OFFICIAL. Members of the public are invited to meet members of the Governing Body informally prior to the meeting, from 10.00am.

Transcription

1 OFFICIAL Meeting of the CCG Governing Body A meeting of NHS North Tyneside Clinical Commissioning Group Governing Body is to be held in Public on Tuesday 23 January 2018, 10.15am-12noon, in Hedley Court Members of the public are invited to meet members of the Governing Body informally prior to the meeting, from 10.00am Agenda Item Item Lead Enc/Verbal No 1 Welcome and Introductions Dr J Matthews Verbal 2 Apologies for Absence Dr J Matthews Verbal 3 Confirmation of Quoracy Dr J Matthews Verbal 4 Declarations of Interest Dr J Matthews / Ms I Walker Enclosure 5 Minutes of the Previous Meeting held on 28 November 2017, 5 December Matters Arising from the Previous Meeting held on 28 November 2017, 5 December 2017 Dr J Matthews Dr J Matthews Enclosure Verbal 7 Action Log Dr J Matthews Enclosure 8 Report from Chair and Chief Officer Dr J Matthews / Mr M Adams Verbal 9 Quality & Safety 9.1 Integrated Quality and Performance Report Mr J Connolly Enclosure 9.2 Quality and Safety Report: January 2018 Dr L Young-Murphy / Dr R Evans Enclosure 9.3 CCG Improvement and Assessment Framework Report 10 Finance & Contracting /18 Finance & Contracts Report Month 8 November Strategic and Commissioning Items Dr L Young-Murphy Mr J Connolly Enclosure Enclosure 11.1 Urgent Care Update Mrs A Paradis Verbal 11.2 North Tyneside Falls Strategy Dr L Young-Murphy Enclosure 1

2 OFFICIAL 12 Public and Patient Involvement 12.1 Report from the Patient Forum Dr L Young-Murphy / Mrs E Hayward Verbal 13 Governance and Assurance 13.1 Risk Assurance Framework Q3 2017/18 Mrs I Walker Enclosure 13.2 Legal Directions Mark Adams Verbal 14 Minutes from Committees 14.1 Patient Forum Primary Care Committee: , Quality & Safety Committee: , Clinical Executive: , Enclosures 15 Date of Next Meetings Tuesday 27 March 2018: 10.00am-10.15am: Members of the Public meet the Governing Body 10.15am-12noon: Governing Body Meeting in Public Venue: Longsands North, NTCCG, Hedley Court 2

3 Published Register of Declarations of Interests by Decision Makers v11-0 issued 11 December 2017 This register lists members of Governing Body; members of Governing Body committees; staff grade 8d and above if not already listed; members of new care models joint provider/commissioner groups/committees; members of advisory groups which contributes to direct or delegated decision making on the commissioning or provision of tax payer services Type of Interest (tick as appropriate) Surname Adams Adams Adams Adams Connolly Coyle Coyle Coyle Coyle Evans Forename Mark Mark Mark Mark Jon Mary Mary Mary Mary Ruth Current Position(s) held in CCG i.e. Governing Body member; Committee member; Council of Practices member (Member practice); CCG GP Practice (if employee; other applicable) Governing Body member/ Committee member Governing Body member/ Committee member Governing Body member/ Committee member Governing Body member/ Committee member Governing Body member/ Committee member Governing Body member/ Committee member Governing Body member/ Committee member Governing Body member/ Committee member Governing Body member/ Committee member Council of Practice member/ Committee Member CCG Employee The Village Green Surgery Declared Interest (name of organisation and nature of business) Beverley Park Leisure Ltd GLSKR.com Ltd NHS Newcastle Gateshead Clinical Commissioning Group Northern CGG Joint Committee JM Connolly Limited Newcastle University, Trustee Member of Pension Trustee Limited Forum Member. Northumbrian Water Forum Non-Executive Director, Gentoo Group Board Chair, Shared Interest Society and Shared Interest Foundation The Village Green Surgery Financial Non Non Financial Financial Professiona Personal l Interests Interests Is the interest direct or indirect? Nature of interest From To Action taken to mitigate risk Direct Direct Direct Direct Direct Indirect Indirect Indirect Indirect Direct Director Ongoing Not relevant to CCG role Director Ongoing Will declare at meetings as appropriate Accountable Officer 01/12/2016 Ongoing Will declare at meetings as appropriate Voting member of the Committee Ongoing I will comply with the NTCCG Standards of Business Conduct and Declarations of Interest Policy Director (Company inactive) Sep-14 No conflict as company inactive There may be a connection between the University and the CCG Ongoing Not required Northumbrian Water and CCG may have some connection Ongoing Not necessary There may be connection between Gentoo and CCG Ongoing Not required There may be connection between Shared Interest and CCG Ongoing Not required I will comply with the Standards of Business Conduct and Declarations of Interest Policy Partner ongoing ongoing I will declare at meetings as required I will not participate in any CCG business relating to the surgery

4 Surname Evans Evans Evans Goldthorpe Grieveson Forename Ruth Ruth Ruth Jeffrey Maureen Current Position(s) held in CCG i.e. Governing Body member; Committee member; Council of Practices member (Member practice); CCG GP Practice (if employee; other applicable) Council of Practice member/ Committee Member CCG Employee The Village Green Surgery Council of Practice member/ Committee Member The Village Green CCG Employee Surgery Council of Practices member/ Committee member/ccg Employee Committee member/ CCG employee Committee member/ CCG employee Han Kyee Clinician Hay Hayward Richard Eleanor Committee member/ CCG employee Governing Body member/ Committee member The Village Green Surgery Secondary care doctor Left Declared Interest (name of organisation and nature of business) Tynehealth GP Federation Action Foundation Village Green Surgery Nothing to declare Nothing to declare North East Ambulance Services NHS FT Great North Air Ambulance Service South Tees Hospitals NHS FT Nothing to Declare Suzanne Duncan - Daughter, HR Manager North Tyneside Council Financial Non Non Financial Financial Professiona Personal l Interests Interests Is the interest direct or indirect? Nature of interest From To Action taken to mitigate risk Direct Indirect Direct Indirect Practice is shareholder in Tynehealh ongoing ongoing Director ongoing ongoing Medical Director (p/t) Trustee A&E consultant (Part time) Ongoing I will comply with the Standards of Business Conduct and Declarations of Interest Policy I will declare at meetings as required I will comply with the Standards of Business Conduct and Declarations of Interest Policy I will declare at meetings as required I will not participate in any CCG business relating to this organisation I will comply with the Standards of Business Conduct policy. Susan Duncan - Daughter, Acting Head of HR North Tyneside Council 4 Years Ongoing Compliance with Business Standards Policy Hemingway Jan CCG Employee None Horsfield Philip Committee Member The Village Green Surgery NHS England CNTW Indirect Daughter is contract manager for health & social justice ongoing ongoing I will comply with the Standards of Business Conduct and Declarations of Interest Policy I will declare at meetings as required I will comply with the Standards of Business Conduct and Declarations of Interest Policy Direct I will declare at meetings as required Horsfield Horsfield James Philip Philip Paul Committee member Committee member Governing Body member/ Committee member Left The Village Green Surgery The Village Green Surgery The Village Green Surgery Tynehealth GP Federation Enterprise Value, Consultancy Direct Partner ongoing ongoing Practice is shareholder in Tynehealh ongoing ongoing I will not participate in any CCG business relating to the surgery I will comply with the Standards of Business Conduct and Declarations of Interest Policy I will declare at meetings as required Pre 2000 Ongoing Declare conflict as appropriate

5 Surname Lackey Lackey Lackey Lunn Lunn Martin Matthews Matthews Forename Shaun Shaun Shaun Dr James Dr James James Dr. John Dr. John Current Position(s) held in CCG i.e. Governing Body member; Committee member; Council of Practices member (Member practice); CCG GP Practice (if employee; other applicable) Council of Practice member/ Committee member/ CCG Employee Council of Practices member/ Committee member/ccg Employee Resigned Council of Practices member/ Committee member/ccg Employee Ceased Woodlands Park Health Centre Woodlands Park Health Centre Woodlands Park Health Centre Declared Interest (name of organisation and nature of business) Woodlands Park Health Centre - GMS GP Woodlands Park Health Centre - GMS GP Tynehealth GP Federation - Provider of Medical Services Council of Practice member/ Committee member Forrest Hall Gas House Lane Surgery, Morpeth Council of Practice member/ Committee member Forrest Hall Forrest Hall Medical Group Committee member/ CCG employee Governing Body member/ Council of Practice member/ Committee member/ CCG Employee/ Governing Body member/ Council of Practice member/ Committee member/ CCG Employee/ Park Road Medical Practice Park Road Medical Practice Northumberland Tyne and Wear NHS Foundation Trust Spouse is a palliative care consultant at Newcastle Hospital FT Partner of Park Road Medical Practice Financial Non Non Financial Financial Professiona Personal l Interests Interests Is the interest direct or indirect? Nature of interest From To Action taken to mitigate risk Indirect Emma Lackey (wife) is a GP employee in member practice (Woodlands Park Health Centre) PRESENT Ongoing Direct Direct Indirect Direct GP Partner in member practice (Woodlands Park Health Centre) until 12/9/17. Resigned. Present 12/09/2017 Shareholder in Tynehealth Fed via Woodlands Park Health Centre until 12/9/17. Resigned. Present 12/09/2017 Spouse is GP partner GP Partner, sit on safety & quality committee for commissioning group and I am also a Conservative party member and campaigner, nothing else to declare Indirect Wife is a Clinical Psychologist working for NTW Mental Health Trust Indirect Direct 01/02/2014 Ongoing I will comply with the Standards of Business Conduct and Declarations of Interest Policy - I will declare at meetings as required I will comply with the Standards of Business Conduct and Declarations of Interest Policy - I will declare at meetings as required I will comply with the Standards of Business Conduct and Declarations of Interest Policy - I will declare at meetings as required Whilst NTW is a provider of services, the wife's role (Clinical Psychologist) is highly unlikely to lead to any conflict of interest. Notwithstanding this the NTCCG Standards of Business Conduct and Declarations of Interest Policy will be Spouse is a palliative care consultant Ongoing I will not participate in decision making Partner of GMS Service 1991 Ongoing I will not participate in decision making

6 Surname Matthews Matthews Matthews Forename Dr. John Dr. John Dr. John Current Position(s) held in CCG i.e. Governing Body member; Committee member; Council of Practices member (Member practice); CCG GP Practice (if employee; other applicable) Governing Body member/ Council of Practice member/ Committee member/ CCG Employee/ Governing Body member/ Council of Practice member/ Committee member/ CCG Employee/ Governing Body member/ Council of Practice member/ Committee member/ CCG Employee/ Park Road Medical Practice Park Road Medical Practice Park Road Medical Practice Declared Interest (name of organisation and nature of business) Practice is a member of Tynehealth Board member/trustee for Wallsend Memorial Hall & Peoples Centre of Community Service Health Education North East Financial Non Non Financial Financial Professiona Personal l Interests Interests Is the interest direct or indirect? Nature of interest From To Action taken to mitigate risk Direct Direct Direct Provider Organisation Ongoing I will not participate in decision making Trustee (provider of community service) Ongoing I will not participate in decision making Trainer Ongoing I will not participate in decision making Matthews Paradis Rundle Rundle Rundle Scott Dr. John Anya Steve Steve Steve Richard Governing Body member/ Council of Practice member/ Committee member/ CCG Employee/ Committee member/ CCG employee Committee member/ CCG employee Committee member/ CCG employee Park Road Medical Practice Northern CGG Joint Committee None Sheila Rundle (Spouse) Dr Jan Panke (Brother in Law) Committee member/ CCG employee Dr Anna Basu (Sister in Law) Council of Practice member/ Committee member Marine Ave Northumbria Healthcare FT Direct N/A Indirect Indirect Indirect Indirect Voting member of the Committee N/A Works as a Public Health Intelligence Analyst (Needs Assessment) at Sunderland City Council Partner at Claypath and University Medical Group, Durham and GP Constituency Deputy (Durham) at NHS North Durham Clinical Commissioning Group Honorary Consultant Paediatric Neurologist at The Newcastle upon Tyne Hospitals NHS Foundation Trust and NIHR Career Development Fellow at Newcastle University Wife, Tracy Scott works as A district Nurse for Northumbria Healthcare FT Ongoing 04/01/2013 Ongoing 04/01/2013 Ongoing 07/01/2013 Ongoing I will comply with the NTCCG Standards of Business Conduct and Declarations of Interest Policy N/A Unlikely to lead to any conflict of interest. Notwithstanding this the NTCCG Standards of Business Conduct and Declarations of Interest Policy will be followed Unlikely to lead to any conflict of interest. Notwithstanding this the NTCCG Standards of Business Conduct and Declarations of Interest Policy will be followed Unlikely to lead to any conflict of interest. Notwithstanding this the NTCCG Standards of Business Conduct and Declarations of Interest Policy will be followed I will comply with the Standards of Business Conduct & Declarations of Interest Policy

7 Surname Scott Scott Scott Soo-Chung Forename Richard Richard Richard Janet Current Position(s) held in CCG i.e. Governing Body member; Committee member; Council of Practices member (Member practice); CCG GP Practice (if employee; other applicable) Council of Practice member/ Committee member Council of Practice member/ Committee Marine Ave Declared Interest (name of organisation and nature of business) Marine Avenue Medical Centre, Whitley Bay member Marine Ave Northern Doctors Urgent Care Council of Practice member/ Committee NDMS (North Tyneside GP member Marine Ave Federation) Governing Body member Left Director of JSC Management Consulting Financial Non Non Financial Financial Professiona Personal l Interests Interests Is the interest direct or indirect? Nature of interest From To Action taken to mitigate risk Direct Direct Direct Direct GP Partner and GP trainer; member of CCG Council of Practices. Sessional out of hours work and NDUC ah-hoc walk-in-centre work Partner in a GP Practice that is a shareholder of TyneHealth Director Mar-13 Ongoing I will comply with the Standards of Business Conduct & Declarations of Interest Policy I will comply with the Standards of Business Conduct & Declarations of Interest Policy I will comply with the Standards of Business Conduct & Declarations of Interest Policy Compliance with Standards of Business Conduct Policy Southern Walker Walker Wicks Willis Alice Irene Irene John Dave Practice ManagerCommitte e member of Quality & Safety Committee Committee member Committee member Committee member Left Governing Body member/ Committee member Governing Body member/ Council of Practice member/ Committee Member/ CCG Employee Practice Manager at GP Practice - Collingwood Surgery Northumberland County Council East Bedlington Community Centre Trust. Charity. John G Wicks Healthcare Management Ltd (Management Consultancy) No conflict of interests None None None Direct Direct Direct Indirect Independent (and paid) member of Northumberland County Council Audit Committee East Bedlington Community Centre Trust. This is a charity responsible for developing and managing a local community centre in the Bedlington area. 01/01/2013 Ongoing 01/01/2014 Ongoing Northumberland County Council is not directly aligned to NTCCG and therefore no special measures are required to manage this conflict of interest other than following NTCCG Standards of Business Conduct and Declarations of Interest Policy. This is unlikely to present any conflict of interest. In any event the NTCCG Standards of Business Conduct and Declarations of Interest Policy will be followed. Director 01/04/2016 Ongoing As per conflicts of interest policy Wright Dr. Martin Left 10 November 2017 Portugal Place Health Centre Dr Livingston Ltd My wife is Director 2016 Ongoing I will comply with the standards business conduct and conflict of interest policy of the CCG

