 13/10/2016 Longer Term Financial Risk to 2020 Delivery There is a risk that due to the increasing pressures on the National and Local Health system, in conjunction with the reduction in available funding, the CCG may fail to deliver its required financial position as mandated by NHS England Consequence of Risk: This may result in the CCG failing to deliver the Five Year Forward view and other NHS England mandated requirements. Debra Crisp Pippa Ross Smith 4 x 3 = 12 Financial 09/11/ x 3 = 12 3 x 2 = 6 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Risk Control Risk Assurance Control/Assurance Gaps The CCG is working closely with other CCGs, Local Authorities, Providers and the third sector These plans are submitted to, and reviewed by, NHS England partners to develop plans that maximise opportunities for delivery of integrated services to ensure efficiency across the system Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Maintain close links with finance network with regular attendance at finance led meetings. Debra Crisp 13/10/ /03/2017 Close working with local organisations to ensure that operating plans dovetail and align to the Sustainable Transformation Plan. As lead for BSUH contract negotiations, ensure strong links with other commissioners are maintained. Closely engaged with other lead commissioners on contracts where not the lead. Debra Crisp Debra Crisp Debra Crisp / / 13/10/ /03/2017 / / 13/10/ /03/2017 / / 13/10/ /03/2017 / / Page 27 of 40 14/12/

149 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 149 Ver. 6 06/06/2016 Delivery of New Community Short Term Services Beds Model Given the delays in commencement of the procurement exercise and the lead in time required to mobilise a complex new model of care it is likely that the new model for CSTS beds will only be implemented in part on 1/4/17 and that there will be a period of transition from the existing to the new model of care. The provider awarded the contract will need to mobilise a complex service, and there is potential for delay in sorting out contracts for any buildings that need to be leased or purchased, as well as sorting any physical works required within those building, agreeing sub-contracts with other providers, employing staff and dealing with TUPE requirements, and establishing pathways and protocols for joint working with other agencies. James Morton Michelle Elston 3 x 4 = 12 Performance And Delivery 14/11/ x 4 = 12 3 x 3 = 9 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. It is uncertain at this time what elements of the model may not be implemented on 1/4/17 and also how long the transition period will be from the existing to the new model of care. The City Council are offering all providers invited to tender the opportunity to purchase or lease Craven Vale and Knoll House and negotiations on this are being led by their Estates Department in parallel to the procurement exercise. Consequence of Risk: The anticipated efficiency gains for the wider health and social care system may not be delivered from 1/4/17, which will have an impact on performance for the acute care, primary care and social care sectors. Risk Control Risk Assurance Control/Assurance Gaps Procurement Steering Group already established that will work in partnership with selected lead provider and wider health/social care system partners to identify and implement mitigating actions. Procurement Steering Group will report on mobilisation progress to Executive Team and Performance and Governance Committee following selection of lead provider Following final scoring of tender by the Evaluation Panel there will be a meeting with senior managers from the CCG and the City Council to review the scoring and consider a recommendation on whether to award the contract. A meeting has been held with the provider to provide greater assurance regarding their proposals and written questions will be sent to the provider for a full response to some of their answers before final scoring by the Evaluation Panel is complete. Page 28 of 40 14/12/

150 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Date Entered: 10/11/16 Entered by: Keith Hoare City Council Estates Department leading on negotiations with interested providers on potential sale or lease of Craven Vale and Knoll House. Service Specification - this has been developed for the new model of care. Contract management - the performance of the new service will be reviewed in regular contract management meetings with support from the CSU following mobilisation of the new service. Providers will be required to submit their plans for buildings in their ITT submission and these will be evaluated by the procurement steering group. The service specification has been consulted on with a ranfge of key stakeholders to ensure it covers all necessary areas of service delivery. The contract will be a standard NHS contract and therefore will contain all of the usual controls and options for addressing performance issues as with other contracts. A performance payment system will also be established for the new service to motivate good performance. ITT submissions that fail to assure the procurement steering group of plans for mobilising the estates element of the service will not be awarded the contract. None Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Following award of contract the Procurement Steering Group will disband and a mobilisation board will be created jointly with the Local Authority to ensure the services are delivered to the standard within the contract. Oversight and scrutiny will continue for 1 year post-contract. This Board will report into the Procurement and Governance Board. Invitation to tender submissions due Evaluation process begins w/c and Recommendation of award of contract to Performance and Governance Committee late November Once contract awarded the CCG will be better placed to review and respond to the risk-mobilisation plans will be reviewed for robustness and provide evidence on the timetable for delivery and the extent to which the service will be implemented by Keith Hoare 01/11/ /03/2017 / / ITT Questions drafted that will require providers to specify the detail of their mobilisation plans so that commissioners can assess readiness for 1/4/17 in advance of award of contract Page 29 of 40 14/12/

151 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 183 Ver. 6 06/10/2016 Delivery of the Clinical Navigation Hub (CNH) Delivery of the Clinical Navigation Hub across 5 CCG's is complex. There are multiple dependencies with the potential to significantly impact upon the key design/development stages and ultimate delivery of the service. These include (but not limited to): _Progress of and alignment to the NHS 111 reprocurement _Effective governance of the NHS 111 re-procurement _Development of supporting IM&T architecture _Access to and quality of data to support activity and financial modelling _Dedicated commissioner/clinical resource. Consequence of Risk: If these key areas are not effectively managed/supported then there is a significant risk that the Clinical Navigation Hub will not be delivered by March Clair Harris Renee Padfield 4 x 3 = 12 Performance And Delivery 09/11/ x 3 = 12 4 x 2 = 8 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. This will negatively impact on the Urgent Care system and the wider healthcare economy. This may result in the following -poor patient experience -quality impact on standards and delivery of care -reputational damage to CCGs and associated providers -increase in A&E referrals -underutilisation of community services. Risk Control Risk Assurance Control/Assurance Gaps Effective governance of the CNH Programme Board (bi monthly meetings) The CNH reports to the Urgent and Emergency Care Network., (Chaired by GP Chair for Horsham and MidSussex0 and supported by the CNH Working Group-Comprised of Commissioning Leads across the STP footprint CCG Executive oversight of alignment (STP footprint)across NHS 111 / CNH. Please work this up Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Page 30 of 40 14/12/

152 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Weekly pan Sussex Operational meetings to progress development of service specifications which inform the bi monthly Programme Board Meetings Renee Padfield 06/10/ /03/2016 Commissioner resources and associated planning for 111 and the CNHs straddle both programmes to ensure alignment in development and mobilisation to manage the interdependencies between the two programmes. Further CCG Commissioner resources need to be identified and agreed across commissioning CCG's to adequately resource the development of both NHS 111 / CNH programmes. The following resources pan Sussex have been identified and need to be recruited to IMT Specialist Sussex Directory of Services Lead Further updates to follow Additional resource to support programme raised by the Central Sussex Alliance and funding gap requested by BHCCG in November Renee Padfield Renee Padfield / / 06/10/ /12/2016 / / 09/11/ /03/2017 / / Page 31 of 40 14/12/

153 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 110 Ver. 8 16/10/2015 Impact of NHS Cancer Strategy and NG There are recommendations from Independent Cancer Task Force Review (2015) for GP's to have direct access for Endoscopy,MRI, CT to improve early diagnosis and detection (NG12). BSUH may not have the capacity to manage the 15% forecast increase demand in these areas of direct diagnostic access. There will also be an increased cost due to a rise in activity NG12 has not been implemented in Brighton and Hove, it is anticipated this will start to happen prior to the end of this financial year. Consequence of Risk: Lack of capacity at BSUH in diagnostics will result in delays for diagnostic services and will impact on Referral to Treatment Time performance. Mari Longhurst Renee Padfield 3 x 3 = 9 Clinical Quality And Patient Safety 21/11/ x 4 = 12 2 x 3 = 6 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. This may result in reputational impact, breach of NHS Constitution standards and poor patient experience. Risk Control Risk Assurance Control/Assurance Gaps The CCG are working across Sussex with providers to implement NG12 ensuring agreement on referral forms across Sussex and predicted capacity and demand plans. Issues are escalated to the BSUH Planned Progress against implementation of NG12 is reported to the Cancer Action Group, the Care and Cancer Programme Board. Planned Care and Cancer Programme Board and the Sussex Cancer Care Operational Group -Sussex Wide Group. Progress against the 2 week wait target is further scrutinised by NHS England on a monthly basis. CCG Cancer Commissioner attends PTL (Patient Tracking List) to track progress on 2 week waits and Referral to treatment times. CCG reporting of progress against 2ww target on monthly basis Reports to CCG Performance and Governance Committee and Governing Body and overseen see above by Quality Assurance Committee Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Page 32 of 40 14/12/

154 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Additional independant sector diagnostic capacity is being sourced as part of the RTT recovery plan-see risk RTT Risk It is expected that once agreed and commissioned this additional diagnostic capacity will have a direct positive impact on sustaining the 2ww performance and meet the additional expected diagnostic demand. See Corporate Risk 146-National Targets and Standards for ongoing progress reports for delivery of RTT Target across disciplines A joint implementation plan with BSUH, HWLH CCG and HMSx CCG has been developed, focusing on upper and lower GI initially. Date Entered: 09/11/16 Entered By: Lara Kiziltuna after discussion with Mari Longhurst Renee Padfield 10/06/ /01/2017 / / Page 33 of 40 14/12/

155 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 187 Ver. 4 13/10/2016 Cost pressure due to mandated Uplift to Funded Nursing Care (FNC) fees In-year notification of the mandated uplift to (FNC) fees was not received until 16/17 plans were finalised, resulting in a new cost pressures. Consequence of Risk: This may impact on the delivery of the CCG Financial Control Total as required by NHS England. Debra Crisp Pippa Ross Smith 4 x 3 = 12 Financial / / 4 x 3 = 12 4 x 2 = 8 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Risk Control Risk Assurance Control/Assurance Gaps Need controls Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date All costs controlled and opportunity for additional savings maximised - regular monitoring of performance against budgets. Debra Crisp 13/10/ /03/ / / Non-recurrent savings have been identified this year which will need to be taken into account when considering the cost pressures of the plans for next year. Page 34 of 40 14/12/

156 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 124 Ver /02/2016 Remaining Lease Cost - Lanchester House The CCG has agreed to transfer its offices from Lanchester House to new offices in Hove Town Hall. There will be a period of around 3.5 years between the CCG's exit of Lanchester House and the next available break date. If an alternative tenant cannot be found then the CCG will remain responsible for the lease costs for this period. Consequence of Risk:.The total annual cost of the lease on Lanchester House is 442,000. Therefore the total impact of failure to assign the lease could be as high as 1,547,000. Owen Floodgate Soline Jerram 3 x 3 = 9 Financial / / 4 x 3 = 12 4 x 2 = 8 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Risk Control Risk Assurance Control/Assurance Gaps NHS Property services has been instructed to market the property as widely as possible. Additionally we options are being explored with other public sector estates manager in the city. Reported to SMT and CCG Exec Team Risk remains high until contracts have been exchanged on assignment. Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Head of Corp Affairs met with NHS Property services regional lead on Confirmed that the assignment of the remaining lease is in hand, with an identified tenant and negotiated terms. Bidder surveyors have assessed costs on and awaiting final agreement Owen Floodgate / / The CCG has now moved office.the financial risk remains. A new tennant has been identified and the 08/11/2016 agreed start date for tenancy and assignment of lease to take place on 1/12/16. The terms have been agreed with the incoming tennant and contract signing is expected on 30/11/16. 01/12/ /10/ /10/2016 / / Page 35 of 40 14/12/

157 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 105 Ver /10/2015 Cancer Waiting Times There is a risk that the CCG will not achieve the NHS England mandated 62 standard from overall referral to treatment. This is because BSUH cancer services are a) experiencing high levels of demand which is expected to increase due to the implementation of new NICE Guidelines for two week wait referrals. (e.g impact of Primary Care direct access to diagnostics) Mari Longhurst Renee Padfield 4 x 4 = 16 Performance And Delivery / / 3 x 4 = 12 3 x 2 = 6 Reduce Inequalities Focus on prevention and early detection.plans should be targeted specifically at areas identified in the Joint Strategic Needs Assessment and the Annual Public Health Report. b) limited capacity in certain area (Urology, lung, colorectal and upper GI) c) Patient flow and patient access for diagnostics-e.g. radiology, pathology, and biopsy diagnostics Consequence of Risk: These factors may result in delayed diagnosis and treatment, poorer national framework outcomes and poor patient experience. Risk Control Risk Assurance Control/Assurance Gaps Cancer Access Waiting Times Monthly Report CCG Commissioner attendance at weekly Patient Tracking List Meeting System Resilliance Group Monthly Oversight Planned and Cancer Delivery Board Report and escalate issues to Contract Monitoring Group, the Planned Care and Cancer Programme Board (by exception) and the Cancer Action Group. Waiting times still exceed 62 day national standard. Cancer 62 day national standards not being met. Contract Monitoring Group -BSUH report progress against recovery against 62 day national standard This reports to the Single Performance Conversation and the System Resilience Group Waiting times not met Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date A Breach Allocation policy is being established across providers. Sharing policies developed across Surre yand Sussex. Shadow monitoring has been in place since October Renee Padfield 09/11/ /12/2016 Currently scoping two week wait guidelines to support future commissioning intentions- Capacity and demand are also being scoped on the impact of implementing the new referral forms establishing commissioning of direct access/straight to test pathways. Renee Padfield / / 30/09/ /03/2017 / / Page 36 of 40 14/12/

158 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Clinical leads are in the process of signing off referral forms which were discussed and agreed at Sussex wide meeting in August Final sign off for high level commissioning intentions expected November 2015 Page 37 of 40 14/12/

159 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 191 Ver. 7 30/09/2016 Brighton and Hove CCG Directions from NHS England There is a risk that the CCG response and associated actions to NHS England Directions are not sufficient to meet the compliance standards expected by the NHS England Board. The Directions cover- -Accountable Officer appointment -Exercise of Functions -Capability and Capacity Action Plan, Governance Review, develop a Commissioning Plan by Produce RTT and A&E Recovery Plan Appointments to Executive Team/Senior Appointments Consequence of Risk: The CCG failure to meet the compliance standard for the Directions may result in negative impacts on -the CCG reputation -financial -organisational -delivery Lola Banjoko John Child 3 x 3 = 9 Performance And Delivery / / 4 x 3 = 12 4 x 2 = 8 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date The CCG will be undertaking a governance review in December in line with NHSE directions. John Child 01/12/ /12/2016 / / Page 38 of 40 14/12/

160 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 174 Ver. 6 12/08/2016 Delivery of Brighton and Hove Strategy for Integrated Care There is a risk that due to the complexity and scale of the ambition that delivery will be delayed or that impact will be gradual and long term. Consequence of Risk: There is a risk that the outcomes will not be achieved in the timescales. Ramona Booth John Child 4 x 3 = 12 Performance And Delivery / / 4 x 3 = 12 3 x 3 = 9 Integration Integration should be at the heart of our commissioning agenda - services should be integrated to ensure efficiency and improve wellbeing Risk Control Risk Assurance Control/Assurance Gaps Better Care Board and Health and Care Partnership Revised Caring Together Plan Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Revised Caring Together Plan completed in line with planning directions. Further amendments and detail will be added during the 17/18 planning round. Communication and engagement to ensure a shared understanding The CCG has secured additional resource to support the delivery of 30/09/2016 Caring Together and to ensure the joint objectives of the city council and the CCG are implemented. Start date: Jan /11/2016 Engagement events with all relevant stakeholders are planned for November and December 2016 Jane Lodge / / 12/08/ /12/2016 Alignment of commissioning between CCG and BHCC to ensure -alignment to key areas of work -co-development and ownership of work -contractual oversight Alignment of commissioning activity between CCG and BHCC Ramona Booth / / 12/08/ /12/2016 Implementation of revised delivery and goverance plan. New Governance arrangements have been approved and there will be a move to these November 2016 through to March 2017 Ramona Booth / / 12/08/ /03/2017 / / Page 39 of 40 14/12/

161 Brighton and Hove CCG Corporate Risk Register 2016/17 Risk No. Risk Date Ver No. Risk Title Risk Cause Risk Event Risk Consequence Assessor Owner Original Score Current Score Target Score Sev x Like=Score Risk Group Link to Strategic Objectives Last Review 169 Ver. 4 11/07/2016 Reprocurement of CCG Support Services There is a risk to Business Continuity as a result of the mobilisation of service transfer to a new Commissioning Support Unit -going live on This covers the following areas- Contracting. Business Intelligence Finance Information Technology. Owen Floodgate Pippa Ross Smith 4 x 3 = 12 Performance And Delivery 07/11/ x 1 = 4 4 x 2 = 8 Quality And Efficiency The CCG should always commission the most cost effective intervention delivered in the most appropriate setting. Our focus should remain on achieving financial balance but equally on improving the quality of local services. Consequence of Risk: This may result in loss of business effectiveness across a number of functions particularly IT as it go live is the same day as the transfer of business to Hove Town Hall. Risk Control Risk Assurance Control/Assurance Gaps Controls and Assurances Needed Mitigating Actions Action Progress Person Responsible Start Date Target Date Comp Date Project mobilisation director has been appointed by CCGs to oversee the delivery of non IT CSU services mobilisation to be kept under review Owen Floodgate 30/09/ /09/2016 / / Page 40 of 40 14/12/

162 162

163 Name of Meeting: Governing Body Date of meeting: January 2017 Item Number: 13/17 Title of report: Month 8 Integrated Performance Report Recommendation: SMT approved the recommendations below to go to the Performance and Governance Committee with the caveats that the report does not provide the management team with reassurance and assurance on performance improvement. The management team agreed that all areas of the report will be fully developed by end of Q4 highlighting the impact of actions and timeframes for delivery The committee are asked to : Note the updated content and format Note that the report is still under development Note areas under development primary; community; CQUIN; contracting and 16/17 QIPP delivery to be improved for the next report Provide recommendation on format and sections of the report for improvement Advise if a supplementary deep dive paper is required for any areas of concern Summary: The attached report provides the Governing Body with a comprehensive update relating to finance, performance, quality and the actions required to deliver compliance against the various indicators. The report is for Month 8 (November 2016) and wherever possible data relates to this month. There are some areas where data is subject to a reporting lag, for these areas the most up-to-date data is included. In areas where un-validated daily/weekly data is available this has been added to ensure the report contains the most up-to-date position possible. Financial Position: We remain on track to achieve our planned surplus of 9.7m, however it has been necessary to utilise 1,548k of contingency reserves to offset expected cost pressures leaving only 343k of reserves available to offset any further cost pressures that materialise. A number of potential risks have been identified and are being reviewed to determine the likelihood of them materialising, while also looking for possible mitigations should this prove necessary. There remains an outstanding balance of 798k of savings required to fully achieve our target QIPP of 10m. This position includes a significant level of non-recurrently identified savings (approximately 3.8m), which will impact on the opening position for 17/18. NHS Constitution Standards: The CCG is failing to meet NHS Constitution targets relating to A&E (pages 8-13 and 25), Cancer (page 21), Diagnostics (pages 19 & 20), Referral to Treatment Times (pages and 26), mental health (CPA- page 22) and Infection control (C.Diff- page 23). 163

164 Improvement and Assessment Framework ( page 34) Clinical and commissioning leads identified for the six clinical areas and action plans agreed. NHS Outcome Framework (page 37): Clinical and managerial leads identified and work to take this forward agreed for next report Quality Position: Key quality issues include patient experience and safety for people waiting over 52 weeks for treatment, and learning identified from 12 hour breach reviews. A renewed focus is required for surgical never events after 3 new incidents were reported in November (page 23) 164

165 Sponsor: Lola Banjoko, Director of Performance, Planning and Informatics John Child, Chief Operating Officer Author: Ramona Booth, Head of Planning and Delivery Date of report: 5 th January 2017 Narrative provided by: Heads of Commissioning, Finance and Quality. Financial implications: N/a Legal or compliance implications: NHS Constitution Standards Link to key objective and/or assurance framework risk: Improvement and Assessment Framework NHS Outcomes Framework 165