8 Surname Forename Current Position(s) held in CCG i.e. Governing Body member; Committee member; Council of Practices member (Member practice); CCG GP Practice (if employee; other applicable) Declared Interest (name of organisation and nature of business) Financial Non Non Financial Financial Professiona Personal l Interests Interests Is the interest direct or indirect? Nature of interest From To Action taken to mitigate risk Governing Body member/ Council of Practice member/ Committee Member/ CCG Employee Indirect Wright Dr. Martin Left 10 November 2017 Governing Body member/ Council of Practice member/ Committee Member/ CCG Employee Portugal Place Health Centre Connect Physical Therapy Indirect A Friend is CEO 1998 Ongoing I will comply with the standards business conduct and conflict of interest policy of the CCG Wright Dr. Martin Left 10 November 2017 Governing Body member/ Council of Practice member/ Committee Member/ CCG Employee Portugal Place Health Centre Chair Dementia Care (dementia charity) Direct Wife is Chair 01/06/2017 ongoing I will comply with the standards business conduct and conflict of interest policy of the CCG Wright Dr. Martin Left 10 November 2017 Governing Body member/ Council of Practice member/ Committee Member/ CCG Employee Portugal Place Health Centre Portugal Place Health Centre Direct 1992 Ongoing I will comply with the standards business conduct and conflict of interest policy of the CCG Wright Dr. Martin Left 10 November 2017 Governing Body member/ Council of Practice member/ Committee Member/ CCG Employee Portugal Place Health Centre Slaters Bridge Group Direct 2008 Ongoing I will comply with the standards business conduct and conflict of interest policy of the CCG Wright Dr. Martin Left 10 November 2017 Portugal Place Health Centre Tynehealth Ltd Northtyneside GP Federation 2013 Ongoing I will comply with the standards business conduct and conflict of interest policy of the CCG

9 Surname Forename Current Position(s) held in CCG i.e. Governing Body member; Committee member; Council of Practices member (Member practice); CCG GP Practice (if employee; other applicable) Governing Body member/ Council of Practice member/ Committee Member/ CCG Employee Declared Interest (name of organisation and nature of business) Financial Non Non Financial Financial Professiona Personal l Interests Interests Is the interest direct or indirect? Nature of interest From To Action taken to mitigate risk Direct Wright Dr. Martin Left 10 November 2017 Governing Body member/ Council of Practice member/ Committee Member/ CCG Employee Portugal Place Health Centre NHCFT Wallsend Development Group Direct 2014 Ongoing I will comply with the standards business conduct and conflict of interest policy of the CCG Wright Dr. Young- Murphy Martin Lesley Carol Left 10 November 2017 Governing Body member/ Committee member Portugal Place Health Centre Dr Livingston Ltd Fellow at Northumbria University Direct Director 2016 Ongoing I will comply with the standards business conduct and conflict of interest policy of the CCG I am an unpaid hon fellow at Northumbria University which has just been extended for another 3 years 01/04/2013 Ongoing Non required

10 North Tyneside CCG Governing Body Minutes of the North Tyneside CCG Governing Body meeting in Public held on Tuesday 28 November 2017, 9.15am-11.05am, in Hedley Court Present: Dr John Matthews Mark Adams Jon Connolly Mary Coyle Dr Ruth Evans Eleanor Hayward Anya Paradis Dave Willis Dr Lesley Young-Murphy In Attendance: Irene Walker Dianne Effard T.Altman Catherine Barnett-Smith Adele Blythe Charlotte Britcliffe Beth Dobinson Clinical Chair (Chair) Chief Officer Chief Finance Officer Deputy Lay Chair Medical Director Lay Member Lay Member Director of Contracting & Commissioning Executive Director of Nursing & Chief Operating Officer Head of Governance PA (Minutes) Resident Ramsay Student Nurse Student Nurse NTGB/17/107 Welcome & Introductions (Agenda Item 1) Dr Matthews welcomed members of the public to the North Tyneside CCG meeting in public. He also welcomed Dr Ruth Evans to her first Governing Body meeting following her appointment as Medical Director. The members of the Governing Body introduced themselves to the members of the public present. Dr Matthews explained that this was a meeting in public with members of the public present, but not a public meeting in which members of the public are able to participate in the discussions. Members of the public had the opportunity to meet members of the Governing Body before the meeting and Dr Matthews invited any member of the public present to make any comments on agenda which would be picked up during the meeting. No additional comments were made. NTGB/17/108 Apologies for Absence (Agenda Item 2) Apologies were noted from Wendy Burke, Director of Public Health. NTGB/17/109 Confirmation of Quoracy (Agenda Item 3) The meeting was confirmed as quorate. Page 1 of 14

11 Mr Willis advised that he would need to leave the meeting at 10am for approx 30 minutes to take a phone call. NTGB/17/110 Declarations of Interest (Agenda Item 4) The register of interests was published on the CCGs website and there were no additional declarations of interest in relation to today s agenda. NTGB/17/111 Minutes of the Previous Meeting held on 26 September 2017 (Agenda Item 5) The minutes were agreed as an accurate record. NTGB/17/112 Matters Arising from the Previous Meeting held on 26 September 2017 (Agenda Item 6) There were no matters arising. NTGB/17/113 Action Log (Agenda Item 7) All actions were either on the planner or were completed. Ms Coyle queried NTGB/17/052 action 2, and whether confirmation had been received from Daljit Lally about attending the January Governing Body meeting. Dr Young-Murphy advised that Ms Lally via her secretary had confirmed her attendance at this time, but that a board level member would attend if she became unavailable. NTGB/17/114 Report from Chair and Chief Officer (Agenda Item 8) Dr Matthews announced the appointment of Dr Neela Shadbe as Secondary Care Doctor with effect from 1 January 2018, which had been approved by the Council of Practices Mr Adams advised that the CCG continues preparations for winter working with Trusts and other CCGs across the region. A letter had been received from NHS England relating to efficient use of ambulances and how they work when they arrive at hospitals. The CCG was playing its part in terms of regional work covering how acute hospitals will work together in the future. There were wider issues around urgent care and enablers across the system relating to IT systems working together. Finance and performance would be discussed later in the meeting. The CCG was broadly on track in terms of finances, and preparing for its next assurance meeting with NHS England. Ms Coyle queried the letter from NHS England about ambulances, and Mr Adams advised it was a general gateway letter asking CCGs to be aware and work actively with Trust colleagues to help alleviate ambulance waits at to release them for other journeys. Page 2 of 14

12 Mr Willis queried winter planning and whether additional funds were being made available by NHS England to Acute Trusts. Mr Adams advised that funds were committed in the recent budget but it was not yet known how it would come into the local system. Mr Willis also queried the assurance meeting with NHS England and whether the legal directions would be lifted. Mr Adams confirmed that it would be discussed in the meeting. The CCG s expectation was that it had delivered a continued direction of travel out of problem areas, particularly finances, and it was hoped that this would help the CCG to come out of legal directions. Dr Young-Murphy advised that the quality assurance element fed into the assurance meeting and that had gone well with no major actions. Action 1 The issue of legal directions would be discussed further at the next Governing Body meeting. NTGB/17/115 Integrated Quality and Performance Report (Agenda Item 9.2) Mr Connolly presented the report and highlighted key issues. Two North Tyneside patients were waiting for treatment for more than one year. One related to Northumbria Healthcare NHC FT (NHC) and had been discussed previously, relating to the cyber attack. Dr Young-Murphy asked for confirmation when the patient received their appointment for treatment. This situation would be monitored to ensure there was no trend emerging. A meeting had been held with NHC on 20 November 2017 and assurance has been taken from some new arrangements they were putting in place around waiting list checks which would also be monitored. The second patient was with Imperial College, London and a routine procedure. They have a big issue with long waits and have carried out a data cleansing exercise which showed up 200 patients. Ambulance handovers were a continuing issue and there were a series of ongoing actions to be completed by the end of quarter 2. There was concern at the speed of progress on the actions and subsequent impact. A letter had been received from NHS England and NHS Improvement about what needed to be done to improve the positon nationally. The implications of the letter have been taken on board and discussed with NHC about lessons which could be learned. An improvement has been seen regarding cancer treatment within 62 days of referral, and the required target was now being met. Changes have been made to indicators around ambulance response times. This was now an emerging picture. Some things were positive in the way indicators have changed but time would be needed to see how these would bed in. Recovery access rates for IAPT psychological therapies had been expected to improve, which had happened. Emergency admissions Page 3 of 14

13 indicators compare to the same period last year. There were issues around coding and reconciliation processes, and reliability and accuracy of information which would be picked up in contract meetings. There had been an improvement in patient experience of consultations at GP practices but there was still a downward trend in overall satisfaction. This was a national trend. Locally it was important that the CCG did everything it could to improve patient satisfaction. There were some new targets around E.Coli in the NHS Quality Premium, but the CCG was still waiting to see what these looked like, and didn t know what it was being measured against. With regard to the Quality Premium for last year, there were some positive indications, but the CCG was still waiting for final numbers. The CCG had expected to get around 150k, but it may be more like 200k. Mrs Hayward queried the handover delays with NHC and the four workstreams for delivery of the framework. Dr Evans explained that part of this related to the change in how calls were categorised, which only started in late October Patients who needed an urgent ambulance would get one, and a patient who did not have an urgent need would have to wait longer. This should enable ambulances to be used in a more targeted way. The way the system had been working was historical. She stated that professionals, as well as practice staff, have had to learn a whole different way of categorising calls for ambulances to request the appropriate level of response. Dr Evans clarified this change affected the whole of North East Ambulance Service (NEAS). Dr Young-Murphy advised that the change would be reviewed on a monthly basis in contract meetings and at the Quality & Safety Committee (Q&SC) meeting. The Quality Review Group (QRG) would look at associated quality metrics. One of the public perspectives was that you could get to hospital quickly but would then have to wait. Dr Young-Murphy reported that she had a positive meeting with Daljit Lally and the new Director of Nursing who would have a fresh pair of eyes to look at the system. Mrs Hayward noted that the same issues and questions were being raised over and over again, and was one of the greatest risks to patient care. Assurance had been given every time, but headlines remained the same and there were always issues. Dr Young-Murphy advised that everyone was trying to do their best to focus on doing the right thing, and the CCG was not being complacent. A range of issues were discussed including patient flow, the physical layout and ambulance waiting times. The CCG would continue to work with the Trust. Dr Young-Murphy stated that with regard to E.Coli, the trajectories have not yet been confirmed, but an action plan was already in place. Work had been done over the last couple of years with nursing homes, community staff and hospitals. A regional event had been held with Public Health England and NHS England to look at best practice across the system. There was a collaborative Health Care Associated Infection partnership Page 4 of 14

14 with Newcastle, Gateshead and Cumbria looking at things together to inform action plans. Work was ongoing whilst waiting for the new trajectories. Ms Coyle queried the patient experience at GP practice level and noted that there had been no improvement in experience of making an appointment. Dr Young-Murphy advised that enhanced access has bene extended into evenings and weekends to help people who can t get an appointment during the week. Members of the public are being signposted to pharmacies and self-care. A lot of work has also been done on patient on-line and the Patient Forum had reported positive experiences of patients using patient on-line. The issue was usually about trying to get through by phone, and some practices were looking at new telephone systems. Dr Evans noted that the patient experience of consultations showed North Tyneside was better than the national average. Everything North Tyneside was doping was part of Future Care to improve general practice. Practices were being asked to work as a group, which was new. Ms Coyle felt communications to patients were important so that they understood what they needed to do. Mrs Hayward thought it was not always about getting an appointment, but advice and signposting. Action 2 Dr Young-Murphy to circulate the letter from NHS England and NHS Improvement about ambulance handovers to Governing Body members. NTGB/17/116 Quality and Safety Report November 2017 (Agenda Item 9.1) Dr Young-Murphy advised members that a lot of the issues had already been covered in the Integrated Quality and Performance Report, and therefore only areas not already covered could be highlighted. The falls strategy had been discussed at the last meeting. Northumbria Healthcare Foundation Trust continue to report an increase in serious incidents in relation to falls and the Quality Review Group had a presentation on incidence of falls and received assurance in respect of action plans. As part of NT Falls strategy Northumbria Healthcare Foundation Trust will focus on delivering improvements in hospital based falls, the appointment of a new Director of Nursing will be responsible for this workstream and is a member of North Tyneside Falls Strategy delivery programme board. There has already been an improvement in terms of turnaround of serious incidents awaiting closure. Two never events had been reported at Newcastle upon Tyne Hospitals NHS FT (NuTH), and across the system there have been a significant number of such events. Measures should be in place to ensure these events did not happen. NuTH had agreed to an external review which came up with a number of recommendations, one of which was the sign up to safety initiative which also covered medication issues. The CCG would continue to meet with NuTH via QRGs. Ms Coyle noted that an independent investigation of NuTH revealed they were not an outlier given their case mix which appeared to out some mixed messages. Page 5 of 14

15 Ms Walker left the meeting at 9.50am. NTGB/17/ /18 Finance and Contracts Report Month 6 September 2017 (Agenda Item 10.1) Mr Connolly presented the report and noted that since the report had been produced, month 7 had been closed down, and he would also give a verbal update on that. Month 6 forecast was an out-turn 2m, consistent with plan. Year-to-date showed a surplus of 1.3m, which was 400k better than plan. Pressures continued around acute activity for the NHC contract. Month 6 forecast delivery of 12.3m against a planned 12.2m on efficiency savings. There were some risks which were being managed. Key targets in terms of financial delivery were planned surplus, managing within running costs, delivering savings plans, mental health investment standards, and the CCG was green against those measures. The summary of performance against various areas of spend showed pressure on acute services of 4.5m, with 1.6m of reserve being applied to help manage the pressure. The CCG was in a positive position at month 6. There were some significant things happening in month 7. The year-todate position remained ahead of plan at 200k ahead. Within the efficiency plan it had been planned to remove 2m from social care in the BCF and redirect elsewhere. Changes in national guidance have meant this could not be done. Mrs Paradis would give more information on this later in the agenda. There would be a full review of how the Better Care Fund (BCF) money was being spent and what the CCG was getting for this investment to ensure the money was being spent in the best possible way. In terms of Quality, Innovation, Productivity & Prevention (QIPP), other schemes had been found or existing schemes extended. The adverse impact had been reduced to around 0.5m. The overall financial position was being managed. The month 7 achievement against the 12.2m QIPP plan was 11.7m, and work was going on to try to make up the gap. The level of delivery was good at 95%. The big risk was around winter and non-elective activity. The CCG was continuing to forecast delivery of the planned 2m surplus. Mrs Hayward queried winter pressures and the central funding which was expected. Mr Connolly advised that it was not yet known how that funding would be applied. There was an issue about how effectively providers would be able to spend the money, at this point in the year. The money may, however, support the overall financial position. Ms Coyle queried the BCF review and how much control the CCG would have over ensuring what the money would be spent on, and was advised that Mrs Paradis would cover this in her later agenda item about the BCF. Page 6 of 14

16 Ms Coyle also queried financial risks detailed in table 10 and month 6 4.7m for risks and mitigations. Month 7 mitigations had come down to 3.4m, so did that mean risks had gone down? Mr Connolly advised that the BCF had been a risk, but was no longer a risk. The table showed what was in reserve and gave an indication of risks which could be dealt with. Dr Young-Murphy noted that page 4 referred to ambulatory care overspend as a result of coding issues, which had been raised with NHC. This would be raised at the CCG s assurance meeting. A full response was awaited from NHC. Some information had been received as an explanation of what had happened, but did not satisfy the original questions, so further discussions were taking place. Dr Matthews queried whether accident and emergency spending locally was out of control. Mr Connolly advised that this was against planned position and sometimes planning numbers could be difficult. The CCG was over-performing financially against some ambitious targets in the contract. On acute activity, the CCG may well spend less this year than last year. It would be expected to see the number go down over the course of the year rather than up because of efficiency schemes and also moving around budgets as a result of what was happening with urgent care. There were ongoing discussions over a number of issues but activity was not out of control. Mr Connolly advised that there was a process in place to identify and deliver efficiency schemes and an important part of the process was impact on quality had to be signed off, which would be done by Dr Young-Murphy and Dr Evans. Schemes in conjunction with NHC are reviewed in meetings with NHC on a regular basis. It was important that the money was spent in the best way possible. Mr Willis left the meeting at 10am to take a call, a previously advised. NTGB/17/ /18 Financial Transactions Authorisation and Delegation Limits (Agenda Item 10.2) Mr Connolly presented a routine report which has been updated to reflect what was delegated from the Governing Body to staff to make approvals within the financial system. There was a general update to ensure systems could be used to make payments. There was also a specific change relating to the Deputy Director of Nursing and the ability to approve packages of care relating to Continuing Health Care. The invoice approval limit had been increased to 300k so the Deputy Director could practically move forward on the packages. The report was presented to the Audit Committee in July and was now being presented to the Governing Body for final approval. The Governing Body approved the report. NTGB/17/119 Better Care Fund Plan (Agenda Item 11.1) Page 7 of 14