166 Integrated Finance, Performance and Quality Report Month 8 January

167 Integrated Finance, Performance and Quality Report Month 8 Contents Introduction and Purpose... 3 Executive Summary... 3 Section 1 Financial Position 2016/ Section 2 Delivering the NHS Constitution Standards... 7 A&E 4 Hour Waiting Time Standard... 8 Acute Delayed Transfers of Care Community Delayed Transfers of Care Mental Health Delayed Transfers of Care Referral Treatment Standards Diagnostic Waiting Time Standard Cancer waiting times Mental Health 7 Day Follow Up Quality Primary Care Section 3 - Improvement and Assurance Framework Cancer Dementia Diabetes Learning Disabilities Maternity Mental Health Section 4 Assessment and Improvement Framework Section 5 - NHS Outcomes Framework Section 6 Contractual KPIs by provider Section 7 CQUIN by providers Appendices Appendix 1- Summary Financial Position 2016/ Appendix 2 Commissioning Services Appendix 3 Corporate Costs Appendix 4 QIPP 2016/ Appendix 5 Improvement and Assessment Framework Appendix 6 Mental Health dashboard Appendix 7 NHS Outcomes Framework

168 Introduction and Purpose The Integrated Finance, Performance and Quality Report has been developed in line with the CCG s ambition to create a health intelligence system to ensure that timely, accurate and appropriate information is available to all relevant staff that will: Provide an appropriate assurance framework to serve internal and external performance management regimes Inform how the CCG commissions and delivers services by understanding about the health (and social) care needs and wants of patients and their experience of the services they use This will act as the intelligent tool that drives the way we commission, contract and drive through delivery into business as usual, improve and sustain performance and transform services. The tool will also support the CCG to deliver value for money and work within its defined financial envelope. Executive Summary Financial Position: We remain on track to achieve our planned surplus of 9.7m, however it has been necessary to utilise 1,548k of contingency reserves to offset expected cost pressures leaving only 343k of reserves available to offset any further cost pressures that materialise. A number of potential risks have been identified and are being reviewed to determine the likelihood of them materialising, while also looking for possible mitigations should this prove necessary. There remains an outstanding balance of 798k of savings required to fully achieve our target QIPP of 10m. This position includes a significant level of non-recurrently identified savings (approximately 3.8m), which will impact on the opening position for 17/18. NHS Constitution Standards: The CCG is failing to meet NHS Constitution targets relating to A&E (pages 8-13 and 25), Cancer (page 21), Diagnostics (pages 19 & 20), Referral to Treatment Times (pages and 26), mental health (CPA- page 22) and Infection control (C.Diff- page 23). Improvement and Assessment Framework Clinical and commissioning leads identified for the six clinical areas and action plans agreed. NHS Outcome Framework: Clinical and managerial leads identified and work to take this forward agreed for next report Quality Position: Key quality issues include patient experience and safety for people waiting over 52 weeks for treatment, and learning identified from 12 hour breach reviews. A renewed focus is required for surgical never events after 3 new incidents were reported in November (page 23). Contractual Key Performance indicators [ To be populated for main providers in next report] Independent sector Optum SCFT SPFT HERE 168

169 Section 1 Financial Position 2016/17 Forecast Surplus We remain on track to achieve our target surplus of 9,685k, however it has been necessary to utilise 1,548k of contingency reserves to offset expected cost pressures, leaving only 343k of reserves available to offset any further cost pressures that materialise. Variance to budget is explained in more detail in the sections below. Risks A number of potential risks to the achievement of reported position have been identified but not yet quantified. Cost pressures have been identified by Sussex MSK Partnership, due to delays in the availability of hub sights, activity growth above plan and changes to the activity case mix. Work is underway to better understand the potential cost pressures of 9.7m across the term of the contract and the element attributable to the CCG. The Better Care pooled fund is also experiencing financial pressures due to the Community Equipment Service, work is currently underway to implement changes to the service to reduce the forecast and to identify savings elsewhere within the pooled budget to offset this cost, however there remains a risk that insufficient funds will be found to fully offset these costs leaving a balance to be shared between the CCG and BHCC. PTS In-Year Performance The month 8 reported position for all acute providers is based on month 6 validated activity data, this being the most reliable information available to determine the financial position for contracts. The reported position for Brighton and Sussex University Hospitals SLA is an underspend of 1,220k at month 8 with a forecast year end underspend of 1,830k. Included within this position is a significant increase in High Cost Drugs charges. At the time of finalising the month 8 position, these cost were being queried with the Trust, subsequently additional data to support the increased charges has been received. An initial analysis of the data suggests in addition to the one off catch up payment, there is evidence of a recent underlying increase in costs which is likely to impact on the underperformance reported in future months. Flex data received for month 7, suggests a significant reduction in the forecast underspend, to approximately 700k, this position is currently being validated. We are continuing to report a forecast overspend of 500k at Western Sussex Hospitals, while the forecast overspend at East Sussex Hospitals remains at 150k, with no change also being reported for Surrey & Sussex Hospitals SLA which is expected to overspend by 550k at the year-end. There is some evidence to suggest a reduction in the volume of referrals being made to these Providers, which may result in a reduction in the reported overperformance in the remaining months of the year. It is expected that this additional activity will be funded from the underperformance seen at BSUH as it is thought that the majority, is due to referrals being redirected from BSUH to assist with the clearance of the waiting list backlog. The forecast overspend at Guys has reduced from 200k, now to 65k above plan. The high activity volumes seen at the beginning of the year have been reducing in recent months and therefore this position may improve further. At month 8 we are reporting an overspend of 135k, resulting in a forecast outturn of 200k above the plan for University College London Hospitals. Following a review of the supporting data, a charge of approximately 100k was found to be included in error, which would result in a corrected forecast overspend of 85k. There continues to be an underperformance on the Spire SLA, 215k at month 8, as the delay in provision of the additional waiting list activity included in the plan continues. Activity levels are now 169

170 beginning to increase, but some slippage is expected to continue resulting in an underspend of 260k at the year-end. Similarly, there has been some delay in the provision of the additional waiting list activity added to the Nuffield SLA, resulting in an underspend of 100k at month 8. However, it is anticipated that the provider will catch up during the remainder of the year and be on track by the year end. We are continuing to forecast an overspend of 525k for Non Contract Activity (NCAs). A review of the underlying data shows a significant increase in activity charges for a number of London and Independent sector providers compared to the same period last financial year. Given that, due to the time lag in the receipt of invoices, this is a particularly difficult area to forecast, we will continue to closely monitor activity charges at a provider level The forecast overspend for Mental Health Placement budgets has now increased to 700k. Negotiations are ongoing to agree funding for joint packages of care and contain expenditure where possible. The expected overspend on CHC budgets, due to the increase in Nursing Home fees for Funded Nursing Care, is now 702k, due to the increase in the full value of the cost pressure to 1,300k. We continue to expect to be able to offset a significant element of these costs ( 600k) against surplus 15/16 CHC creditors, leaving the balance of 702k to be charged against the contingency reserves. We are now forecasting an underspend for Local Enhanced Services budgets of 407k. This continues to be mostly due to slippage against planned investments in proactive care. Corporate Budgets Corporate budgets are forecast to underspend by 194k at year-end. Of this total, 74k is due underspends against our Running Cost Allowance (RCA), the separate allocation we receive for Admin budgets. Given the high number of staffing changes taking place this financial year, expenditure against this budget is being closely monitored. Reserves A summary of Reserves is shown in the table below. We are required to hold a 1% non-recurrent uncommitted reserve fund, it is still not clear how this funding will be used. 000's Contingency 1,893 Forecast Cost Pressure - Mental Health Budgets (700) Forecast Residual Cost Pressure - FNC Uplift (702) Forecast net movement on Other Budgets (148) Balance of Contingency Available 343 Better Care Pooled Fund to be allocated 754 Balance of Reserves Earmarked for Investments 1,529 Total Reserves available 2,283 NR Reserve (1%) 3,594 Total All Reserves available 4,

171 QIPP Performance against QIPP plans is reported at Appendix 4. At month 8, we are forecast to be 798k short of the planned saving of 10,078k. The expected savings against QIPP plans continues to be 1,203k off track in total and are being partially offset by non-recurrent savings and surplus creditors. This now means that approximately 3.8m of 16/17 forecast savings have been identified nonrecurrently, which will impact on the opening position for 17/18. Better Payment Practice Code All NHS organisations are expected to comply with the Better Payment Practice Code, which sets out the requirement for all invoices to be paid within the agreed terms of payment, or within 30 days, whichever is shorter. The target is for 95% of invoices received to be paid within the target time. During November, performance remains above the 95% target in all areas, except for the volume of NHS invoices for which only 93.5% of invoices were paid on time. This appears to have been partially caused by invoices not being correctly placed on hold while queries are being resolved. We continue to review all payments which were made late to ensure that no unnecessary delays occur in future months. Further detail is provided in appendices 1-4: a. Appendix 1 Summary Financial Position (Month 8) b. Appendix 2 Commissioned Services (Month 8) c. Appendix 3 Corporate Services (Month 8) d. Appendix 4 - QIPP 2016/17 (Month 8) 171

172 Section 2 Delivering the NHS Constitution Standards The CCG is failing to meet a large number of NHS Constitution Standards at Month 8. The table below provides a summary view of current performance. Table 2. NHS Constitution Standards. Source: CSU Intelligence Point, monthly, last updated November 2016 The sections that follow provide further detail on the actions being taken to improve performance and the locally agreed plans and trajectories to support delivery as well as the key risks. 172

173 Performance Metric Exec Lead: Commissioner: Clinical Lead: A&E 4 Hour Waiting Time Standard John Child Renee Padfield Tim McMinn Performance Summary BSUHT total performance against the 4 hour standard for December 2016 was 80.4% against trajectory of 86.0% (70.6% at RSCH and 80.9% at PRH). Chart 1: BSUHT A&E 4 hour Performance Source: BSUHT ECP, monthly, last updated December 2016 BSUHT A&E attendance actuals vs plan year to date (M8, April-November 2016 flex) is 6.8% over plan for the trust total and 4.6% more than last year. Brighton and Hove CCG A&E activity is 6.9% over plan (3876) and 4.5% more than last year (2575). BSUHT total there was two breaches in Nov-16, 22 YTD (Apr-Nov-16). All breaches occurred at the RSCH hospital site. There have been 5 validated breaches in Dec-16 so far. BSUHT 12 hour breaches Chart 2: BSUHT A&E 12 Hour Breaches Source: BSUHT, *December 2016 up to 8 th Dec

174 The urgent care system performance is summarised in the table below and reviewed monthly at the A&E delivery Board. Provider Measure Current Period Actual Recovery/Lo cal Plan National Standard Trend (last 12 periods) BSUHT A&E 4 hour Dec % 86.0% 95.0% BSUHT A&E 12 hour Dec-16* 5-0 Apr - Nov 16 BSUHT A&E activity versus plan 105,775 YTD Emergency Spells activity Apr - Nov 16 BSUHT 28,958 versus plan YTD BSUHT DToC Oct % 3.9% 3.5% WIC IC24 OOH Total Activity Total Contacts Weeks 1-36 YTD Apr - Oct 16 YTD 15,273 15, KMSS 111 % of 111 calls handled by Apr - Oct 16 a clinician YTD 21.9% - - KMSS 111 Advised to go to A&E Apr - Oct 16 YTD 7.57% - - SECAmb >30 min Handover Delays at BSUHT Oct SCFT DToC (Trust Total) Nov % 9.0% - SCFT SPFT Community Rapid Response (CRRS) Community Short Term Services (CSTS) DToC (B&H, HMS, HWLH CCGs) Apr - Nov 16 YTD Apr - Nov 16 YTD 98,994-25,985-3,566 3,242 - SCFT 2,315 1,786 - Nov % 7.5% - Table 3: Performance at a glance, *12 Hour breaches up to 8 th December 2016 Source: Provider reports, monthly, updated December 2016 Actions to Improve Performance The Trust continues to report low but consistent numbers of 12 hour breaches (average one a month for the last 3 months), with one reported in October and a further 2 in November. However this is an improvement on the numbers reported at the start of the financial year. These continue to be reported as individual serious incidents; however NHSE England and NHSI acknowledge there is inconsistency in the way different organisations report 12 hour breaches and are in the process of developing a standardised investigating tool for all providers. Furthermore the CCG is working with the Trust to implement a process for identifying any harm associated with patients waiting for a specified amount of time in A&E, in recognition that the 12-hour standard often does not reflect the total length of time of time that people are waiting in the department. The CCG is seeking assurance of Trust Board agreement for new governance standards that are planned for implementation within A&E and the acute floor. This is being implemented following successful implementation elsewhere, and holds all directorates to account in ensuring effective patient flow through A&E. This will also help to provide a more significant level of assurance in relation to learning across the Trust of the patient impact of 12-hour breach incidents. The CCG is focussed on Discharges before 10am which is reported monthly by the Trust. This target applies to the RSCH site only, where the target is for 1 discharge to take place per ward before 10am. In 174

175 October the Trust reported achievement of 16% against the 100% target. The CCG has requested via the Quality Review meeting for further information from the Trust about how they plan to achieve this target. Specific Actions Immediate Actions: Working with primary care to reduce attendances using the revised GP dashboard issued November 2016, peer to peer support and proactive management. Winter communications to campaign via CCG website and social media reminding patients to ensure they have enough medication for the holiday period; use NHS 111 and the Walk-in Centre as an alternative to A&E. Also Heroes advertising campaign on bus shelters and at petrol pumps. (December 16 to February 17) Single point of access for responsive community services went live 24th October 2016 and supports timely access to these services. Robust contract management and contract levers in place to manage performance against 4hr standard. (January 17) Scrutiny of SI investigation reports for 12 hour breaches. Working with care homes to target frequent attenders and robust review and management of medications. Monitor progress against the Trust's CQC quality improvement plan via Quality Oversight Group and QRM. Out of Hours GP contract extension agreed for with refreshed targets for key performance indicators. (December 16) Long Term Plans: Primary Care Led integrated front door (April 2018) Clinical hub/111/ooh (April 2019) Urgent and Emergency Care Improvement Programme implementation (On-going programme of work) 175

176 Performance Metric Exec Lead: Commissioner: Clinical Lead: Acute Delayed Transfers of Care John Child Renee Padfield Tim McMinn Performance Summary Acute Delays The percentage of Brighton and Hove patients at BSUH whose discharge has been delayed is 8.9% and is significantly higher than nationally required standard of 3.5% and locally agreed trajectory of 3.9%. 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 As at Oct- 16 Plan 3.9% Dec-16 Jan-17 Feb-17 Mar-17 Percentage occupied beddays DToC Recovery plan National Target Chart 3: BSUHT DTOC BSUHT, all sites. Source: NHS England statistics, monthly, updated October 2016 The significant reduction seen in un-validated December 2016 data is in line with expected seasonal reduction. Chart 4. BSUHT, all sites, Brighton and Hove LA only. Source: BSUHT daily summary report, updated 23/12/16 The following chart shows the latest available breakdown of the causes of DToC at BSUHT (for the month of Oct-16). The reasons causing the greatest number of days delayed are Waiting further NHS non-acute care which accounts for 32% of days delayed and Patient or Family choice, which accounts for 25% of days delayed. 176

177 Chart 5: BSUHT DTOC delayed days by reason BSUHT, all sites. Source: NHS England statistics, monthly, updated November 2016 Actions to Improve Performance Acute Delays Discharge Improvement Group pilot rolled out across RSCH and implementing trusted assessor (December 2016) Choice Policy implementation (December 2016) Home 15 patients by January 2017 Moving CHC assessment from acute into the community setting and improving time to assessment (February 2017) Appointed Director of System Resilience (December 2016) BSUH to lead face to face weekly senior meetings re top 20 at both RSCH / PRH site There are two local CQUINs in place for the Trust to support DToC as follows: i. Improved patient flow ii. Integration this involves working closely with the Care Home and Home Care sector for the frailty population, in order to improve the quality of hospital discharges. Meetings between BSUH and Home Care providers has identified projects around improving timeliness of take home medicines and electronic sharing of medication information 177

178 Performance Metric Exec Lead: Commissioner: Clinical Lead: Community Delayed Transfers of Care John Child Michelle Elston Performance Summary Community Delays The chart below shows performance against the proposed improvement plan trajectory. SCFT Delayed Transfers of Care 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 15/16 16/17 Nov actuals 15/ % 16/17 Improvement plan (proposed) Chart 6: SCFT % DToC. Source: SCFT Quality Dashboard, updated December 2016 The following chart shows the latest available breakdown of the causes of DToC at SCFT (for the month of Oct-16). The reason causing the greatest number of days delayed are Awaiting Care Packages in Own Home which accounts for highest number of days delayed. Chart 7: SCFT DTOC delayed days by reason SFCT, all sites. Source: NHS England statistics, monthly, updated November 2016 Actions to Improve Performance Community Delays Daily system calls including an actual vs plan for discharges at both sites and a look forward re community capacity. (December 16 to March 17) CCG agreement to spot purchase beds to support flow when community bed capacity is full (December 2016) CCG facilitated weekly SCFT LA telecom on escalated DToC Daily Board Rounds in 2 community bedded units (SAFER) commenced (December 16) SPFT Safer Care and Flow Diagnostic work underway and due for completion in Q4 16/17 178

179 Performance Metric Exec Lead: Commissioner: Clinical Lead: Mental Health Delayed Transfers of Care John Child Anne Foster Becky Jarvis Performance Summary Mental Health Delays DTOC s for SPFT are above the target of 7.5%. The main reason for DTOC s are waiting for care home placements & supported accommodation because of: insufficient capacity in the system ability of providers to manage patient risk in the community particularly for people with multiple and complex needs including forensic and dual diagnosis 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Weekly SPFT DToCs % - Brighton & Hove As at 18/12/16 DToC % - 7.1% 10/04/ /04/ /04/ /05/ /05/ /05/ /05/ /05/ /06/ /06/ /06/ /06/ /07/ /07/ /07/ /07/ /07/ /08/ /08/ /08/ /08/ /09/ /09/ /09/ /09/ /10/ /10/ /10/ /10/ /10/ /11/ /11/ /11/ /11/ /12/ /12/ /12/2016 DToC % Target Chart 8: SPFT DTOC %SFCT, all sites, Brighton and Hove CCG. Source: SPFT weekly delays, updated 18/12/16 Actions to Improve Performance Mental Health Delays Actions in place include: Implementation of the Improving Patient Care and Flow CQUIN that aims to reduce length of stay through addressing process issues in the acute care pathway as well as broader system issues. Diagnostic work has been complete and an action plan in the process of being developed for approval in January CCG leads multi-agency mental health accommodation group to address system issues. Proposals being considered/developed include: o The development of partnership models of care between SPFT and supported accommodation providers particularly for those with multiple and complex needs to enable greater management of risk in the community.. 179