17 Mrs Paradis presented the report and explained that national planning requirements around BCF had been received on 4 July 2017, which was after budgets had been set. The BCF planning guidance was different to what had been expected and stated that in terms of healthcare expenditure on social care services, the CCG was not allowed to reduce funding levels and had to increase it in line with inflation. The CCG had expected to do work around the 2m of services to reallocate it to different services. The planning guidance also stated that in the Improved Better Care Fund (IBCF) an additional 5m for North Tyneside should be spent on three areas: recognising pressures on home care, national living wage pressures and pressures on the NHS. Discussions have been held with the Local Authority on how the funding would be allocated, and the narrative had been worked out quickly and what the categories would be. It had been hoped that some of the ibcf funding could be used to recognise National Living Wage pressures on care services commissioned by the CCG. However, a letter was then received stating that the IBCF had to be retained in social care. During the escalation meeting in London the CCG understood its position in that it could not reduce the social care allocation or relocate it and no funding could be released from the IBCF funding. At that meeting, the Local Authority raised the fact that they had issues around other areas of funding. It was made clear during the meeting, and subsequently, that the two issues were different and would be treated separately. The BCF plan has been presented to the Health & Wellbeing Board (HWB) and the Adult Social Care Health and Wellbeing Sub-Committee (known as OSC). Both had agreed the plan and it was now being presented to the Governing Body for approval. The report attached to the executive summary explained what had been spent. The fuller, large, document was available on request. Referring to Ms Coyle s earlier query regarding and how much control the CCG would have over ensuring what the money would be spent on, Mrs Paradis advised that a paragraph had been inserted into the narrative stating that during the remainder of 2017/18, the CCG would work with the Local Authority to review all services, not just the 2m part. The first meeting of the Partnership Board between the CCG and the Local Authority has been held. The Local Authority was keen to look at services, as it knew some services may not be offering value for money. A template for services would be completed so that each could be reviewed in detail. The process should be completed by the end of March Mrs Paradis was as confident as she could be that good outcomes would be achieved and funding would be appropriately spent. It was noted that the CCG funded 15m of the BCF services, and the Local Authority s contribution prior to this year was 1m relating to specific items. This year, as well as the Disabled Facilities Grant, the Local Authority has put in 5m to the BCF via the ibcf payment, as mandated by the BCF Planning Guidance. Page 8 of 14

18 Dr Young-Murphy advised that the HWB thought that the money was going to offset their expenditure in terms of the living wage and not for additional services, which was allowable under the guidance. However, the letter stated that the money had to stay in social care. The Governing Body approved the BCF plan. Mr Willis returned to the meeting at 10.25am NTGB/17/120 Urgent Care Update (Agenda Item 11.2) Mrs Paradis advised that at the previous meeting she had reported on the process the CCG was going through following the previous procurement process. All contracts have been stabilised with existing providers. The CCG was now preparing to go undertake a second procurement. A timetable had been produced, a specification written and an extraordinary Governing Body meeting would be held on Tuesday 5 December 2017 to consider the information and to make a decision on whether to go ahead with the procurement. A consultation process was being undertaken with the knowledge, understanding and approval of the Consultation Institute. Previously there had been six month engagement and three month formal consultation. The minimum required this time was two weeks consultation, but this was not felt to be sufficient, so a four week consultation process was undertaken, the results of which were being analysed. There were different ways in which people were able to provide their views, including surveys and meetings. So far 393 surveys have been received, 199 people had been involved in discussions, there has been 20 locality group meetings and 4 larger locality level meetings. This was comparable with a twelve week consultation process. Information on the process has been presented to the HWB and will go to the OSC on Thursday 29 November Once all information has been received and reviewed. Governing Body will receive a report for their consideration regarding procurement. Mr Adams advised that the CCG was aware of comments made at some meetings recently. In particular it was understood that at the Council meeting last week it had been reported that the CCG had awarded the contract to the existing provider, but Mr Adams confirmed that was not the case. The CCG wrote to the Council of Friday 24 November 2017 to set out its position that the process was ongoing and no decision had been made regarding the contract. Dr Young-Murphy advised that the original consultation had indicated the preference for a single point of access, and the Rake Lane site. It was acknowledged that the terminology to describe urgent care services was not helpful for patients and public understanding. Dr Young-Murphy confirmed that Rake Lane and Battle Hill both see minor injuries. If a patient needs more than that then 999 would be rung for an ambulance and the patient would then be transported to a hospital. Patients requiring emergency care transport from the Battle Hill walk-in centre could access Northumbria Specialist Emergency Care Hospital (NSECH) or the Royal Page 9 of 14

19 Victoria Infirmary (RVI). There was only 0.3 miles difference between the RVI and NSECH from North Shields, and often it is quicker to go to the RVI. The new proposal would be for a walk-in centre and a home visiting service for people who needed care overnight. 111 would still be available, and 999 if a patient really needed to go to A&E. Mr Willis noted that when the CCG originally went to procurement there was only one bid within the financial envelope, and queried whether there was confidence there would be bids to meet the financial threshold this time. Mrs Paradis confirmed there was confidence that the proposal would attract more interest. There were changes to the service model itself. The national model required 12 hour opening, but the CCG felt this was not right for North Tyneside residents, and has extended opening to 14 hours. Diagnostic facilities were not now required under the national model which made it easier for potential providers to offer a walk-in service. Also the financial envelope had been increased by 0.5m. Dr Young-Murphy advised that that the only risk was the issue about the site for the service. The public preference had been for Rake Lane, and if NHC were not the successful bidder they may not allow another provider to use the site, and the CCG could be in the same position that it was after the first procurement. Mrs Paradis advised that the Trusts had been written to about the possibility of their sites being used. NuTH had replied positively in respect of Battle Hill, but NHC had not yet responded, which was being chased up. Existing providers were willing to work together, and there may be other providers. Mrs Coyle felt there was a lot of information provided to the meeting, which was helpful, but was aware of a view among members of the public that this may lead to the closure of Rake Lane. Information given in the Council meeting was a concern and reassurance was needed for the Governing Body and members of the public about what this meant for the future of the hospital. Dr Young-Murphy advised that hospital beds would always be needed. NHC s model was for emergency cases to go to NSECH or back to the base site. The CCG has worked with NHC in terms of pathways for older people as it was not good for patients to be moved around. In time due to a change in technology and surgical techniques, with people going home from hospital earlier, it was likely there would be a reduction in beds. It was noted there would be further information relating to this in a later agenda item on winter planning. Mrs Paradis stressed that with regard to urgent care it was important to remember that the service was hardly used overnight. Between midnight and 6am there were only two patients per night, most of whom attended for services which they didn t need. Ms Coyle queried whether communications were good enough, and felt the public generally didn t know how to use the service correctly. Dr Young- Page 10 of 14

20 Murphy advised that the CCG was working with partners on communications. NTGB/17/121 Report from the Patient Forum (Agenda Item 12.1) Mrs Hayward advised that the Patient Forum was very robust in its working groups and meetings. A Forum member was on the Integrated Mental health Board, which was quite an achievement. A member was also attending the Healthwatch Steering Group meeting exploring mental health issues, and had also attended the World Health mental health event. Members of the Forum were working with health navigators and visiting different services including the intermediate care rehabilitation unit at Royal Quays and had been impressed with the improvements that have taken place. They found the mental health work quite new and innovative. Dr Young-Murphy advised that once again a work plan would be produced for next year for the members to work through the detail which would align with other strategic priorities. Dr Young-Murphy notes that The Community Health Forum and CCG have continued to try to encourage the inclusion of the Voice of Young People and Young Adults had been having conversations with the Young Mayor, schools and other young people. It is important to widen engagement for practice patient groups and CCG priorities to include different views about health care delivery as they will be the service users of tomorrow if we are to ensure responsive sustainable health systems. Mr Connolly advised that he had agreed to have a session with the Patient Forum to identify possible efficiency savings for next year and would meet with them on 14 December 2017 to discuss idea generation. Dr Matthews thanked Mrs Hayward, Dr Young-Murphy and Mr Connolly for their hard work with the Patient Forum. NTGB/17/122 Northern CCG Joint Committee Terms of Reference (Agenda Item 13.1) Dr Matthews advised that the final Terms of Reference for the Northern CCG Joint Committee was being brought to the NTCCG Governing Body for approval. The Governing Body approved the Terms of Reference. NTGB/17/123 Winter Planning 17/18 (Agenda Item 13.2) Mrs Paradis advised that the presentation included with her executive summary was an overview of the winter plan which has been agreed and what was happening across the system involving a number of organisations. A number of risks had been identified including A&E waiting time standards and handover delays. In North Tyneside there was an increase in delays Page 11 of 14

21 of transfers of care and risks around social care delays. Other risks identified related to NEAS performance and capacity in the domiciliary care sector. A winter readiness board would meet regularly to look at the development of winter plans from the Trusts and would scrutinise the plans to understand any escalation. Modelling suggests there would be an increase in activity of 3% which was the same as previous years. For North Tyneside this would probably mean an additional bed required at North Tyneside General Hospital (NTGH) and an increase in the number of beds at NSECH. NHC was predicting winter pressures would begin on 22 December 2017 and continue for a minimum of 6-8 weeks. If there were 90 or more admissions for three or more days the Trust anticipated it would come under sustained pressure. The CCG received daily reports from North East Commissioning Support (NECS) giving information across the whole of the patch. If Trusts were reporting a higher level of pressure, an alert would be issued and escalation put in place. NHS had asked CCG s to ensure that different parts of the system were aware of collective pressures. The CCG will need to ensure it worked with primary care to minimise referrals to hospitals at times of escalation. The CCG also had extended access with more appointments available on evenings and weekends. The Director of Services would be made available to the ambulance service with the NHS 111 directories. Dr Young-Murphy advised that the clinical team was linking with the three local hospitals to ensure there are no delayed transfers of care, and to work together for the benefit of patients. Mr Willis noted that in previous years, some GP surgeries have been open over Christmas and queried whether the same was happening this year. Dr Young-Murphy advised that nothing has come out from NHS England to request this. NTCCG had extended access and streaming with NHC and NuTH. Patients were being encouraged to ensure prescriptions were filled beforehand. Patients should be encouraged to ring 111 or their GP surgery first, and not just turn up. They would be triaged and directed to the right place. Dr Young-Murphy confirmed that communications were in place to get the right message to patients. A supplement would go in newspapers delivered to homes, but it was suggested this may not be the best way to get the message across, and should consider posters in chemists and GP surgeries. Action 3 Dr Young-Murphy to arrange for overview of communications to be shared with the Governing Body. NTGB/17/124 Value Based Clinical Commissioning Policy (Agenda Item 13.3) Page 12 of 14

22 Dr Evans presented the policy which had been worked up across the region and updated in September 2017 with a number of changes. Each change was evidence based and supported regionally by specialists and primary care. The policy aimed to reduce variation and create standards for all organisations to work to as a standard process. Even for conditions where it was thought not to be of clinical value, there would be a process for appeal through the IFR system. The Governing Body approved the Value Based Commissioning Policy. Once approved by all organisations, it would be uploaded onto NTCCG s website. NTGB/17/125 Audit Committee Terms of Reference (Agenda Item 13.4) Dr Young-Murphy presented amended Terms of Reference for the Audit Committee, reviewed on an annual basis. There was only one minor change to the Terms of Reference: NHS Internal Audit Standards be changed to read Public Sector Internal Audit Standards. The Governing Body approved the change to the Terms of Reference. NTGB/17/126 Minutes from Committees (Agenda Item 14.1) The Governing Body received the following Minutes from Committees of the Governing Body for Assurance: Clinical Executive , Council of Practices Patient Forum Quality & Safety Committee , NTGB/17/127 Date of Next Meeting (Agenda Item No 15) The next meeting of NHS North Tyneside Clinical Commissioning Group Governing Body is to be held on: Tuesday 5 December 2017: 10.45am-11am: Members of the Public meet the Governing Body 11am-12noon: Extraordinary Governing Body Meeting in Public Venue: Longsands North, NTCCG, Hedley Court Tuesday 23 January 2018: 9.00am-9.15am: Members of the Public meet the Governing Body 9.15am-11.15am: Governing Body Meeting in Public Venue: Longsands North, NTCCG, Hedley Court Dr Matthews thanked the members of the public for attending the meeting, which closed at 11.05am Page 13 of 14

23 Page 14 of 14

24 North Tyneside CCG Governing Body Minutes of the Extraordinary North Tyneside CCG Governing Body meeting in Public held on Tuesday 5 December 2017, 11.00am-12.25pm, in Hedley Court Present: Dr John Matthews Mark Adams Mary Coyle Jon Connolly Eleanor Hayward Anya Paradis Dave Willis Dr Martin Wright Dr Lesley Young-Murphy In Attendance: Wendy Burke Mathew Crowther Shaun Lackey Dianne Effard Ben Landon T. Maltman Michelle Spencer Willian Harrett John Hoare Elizabeth Morris David Sedgwick Pete Murray Adrian Smith Clinical Chair (Chair) Deputy Lay Chair Chief Officer Chief Finance Officer Lay Member Lay Member Director of Contracting & Commissioning Medical Director Executive Director of Nursing & Chief Operating Officer Director of Public Health Commissioning Manager Clinical Director PA (Minutes) NECS Comms CHCF Save NT NHS Save NT NHS NECS News Guardian Member of Public Member of Public NTGB/17/128 Welcome & Introductions (Agenda Item 1) Dr Matthews welcomed members of the public to the North Tyneside CCG meeting in public to consider the outcomes of the public engagement exercise and the North Tyneside urgent care procurement. He thanked the members of the public for coming along and showing interest in this important area, and hoped they had picked up a copy of the summary of the papers to be considered in today s meeting. All the papers which the Governing Body had access to for the meeting were available on the CCG s website. There was also a lot of information on the process which the CCG had gone through to gather views on urgent care services in North Tyneside over the last two years as part of a formal consultation and engagement process. Dr Matthews advised that the meeting was a meeting held in public rather than a public meeting to enable the public to hear the decision making Page 1 of 10

25 process which the CCG would go through. As it was not a public meeting members of the public would not be able to participate in the discussion. Dr Mathews offered members of the public the opportunity to make any comments at the beginning of the meeting on the agenda items for members of the Governing Body to hear which would be picked up in the discussion during the meeting. The Governing Body members introduced themselves. William Jarrett stated that he had been involved in the Save North Tyneside NHS campaign for over a year during which time members of the campaign had asked questions which had taken as long as six months to get a response. He reported that the campaign had been in town centres and had experienced anger and outrage from residents, and had communicated that to the CCG. People felt betrayed that this was a hostile attack on services. They felt that the change would affect people on low income and people who couldn t afford transport to Cramlington to reach an urgent care centre. The campaign understood the CCG was working to budgets imposed by central Government but strongly urged the CCG to reconsider its plans. They had a petition signed by patients asking for the withdrawal of the consultation process. Another member of the public stated that he lived in West Monkseaton and had been unaware of the service change and unaware of today s meeting until he heard about it at a campaign meeting at the weekend. Patients did not want to see a reduction in services. John Hoare advised he was also part of the Save North Tyneside NHS campaign. He felt that the 44 Sustainability and Transformation Plan (STP) groups had been set up as part of a Government programme to privatise the NHS, and the CCG was part of that process. As a Unite union member he opposed the objectives of the CCG and what it set out to do. If the CCG wanted to have consultation it should have gone out onto the streets. People may not know what they wanted, but they knew what they didn t want, and they didn t want a deterioration of services. One in five people were suffering massively from cuts. Dr Matthews stressed that the CCG was not addressing wider issues today as its focus was on Urgent Care Services. Mr Hoare stated that the closure of the service, particularly at Battle Hill, would be a massive set back. Their campaign would be stepped up. Adrian Smith expressed his concern that the CCG did not have all the information available when it took its original decision, and was pleased to see the information was now available for a decision to be able to be made. He did not agree with the conclusion the CCG was making, but there was better information available than when the original decision had been made. A member of the public questioned how efficiency was being measured, as Page 2 of 10