180 Performance Metric Exec Lead: Commissioner: Clinical Lead: Referral Treatment Standards John Child Renee Padfield Jim Graham Performance Summary During the last three years the demand for planned care services has been greater than the available capacity as a result a large waiting list has developed and the NHS Constitutional standard for Referral to Treatment time has not been met since May The CCG is currently ahead of the locally agreed recovery trajectory 83% against 79%. Chart 9. Brighton and Hove CCG 18 Weeks RTT incomplete. Source: NHS England Statistics, monthly, updated December 2016 The table below shows the performance by specialty. The poorest performing specialities continue to be General Surgery (includes Digestive Diseases), Neurology and Neurosurgery APR MAY JUN JUL AUG SEP OCT Cardiology 93% 95% 95% 91% 87% 89% 86% Cardiothoracic Surgery 87% 80% 100% 92% 87% 82% 100% Dermatology 95% 96% 95% 95% 96% 98% 97% ENT 89% 88% 87% 85% 82% 84% 86% Gastroenterology 76% 77% 82% 81% 79% 88% 90% General Medicine 93% 92% 78% 93% 95% 94% 96% General Surgery 62% 61% 62% 67% 66% 67% 68% Geriatric Medicine 100% 100% 98% 93% 100% 96% 100% Gynaecology 89% 89% 89% 87% 86% 90% 88% Neurology 58% 59% 61% 62% 61% 62% 64% Neurosurgery 49% 47% 60% 63% 66% 70% 64% Ophthalmology 88% 90% 88% 86% 86% 86% 91% Oral Surgery - 17% 0% Other 76% 76% 74% 73% 72% 74% 76% Plastic Surgery 87% 88% 90% 89% 85% 82% 86% Rheumatology 70% 70% 77% 86% 80% 85% 86% Thoracic Medicine 93% 92% 91% 88% 85% 83% 81% Trauma & Orthopaedics 81% 82% 83% 82% 84% 83% 82% Urology 72% 72% 76% 76% 77% 81% 82% Grand Total 78% 79% 79% 79% 79% 80% 81% Table 4. Performance by specialty at BSUH. Source: BSUH Weekly SitRep, updated October

181 In October 68% of referrals were to BSUH and 32% to other providers. In November the percentage of referrals to other providers had reduced to 28%. Chart 10. Brighton and Hove monthly Optum referrals by month. Source: Optum monthly performance report, updated December 2016 There were 160 patients waiting more than 52 weeks as at 18th December The number of patients with an unknown status has reduced from 80 (when they were first reported) to 9. However the number of 52 week waiters is over 4 times higher than the recovery plan. Chart 11. BSUH 52+ Week Waiters. Source:BSUH data, fortnightly, updated 18/12/ Waiting Times by Week and CCG Table Week waiting times by week and CCG. Source: BSUH >52week list, updated week ending 18/12/16 181

182 52+ Waiting Times by Week and Specialty Table Week waiting times by week and specialty. Source: BSUH >52week list, updated week ending 18/12/16 The planned care system performance is summarised in the table below and reviewed monthly at the Planned Care Board. Table 7. Planned Care BSUH performance. Source: Heads of Performance meeting papers, updated December 2016 Chart 12. Cancellation of routine operations by week. Source: BSUH Weekly SitRep, updated December

183 Actions to Improve Performance The CCG has worked closely with the Trust to have in place a monthly Clinical Harms Review group, which carries out retrospective reviews for all patients who waited over 52 weeks for required treatment. Where there is evidence of harm identified, this is logged on the Trust s incident reporting system, and outputs from this group are reported internally within BSUH and to the monthly quality review meetings. The group has been in place for 12 months case note reviews have taken place, with moderate physical harm evident in 3 cases, and no serious harm has been identified to date. The majority of cases have concerned surgical treatment within Digestive Diseases. However the CCG has seen reducing numbers affecting Digestive Diseases, and is looking to ensure similar progress is being made within the neurosurgery directorate. At the same time the CCG is seeking assurance that a robust process is in place for reviewing prospective harm for people who are waiting over 52 weeks and not yet received their planned treatment intervention. Specific Actions Immediate: Demand management working with GPs to address unwarranted variation and shared decision making. Commission evidence based pathways- Low Priority Procedures (LPPs) phase 1 complete (November 16). Increasing commissioned activity at alternative providers especially the independent sector Working with referral management provider to enhance patient choice especially in challenged specialties. Working with BSUH to support roll out of increase advice & guidance across the majority of specialties. Standing agenda item at QRMs to monitor complaints linked to long waits, and to receive outputs from the Clinical Harms Review panel Seek assurance that actions from reviews of patients who are waiting 52 weeks (and not yet been seen) are being implemented Further work to support BSUH to manage 52 week waits scoping potential to use alternative providers where possible. Medium term: Commissioning alternative capacity at scale using the market, including straight to test pathways for endoscopy and MRI. Redesign streamlined pathways across a number of challenged specialties. Commission evidence based pathways- Low Priority Procedures - phase two commenced (April 17). Use technological solutions to optimise service delivery, improve coordination of care, patient self-management and remote-monitoring. Monitor implementation of learning for the Trust arising from the Clinical Harms Review panel, e.g. review of hernia pathway Longer term: Review of community ENT service with a view to widening the scope of the service (April 2018) Multi-disciplinary diagnostic hub(s) across the Central Sussex and East Surrey Alliance (CSESA) footprint to deliver direct to test diagnostics (April 18) Transformational change programme for Opthalmology across the CSESA footprint (April 18) 183

184 Performance Metric Exec Lead: Commissioner: Clinical Lead: Diagnostic Waiting Time Standard John Child Renee Padfield Jim Graham Performance Summary In November % of patients waiting for a diagnostic test waited longer than 6 weeks: Chart 13. Brighton and Hove CCG Diagnostic Waiting Times. Source: NHS England Statistics, monthly, updated November 2016 Since April 2016 the waiting list for diagnostic tests has increased by 6%: Chart 14. Brighton and Hove CCG Diagnostics waiting list size. Source: NHS England Statistics, monthly, updated November 2016 Most of the breaches occur at BSUH (38 out of 79) Provider Breaches BRIGHTON AND SUSSEX UNIVERSITY HOSPITALS NHS TRUST 38 HERE (Formerly BICS) 20 WESTERN SUSSEX HOSPITALS NHS FOUNDATION TRUST 0 SUSSEX MEDICAL CENTRE LTD (CLIVE AVENUE) 0 SURREY AND SUSSEX HEALTHCARE NHS TRUST 13 GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 0 Other Providers 7 November Table 7. Diagnostic wait time target breaches by provider. Source: NHS England Statistics, monthly, updated November

185 Scopes account of 38% of all breaches (gastroscopy, flexible signmoidoscopy, colonoscopy). MRI accounts for a further 38%: Diagnostics Test Breaches Non Obstetric Ultrasound 7 Sleep Studies 4 Gastroscopy 11 Echocardiography 0 Dexa Scan 0 CT 3 MRI 30 Cystoscopy 0 Flexible Sigmoidoscopy 9 Audiology 1 Colonoscopy 10 Peripheral Neurophysiology 3 Urodynamics 0 Barium Enema 0 Electrophysiology 0 November Table 8. Breaches by diagnostic test type in November Source: NHS England Statistics, monthly, updated November 2016 Actions to Improve Performance Immediate Longer term Working with lead commissioner at other providers to improve performance Commissioning additional capacity for direct to test MRI in collaboration with HMS CCG Commission additional capacity at other providers e.g. independent sector and straight to test model Working with other CCGs to commission a diagnostic hub to provide high quality diagnostics in a community based setting to meet current and future demand. (April 18). 185

186 Performance Metric Exec Lead: Commissioner: Clinical Lead: Cancer waiting times John Child Renee Padfield Jim Graham Performance Summary The 62 day cancer target was not met in October Chart 15. BSUH Cancer 62 day standard. Source: BSUH Performance Scorecard October 2016 Table 9. Cancer waiting times by tumour site. Source: BSUH Monthly Cancer Scorecard, monthly, updated October 2016 Actions to Improve Performance Clinical reviews of patients waiting for 104 days whilst the Trust is looking at improving the quality of patient pathways to deliver care and treatment in a more timely way, the CCG has not received adequate assurance that there is a systematic way for conducting reviews in accordance with recent guidance on 104 day waits. The Trust plans to implement a system that is working well in East Sussex, whereby 104 day wait reviews are discussed on a weekly basis. The CCG will receive an update via the QRM on its progress against this plan in 2 months time. Refreshed Cancer Strategy (December 2016) Early Detection Cancer LCS developed with public health (Apr-17) Significant Event Audit (Q4 16/17) Working with Macmillan - Improving the Cancer recovery Package treatment summaries; cancer care reviews and holistic assessments Developing a Sussex wide NG12 implementation plan including demand and capacity modelling (Dec-16) Reporting on Cancer recovery packages to be negotiated for inclusion in the 2017/18 contract 186

187 Performance Metric Exec Lead: Commissioner: Clinical Lead: Mental Health 7 Day Follow Up John Child Anne Foster Becky Jarvis Performance Summary There has been an upward trend in achievement against this target during the year although the performance still remains below target. All exceptions are reported on an individual basis to the CCG. In November 2016 there were (36/ %) breaches. A query notice was issued to SPFT in June 2016 following the submission of April 2016 data and a recovery plan is in place with SPFT to improve performance. Chart 16. Mental Health 7 day follow up data for Sussex and Brighton and Hove CCG. Source: SPFT monthly performance report, updated October 2016 Actions to Improve Performance Actions already in place include: Development of guidance for staff and associated staff training. Development of robust breach system to ensure that any potential breaches are identified early SPFT Senior operational management review of any breaches as they arise. A full analysis of the breaches has been carried out to understand the cause of the 7 day follow ups. There have been a total of 42 breaches (394/ %) breaches in 2016 to date. One of the single biggest reasons for relates to homelessness and the ability of SPFT to locate the patient at their given address and also the number of people that are housed in emergency accommodation outside Brighton & Hove. 187