26 finance was different to needs-based efficiency. Efficiency should be about what people in the local area needed. Dr Matthews advised that all views and correspondence had been reproduced on the CCG s website and no responses had been held back, and he reiterated that this had been a two year process with extensive consultation which had been listened to. NTGB/17/129 Apologies for Absence (Agenda Item 2) Apologies were noted from Ms Irene Walker NTGB/17/130 Confirmation of Quoracy (Agenda Item 3) The meeting was confirmed as quorate. NTGB/17/131 Declarations of Interest (Agenda Item 4) The declarations of interest were published on the CCG website. Dr Matthews advised that he and Dr Evans, as GPs providing healthcare services, could provide an urgent care service, and so were conflicted. Therefore he handed the Chair of the meeting over to Ms Coyle as Deputy Lay Chair. Ms Coyle checked with members of the Governing Body that they were happy for Drs Matthews and Evans to participate in the discussion on urgent care, and they would be asked to leave the meeting when the decision was to be made. The Governing Body agreed. NTGB/17/132 North Tyneside Urgent Care Public Engagement (Agenda Item 5) Dr Lackey gave an update on the current situation around the future of urgent care in North Tyneside. Patients found the current urgent care system for minor ailments and injuries confusing and wanted a one-stop shop for urgent care, which was an outcome of the previous consultation. The proposed model responds to the previous consultation. Nationally, the way the NHS commissions urgent care was changing, and the CCG had a duty to comply with those changes in service specifications in line with best practice. The current service provision has not made the best use of resources, either workforce or financial, and was unaffordable and unsustainable. Dr Lackey noted that the information gained during the most recent engagement builds upon the previous consultation and engagement process and the recommendations. Previously it had been agreed that there would be a single Urgent Care Centre in North Tyneside with access to services 24 hours per day. That has not changed, the ratio of public walk-in to booked appointments and home visits has changed as can be seen in the paper. In addition the paper proposes the permanent closure of the overnight Page 3 of 10

27 walk-in urgent care service at Rake Lane which has been closed temporarily for over six months. Dr Lackey advised that the staffing have been redirected elsewhere in the emergency care system to see patients who require emergency care. The impact of the closure, including the impact on the previously three people attending the department after midnight for minor injuries and illnesses often requiring no intervention, can be seen in the papers. Dr Lackey talked through a presentation on urgent care, after which Ms Coyle advised that all the documents had been made available on the website apart from a late document which had been tabled. As Governing Body members had not had time to consider properly, Mr Crowther was asked to explain it. Mr Crowther advised that the document was a matter of public record and was a list of points raised by members of the Adult Social Care Health & Wellbeing Sub-Committee (ASC), which was effectively the Overview & Scrutiny Committee for North Tyneside, at their meeting on 30 November The ASC had received a similar presentation to that given to the Governing Body members today. The ASC had raised two specific issues in their document: extending the proposed opening hours to midnight for walk-ins; and possibly allow walkins overnight. The small number of people attending after midnight can receive care either via a booked appointment or, if an emergency, they would dial for an ambulance as is the case now. Patients with a need for a medical assessment should contact NHS111 and would be assessed and offered an appointment in the centre or seen at home or given advice Mr Crowther advised that activity had been looked at on an hour-by-hour basis and attendance started to drop off after around 8pm. National guidance required an urgent treatment centre to be open from 8am until 8pm, but this was felt to be restrictive for North Tyneside. It is therefore proposed to extend walk-in opening hours from 8am until 10pm. After that it would be difficult to justify keeping the service open given the small numbers of people attending. Mr Willis understood that NHS resources across the country were tight, and if there were more specialists in North Tyneside there would be less for the community on the North East. Mr Willis clarified that the funding envelope was 3.8m, and it is proposed the walk-in service would be open until 10pm. He queried whether the procurement could be framed to say that the walk-in element of the service should be to a minimum of 10pm and a maximum of midnight, and to be within the funding envelope of 3.8m. The providers may be able to provide that. Mr Crowther agreed that the proposal could be considered. Dr Young-Murphy noted that with regard to quality and equality and transport etc, which had been raised as concerns, there was already a 24 hour urgent care service where people could be directed with transport Page 4 of 10

28 already in place or, where indicated, a home visit. Mrs Hayward sought reassurance regarding the NHS111 service as it was crucial to the plan, and queried what the CCG was doing to increase clinical input to NHS111. Dr Lackey advised that the service was running well, but the public perception was slightly skewed by the national picture of NHS111. There is an option for providers to offer triage overnight to ensure advice given by NHS111 is appropriate. One criticism of NHS111 is that it is too risk-averse and sends too many patients to the emergency department who could be dealt with through other resources. Clinicians are in place and any caller who needs to be seen in an emergency department will be passed to a clinician. Services are mapped appropriately to ensure people are directed to booked appointments or a walk-in service to meet their needs. Overnight the provider decides whether a booked appointment or home visit is appropriate. The calls are assessed on a needs basis, and how they are dealt with is the responsibility of the provider of the urgent treatment centre. Dr Evans remembered when GPs did their own home visits during the night. Workforce should be used in the most appropriate way and patients should be triaged appropriately as to whether they received a home visit or not. Dr Young-Murphy acknowledged there was confusion caused by a lack of understanding around the urgent care and emergency care system. Communication was important as most people did not understand that both Battle Hill and Rake Lane are staffed with a mix of GPs, emergency care practitioners and healthcare assistants. As with any other service, if a patient attends a minor injury or illness centre but has emergency level needs, an ambulance would be called and the patient taken to an appropriate emergency department at either NSEC in Cramligton or the RVI in Newcastle. Currently the Battle Hill urgent care service sees significantly more people than the Rake Lane urgent care service. It was acknowledged that there was a lot of confusion, which was not helped by language. It was agreed communications needed to be improved locally, with clear language and Dr Lackey advised that the CCG was not in control of the language at a local level; there are national mandated terms which have to be used, and which sometimes change. Dr Young-Murphy advised that the Patient Forum Reference Group has offered to help with messages to patients. Mrs Burke raised some concerns on behalf of the Local Authority voiced by local politicians. There were implications of procuring a new urgent care centre if it couldn t be located at the Rake Lane site, which would mean a further reduction in services from the hospital and would reinforce the commonly held view that the hospital was being run down, but that was not the case. She questioned how the CCG would manage the messages should this situation arise given the current public perception. Dr Lackey advised that during the previous consultation there had been discussions about the services being provided currently ceasing and being Page 5 of 10

29 replaced by a single centre. There are two known sites for the provision of an urgent care centre in North Tyneside, Battle Hill and Rake Lane, but any other suitable site could be considered. There had also been discussions about options to provide the services in localities in primary care, called hubs. Because there are at least two known potential locations, Procurement laws mean that the CCG cannot specify in the procurement documents where the service is to be located. What is important is that the locations meet the service specification and delivers what it needs to deliver. A clear vision needs to be presented on how services in North Tyneside are expected to be run. It was understood Northumbria Healthcare NHS FT (NHC) was planning to carry out a strategic review of all of its services. The CCG needs to ensure the future of Rake Lane was well represented in the process. Dr Young- Murphy advised that people are used to seeing A&E as the shop window to a traditional hospital. North Tyneside has more beds available than many local areas and will continue to need bed based care at the Rake Lane site. However, it was important to note that healthcare was not just about beds, and whenever possible the best place for a person to be cared for is their own home. The CCG is committed to ensuring local bed based care in North Tyneside, however as extensive work to commission services closer to home continues, inevitably less beds will be needed and more care in the community will be provided to support people to return home in a timely fashion and prevent unnecessary admissions of people who can be cared for at home. Dr Young Murphy advised that we shouldn t forget that approximately 40% of North Tyneside people are seen in Newcastle upon Tyne Hospitals Mrs Burke raised another issue relating to fragmentation for accessing urgent care. It was not clear how the Northumbria Specialist Emergency Care Hospital (NSECH), the Royal Victoria Infirmary (RVI), the urgent care centre, extended primary care and NHS111 would all work together. She questioned how the CCG would ensure there was a single voice across all providers and how it would ensure there was consistency of messages across providers, as there had been issues around this in the past. Mr Crowther advised that there was a move in that direction as all the organisations in the North East have signed up to be part of a network. There is now an agreed regional position on certain areas, although this is not working as quickly as we would have liked, but it is moving in the right direction. How it should work would be about proactively down-shifting activity into more suitable settings. Dr Lackey advised that the regional level A&E Delivery Board was committed to ensure that the urgent care system works with Trust urgent care providers represented. Dr Young-Murphy noted that the local A&E Delivery Board has been refreshed and there have been a number of staffing changes with a renewed sense of purpose. The reality was that quite often a number of different organisations are involved with patients and there needs to be collaboration in terms of planning and care delivery, otherwise people will fall through the gaps. Page 6 of 10

30 Dr Matthews felt patients would think overnight closure of a walk-in service would be the last stop, and the CCG will ensure there is no loss of a 24 hour available service when it commissions the new service. He referred to winter planning, discussed at a recent Governing Body meeting, which noted there were 286 beds in North Tyneside, which was more than at NSECH. There is still a lot of resource in North Tyneside which needs to be retained. The CCG will undertake enquiries into where North Tyneside patients are followed up, as some had been taken to Wansbeck. The evaluation criteria for the new service must prioritise issues around accessibility, or patients would feel it was a deterioration. Mrs Paradis confirmed that all procurement documentation would make it clear that the service would be North Tyneside based. As a standard, items such as car parking, disabled access and available facilities are looked into and included in the specification, and bidders are questioned on them. Once bids are evaluated, and if acceptable, what bidders state in their bid is included in the contract documentation to ensure they worked to the required standard. Dr Evans referred to the query about fragmentation of the urgent care service. It had been difficult to speak to practices as one organisation, but she assured the Governing Body that great steps were being made in that direction and practices were now working together in clusters. Communication with practices had been difficult but was improving. Mr Landon responded to the issue around communications and understood the need to ensure that messages were based on the wider narrative, to include celebratory roles of different parts of the local healthcare system and understanding around the role of Rake Lane and how it would change. With regard to what the centre would be called, that would depend on how far the national guidance would allow the CCG to go. Different ways to describe the centre would be looked at. Mr Willis noted that today was the first time he had heard about NHC undertaking a strategic review, and the last time they did a review they developed NSECH. He suggested the Governing Body should hold a development session around the strategic review to ensure that as commissioners, voices are heard. Dr Matthews advised that he met the Chair of the Trust recently who advised they would like to see the CCG involved in the review. Action 1: Dr Young-Murphy to arrange a Governing Body development session around the NHC strategic review. Mr Willis queried the need for patients to drive from Rake Lane to Wansbeck. At the contract setting meeting in the Spring there should be an opportunity to address that so patients didn t have to travel. Dr Young- Murphy advised that there would always be some specialities which would be site specific based on the nature of the speciality service in line with national best practice. For the majority of cases there should be no reason why care couldn t be provided from Rake Lane. Page 7 of 10

31 Mr Willis also queried whether the procurement process will be carried out under EU rules. Mrs Paradis confirmed it will be carried out in line with both EU and UK legislation. Dr Evans referred to a query raised by one of the members of the public in attendance about the process being financially driven, and confirmed that it was about having a sustainable system in place which was value for money. Mr Connolly advised that finance was one of the components of the original decision but the most recent change about overnight walk-in centre opening was a workforce decision. Dr Matthews noted that there was not a big problem in North Tyneside in recruiting staff, but if best use was not made of the workforce, they could be needed in other parts of the country. Mrs Paradis stated that it was important to remember that what the patients were saying was that they wanted a single place to go, a one-stop shop with integrated walk-in and GP out of hours service. Ms Coyle asked members if they had any further questions before asking Drs Matthews and Evans to leave the meeting. Mr Crowther was then asked to make clear to the Governing Body what they were being asked to make a decision on. 1) North Tyneside CCG will decommission the existing urgent care services at Rake Lane, Battle Hill, and the Out of Hours service from 30 September ) These services will be replaced by an Integrated Urgent Care Service consisting of an Urgent Treatment Centre and an Out of Hours Home Visiting Service from 1 October ) The contract will be awarded for three years (with the option to extend for a further two years) at a maximum annual value of 3.8m. 4) The contract will be awarded by an open procurement (ie competitive tendering process). 5) The CCG will specify that the service can be provided from any suitable location in North Tyneside. The location of the service will therefore depend on the outcome of the procurement and the chosen site of the winning bidder. Mr Willis queried whether the CCG was going to procure a service which finishes at 10pm, or a minimum finish of 10pm and maximum of midnight within the funding envelope, as he had earlier suggested. Dr Young- Murphy stated that this could be added to the evaluation criteria. It was agreed this point would be included in the decision-making. Drs Matthews and Evans left the meeting. Dr Lackey confirmed that he was not a member of the NTCCG Governing Body and so was not conflicted. Dr Lackey put each of the original recommendations in the executive summary to the Governing Body, including the additional one from Mr Willis: Page 8 of 10

32 From Mr Willis: Service to be available until 10pm, or a minimum finish of 10pm and maximum of midnight within the funding envelope of 3.8m for walk-ins and thereafter bookable appointments. The Governing Body agreed to the recommendation. 1) North Tyneside CCG will decommission the existing urgent care services at Rake Lane, Battle Hill, and the Out of Hours service from 30 September The Governing Body agreed to the recommendation. 2) These services will be replaced by an Integrated Urgent Care Service consisting of an Urgent Treatment Centre and an Out of Hours Home Visiting Service from 1 October The Governing Body agreed to the recommendation. 3) The contract will be awarded for three years (with the option to extend for a further two years) at a maximum annual value of 3.8m. The Governing Body agreed to the recommendation. 4) The contract will be awarded by an open procurement (ie competitive tendering process). The Governing Body agreed to the recommendation. With regard to overnight suspension Dr Lackey asked that if the model was to be a walk-in service up to a maximum of midnight, and was currently midnight, was the Governing Body happy to recommend that the existing suspension was enforced and maintained until the commencement of the service. The Governing Body agreed to the recommendation. With regard to recommendation 5: The CCG will specify that the service can be provided from any suitable location in North Tyneside. The location of the service will therefore depend on the outcome of the procurement and the chosen site of the winning bidder. Ms Coyle stated that something was needed to say that the CCG was cognisant of what its population had said it wanted. Dr Lackey advised there were restrictions on this under EU procurement law, but a form of words would be found to reflect what the CCG had heard from its population, but could not specify a specific site. The CCG has written to NHC and Newcastle upon Tyne NHS Foundation Trust (NuTH) to request confirmation that Trusts would allow other bidders to use their premises for the new service. So far NHC had not responded on this point, which would be followed up. However, confirmation has been received in writing from NuTH that it would allow bidders onto the Battle Hill site. The Governing Body agreed to the recommendation as it stood. Drs Matthews and Evans returned to the meeting. Ms Coyle advised them that the Governing Body had agreed all the points that had been recommended. She handed the Chair back to Dr Matthews. Page 9 of 10

33 NTGB/17/133 Date of Next Meeting (Agenda Item No 6) The next meeting of NHS North Tyneside Clinical Commissioning Group Governing Body is to be held in public on Tuesday 23 January 2018: 9.00am-9.15am: Members of the Public meet the Governing Body 9.15am-11.15am: Governing Body Meeting in Public Venue: Longsands North, NTCCG, Hedley Court Dr Matthews thanked the members of the public for attending the meeting and for their interest. He hoped the Governing Body had been able to pick up all the things that were important in terms of the CCG s responsibility for the urgent care system in North Tyneside, and he recognised that it may have been an unpopular decision. The meeting closed at 12.25pm. Page 10 of 10

34 OFFICIAL North Tyneside Governing Body (Public) Date Minute Action No NTGB/17/052 2 Integrated Quality and Performance Report: Dr Wright to invite NHC to attend a future NTCCG Governing Body meeting NTGB/17/095 1 Integrated Quality and Performance Report: Dr Young-Murphy to bring an update to the Governing Body on the work of the transformation team NTGB/17/096 2 CCG Improvement and Assessment Framework: Dr Young-Murphy to provide an update on maternity NTGB/17/100 4 Risk Assurance Framework: Review of Risk Appetite to be discussed at Governing Body Development session NTGB/17/103 5 General Data Protection Regulation (GDPR): Ms Walker to ensure the Governing Body would be updated on General Data Protection Regulations on an annual basis NTGB/17/114 1 Report from Chair and Chief Officer: The issue of legal directions would be discussed further at the next Governing Body meeting. Action Resp. Officer Target Date Status Dr Young-Murphy January 2018 Dr Young-Murphy January 2018 Dr Young-Murphy January 2018 Dr Young-Murphy February 2018 Ms I Walker Mr M Adams September 2018 January 2018 Agreed to invite Daljit Lally or Dave Evans to attend private GB meeting after scope of strategic review agreed. Outstanding To be included in Annual Review to come to the Governing Body in March On Planner To be included in the IAF report for the January 2018 meeting in Public. On Agenda for meeting To be scheduled for the 27 February 2018 development session. On Planner Update required on annual basis. On Planner On Agenda for meeting

35 OFFICIAL NTGB/17/115 2 Integrated Quality and Performance Report: Dr Young-Murphy to circulate the letter from NHS England and NHS Improvement about ambulance handovers to Governing Body members NTGB/17/123 3 Winter Planning 17/18: Dr Young-Murphy to arrange for overview of communications to be shared with the Governing Body NTGB/17/132 1 North Tyneside Urgent Care Northumbria Healthcare Foundation Trust Dr Young-Murphy to arrange a Governing Body development session around the NHC strategic review. Dr Young-Murphy January 2018 Dr Young-Murphy January 2018 Dr Young-Murphy TBC Letter sent to Governing Body members. Complete Information sent to Governing Body members. Complete The review will be included in the SDIP contract schedule. Once scope confirmed the development session will be scheduled. Outstanding

36 OFFICIAL Report to: Governing Body Date: 23 January 2018 Agenda item: 09.1 Title of report: Integrated Quality and Performance Report Sponsor: Jon Connolly, Chief Finance Officer Authors: Teresa Ho, Performance and Monitoring Manager and Clair Carpenter, Information Analyst Purpose of the report and action required: To report progress against the CCG quality and performance measures. Members are asked to note the current progress in 2017/18 against the listed measures. Executive summary: The 2017/18 Integrated Quality and Performance Report shows delivery against NHS Constitution, CCG Health Outcomes, Quality Premium, and Quality measures. The CCG is held to account for the delivery of these measures by NHS England. The performance to note identified in this report is: NHS Constitution The numbers of ambulance handover delays at Northumbria FT have continued to be an issue. Work is ongoing within the system-wide Unscheduled Care Performance Improvement Plan. The Framework for Delivery has been sectioned into four major work-streams: Assess to Admit, Today s Work Today, Discharge to Assess and Responsive Transport, all supported by overarching Engagement and Communication actions. Additional bays for use by ambulance crews have been created to increase handover capacity and patient streaming has begun at NSECH. All Trusts are engaged in a project to standardise handover protocols in the hope of reducing variation across the patch. The CCG position for Cancer treatment within 62 days of urgent referral has increased to 92.2% for October despite ongoing underperformance at both Northumbria and Newcastle FTs. Tumour specific actions for improvement have being implemented by both Trusts particularly in urology and lower GI. The Trusts expect performance to improve back above the standard in December. A&E waits under four hours at Northumbria FT were marginally under 95% for both October and November by 0.3% and 0.4% respectively. Since reaching the 95% threshold in June both FTs have struggled to return any higher than 96% over the warmer months. Work within the trust A&E improvement plan continues with high impact shorter term actions becoming the focus to boost improvements in waiting times. 1

37 OFFICIAL NHS Health Outcomes Framework: 14 indicators are currently performing above their thresholds and are rated as green. Three of the Emergency Admissions Indicators are over-performing compared to the same period last year. Issues with Trust coding and reconciliation processes are being addressed in the Contract meetings with providers. Once these issues are resolved it will be possible to determine whether over-performance is still an issue to address during 2017/18. While there has been an improvement in patient experience of consultation at GP practices locally in the July 2017 GP survey release, the actions taken to improve the patient experience of making an appointment have failed to reverse the decreasing trend. Nationally these measures have been gradually declining over the comparable periods since 2011 suggesting this is a wider problem than just North Tyneside. A report including analysis of the newly published data was presented at the GP quality review meeting in August and resulting improvement actions agreed to formulate a new improvement plan for 2017/18 supported by the CCG Transformation team. NHS Quality Premium There are a number of new national Quality Premium measures for 2017/18, one of which does not have any data available as yet. The availability of epact2, the new prescribing information system, has supplied the first figure for prescribing of Trimethoprim for those aged over 75. As expected from baseline figures the CCG is significantly under the greater than 10% reduction trajectory for 2017/18 and is on course to achieve this measure without the need for intervention. Bloodstream infections is a new area of monitoring; based on October YTD the CCG is over the trajectory however programmes to improve the number of E. coli infections over 2017/18 have not yet been implemented to their full effect. It is expected that it will be later in 2017/18 when the trajectory will seem more achievable. Work to investigate the shift in antibiotic prescribing across the other prescribers has been completed and potential issues with these institutions driving antibiotic prescribing have been suggested. Other Quality Measures - The NHS Quality Dashboard for December 2017 highlighted Northumbria FT as an outlier regarding an alert on the Central Alerting System and Newcastle FT reported two never events in the previous three months, one of which was in October. There were no never events reported for November. 2

38 OFFICIAL Governance and Compliance 1. Links to Corporate Objectives 2017/18 Corporate Objectives Item links to objectives 1. Commission high quality care for patients, that is safe, value for money and in line with the NHS Constitution 2. Deliver the Financial Recovery Plan, leading to the achievement of the CCG s statutory financial duties and future sustainability 3. Work collaboratively with partners and stakeholders to develop health and social care fit for the future in North Tyneside 4. Continue to develop North Tyneside CCG as a patient focused, clinically led commissioning organisation with a continuous learning culture 2. Consultation and Engagement Not applicable 3. Resource Implications Not applicable 4. Risks Not applicable 5. Equality Assessment Not applicable 6. Environment and Sustainability Assessment There are no environmental or sustainability issues arising from this report. 3

39 OFFICIAL Quality and Performance Report January

40 Contents OFFICIAL This quality and performance report is based upon data available up to 2nd January Section Indicators Page NHS Constitution Referral to access treatment times Diagnostic waits A&E waits Cancer waits Red category ambulance response times Mixed sex accommodation Cancelled operations Care programme approach 6 9 Ambulance Handover Delays Trend monitoring of Ambulance Handover Delays at Northumbria FT 10 Preventing people from dying prematurely Enhancing quality of life for people with LTC CCG Health Outcomes Helping people to recover from episodes of ill health Ensuring people have a positive experience of care Ensuring a safe environment Healthcare Associated Infections C. Difficile Trend monitoring of C. Difficile infections for North Tyneside CCG, Northumbria FT and Newcastle FT 14 National measures Quality Premium Local measures NHS constitution measures Other Quality Measures NHS England Quality Dashboard

41 NHS Constitution Note: QP - Linked to Quality Premium 6

42 Issues to Note on Constitution Measures Constitution measure OFFICIAL Synopsis of Issue Actions taken to resolve issue Timeline Level of risk Owner Diagnostic Waits Newcastle FT reported an underachievement at 98.3% against a threshold of 99%. Q2 2017/18 overall performance for Newcastle FT was 98.3%. The CCG continues to meet this standard. Newcastle FT has reported there are still ongoing staffing difficulties for MRI and CT scan and is not expecting to sustain a return to compliance in the immediate future. A recruitment drive in Rome appointed twenty new radiographers, three of which started in post during December. Improvement trajectories are being monitored monthly and actions within the Trusts action plan have been implemented. Q4 2017/18 Low TH A&E 4 hour waiting times Northumbria FT marginally under 95% in November at 94.6%. Usual seasonal patterns have been observed in 2017/18 as expected however the FTs have struggled to return any higher than 96% from June. The Trust continues to implement its A&E improvement plan with dedicated clinical and nursing leadership driving the improvements, a team from ECIP (Emergency Care Improvement Programme) visited the ED Department on 25th and 26th September 2017 to help identify additional opportunities for improvement. Q4 2017/18 Med MC Cancer waiting times treated within 62 days of an urgent GP referral CCG performance had been declining earlier in 2017/18 however improvements over Q2 have recovered the CCG monthly YTD performance. Performance for October at Northumbria FT was 80.4% and 81.6% at Newcastle FT against an 85% threshold.. CCG: Work is underway with both Newcastle and Northumbria FTs to improve cancer target performance following recent declines. Patients with inter-trust referrals have been facing delays in Urology, particularly with Prostate referrals. There is limited guidance from NICE regarding these referrals which has generated variations within the patient pathways. This was identified by clinicians at the trusts and a workshop scheduled in January to agree on a pathway for Urology referrals led by a Directorate Manager and Consultant from Northumbria FT. Diagnostics for colorectal patients are to be scheduled earlier in the patient pathways, with the scheduling of examinations taking place at the first appointment with the clinician. A Service Improvement Specialist Adviser from the Northern Cancer Alliance is working within Northumbria to review services and improve performance. Q3 2017/18 Med TD/TH 7

43 Issues to Note on Constitution Measures Constitution measure OFFICIAL Synopsis of Issue Actions taken to resolve issue Timeline Level of risk Owner Cancer waiting times treated within 62 days of an urgent screening service referral The CCG had 4 of 5 patients receiving treatment within 62 days resulting in an 80% value for October. Underperformance was present at both Newcastle (83.2%) and Northumbria (85.7%, 6 of 7 patients). There are common fluctuations in the cancer wait targets where the cohort of patients is low. In this instance the CCG had only one patients breaching the 62 day standard.; The overall provider cohort of patients for October was low with Northumbria FT only treating 7 patients. Although neither provider met the threshold of 90% for Q2 2017/18 the CCG did achieve 90% for Q2 overall (9 of 10 patients). Continue to monitor the CCG position against the standard and that it is sustained above 90%. Q3 2017/18 Low TD Cancelled operations for nonclinical reasons to be rescheduled within 28 days In Q2 2017/18 there were 3 operations at Newcastle FT and 5 at Northumbria FT cancelled for non-clinical reasons and not rescheduled within 28 days. CCG: Individual patients are raised in contract performance meeting with the Trust. Expectation is that these were all one off cases rather than a systemic issue. Newcastle FT has expressed concern over the number of operations cancelled during the current financial year and the resulting penalties to the trust. On-going Low TH Follow-up within 7 days of discharge from psychiatric inpatient care CCG under the 95% threshold for Q2 2017/18 at 91.8%, down from 94.1% in Q /17 performance overall was 97.6%. Further analysis of patient numbers highlighted the CCG fell short of the 95% threshold for Q2 due to 2 patients (a total of 45 out of 49 patients were followed up within 7 days). Across the patch there can be erratic dips in performance and due to the small cohort of patients. A small change can greatly impact the threshold achievement. Patients who are not able to be followed up within 7 days are discussed in detail at the monthly contract meetings with the trust and a review of all actions taken with each individual patient is reported to the CCG. Any significant performance issues are likely to be picked up within this process before the quarterly aggregations are available. Q3 2017/18 Low JA 8

44 Issues to Note on Constitution Measures Constitution measure OFFICIAL Synopsis of Issue Actions taken to resolve issue Timeline Level of risk Owner Ambulance handover delays Handover delays have continued to decline at Newcastle FT and in October accounted for 0.4% of arrivals. Although the overall percentage of arrivals with a notable handover delay is above expectations at Northumbria, there was a shift from 60 minutes plus to minute delays compared to recent months. Delays were recorded for 6.9% of arrivals in both October and November. CCG: Work is ongoing within the system-wide Unscheduled Care Performance Improvement Plan. The Framework for Delivery has been sectioned into four major work-streams: Assess to Admit, Today s Work Today, Discharge to Assess and Responsive Transport, all supported by overarching Engagement and Communication actions. Providers: The trust has begun to roll out an assessment and streaming service at NSECH but currently this only operates on an ad hoc basis during busy periods. Implementation of the on-site primary care service has been delayed as the service model and business rules have still to be agreed. North Tyneside is currently working with Northumberland CCG to try and resolve this issue. Northumbria have created 8 additional bays for ambulance staff to handover in. All Trusts are engaged in a project to standardise handover protocols in the hope of reducing variation across the patch. Q42017/18 High MC 9

45 Ambulance Handover Delays Following the opening of NSECH in June 2015, Ambulance Handover Delays for Northumbria FT have increased significantly, with the emergence of a significant proportion of delays over 60 minutes over the Winter/Spring months. The problem of ambulance handover delays at NSECH represents one of the foremost risks to system performance and resilience across the North Tyneside Northumberland CCG footprint. The issue has been under continuous review for a period of over a year, with numerous local action plans being agreed and implemented in that time however the various changes have all failed to produce a significant and sustained reduction in the number of ambulance delays. There is a Northumberland and North Tyneside Systemwide Unscheduled Care Performance Improvement Plan in place and the actions expected to impact handover delays are detailed below. The majority of these actions are expected to be completed in Q2 and Q3. The CCG has raised concerns with the speed with which progress is being made to implement identified actions and NHS Improvement and NHS England are now co-chairing an executive task-and-finish group to address this issue. Priorities Discharge to assess / Going home work group Embed home first philosophy right at the front end always asking why not home? Expansion of discharge to assess/ at scale Expansion of Trusted Assessor model Estimated date of discharge proactive planning form admission for discharge with reduced function/ challenge as to why the EDD changes so much Understand what can be done in community that can aid discharge Find any duplication and streamline across providers Map the NEAS/ Northumbria FT plan to the three work stream areas Transport important element including reducing NEAS cancellations, tailored transport options, PTS Explore expansion of end of life rapid response Review of Family Choice policies and how we work with families to facilitate decisions in a more timely way 10 Explore how NDUC out of hours can enhance discharge e.g. planned calls or visits to discharged patients Expansion and development of enhanced care models such as virtual wards, hubs, complex MDTs Priorities Assess to admit work group Assessment criteria for implementing ED streaming Analysis of GP urgent visits Work to date compiled on primary care access Consultant triage for GP referrals Advice and support for ambulance crews on See and Treat Transport arrangements alternatives available and conveyance of patients between NSECH/base sites Consistency in response times to GP urgent referrals Priorities Today s work today work group Home first is home suitable for the patient links to carers / paramedic pathfinder GP Hotline Better use of consultant physician Frailty Bed Management Ambulatory care and correct use of Urgent Care Centres for those patients suitable More appropriate use of discharge ambulance

46 CCG Health Outcomes Note: QP - Linked to Quality Premium TBC - To be confirmed * - North of England Commissioning Support (NECS) calculated data 11

47 Issues to note on CCG Health Outcome Indicators OFFICIAL There are 22 indicators relating to health outcomes. The CCG currently has 14 indicators with a green rating and 8 indicators with an amber rating. Outcome measure Hospitalisation for ambulatory care sensitive conditions Under 19s admissions for asthma, epilepsy and diabetes Readmissions within 30 days of discharge IAPT Recovery Rate Synopsis of Issue Actions taken to resolve issue Time -line CCG weighted value for October YTD is 663 compared to 534 for the equivalent period last financial year. Weighted admissions for October YTD are over the same period last financial year at 243. Percentage for the CCG September YTD is 15.3% compared to 14.8% in the equivalent period last financial year. Recovery rate in October is 44.4% against the standard of 50% Ambulatory care over-performance has been discussed with Northumbria FT at the contract meeting. It is suspected that re-classification of some of the short-stay non-elective wards to ambulatory care in 2017/18 has resulted in more Ambulatory Care being coded through 2017/18 compared to 2016/17. The CCG is in the process of challenging this coding and counting change with the trust. Review of admission numbers reveals there was an unexpected increase in admissions for asthma in this patient cohort during September 2017, which has resulted in an increased level of over-performance for 2017/18 to date when compared to 2016/17 admissions. As patient numbers are small a single month outside of expectations can negatively impact the performance of this measure for the remainder of the financial year. Continue to monitor through Q3 2017/18 to see if admissions continue to increase above expected levels. General growth in the proportion of admissions which were readmissions within 30 days of discharge has been evident since October The proportion of 16.1% recorded for June 2017 is the highest observed for the CCG since September Reconciliation processes for the readmissions for 2016/17 are underway which is likely to affect the 2016/17 position. This makes it difficult to inspire confidence in comparisons between YTD 2017/18 and 2016/17. The outcome of reconciliation and 2017/18 baseline adjustment will be followed up to determine whether over-performance is an issue compared to the adjusted 2016/17 figures. Analyses of patient admission figures currently suggest there is no significant difference between YTD 2017/18 and the equivalent period in 2016/17. The projected recovery rate for November will continue to underperform, with improvements anticipated early North Tyneside Talking Therapies have identified a number of issues which are impacting upon Qtr 3 performance: severity of patients, increased waiting lists and staffing issues. The service has a large number of trauma cases, reflecting a higher severity of patient need to move through recovery. A waiting list initiative has been introduced to try and reduce the overall wait time by encouraging the use of group sessions. A shortage of qualified therapists means that services are vying for the same cohort of people. With a greater mix of new and inexperienced workers, caseloads are reduced to fulfil supervisory duties. Four new counsellors have started with the service which will begin to reduce the waiting list time. Q /18 Q /18 Q /18 Q3 2017/1 8 Level of risk Med Low Low Low Owner MC MC MC JA 12