188 Performance Area Exec Lead: Commissioner: Clinical Lead: Quality Soline Jerram Ian Wilson Soline Jerram Performance Summary Infection Control There were five cases of C.Difficile recorded in October and nine in November, with 41 cases reported in total since April. This is above the monthly trajectory for meeting their year-end target.. During December the Trust was affected by a norovirus outbreak at PRH, which resulted in 3 wards being closed at the same time at its peak. This impacted on services for both hospital sites. The Trust managed this outbreak in accordance with standard procedures. Actions to Improve Performance Root cause analysis of every hospital acquired C.Diff case is undertaken by BSUH, with the CCG agreeing final decision about whether a lapse in care occurred. For community acquired CDiff infections, a root cause analysis template is sent to the GP practice for completion. Further work needed to minimise current variation that exists in terms of completing the template, and the quality of the RCA. Work towards having a healthcare economy-wide approach to reviewing and learning from CDiff RCAs Organisational plans for prevention of HCAIs reviewed at the Quality Review meetings. Performance Summary - Other quality standards Serious Incidents broken down by Providers: BSUH - reported six serious incidents during November, three of which were never events (retained swabs) as follows: (i) (ii) (iii) (iv) (v) (vi) A patient was admitted for urgent removal of an ulcerated, non-healing, toe lesion. The toe was required to be surgically removed which took place. Three days later the patient suffered a cardiac arrest and died. A lady underwent a hysteroscopy at Lewes Victoria hospital. The procedure was noted to have been completed without complication and the theatre counts appeared correct. Approximately 6 weeks later, her GP carried out an examination and retrieved what appeared to be a piece of gauze, which constitutes a never event. A lady underwent surgery to remove sternal wires and excise a sternal sinus. An excision was made to remove the sinus and an X-ray detectable swab was identified and removed from behind the patient's sternum. The lady had had aortic valve surgery in BSUH in August A retained swab was identified and removed from a lady who was being treated on a post-natal ward after having given birth. Slips/trips/falls incident an 86-year old lady had a witnessed fall whilst walking on the ward, which resulted in a fractured neck of femur. Screening issues - it has been identified that the number of patients on the Diabetic Eye Screening Programme register differs from the total number of diabetic patients requiring screening produced by GP Practices a difference of 632 people. The discrepancy means that there are patients potentially at risk because they have not had their eyes screened. SCFT - reported five new Trust-wide SIs during November, none of which related to Brighton & Hove CCG residents. 188

189 SPFT - reported 15 new Trust-wide SIs during November, none of which related to Brighton & Hove CCG residents. IC24 - reported three SIs across the organisation during November, one of which related to a Brighton & Hove resident. A patient presented a prescription to a community pharmacy who suspected it was fraudulent. They contacted IC24 who confirmed no record of the patient being seen by an IC24 doctor. The patient was subsequently arrested; however IC24 have since seen the prescription and confirmed that it was in fact not fraudulent. The patient was seen by an IC24 doctor in A&E, where consultations are recorded on a different IT system. The CCG has met with IC24, together with the police, to ensure immediate actions are in place to ensure this cannot happen again. Pavilions- substance misuse service reported two SIs during November. Both were reported as apparent /actual/ suspected self-inflicted harm as follows: (i) (ii) A service user died in Worthing Hospital circumstances unknown at time of notification An unexpected death of a service user was confirmed by the Criminal Justice section of Pavilions again circumstances not known at time of writing The CCG scrutinises investigation reports that are submitted by providers following the 60 working days they have to complete a root cause analysis investigation, to ensure that a robust investigation has been undertaken with actions to address learning. Children- standards Recovery Trajectory Target Compliance Date Comments Children waiting less than 17/18 = 92% Quarter New target reporting will be reported from 1 st April 18 weeks for a wheelchair 18/19 = 100% Quarter Onwards Table 10. Compliance for recovery of children waiting less than 18 weeks for a wheelchair. Source: 2017/18 planning template, updated November

190 Performance Area Exec Lead: Commissioner: Clinical Lead: Primary Care John Child Michelle Elston & Katy Jackson LMG Chairs Performance Summary - Urgent Primary Care Chart 17. A&E attendances per 1,000 patients November 2015-October 2016 (non-elective GP referrals). Source: Brighton and Hove GP Dashboard, Updated October 2016 Proactive activity: Apr May Jun Jul Aug Sep Oct Nov Planned Activity Actual Activity Variance from Plan Table 11. Proactive activity April November A deep dive analysis of hospital data in October 2016 suggests that the number of frequent fliers (those who attend A&E more than 2 a year) increased significantly since last year. Chart 18. Minor A&E attendances per 1,000 patients after implementation of the EPIC Extended Hours Pilot. Source: SUS, updated November

191 Actions to Improve Performance Urgent Primary Care Working with primary care to reduce attendances Launched revised GP dashboard in November 2016, peer to peer support and proactive management Care homes - Working with Local Authority to target high attendances/frequent fliers, managing medications Preparatory work is in place for the new CQUIN for 2017/18 and 2018/19 Improving services for people with mental health needs who present to A&E which aims reduce A&E attendances of frequent attenders who would benefit from mental health and psychosocial interventions. Mobilisation plans are in place for the new Homeless Primary Care Plus with a new contract due to start on 1 February One of the aims of providing enhanced primary care for this cohort of patients is to reduce demand for unplanned care with an anticipated reduction in A&E attendances. This is a KPI in the Homeless Primary Care Plus contract and will be monitored closely. Performance Summary - Elective Primary Care Chart 19. First outpatient attendances per 1,000 patients (elective GP referrals by cluster). Source: Brighton and Hove GP Dashboard, updated October 2016 Top 15 Specialties Cluster 1 Cluster 2 Cluster 3 Cluster 4 Cluster 5 Cluster 6 Grand Total TRAUMA & ORTHOPAEDICS ,431 DERMATOLOGY ,453 PAEDIATRICS ,335 BREAST SURGERY ,079 PHYSIOTHERAPY OPHTHALMOLOGY GYNAECOLOGY ENT NEUROLOGY COLORECTAL SURGERY ORAL SURGERY GENERAL SURGERY GASTROENTEROLOGY UROLOGY PAIN MANAGEMENT Other ,126 Total 3,048 2,705 2,250 2,453 1,470 3,487 15,413 Table 12. Number of discharges following an first outpatient appointment (BHCCG). 191

192 Actions to Improve Performance Elective Primary Care Working with primary care to reduce attendances Launched revised GP dashboard in November 2016, peer to peer support and proactive management Patient choice Development of a paediatric outreach pilot to support GP practices manage more patients in primary care. First clinic to start in December Performance Summary - Primary Care Quality Quality and Outcomes Framework The information and averages used within this report includes 44 practices, however practices that have closed are not reported on. Overall Achievement & Exceptions BHCCG level Achievement Exceptions B&H CCG National Comparators B&H CCG National Comparators % 95.50% 95.90% 6.83% 6.04% 6.71% % 94.74% 6.65% 5.46% % 93.68% 4.65% 4.13% Figure 2. Achievements and exceptions of primary care compared to national and comparative averages. Source: NHS Digital QOF, updated 27/10/16 Brighton & Hove CCG scored an overall achievement of 91.8% (93.24% in and 92.10% in ) compared to the National average of 95.5% (94.74% in and 93.68% in ). Brighton and Hove ONS comparator CCGs average achievement was 95.9% in Brighton & Hove CCG exception rate is 6.83% (6.65% in and 4.65% in ) compared to the National average of 6.04% (5.46% in and 4.13% in ). Brighton and Hove ONS comparator CCGs average exception rate was 6.71% in In 2013/14 BHCCG achieved the same average as the National average, although had higher exception reporting. It is unclear why BHCCG is not achieving and has great exception reporting compared to the National averages and CCG comparators. 192

193 Section 3 - Improvement and Assurance Framework Clinical Priority Area Overall Rating Indicators Cancer Dementia Diabetes Learning Disabilities Maternity Mental Health Needs Improvement Greatest Need for Improvement Performing Well Needs Improvement Needs Improvement Needs Improvement 47.30% 82.10% 68.90% 86.30% New of cases of cancer diagnosed at stage 1 and 2 as a proportion of all new cases of cancer Of people with an urgent GP referral having first definitive treatment for cancer within 62 days of referral of adults diagnosed with any type of cancer in a year who are still alive one year after diagnosis % 73.60% Estimated diagnosis rate for people with dementia of responses,which were positive to the question "Overall, how would you rate your care?" of patients diagnosed with dementia whose care plan has been received a face-to-face review in the preceding 12 months 40.70% 6.20% 88.90% of diabetes patients have achieved all the NICE-recommended treatment targets of people with diabetes diagnosed for less than a year who attended a structured education course 43 36% Rate of inpatients per million GP registered adult population for each Transforming Care Partnership. CCGs are then assigned the score of the TCP they belong to of GP practices that participated in the National Diabetes Audit of people with a learning disability who are on the GP register and receiving an annual health check during the year. Measured as a percentage of the CCG s registered learning disability population % The score out of 100 for women s experience of maternity services based on the 2015 CQC National Maternity Services Survey The score out of 100 for choices offered to women in maternity services based on the National Maternity Services Survey The rate of stillbirths and deaths within 28 days of birth per 1,000 live births and stillbirths, reported at CCG of residence level by calendar year % 71% of people who were initially assessed as at caseness, attended at least two treatment contacts, are coded as discharged, and are assessed as moving to recovery of women who were smokers at the time of delivery of people with first episode of psychosis starting treatment with a NICErecommended package of care and treated within 2 weeks of referral Table 13. Brighton and Hove CCG scores for the Improvement and Assurance Framework indicators 193

194 Clinical Priority Area Exec Lead: Commissioner: Clinical Lead: Cancer John Child Renee Padfield Jim Graham Performance Summary Latest CCG England Trend Better Care Period Cancers diagnosed at early stage % 50.7% People with urgent GP referral having first definitive treatment for cancer within 62 days of referral Q1 16/ % 82.2% One-year survival from all cancers % 70.2% Cancer patient experience #N/A Table 13. Brighton and Hove cancer indicators compared to England average, 2013-Q1 2016/17. Source: NHS England CCG IAF Dashboard, last updated July 2016 Actions to Improve Performance Findings from the national patient survey the Trust has been identifying ways to improve in areas where they scored poorly, notably around patients not having an understanding of how well their radiotherapy treatment was working. The plans for the Trust generally are around how communication with patients can be improved based on the survey findings. The new Horizon Centre will play a significant role in these plans. Refreshed Cancer Strategy (December 2016) Early Detection Cancer LCS developed with public health (Apr-17) Significant Event Audit (Q4 16/17) Working with Macmillan - Improving the Cancer recovery Package treatment summaries; cancer care reviews and holistic assessments Developing a Sussex wide NG12 implementation plan including demand and capacity modelling (Dec-16) 194

195 Clinical Priority Area Exec Lead: Commissioner: Clinical Lead: Dementia John Child Michelle Elston Rachel Cottam Performance Summary Chart 20. Dementia diagnosis rates for people over 65 years old in Brighton and Hove September Source: NHS England Dementia Diagnosis monthly workbook, updated September 2016 Actions to Improve Performance CCG achieved diagnosis rate target in September 2016 Changes in target definition from resident to registered population will have a detrimental impact for Brighton and Hove CCG Re-procuring Memory Assessment Service in 2017/18 (new service commencing in April 2018 to achieve 70%+ diagnosis rate) Working with current provider to ensure performance continues to improve throughout the last year of the contract (under performance notice) 195

196 Clinical Priority Area Exec Lead: Commissioner: Clinical Lead: Diabetes John Child Michelle Elston Rachel Cottam Performance Summary Better Care Diabetes patients that have achieved all the NICE recommended treatment targets: Three (HbA1c, cholesterol and blood pressure) for adults and one (HbA1c) for children People with diabetes diagnosed less than a year who attend a structured education course Latest Period CCG England Trend % 39.8% % 5.7% Table 14. Brighton and Hove diabetes indicators compared to England average, 2014/15. Source: NHS England CCG IAF Dashboard, last updated April 2015 New Diabetes Care for You service opened in July 2016 All type 1 reviews undertaken by the new MDT 100% participation in the National Diabetes Audit 2015/16. Clinical Priority Area Exec Lead: Commissioner: Clinical Lead: Learning Disabilities Soline Jerram Anne Foster Soline Jerram Performance Summary Better Care Reliance on specialist inpatient care for people with a learning disability and/or autism Proportion of people with a learning disability on the GP register receiving an annual health check Latest Period CCG England Trend Q1 16/17 43 #N/A % 47.0% Table 15. Brighton and Hove Learning Disability performance compared to England average. Source: NHS England CCG IAF Dashboard, last updated July 2016 Actions to Improve Performance Reducing Reliance on Specialist Inpatient Care Plans are being developed to improve community services including crisis response to reduce reliance on specialist inpatient care preventing unnecessary admissions to hospital. The Transforming Care Partnership held a whole system workshop on 14 December 2016 and an action plan is being developed to further enhance community support services. Bids are being developed to the NHSE for additional financial support including: o Capital bids for bespoke accommodation to support discharge from hospital 196

197 o New NHSE Transformation Funding announced in December 2016 with bids due for submission on 18 January The CCG is developing a patient dowry policy (in line with NHSE guidance) to support discharge of patients. Annual Health Checks Plan to achieve the 75% target includes: Analysis of cohorts of patients not receiving an annual health check and the reasons for this. Clinical lead to support the work of the health facilitator once analysis is complete Development and promotion of a local Accessible Information Standard Development of a local online accessible information for people with learning disabilities, carers, providers of social care services and health care professionals to provide easy read Clinical Priority Area Exec Lead: Commissioner: Clinical Lead: Maternity John Child Anne Foster Elizabeth McCulloch Performance Summary There are four indicators that make up the rating and data is updated on an annual basis. Actions in place to drive improvement against each of the four indicators include: Patient Experience An outline plan has been agreed with the Maternity Services Liaison Committee (MSLC) to target areas of the patient survey where improvement are needed. The plan will be implemented during Postnatal care is an area where improvement is needed. A community hub pilot has been developed (based at Goodwood Court Surgery) and will be evaluated during 2017 to inform future model of care and improvement in this area. The MSLC are now part of midwifery training programme which will enable women s voice to be influenced which is anticipated will have a positive impact on patient experience. Patient Choice The lack of midwifery led unit means there is only a choice of a hospital or home birth. Still Births Improved foetal monitoring has the potential for improvement in this area. Sonography staffing is the major barrier quarterly updates on staffing are provided to the Quality Review meetings. Smoking Rates This is an area where we perform comparatively well The Public Health Team is undertaking a benchmarking exercise against NICE guidance to inform further improvement in this area. Actions to Improve Performance Maternity is an agenda item at CCG-led Quality Review meetings with BSUH on a quarterly basis. The next focussed agenda item for maternity will be at the January QRM, so a more detailed update will be provided in next month s report in relation to BSUH s improvement plans. 197

198 Clinical Priority Area Exec Lead: Commissioner: Clinical Lead: Mental Health John Child Anne Foster Becky Jarvis Performance Summary IAPT Recovery Rate Chart 21. Brighton and Hove recovery rate for IAPT treatment. Source: HERE Wellbeing Service KPI report, updated October 2016 The current contract is under-performing against all three key indicators: a. Activity levels b. Recovery rates c. Waiting Times A contract performance notice issued in September 2016 and a remedial action plan (RAP) was agreed in November Actions to Improve Performance Trajectories are now in place to meet all three indicators. The trajectories are for d. Coverage target to be achieved by March 2017 e. Waiting times to be achieve by March 2017 f. Recovery rate to be achieved by May 2017 Performance against this target is subject to NHSE monitoring through a high risk return. The actions in the plan to increase recovery rate include: g. Piloting Silver Cloud (computerised CBT) as an alternative form of treatment h. Increasing self- referral rates on the assumption that people that self-identify will be ready for treatment. Evidence from elsewhere indicates that there is a positive relationship between self-referral rates and recovery rates. i. Piloting changes to the triage and assessment process to include direct clinical contact as soon as referral has been received to help identify suitability and readiness for treatment. 198

199 A formal review of the RAP is planned to take place by the end of January.. The CCG is currently re-procuring service to meet new national targets to increase coverage and develop integrated model of care. The new service due to start in June Early Intervention in Psychosis. The CCG has consistently exceeded the national target and the November performance for this indicator was 100%. Serious Incidents for Wellbeing and IAPT The quality of serious incident investigations for the service has been identified as needing improvement. A CCG Quality Manage has provided support and guidance to ensuring better quality reports are submitted. This matter was raised formally at the last contractual meeting with the CCG. Two serious incidents remain open and ongoing for the service. Section 4 Assessment and Improvement Framework In addition to the clinical priority areas there are 3 IAF indicators where Brighton and Hove CCG is an outlier compared to England average: Utilisation of e-referral the CCG is working with providers (OPTUM and BSUH) to achieve 80% by October 2017 Compliance Recovery Trajectory Target Comments Date 17/18 = 80% Oct-17 Contractual requirement E-referral coverage 18/19 = 100% Apr-18 linked to payment Table 16. E-referral coverage trajectory compliance. Source: 2017/18 planning template, updated November 2016 Chart 22. Advice and Guidance requests response rates, June-7 th December Source: BSUH monthly data, updated 07/12/16 199

200 Actions: Develop a Service Development Improvement Plan for e-referral to be inserted into the BSUH contract (April 17) Develop a programme of awareness for GP practices Work with GP practices to phase out the use of paper and fax referrals by Q2 17/18 Achievement of milestones in the delivery of an integrated urgent care service Developing Clinical Hub Actions CCG decision to support the extension of the current NHS 111 contract to 31 st March 2019 Financial and operational risks to be scoped and mitigated for OOHs and Walk-in centre contracts as a result of the above Governance structure developed to support delivery of CNH across the CSESA footprint CCG commissioning resource identified to lead for B&H Primary Care workforce workforce plan being developed as part of the Central Sussex and East Surrey Alliance Five Year Forward View Mental Health Dashboard (see Appendix 6) Actions against each of the priorities are as follows: Perinatal Data is not yet available to report against this indicator. A successful bid to NHSE for transformation funding to expand the existing perinatal service will result in an expanded service being in place from 2017 onwards to enable more women to receive specialist perinatal care. Children and Young People Mental Health The CYP Transformation Plan has been refreshed with clear actions in place to improve access. New services will be in place from June2017 to enable the access targets to be achieved and to support a reduction in unnecessary inpatient admissions. Eating Disorder. A new service was launched in October 2016 which will enable the waiting time targets to be achieved by the 2020 target. A plan is in place to improve the IAF Transformation score which is at 20% at Q3 2016/17 and it is anticipated that the score will increase in Q4 as a result of the new eating disorder service started on 1 October Future improvements to scores will be achieve through the ongoing o Development of collaborative commissioning plans with NHSE regarding Tier3/Tier 4 services 200

201 o Development and publication of joint workforce plans. Adult Common Mental Health Problems (IAPT) The current contract is under-performing against all three key indicators: o Activity levels o Recovery rates o Waiting Times A contract performance notice issued in September 2016 and a remedial action plan (RAP) was agreed in November Trajectories are now in place to meet all three indicators. The trajectories are for o Coverage target to be achieved by March 2017 o Waiting times to be achieve by March 2017 o Recovery rate to be achieved by May 2017 Performance against this target is subject to NHSE monitoring through a high risk return Actions in Place to improve performance include: o o o o Increasing capacity in the service to reduce waiting times and increase activity levels. Increasing treatment choice to help increase activity levels. Increasing self referrals to increase recovery rates Changing assessment and triage processes to reduce DNA rates. Adult Mental Health Community, Acute and Crisis Care EIP. The targets are being achieved. Physical Health Outcomes for People with SMI. Plans are in place to roll out the SMI Locally Commissioned Service to the whole of the City during 2017 which will help improve performance against this indicator. Employment Support. Plans are in place to recommission the employment support service for people in contact with secondary mental health services in A new contract will be in place on 1 April 2018 and have additional capacity that aims to improve the proportion of people that are supported to both obtain and retain employment. Crisis and Acute Care. The IAF Crisis Care score is at 40% at Q3 2016/17. Actions to improve include The CRHT and MHLT have been bench-marked Plans are in place to enhance both of these services. The CCG will bid for the NHSE Transformation Funding for MHLT that has been announced for January The IAF Out of Area Treatment score is 75%. Actions include Additional investment in the CRHT will support reduction in length of stay and use of OAT s. Planned increase in CRHT capacity from October