48 Issues to note on CCG Health Outcome Indicators OFFICIAL Outcome measure Discharges into rehabilitation services Friends and Family Test A&E GP patients experience Synopsis of Issue Actions taken to resolve issue Time -line North Tyneside had 0.7% fewer discharged patients into rehabilitation services still out of hospital after 91 days for 2016/17 than in 2015/16. Recommended score for Northumbria FT A&E less than the National average for October at 81%. Satisfaction with consultation quality has increased by almost 4 percentage points however overall experiences of GP services and making an appointment have fallen further. This measure is linked to the implementation of the BCF. There has been a slight decline in performance in 2016/17 compared to 2015/16, Although there has been a slight decrease in performance North Tyneside remains the highest performing in the North East region and significantly above the National position of 82.7%. Northumbria FT has fluctuated above and below the National average during 2017/18. For September the recommended score was the lowest of the main providers in the North East region. A point to note is that September also had the highest response rate recorded for the trust since April These trends have been previously highlighted to the Trust. A number of actions were taken following the 2016 survey results to work with the practices that scored lower for these measures. These including supporting workforce planning, implementation of a new telephone system, review of appointment and admin systems, and the release of an app for patients at two practices. Additionally there was a supported process for practices to review their capacity and demand. While there has been an improvement in patient experience of consultation in the July 2017 survey release the actions taken have failed to reverse the decreasing trend in patient experience of making an appointment. Nationally these measures have been gradually declining over the comparable periods since 2011 suggesting this is a wider problem than just North Tyneside. CCG actions: A report including analysis of the newly published data was presented at the GP quality review meeting in August and resulting improvement actions agreed to formulate a new improvement plan for 2017/18 supported by the CCG Transformation team. 2017/ 18 Q3 2017/ 18 July 2018 Level of risk Low Low Medium Owner TD MC JM 13

49 Safe Environment - Healthcare Associated Infection (C.Difficile) North Tyneside CCG has a 2017/18 target of 74 C. diff cases. There have been 27 infections reported for October YTD, 20 infections under the expected trajectory. Northumbria FT has a 2017/18 target of 30 C. diff cases. There have been 15 infections reported for October YTD, 3 infections under the expected trajectory. Newcastle FT has a 2017/18 target of 77 C. diff cases. There have been 45 infections reported for October YTD, 2 infections under the expected trajectory. 14

50 2017/18 Quality Premium Note: OF - Linked to CCG Health Outcomes (Outcomes Framework) NHSE - Linked to Strategic Plan C - Linked to NHS Constitution * - North of England Commissioning Support (NECS) calculated 15

51 Issues to Note on Quality Premium Indicators OFFICIAL The CCG currently has seven of the eleven Quality Premium indicators with a green rating, two indicators with an amber rating, however there are two measures with data not yet available. The total Quality Premium payment for a CCG is reduced if the listed NHS Constitution rights or pledges for patients are unmet. Currently the CCG is achieving two of the four Constitution measures. QP measure Synopsis of Issue Actions taken to resolve issue Timeline Level of risk Owner Data availability Bloodstream infections reduction in E. coli infections Reduction in antibiotic prescribing CCG Mapped 4 hour A&E waits New data collections do not have any current data available for monitoring. CCG October YTD infections at 130, 18 infections over the YTD trajectory. The 12 month rolling antibiotic prescribing is above trajectory in October with 1.20 items per STAR- PU. A&E attendances completed within 4 hours under the 95% threshold at 94.5 % YTD. Underperformance in April/May are affecting the YTD position; the 95% threshold was met monthly between June and September, and were marginally under 95% in October/November. Measures will be updated as and when information becomes available. Bloodstream infections is a new indicator in the Quality Premium; based on September YTD the CCG is over the trajectory however programmes to improve the number of E. coli infections over 2017/18 have not yet been implemented to their full effect. It is expected that it will be later in 2017/18 when the trajectory will seem more achievable. Review of the data shows that GP prescribing is at a level of 1.13 items per STAR-PU and therefore within the trajectory. Growth in antibiotic prescribing through Battle Hill Walk In Centre has been identified as the major contributor affecting achievement of the antibacterial threshold. Historically prescribing begins to increase from October into the winter months thus a notable increase next month may warrant further review. Organisations across the North of Tyne patch are working towards a sustainable program of delivering Urgent Care across the network. Further details of actions can be found in the NHS Constitution section and under Ambulance Handover Delays headings. Both Newcastle and Northumbria FTs achieved the 95% threshold for Q2 2017/18 however the positions are marginal. November 2017 Q3 2017/18 November 2017 Q3 2017/18 Low Low Low Med TH MG SR MC 16

52 Quality Dashboard December 2017 The quality dashboard shows performance indicators for quality measures that have not already been included within the NHS Constitution, Outcomes Framework or Quality Premium. Glossary: DTOC Delayed Transfer of Care NRLS National Reporting and Learning System VTE - Venous Thromboembolism 17

53 Other Quality Measures OFFICIAL Quality Dashboard - The quality dashboard is a snapshot of NHS England s quality dashboard and shows performance indicators for quality measures that have not already been included within the NHS Constitution, Outcomes Framework or Quality Premium. Quality Dashboard measure Never events declared Central Alerting System patient safety alerts Synopsis of Issue Actions taken to resolve issue Timeline Level of risk Two never events recorded at Newcastle FT in the previous three months. Northumbria FT highlighted as an outlier with 1 outstanding patient safety alert. The never event in October at Newcastle FT involved the wrong route of medication. The Never Event did not relate to a North Tyneside patient. No never events were recorded at Newcastle FT during November. An alert was issued by NHS Improvement in September 2016 regarding restricting the use of an open system for injectable medicines for completion by June Northumbria FT currently has a status of ongoing regarding this alert. The Trust is currently working with other Trusts who have signed off the alert and has signed up to the Newcastle solution. The medical director advised the QRG that he did not feel that there was an issue with the implementation of the requirements of the alert and would ensure that it was implemented following the meeting November 2017 Low Owner MG Q3 2017/18 Low MG 18

54 OFFICIAL Report to: Governing Body Date: 23 January 2018 Agenda item: 9.2 Title of report: Quality and Safety Report January 2018 Sponsor: Dr Lesley Young-Murphy, Executive Director of Nursing and Chief Operating Officer, North Tyneside Clinical Commissioning Group Author: Gillian Airey, Senior Officer Clinical Quality, North of England Commissioning Support (NECS) Purpose of the report and action required: This report provides the Governing Body of North Tyneside Clinical Commissioning Group (NTCCG) with a summary of activity where available up to the end December 2017 in those areas of clinical quality not covered by the Quality and Performance Report. A full report is provided to the Quality and Safety Committee and exceptions are reported here. Executive summary: Northumbria Healthcare NHS Foundation Trust (NHCFT) QRG 14 November 2017 Mortality, Sepsis and HCAI update - Concern was expressed over the lack of mortality update reports and this is on the January 2018 QRG agenda. SIRMS Reporting - The Trust advised they would provide more detailed feedback to reporting practices and the CCG agreed to implement a reciprocal process for management of Trust reported issues about Primary Care. Falls update A separate meeting is to be arranged outside of the QRG to discuss falls performance and resolve issues. Trust representatives attended the CCG s SI Panel in December 2017 and discussed SIs being considered for closure; this was a very positive meeting. As of 8 January 2018, there are 21 SIs awaiting closure by North Tyneside CCG. This includes 17 where root cause analysis (RCA) reports are awaited, including 3 overdue RCAs. 1 never event was reported by Newcastle upon Tyne NHS Foundation Trust (NuTHFT) in December 2017, which will be managed by Northumberland CCG. 14 SIs were closed at the CCG s SI panels in November and December SIs were reported between November 2016 and December 2017 that required closure by North Tyneside CCG. Of these, 61 were closed within the same timeframe. In November and December 2017, 17 (57%) North Tyneside practices reported a total of 96 incidents of which 43 related to Northumbria Healthcare NHS Foundation Trust. (NHCFT).

55 OFFICIAL Safety Thermometer data demonstrated that: NHCFT s pressure ulcers (all) decreased to 4.6% in November 2017, but remained above the national average (4.3%). NuTHFT s pressure ulcers (new) increased to 1.4% in November 2017 above the national average (0.9%). Northumberland Tyne & Wear NHS Foundation Trust s (NTWFT) falls with harm was 0.8% above the national average (0.6%) in November Healthcare Acquired Infection data demonstrated that NuTHFT had 7 published C- Difficile cases in November 2017 above their monthly trajectory (n=6). The year to date (YTD) published figure was 52 in November 2017, the Trust s YTD published trajectory is 53. NHCFT and NuTHFT performed below the England Friends and Family Test average.

56 OFFICIAL Governance and Compliance 1. Links to corporate objectives 2017/18 corporate objectives 1. Commission high quality care for patients, that is safe, value for money and in line with the NHS Constitution 2. Deliver the Financial Recovery Plan, leading to the achievement of the CCG s statutory financial duties and future sustainability 3. Work collaboratively with partners and stakeholders to develop health and social care fit for the future in North Tyneside 4. Continue to develop North Tyneside CCG as a patient focused, clinically led commissioning organisation with a continuous learning culture Item links to objectives 2. Consultation and engagement Not applicable 3. Resource implications Not applicable 4. Risks Patient safety risks following serious incidents, process in place to undertake root cause analysis following SI to ensure lessons learned 5. Equality assessment Not applicable 6. Environment and sustainability assessment Not applicable

57 Governing Body Quality and Safety Report January

58 Contents Section Content Page Provider Quality Updates Updates from Quality Review Groups 6-8 Serious Incidents Reporting Rates 9-10 GP Practice Reported Issues (SIRMS) Status of Reports Never Events Reporting Rates 10 Reporting Providers Key Quality Indicators Safety Thermometer 11 Healthcare Acquired Infections Friends and Family Test Other Quality Issues Complaints 12 Information Access Requests 5

59 Provider Quality Updates Quality Review Groups: Quality Review Groups (QRGs) are held with Providers to obtain assurance on the quality of services delivered and take place every two months for Acute Trusts and quarterly for the Mental Health Trust. QRGs were held on the following dates for the named providers and some of the issues raised are noted below, along with updates where available: Northumbria Healthcare NHS Foundation Trust 14 November 2017 Newcastle Upon Tyne Hospitals NHS Foundation Trust 14 December 2017 North East Ambulance Service NHS Foundation Trust 24 November 2017 Northumberland, Tyne and Wear NHS Foundation Trust 1 November 2017 Northumbria Healthcare NHS Foundation Trust: 14 November 2017 Mortality, Sepsis and HCAI update - The Trust has specific CQUIN targets for reducing Carbapenem and Piperacillin-tazobactam prescribing, as well as overall antibiotic consumption. Prior to the CQUIN, NHCFT implemented guidance for consultant authorised Carbapanem prescribing only; the Trust believe this may make meeting the CQUIN targets difficult. In addition, there have been supply issues of Piperacillin-tazobactam increasing the use of Carbapenem. The Trust is a high user of other antibiotics due to their successful reduction plans for C-Difficile infection; they anticipate difficulties reintroducing medications that may result in an increase of C-Difficile infections and mortality rates. The Trust Electronic Prescribing & Management Administration (EPMA) system will improve analysis of prescribing data. Mortality from sepsis has reduced whilst at the same time compliance with the sepsis 6 (S6) bundle has decreased; the Trust was to investigate whether S6 compliance is reflective of actual reduction in sepsis. The Trust advised that the implementation of the Nerve Centre clinical software would hopefully much improve the completion of the S6 bundle records. Action: Concern was expressed over the lack of mortality update reports and this is on the January 2018 QRG agenda. Central Alerting System (CAS) compliance The Trust is an outlier for an alert (NHS/PSA/D/2016/008) due to their continued use of gallipots. The Trust has decided to use a similar solution as NuTHFT, however there is no timeline for implementation. Q2 CAS Alert compliance is on the January 2018 QRG agenda. Cyber-attack response The Trust was affected by the WannaCry cyber-attack and external experts conducted a review. The Trust switched to a paper-based DATIX system and matrons were monitoring incidents and issues. The Trust reported that no harm had been experienced by patients and the Trust is up to date with the cancellations made. The Trust was confident that delays to treatment had not caused any harm to patients. Action: The Trust will provide a response to the National Audit Office report. Cancer 62 day waits The Trust developed action plans for all departments where wait issues had been noted and has identified factors that contributed to the Trust s performance. Action: At the QRG held in November 2017 it was agreed that Cancer 62 Day Wait performance is to be included in the forward plan on a quarterly basis. 6

60 SIRMS Reporting - Feedback was requested from the Trust to assure GPs that actions were being taken to the issues reported. The Trust reported that when they report incidents about Primary Care they do not receive feedback. Action: The Trust advised they would provide more detailed feedback to reporting practices and the CCG agreed to implement a reciprocal process for management of Trust reported issues about Primary Care. Falls update the Trust did not submit the anticipated results of the 6 month audit on the Falls Bundle. Action: A separate meeting is to be arranged outside of the QRG to discuss falls performance and resolve issues. Trust representatives attended the CCG s SI Panel in December 2017 and discussed SIs being considered for closure; this was a very positive meeting. Newcastle upon Tyne Hospitals NHS Foundation Trust: 14 December 2017 Patient Experience Children and Young Patient's Survey - Trust Response - The results were overall very positive and generally an improvement on the previous survey. The Trust had significantly worsened compared to other trusts on distracting children from procedures or operations. Patient Led Assessments of the Care Environment (PLACE) Results - Trust Response - the Freeman Hospital s food score dipped due to the change to plated meals at the request of the patients. This had since been reversed and an improvement should be seen in the next survey. Discharge Summaries Use of Keystone - The CCG requested assurance on the known issue with the software system Keystone. The Trust used an EMIS product and was not aware of any issue relating to discharge letters for the Trust. Action: Trust to confirm with Trust ICT whether any issues have arisen regarding discharge letters. North East Ambulance Service NHS Foundation Trust: 24 November 2017 Quality Governance Report Incident reporting decreased with low or no harm the main status of incidents reported. No serious incidents were reported in October Personal Protective Equipment (PPE) and hand hygiene fell below the required level of compliance in September 2017, Trust to investigate. Northumberland Tyne & Wear NHS Foundation Trust: 1 November 2017 Patient safety The Trust reported that it had finalised its response to the learning from deaths report and would be highlighting learning from issues with other organisations. The report also incorporated the progress of actions and learning from the Safer Care Scheme. Action: The Trust response letter with actions is to be provided to the QRG members. 7

61 Northumberland Tyne & Wear NHS Foundation Trust (Continued) Physical assaults 2016/ Reporting on NHS Protect was no longer a national requirement however the Trust is continuing to report on physical assaults to give assurance to their Board. During 2016/17 there was a 1% increase in the number of assaults on the previous year; it is important to acknowledge that overall there has been an increase of 13.5% in incident reporting. 95% of the incidents reported were of no or minor harm and the remaining 5% had incurred some time lost due to sickness, and/or requiring treatment in hospital. The Trust continued to be open and transparent about the frequency of assaults, and ensured the right measures were in place to support staff involved. Discharge summaries pilot The system was due to be implemented on 23 November 2017 and it was hoped that the number of SIRMS relating to discharges will reduce as a result of the pilot going live. Action: NECS Clinical Quality Team to monitor the numbers of SIRMS reported regarding discharge issues from NTWFT and continues to share with the Trust. Patient Led Assessments of the Care Environment (PLACE) Results - Overall the Trust scored higher than the national average in all of the domains, although it did score slightly below the national average for organisational food. In four out of the five categories where comparison could be made with the previous year there has been an increase in the score achieved. A key factor in the process is to ensure each ward and department devises its own action plan to address any exceptions identified and that appropriate monitoring arrangements are in place both in the clinical groups and the supporting services. 8

62 Serious Incidents The graph below shows the level of SI reporting for the four main providers between November 2016 and December Caseload As of 8 January 2018 there are 21 SIs awaiting closure by NTCCG, including: 14 RCA reports not due 3 RCA reports overdue: o NHCFT (n=1) o NuTHFT (n=1 - police investigation) o NTWFT (n=1 extension granted) 2 RCA reports awaiting review prior to listing for panel 2 SIs where additional information has been requested by the Panel 9

63 Serious incident close down panels were held in November and December 2017, where 12 new cases were presented and 14 SIs were closed. Serious incidents are closed when the panel is assured that the investigation report and resulting action plan is complete and the provider has demonstrated that, where appropriate, lessons have been learned from the incident and associated actions have been taken. 81 SIs were reported between November 2016 and December 2017, which required closure by North Tyneside CCG. Of these 81 SIs, 61 were closed within the same timeframe. Never Events 1 never event was reported in December 2017 relating to a wrong lens implant; this occurred at Newcastle-upon-Tyne Hospitals NHS Foundation Trust and will be managed by Northumberland CCG. GP Practice Reported Issues (SIRMS) All 30 GP practices in North Tyneside are registered on SIRMS to report incidents. In November and December 2017, 17 (57%) North Tyneside practices reported a total of 96 incidents. A full SIRMS report is produced quarterly with details of themes, trends and feedback, this is shared across the CCG, practices and provider Trusts. The Q3 2017/18 report is due to be produced at the end of January

64 Key Quality Indicators: Provider Pressure Ulcers All Nov 17 Pressure Ulcers New Nov 17 Falls with Harm Nov 17 Catheters with UTIs Nov 17 VTEs New Nov 17 C.Diff* Nov 17 MRSA* Nov 17 FFT Oct 17 Northumbria Healthcare NHSFT The Newcastle upon Tyne Hospitals NHSFT Northumberland Tyne and Wear NHSFT KEY: Improving/ better than national average/on target/trajectory Performance worse than national average Deteriorating performance/worse than national average NHCFT pressure ulcers (all) decreased to 4.6% in November 2017 but remained above the national average (4.3%). NuTHFT o Pressure ulcers (new) increased to 1.4% in November 2017 above the national average (0.9%). o C-Difficile 7 published cases in November 2017 above the trajectory (n=6). The year to date published figure is 52 (trajectory=53). NTWFT falls with harm (0.8%) were above the national average (0.6%) in November NHCFT and NuTHFT performed below the England FFT average. 11

65 Other Quality Issues Complaints In October 2017, 4 formal complaints and 2 concerns were considered by the NECS complaints team in respect of North Tyneside CCG residents. Of the 4 complaints, 1 was closed, 2 were passed to the provider(s) and 1 is ongoing. The 2 concerns were actioned and closed. In November 2017, 7 formal complaints, 1 concern and 1 re-opened advice case were considered by the NECS complaints team in respect of North Tyneside CCG residents. Of the 7 complaints, 2 were closed and 5 are ongoing; the 5 all relate to the proposed closure of a practice surgery. The 1 concern was closed. In December 2017, 2 formal complaints, 5 concerns and 1 advice cases were considered by the NECS complaints team in respect of North Tyneside CCG residents. 2 concerns remain ongoing, the remaining cases were closed. Information Access Requests In October 2017, 17 requests were received. All were acknowledged within 2 working days. 12 were responded to within the statutory 20 working days with an average response time of 12 working days. The 5 outstanding requests had deadline dates in November exemption was applied to one request a part exemption, section 43 commercial interests. In November 2017, 22 requests were received. All were acknowledged within 2 working days. All were responded to within the statutory 20 working days with an average response time of 14 working days. No exemptions to disclosure were applied. 12

66 OFFICIAL Report to: Governing Body Date: 23 rd January 2018 Agenda item: 09.3 Title of report: North Tyneside Clinical Commissioning Group (NT CCG) Improvement and Assessment Framework (IAF) Report Sponsor: Dr Lesley Young-Murphy, Executive Director of Nursing and Chief Operating Officer Author: Teresa Ho, Performance and Monitoring Manager Purpose of the report and action required: To report progress against the CCG Improvement and Assessment Framework. Members are asked to note the current position against the listed measures and review actions to improve areas of underperformance noting that to improve some areas may require additional resource. Executive summary: The CCG IAF Report shows the latest reported position against NHS England s IAF for CCGs. The CCG IAF has been updated for 2017/18. It builds on the IAF introduced in April 2016, which replaced both the existing CCG assurance framework and CCG performance dashboard. It has been designed to provide a greater focus on assisting improvement, alongside statutory assessment functions. The IAF aligns with NHS England s Mandate and planning guidance, with the aim of unlocking change and improvement in a number of key areas. This approach aims to reach beyond CCGs, enabling local health systems and communities to assess their own progress from ratings published online. The framework is intended as a focal point for joint work and support between NHS England and CCGs. It draws together the NHS Constitution, performance and finance metrics and transformational challenges and plays an important part in the delivery of the Five Year Forward View. The revised CCG IAF contains a set of 51 indicators set out across 27 areas within four domains. The majority of the indicators are reported quarterly, but there are a number that are updated annually. In addition the CCG will receive an annual assessment against 6 key clinical areas - mental health, dementia, learning disabilities, cancer, maternity and diabetes. The overall summary rating for the CCG for 2016/17 is a rating of Good. This is a significant improvement on the rating given for 2015/16 The latest data shows that North Tyneside CCG is a positive outlier and in the top quartile of CCGs nationally for 13 (34%) of the 38 benchmarked measures. 1. People with diabetes diagnosed less than a year who attend a structured education course 1

67 OFFICIAL 2. Staff engagement index 3. Progress against the Workforce Race Equality Standard 4. High quality care acute 5. High quality care primary care 6. People with urgent GP referral having first definitive treatment for cancer within 62 days of referral 7. Cancer patient experience 8. Proportion of people with a learning disability on the GP register receiving an annual health check 9. Neonatal mortality and still births 10. Percentage of patients admitted, transferred or discharged from A & E within 4 hours 11. Delayed transfers of care attributable to the NHS per 100,000 population 12. Patients waiting 18 weeks or less from referral to hospital treatment 13. Percentage of NHS Continuing Healthcare full assessments taking place in an acute hospital setting The CCG is a negative outlier and in the bottom quartile for the following measures 1. Injuries from falls in people aged 65 and over 2. Appropriate prescribing of antibiotics in primary care 3. Provision of high quality care adults social care 4. One-year survival from all cancers 5. Improving access to Psychological Therapies access 6. People with first episode of psychosis starting treatment with a NICErecommended package of care treated within 2 weeks of referral 7. Reliance on specialist inpatient care for people with a learning disability and/or autism 8. Dementia care planning and post-diagnostic support 9. Emergency admissions for urgent care sensitive conditions 10. Population use of hospital beds following emergency admission Within the published NHS England data, it reported that North Tyneside CCG was a negative outlier for the Percentage of NHS Continuing Healthcare full assessments taking place in an acute hospital setting. Investigations into the reported performance figure showed that the polarity of performance was set up incorrectly IN NHS England and that North Tyneside CCG was actually within the best performing CCGs not the worst performing. The issue has been reported to NHS England and the CCG await a response. The CCG is satisfied based on local performance data as well as other NHSE monitoring mechanisms that the CCG is delivering well against this measure. An improvement in performance means that North Tyneside CCG is no longer a negative outlier in the Effectiveness of working relationships in the local system measure. The CCG has been given the following rating for three of the six clinical areas for 2016/17. Cancer Good Dementia Requires Improvement Mental Health Good 2

68 OFFICIAL The remaining three clinical areas will receive a rating later in the year. The 2015/16 ratings are as follows Learning Disabilities Needs Improvement Maternity Needs Improvement Diabetes Performing Well Governing Body are requested to note current performance against the CCG IAF and review actions to improve areas of underperformance noting that to improve some areas may require additional resource. 3

69 Governance and Compliance 1. Links to corporate objectives 2017/18 Corporate Objectives Item links to objectives 1. Commission high quality care for patients, that is safe, value for money and in line with the NHS Constitution 2. Deliver the Financial Recovery Plan, leading to the achievement of the CCG s statutory financial duties and future sustainability 3. Work collaboratively with partners and stakeholders to develop health and social care fit for the future in North Tyneside 4. Continue to develop North Tyneside CCG as a patient focused, clinically led commissioning organisation with a continuous learning culture 2. Consultation and engagement Not applicable 3. Resource implications Not applicable 4. Risks Not applicable 5. Equality assessment Not applicable 6. Environment and sustainability assessment There are no environmental or sustainability issues arising from this report. 4

70 CCG Improvement and Assessment Framework Report January

71 Background The CCG IAF Report shows the latest reported position against NHS England s IAF for CCGs. The CCG IAF has been updated for 2017/18. It builds on the IAF introduced in April 2016, which replaced both the existing CCG assurance framework and CCG performance dashboard, and was designed to provide a greater focus on assisting improvement, alongside statutory assessment functions. The IAF aligns with NHS England s Mandate and planning guidance, with the aim of unlocking change and improvement in a number of key areas. This approach aims to reach beyond CCGs, enabling local health systems and communities to assess their own progress from ratings published online. The CCG IAF aligns with NHS England s Mandate and planning guidance, and has been designed to supply indicators for adoption in STPs as markers of success. This approach aims to reach beyond CCGs, enabling local health systems and communities to assess their own progress from ratings published online. The CCG IAF contains a set of 51 indicators set out across 27 areas within four domains as set out below. It is intended that the indicators will be reported quarterly. Better Health: this section looks at how the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve; Sustainability: this section looks at how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends; Leadership: this domain assesses the quality of the CCG s leadership, the quality of its plans, how the CCG works with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity, for example in managing conflicts of interest; Better Care: this principally focuses on care redesign, performance of constitutional standards, and outcomes, including important clinical areas. 6

72 Background 7

73 CCG IAF Measures Highlighting Success 8 `

74 CCG IAF Measures Highlighting Success The above table shows the reported performance for the CCG IAF measures where data is available. The overall summary rating for the CCG for 2016/17 is a rating of Good. This is a significant improvement on the rating given for 2015/16 The coloured England column on the right hand side show the benchmarked rank for North Tyneside against the 207 CCGs against 51 of the measures. North Tyneside CCG is a positive outlier and in the top quartile of CCGs nationally for 13 (34%) of the 38 benchmarked measures. Within the published NHS England data, it reported that North Tyneside CCG was a negative outlier for the Percentage of NHS Continuing Healthcare full assessments taking place in an acute hospital setting. Investigations into the reported performance figure showed that the polarity of performance was set up incorrectly and that North Tyneside CCG was actually within the best performing CCGs not the worst performing. The issue has been reported to NHS England and the CCG await a response. 1. People with diabetes diagnosed less than a year who attend a structured education course 2. Staff engagement index 3. Progress against the Workforce Race Equality Standard 4. High quality care acute 5. High quality care primary care 6. People with urgent GP referral having first definitive treatment for cancer within 62 days of referral 7. Cancer patient experience 8. Proportion of people with a learning disability on the GP register receiving an annual health check 9. Neonatal mortality and still births 10. Percentage of patients admitted, transferred or discharged from A & E within 4 hours 11. Delayed transfers of care attributable to the NHS per 100,000 population 12. Patients waiting 18 weeks or less from referral to hospital treatment 13. Percentage of NHS Continuing Healthcare full assessments taking place in an acute hospital setting In addition the CCG has seen an improvement in 17 of the measures, with a decrease in performance in 15 of the measures. 9

75 CCG Areas for Improvement There are ten measures where North Tyneside CCG benchmarks as an outlier and within the worst quartile nationally. IAF measure Injuries from falls in people aged 65 and over per 100,000 population Key points The CCG recognises its outlier position in respect to falls, a position that has remained despite a number of initiatives to improve performance. A programme of work has been initiated to ensure there is consistent approach across North Tyneside to falls that links in with all organisations and integrates with Right Care work. Actions identified to take this forward include:- A whole system falls strategy has been developed and the actions from this are currently being implemented. New community falls service has been co-produced and developed with key stakeholders. The Falls Service was operational from 30 th November and includes 4 strands community falls clinic, strength and balance classes, safe and well checks, and falls first responder service. There is continued collaborative work with nursing homes including a dementia friendly falls training programme falls and a module on the development list for HYDR8 app. The CCG together with the Academic Health Science Network (AHSN) have developed a system wide Falls prevention campaign with core elements designed by the CCG patient forum. The CCG is working with the AHSN in relation to Bone Health tool to identify patients on the practice patient list that are at risk of osteoporosis. Practices are being encouraged to sign up to this through locality meetings and signs of engagement have been positive. The CCG is in discussion with secondary care providers in relation to setting up a bone health clinic. There is a falls and frailty education event planned for January. 10

76 CCG Areas for Improvement IAF measure Key points Antibiotic Prescribing The CCG is an outlier in terms of antibiotic prescribing and currently ranked 189 out of 207 CCGs. Review of prescribing data shows a decrease of 3.5% in 2016/17, following a decrease in prescribing in 2015/16. This decrease in prescribing of antibiotics increases to 7.6% in GP practices, with prescribing by other providers such as walk in centres inflating the figure. There are a number of workstreams underway to continue this reduction including:- Review of data at practice level by the medicines optimisation practice teams to identify practice specific actions to support appropriate prescribing Review of data for other prescribers to identify specific actions to support appropriate prescribing Actions to target a reduction of inappropriate antibiotic prescribing for UTIs in primary care focusing on looking at catheter and continence management with the aim to reduce the incidence of catheter associated infections Actions to reduce care home related infections by improvements in hydration, better body posture and dental hygiene with promotion of good practice Looking at the management of leg oedema using compression hosiery to help reduce antibiotic prescribing to manage query cellulitis High Quality Care adult social care This aggregated CQC score for adult social care in North Tyneside is 59 which place North Tyneside in the bottom quartile for this measure. The aggregated score comprises of points linked to CQC ratings against all five key lines of enquiry across residential and nursing homes in the borough. 6 (30%) of care homes are under notice of closure from CQC Quality improvement visits being undertaken jointly with the local authority and monitoring action 11

77 CCG Areas for Improvement IAF measure Key points plans. Additional support being provided by: CCG Clinical Team CCG transformation team Care home medicines optimisation team Tissue viability training Continence and catheter training Dietetics training SALT assessments As well as the ongoing support and joint working between the homes, Local Authority and the CCG. The current Nursing Home GP alignment and practice activity scheme is being reviewed in order to enhance care quality delivery. The Future Care transformation programme particularly in respect of Primary Care Home will ensure that Nursing and Care Homes residents are central to this work. There is a joint system quality meeting scheduled with senior officers from the homes, Local Authority and CCG. One-year survival from all cancers Although North Tyneside CCG is still an outlier for this measure there has been good improvement seen in the latest published data (2014) with survivorship increasing by 6.9% to 68.2%. A key priority for North Tyneside during the last three years has focussed on early detection of cancer. Work has been undertaken to promote and improve the uptake of the three national screening programmes, education and support for GPs and strengthening clinical engagement 12

78 CCG Areas for Improvement IAF measure Key points between primary and secondary care. North Tyneside CCG has seen a 13.7% increase in cancers diagnosed at an early stage to 52.9%. North Tyneside CCG continues to work with local providers on developing survivorship pathways. The long-term aim is to focus on self-management as early as possible after diagnosis for all cancer pathways with initial focus on developing three new cancer survivorship pathways in breast, prostate and colorectal. Key areas of work include: Development of Risk Stratification tools. Health needs assessments and holistic care plans Introduction of remote monitoring and, Improved care coordination Work on the breast survivorship pathway begun in April All newly diagnosed patients have received a Health needs assessment and three cohort types have been identified in terms of level of risk and complexity. Thirty patients have been identified as low risk and will join the survivorship pathway which will commence in April Work has been completed to develop the colorectal survivorship pathway. A risk stratification plan will begin as from April 2018 for those patients newly diagnosed with colorectal cancer. Planning is also underway with the urology team to ensure systems and processes are in place for developing the Prostate Cancer Survivorship Pathway. Improving access to Psychological Therapies access Coverage is shown as 2.4% for July 2017 in the IAF data The access rate had fallen below trajectory in 2017/18 due to the loss of staff to the IAPT Long Term Conditions programme but has now recovered to 10.1% in October with an expected year 13