202 Suicide Prevention The Patient Care and Flow CQIN aims to support reduction in inpatient length of stay and there reduce the need for out of area treatments. a. There is a downward trajectory in suicide rates but the Brighton and Hove rate is higher than the national average. The suicide prevention action plan is in the processes of being refreshed to meet the new target to reduce suicide rates by 10%. Section 5 - NHS Outcomes Framework 1. People who have a follow-up assessment between 4 and 8 months after initial admission for stroke Clinical and managerial leads identified and work to take this forward agreed for next report 2. Unplanned readmissions to mental health services within 30 days of a mental health discharge - We have identified a potential data discrepancy and are currently investigating this. Actions will be agreed when this has been resolved. - Re-admission rates are being consider as part of the Patient Care and Flow CQIN and an action plan is being developed 3. Percentage of adults in contact with secondary mental health services in employment - The CCG commission an employment support service for people in contact with secondary mental health services. - The service performs well but there is scope to increase capacity available and the CCG is recommissioning this service in 2017 to increase available capacity. New contract to start on 1 April 208. Section 6 Contractual KPIs by provider Under development 202

203 Section 7 CQUIN by providers Number Description Financial Value (assuming 100% achievement) 1a - National Health and Wellbeing initiatives for staff 1b National Healthy food for NHS staff, visitors and patients 1c National Uptake of flu vaccinations for frontline staff 2a National Sepsis timely identification and Quarterly progress against agreed deliverables 642,910 Q1 achieved Q2 no targets 642,910 Q1 achieved Q2 no targets 642,910 No targets until end of Q4 321,455 Q1 partial achievement treatment within ED Q2 partial achievement 2b - National Sepsis timely identification and treatment within acute wards 321,455 Q1 achieved Q2 to be agreed 4a National Reduction in antibiotic prescribing 514,328 Q1 achieved Q2 no target 4b National Empiric review of antibiotic prescriptions within 72 hours 128,582 Q1 achieved Q2 - achieved 5 Local System Integration focus on frailty population and collaborative work with Care Home and Home Care sector 893,645 Q1 no target Q2 - achieved 6 - Local Interoperability of IM&T systems 636,481 Q1 and Q2 to be agreed Local Improving Patient Care and Flow e.g. SAFER work, implementation of CUR (Clinical Utilisation Review) 1,086,518 Q1 no evidence submitted Q2 to be confirmed 8 - Local Patient Activation (Motivational Interviewing) SCFT 604,335 Q1 achieved Q2 - achieved Table 17. BSUH CQUINs Request has been made to the coordinating CCG for a full schedule Number Description CQUIN Value Quarterly progress against agreed deliverables 1a - National Health and Wellbeing initiatives for staff 0.125% Q1 achieved Q2 - tbc 1b - National Healthy food for NHS staff, visitors 0.25% Q1 and Q2 - tbc and patients 1c - National Uptake of flu vaccinations for 0.25% No target until Q4 2a - National frontline staff Improving physical healthcare to reduce premature mortality in people with severe mental illness (PSMI) 0.2% Q2 position agreed achieved 2b - National Communication to GPs 0.05% Q2 position agreed achieved 4 - Local System Interoperability 0.75% tbc 5 - Local Improving Patient Care and Flow 0.75% tbc Table 18. SPFT CQUINs relevant to Brighton and Hove CCG. 203

204 Appendix Appendix 1- Summary Financial Position 2016/17 (Month 8) Year to Date Budget Year to Date Actual Year to Date Variance Full Year Budget Full Year Forecast Full Year Forecast Variance 000's 000's 000's 000's 000's 000's Commissioning Services Total Acute services 119, ,058 (85) 178, ,499 (160) Total Mental Health services 32,946 33, ,060 50, Total Community services 30,631 30, ,039 46, Total Continuing Care services 18,864 19, ,179 28, Total Primary Care services 31,253 30,923 (330) 47,064 46,617 (447) Total Other Programme services 3,969 3,879 (90) 2,480 3, Total - Commissioning services 236, , , ,224 1,744 Corporate Costs - Running Costs 4,153 4,075 (78) 6,386 6,312 (74) Corporate Costs - Non Running Costs 1,216 1,117 (99) 1,823 1,703 (120) Total - Corporate costs 5,368 5,192 (177) 8,209 8,016 (194) Contingency (610) 1, (1,550) Reserve to be allocated (0) 0 0 2,283 2,283 0 NR Reserve (1%) ,594 3,594 0 Net operating costs for the year 242, ,785 (0) 368, ,460 (0) Revenue Resource Limit - Programme & RCA 248, , , ,145 0 Planned Surplus / (Deficit) 5,960 5, ,685 9,

205 Appendix 2 Commissioning Services (Month 8) Commissioning Services Year to Date Budget Year to Date Actual Year to Date Variance Full Year Budget Full Year Forecast Full Year Forecast Variance Brighton & Sussex University Hospitals 83,676 82,456 (1,220) 125, ,683 (1,830) SE Coast Ambulance Service 8,200 8, ,299 12,299 0 Western Sussex Hospitals 3,197 3, ,795 5, Guys & St Thomas' 1,206 1, ,809 1, Queen Victoria Hospital (95) 1, (140) East Sussex Hospitals Royal Surrey County Surrey & Sussex Healthcare Maidstone & Tunbridge Kings College Hospital University College London Royal Nat Orthopaedic Hospital Royal Marsden St Georges Healthcare Great Ormond Street Spire Healthcare (215) (260) Nuffield Health (100) Planned Care 3,715 3,711 (5) 5,528 5,528 0 Urgent Care (5) MSK 11,997 12, ,995 17,995 0 Non Contract Activity 2,874 3, ,227 4, Total - Acute services 119, ,058 (85) 178, ,499 (160) Sussex Partnership Trust 20,893 20, ,340 31,340 0 Wellbeing Service 2,722 2,720 (2) 4,084 4,084 0 Learning Difficulties 1,170 1, ,755 1, Child & Adolescent MH ,576 1,576 0 Dementia (1) 1,328 1,328 0 MH Advocacy MH NCA Mental Health general 4,814 4,782 (32) 7,221 7,181 (40) Mental Health - Placements 1,451 1, ,176 2, Total Mental Health services 32,946 33, ,060 50, Sussex Community Trust 18,674 18, ,011 28,011 0 Intermediate Care 3,848 3, ,772 5, Diabetes Community Service Long Term Conditions Long Term Conditions - Anti-Coag (4) 1,181 1,181 0 Palliative Care ,315 1,315 0 Carers Community Services - Other 5,137 5,133 (4) 7,706 7,706 0 Total Community services 30,631 30, ,039 46, Adults 17,298 17, ,007 26, CHC Risk Pool - Retrospective Claims Personal Health Budgets (2) Children (97) 1, (150) Total Continuing Care services 18,864 19, ,179 28, Prescribing 26,382 26,293 (89) 39,552 39,452 (100) Out of Hours 1,048 1, ,572 1,572 0 Local Enhanced Services 2,768 2,484 (284) 4,356 3,949 (407) Medical Fees Oxygen (8) (10) Primary Care IT Total Primary Care services 31,253 30,923 (330) 47,064 46,617 (447) Patient Transport 1,251 1, ,877 1,877 0 Commissioning - Non Acute - NHS (6) 1,116 1,106 (10) Programme Projects - Patient Engagement (3) Programme Projects - Interpreting Services (11) Safeguarding (34) (10) Winter Resilience (9) Cancer (5) Office Move Other Programme Projects (33) (50) QIPP Target (3,490) (2,692) 798 Total Other Programme services 3,969 3,879 (90) 2,480 3, Total - Commissioning services 236, , , ,224 1,

206 Appendix 3 Corporate Costs (Month 8) Corporate Costs Year to Date Budget Year to Date Actual Year to Date Variance Full Year Budget Full Year Forecast Full Year Forecast Variance Governing Body Clinical Leadership (51) (19) Clinical Quality & Governance Medicines Management (1) Commissioning (41) 1,233 1,232 (1) Planning & Delivery (56) (103) Corporate Business 1,243 1, ,864 1,864 0 Finance Total - Corporate Costs (Running Costs) 4,153 4,075 (78) 6,386 6,312 (74) CHC Assessment (77) (100) Medicines Management (23) (50) Clinical Leadership Corporate Costs Total - Corporate Costs (Non Running Costs) 1,216 1,117 (99) 1,823 1,703 (120) Total - Corporate Costs 5,368 5,192 (177) 8,209 8,016 (194) 206

207 Appendix 4 QIPP 2016/17 (Month 8) Plan 000s In Month Year to Date Forecast Actual 000s Variance 000s Plan 000s Actual 000s Variance 000s Plan 000s Actual 000s Variance 000s RAG Better / Urgent Care Proactive Care - Reduction Non-Electives (208) (59) 149 (739) (309) 430 (1,690) (547) 1,143 R Total Better Care/Urgent Care (208) (59) 149 (739) (309) 430 (1,690) (547) 1,143 Planned Care LUTS Community Pathway (13) (13) - (64) (26) 39 (116) (77) 39 A Planned Care LUTS Community Pathway (16) (16) A Planned Care Irritable Bowel Service (Community) (15) - 15 (76) - 76 (138) R Planned Care Irritable Bowel Service (Community) 11 - (11) 56 - (56) (100) R Planned Care Referral Management Service (32) (32) - (253) (253) - (380) (380) - G Total Planned Care (43) (39) 4 (311) (268) 43 (485) (425) 60 Mental Health LD - Crisis Prevention Pathway (4) (4) - (33) (33) - (50) (50) - G Total Mental Health (4) (4) - (33) (33) - (50) (50) - Community Integrated respiratory service/model (4) (4) - (34) (34) - (51) (51) - G Community Integrated respiratory service/model G Total Community Med Man Medicines Management (158) (158) - (1,267) (1,267) - (1,900) (1,900) - G Total Medicines Management (158) (158) - (1,267) (1,267) - (1,900) (1,900) - PTS - New Service PTS - New Service (120) (120) - (960) (960) - (1,440) (1,440) - G Total PTS new service (120) (120) - (960) (960) - (1,440) (1,440) - Unidentified QIPP (506) (115) 391 (1,517) (2,035) (519) (4,550) (4,955) (405) A Total Un-identified (506) (115) 391 (1,517) (2,035) (519) (4,550) (4,955) (405) TOTAL ALL 16/17 QIPP (1,036) (493) 544 (4,803) (4,848) (45) (10,078) (9,280) 798 A 207

208 Appendix 5 Improvement and Assessment Framework 208