79 CCG Areas for Improvement IAF measure Key points end position of 17.3%. A combination of new agency staff and additional Psychological Wellbeing Practitioner (PWP) workers starting in the service is improved the access rate. The service is also offering options into either Cognitive-Behavioural Therapy (CBT) or other forms of therapy/group work to ensure that they are receiving some form of timely and appropriate therapy. 2016/17 ended with coverage of 17.3% against a 15% threshold. People with first episode of psychosis starting treatment with a NICE-recommended package of care treated within 2 weeks of referral North Tyneside CCG is shown as an outlier for this measure with a score of 66.7% August The data used is only for one month (August 2017) and there are a low number of patients on this pathway. 2 out of 3 were seen within two weeks of referral. There are typically between two and four patients on this pathway every month and therefore the impact if one patient not meeting the standard is proportionally very large. The figures are reviewed on a monthly basis during the contract meeting with the provider with a follow up into specific patient cases if necessary. People with a learning disability and/or autism receiving specialist inpatient care per million population The score for this measure of 80 people receiving specialist inpatient care per million populations relates to the North East and Cumbria Transformation area rather than North Tyneside CCG only. There has been a reduction of 3 people from the last published information. North Tyneside CCG continues be part of the North East and Cumbria Transforming Board and a local implementation plan is in place to reduce the use of inpatient beds for this cohort. North Tyneside CCG commissions the equivalent of 2.5 assessment and treatment beds under a block contract arrangement. These numbers meet the requirements set out in Building the Right Support which suggests that a CCG with the population size of North Tyneside should commission no more than 3 assessment and treatment beds. 14

80 CCG Areas for Improvement IAF measure Key points The CCG has 3 patients residing in hospital beds with 2 of those in the community, 1 patient in CCG funded step down beds. All patients have received a Care and Treatment Review (CTR) and care providers are working towards discharge delivery dates. There are 5 North Tyneside adult patients residing in Specialist Commissioned beds and two young people receiving in patient treatment. NT CCG has focussed on embedding the CTR and Care, Education and Treatment Reviews (CETR) policy for those patients living in the community who are at risk of a hospital admission. Since April 2017, the CCG has conducted 2 community based CTRs and 11 community based CETRs. All which resulted in strengthening support interventions in the person s place of residence and admissions were avoided in all cases. Dementia care planning and postdiagnostic support 74.1% of dementia patients had their care plan reviewed in a face-to-face review in North Tyneside. This is a Quality and Outcomes Framework (QOF) indicator, and the figures used do not include patients excepted from the process by practices. With these patients removed the CCG percentage is reduced to 80.7%. All practices are achieving a full QOF payment for this measure. Updated data for 2016/17 shows a significant improvement in this measure and we expect the CCG position to improve in the next publication of the IAF data. This measure has been selected as the local measure with the Quality Premium. Benchmarking analysis for this measure at practice level has being produced and shared with practices so there is visibility of their position in comparison to other practices nationally. Practices have been asked to focus on maximising their achievement for this measure. The analysis has also highlighted the practices where support can be offered to improve the position, through the CCG Transformation team. 15

81 CCG Areas for Improvement IAF measure Key points Emergency admissions for urgent care sensitive conditions per 100,000 population Emergency bed days per 1,000 population Population use of hospital beds following emergency admission North Tyneside CCG continues to be an outlier for 2 of the emergency admission indicators. The North Tyneside position compared to other CCGs is artificially inflated by the coding of ambulatory care activity as an emergency admission by Northumbria FT, where for a lot of organisations it is coded differently and therefore not included in these indicators. Discussions are ongoing with the Trust, NT CCG and Northumberland CCG. Following the implementation of Quality, Innovation, Productivity and Prevention (QIPP) projects over the last two financial years and the opening of Northumbria Specialist Emergency Care Hospital (NSECH) in June 2015, there has been a significant reduction in non-elective admissions for urgent care sensitive conditions and ambulatory care sensitive conditions. Although the CCG remain an outlier for these measures the trend continues to be a reduction in the levels of emergency admissions for these with the North Tyneside figure moving towards the national average. The emergency bed days per 1,000 population has shown a small increase in the latest data, this is in line with the national trend. The CCG continue to move forward with plans to reconfigure urgent care services, alongside developing it s out of hospital model Future Care. This includes increased provision of GP appointments in extended hours. 16

82 CCG IAF 6 clinical priority areas refreshed annually In addition to the quarterly reporting against the 51 measures within the CCG IAF framework NHS England have also committed to undertaking an annual assessment against 6 key clinical areas - mental health, dementia, learning disabilities, cancer, maternity and diabetes. The assessments in the clinical priority areas will be overseen by independent groups with a clear rating for each of these six clinical areas being given on a four point Ofsted-style scale. For 2016/17 North Tyneside CCG has been given the following ratings for the Cancer, Dementia, and Mental Health clinical areas. Ratings for the remaining 3 clinical areas will be available later in the year. 17

83 CCG IAF 6 clinical priority areas refreshed annually Cancer The rating of Good represents an improvement on 2015/16 when the CCG was given a rating of Needs Improvement for this clinical area. The CCG is significantly above the England figure for the Cancer 62 day referral to treatment and Cancer patient experience measure. There has been an improvement of 13.7% in the number of cancers diagnosed at an early stage which moves North Tyneside in line with the national average. Although still a negative outlier for one year survival rates this has improved by 6.9%. As detailed in the above there are ongoing plans in place for 3 survivorship pathways to continue this increasing trend. Dementia The Needs Improvement rating is due to the CCG percentage of dementia patients whose care plan has received a review in the past 12 months falling into the bottom of 4 categories in the assessment of that measure. This is a QOF indicator and nearly all practices are achieving a full QOF payment for this measure. As detailed in the section above this measure has been selected as the local indicator for improvement within the Quality Premium for 2017/18 and there is an improvement plan in place. The CCG is well above the national average and the standard target of 66.7% for the diagnosis rate for people with dementia. An improvement of just 3.5% to 77.6% in the care plan indicator would move the CCG into the Good assessment category for this Clinical area 18

84 CCG IAF 6 clinical priority areas refreshed annually Mental Health The rating of Good represents an improvement on 2015/16 when the CCG was given a rating of Needs Improvement for this clinical area. The IAPT recovery rate indicator is marginally below the 50% standard and there are monthly performance meetings with the provider to ensure improvement. The CCG is a pilot area for increased IAPT for long term conditions and the changes to the service to increase the workforce had resulted in a decrease for this measure but recovery rates have now improved. The proportion of patients treated within 2 weeks of an episode of psychosis has increased and the CCG is within the top half of CCGs for this measure. The number of patients per month remains low which can lead to fluctuations in performance on a monthly basis. The CCG continues to move forward with plans to transform Children and Young people s mental health service, and to transform out of area placements for acute mental health inpatient care, and the implementation of Crisis Care and Liaison services in line with national requirements. 19

85 OFFICIAL Report to: Governing Body Date: 23 January 2018 Agenda item: 10.1 Title of report: 2017/18 Finance and Contracts Report Month 8 November 2017 Sponsor: Jon Connolly - Chief Finance Officer Author: Jeff Goldthorpe Head of Finance Purpose of the report and action required: The report details North Tyneside Clinical Commissioning Group s financial position as at month 8. The Governing Body is requested to acknowledge and note the specific issues as set out in the executive summary. 1

86 OFFICIAL 1. Executive Summary 1.1 Key Messages At Month 8 the CCG is forecasting an outturn surplus position of 2m. This is consistent with the annual plan prepared by the CCG. The year to date surplus is 1.96m, 0.62m better than plan. Pressures continue around acute activity, particularly for the Northumbria Healthcare contract. Measures are in place to mitigate the current levels of performance. The CCG forecasts delivery of 11.7m (96%) of the 12.2m efficiency savings target. There are now limited risks to this level of delivery. These risks continue to be managed. 1.2 Overview North Tyneside Clinical Commissioning Group (CCG) is required to deliver against a number of national and local financial targets. Table 1 shows the forecast delivery against these targets. Table 1 Key financial targets Metric Annual/ Year To Date Metric (A/ YTD) Description of Metric CCG Plan m Forecast Delivery Delivery Rating against plan m Financial Outturn A To deliver a 2m surplus of revenue resource limit over expenditure (2.0) (2.0) Running Costs A To operate within the allocated CCG running cost allowance Reserves A To hold a 0.5% reserve Efficiency Savings Plan A To deliver against an efficiency savings target of >90% (12.2) (11.7) Cash Limit A The maximum amount to be left in the CCG bank account on close of play 31 March Better Payment Practice Code YTD To ensure that 95% of invoices are paid within 30 days of receiving invoice 95% 99.3% Mental Health Investment Standard A To increase Mental Health spend by at least 2% 2% 2.8% 1.3 Context The CCG reported a deficit position of 16.2m in the 2016/17 financial year resulting in an equivalent 16.2m allocation reduction in 2017/18. The CCG is planning to deliver a 2m in-year surplus in 17/18 which will reduce the brought forward deficit to 2

87 OFFICIAL 14.2m. To deliver the in-year surplus of 2m the CCG plans to deliver efficiency savings of 12.2m. 2 Financial position 2.1 Summary Financial Position The CCG is reporting a forecast outturn surplus of 2.0m. The year to date surplus is 1.96m, 0.62m better than plan. Table 2 Financial Position Annual Budget 000's YTD Budget 000's YTD Actual 000's YTD Variance 000's Forecast Outturn 000's In Year Allocation 345, , , ,995 0 Forecast Variance 000's Healthcare Commissioned Services Acute Services 179, , ,038 1, ,933 4,656 Mental Health Services 24,467 16,294 16, ,747 (720) Community Health Services 25,754 16,704 17, ,690 (64) Continuing Care Services 21,468 14,312 13,570 (742) 20,347 (1,121) Prescribing 36,933 24,622 24, , Primary Care 33,090 21,859 21,628 (232) 32,808 (282) Better Care Fund 7,497 4,998 6,331 1,333 9,497 2,000 Other Programme Services 2,285 1,523 1,210 (313) 1,802 (483) Reserves - Mandated 4,725 1,056 1, ,725 0 Reserves - CCG 3,654 2, (2,168) 377 (3,277) Reserves - In Year Allocations (71) 36 (106) 1617 Accruals Benefits 0 0 (795) (795) (795) (795) Healthcare Commissioned Services Total 339, , ,669 (335) 339, Running Costs Total 4,703 3,135 2,848 (287) 4,280 (423) Total Expenditure 343, , ,518 (622) 343,996 (0) In Year (Surplus)/Deficit (2,000) (1,333) (1,955) (622) (2,000) (0) The key variances are acute activity, continuing care, the Better Care Fund, mental health services and the application of reserves. These are considered in sections 2.3 to 2.11 below Underlying position At Month 8 the CCG is forecasting delivery of an underlying (recurring) surplus financial position of 3.3m for 2017/ Run rate If we extrapolate Month 8 expenditure across the remaining months of the year, the CCG would be expected to spend 4.2m less than plan. This can be explained by the phasing of budgets. More costs are factored into the latter part of the year and as at Month 8 reported costs account for 65.8% of total expenditure as opposed to 66.7% if phased equally. In particular we hold reserves that we expect to be released later in the year. 2.2 Revenue Resource Limit The initial revenue resource limits for the CCG are 313.5m for programme expenditure, 4.7m for running costs and 28.4m for the primary care delegated budget. At the end of November 2017 the allocations available to the CCG total 329.8m. Table 3 below details the baseline allocation and the year-to-date resource 3

88 OFFICIAL limit adjustments. The deficit of 16.2m that was incurred in 2016/17 has been deducted from the initial allocation. This is in line with NHS CCG accounting regulations that mandate that this has to be repaid in the following year. Table 3 - Revenue Resource Limit Recurrent Non Recurrent Total 000's 000's 000's Initial CCG Programme Allocation 313, ,469 Initial CCG Running Cost Allocation 4,694 4,694 Newcastle Hospitals - Ambulatory Recoding Newcastle Hospitals - block drugs disaggregation Allocation adjustments of the drugs block in the Newcastle contract (126) (126) IR Changes (1,366) (1,366) HRG4+ changes (726) (726) Primary Care Delegated budget 28,426 28,426 Total NHS Allocation April ,255 (2,092) 345,163 Surplus/Deficit Carry Forward - Planned (16,210) (16,210) Surplus/Deficit Carry Forward Final Outturn Allocations received within 1718 financial year 1,160 (328) 832 Total NHS Allocation November ,415 (18,611) 329,805 In Year Allocation 345, Acute Contracts The CCG has two main acute contracts totalling 164m. These contracts are with Northumbria Healthcare and the Newcastle upon Tyne Hospitals Trust. Overall, the acute contracts are forecast to overspend by 4.7m by the year end. The year to date position against each contract is set out below Northumbria Healthcare Plan Activity (YTD) Actual Variance against Plan 000s (YTD) Actual Variance against POD Summary POD Summary AandE 35,146 37,655 2,509 AandE 4,380 4, Critical Care 1,703 1,673 (30) Critical Care 1,903 1,739 (164) Drugs and Devices Drugs and Devices 1,050 1,027 (23) Elective 7,811 7,591 (220) Elective 8,813 9, Emergency Readmissions Emergency Readmissions 0 0 (0) Emergency Threshold Emergency Threshold Excess Beddays 4,212 3,656 (556) Excess Beddays (134) Maternity Pathways 2,559 2,492 (67) Maternity Pathways 2,409 2,266 (143) Non Elective 9,737 8,838 (899) Non Elective 19,275 19,251 (25) Other Services 492, ,725 (8,492) Other Services 10,789 10,612 (177) Outpatient Diagnostics 9,607 8,040 (1,567) Outpatient Diagnostics (115) Outpatient First 21,474 23,965 2,491 Outpatient First 2,872 3, Outpatient Follow Up 66,371 70,876 4,505 Outpatient Follow Up 3,851 4, Outpatient Procedures 6,658 8,554 1,896 Outpatient Procedures 1,063 1, Ambulatory Care 5,316 7,582 2,266 Ambulatory Care 2,155 3, QIPP QIPP (1,360) 0 1,360 Penalties Penalties 0 (224) (224) Challenges Challenges 0 (59) (59) CQUIN CQUIN 1,446 1, Flex Month 7 Total 662, ,647 1,835 Flex Month 7 Total 60,427 62,958 2,531 Estimate for Month 8 92,553 94,910 2,357 Estimate for Month 8 8,345 8, Reported Month 8 Positio 755, ,557 4,192 Reported Month 8 Position 68,773 71,771 2,998 4

89 OFFICIAL Data Issues The data represented above is based on the Month 7 Flex data received from the Trust. Financial Performance The current financial position is showing a year to date over performance of 2,531k against the contract plan at Month 7. Significant variances are detailed below: Ambulatory Care is showing a large overspend YTD ( 1,003k). CCG analysis showed an apparent switch from Ambulatory Care to NELST activity in 16/17, which would explain part but not the whole variance. Elective activity is showing a financial over performance against contract plan at Month 7 ( 300k) and an activity under performance. Currently, the main area of over performance is Skin, Breast and Burns ( 80k), which is being offset by an under performance against Digestive System ( 263k). Maternity - Under performance against contract plan at Month 7 ( 154k). This is mainly due to under performance against the antenatal pathway ( 219k). Non elective activity is showing a financial performance in line with the plan and an activity under performance. Currently, the main areas of underperformance are Urinary Tract and Male Reproductive System ( 475k), Respiratory System (- 354k) and Digestive System ( 185k). This is being offset by an over performance against Immunology, Infectious Diseases and other contacts with Health Services ( 684k). Outpatients - Activity is showing a financial over performance against the contract plan for first attendances, follow-up attendances and procedures. The main areas of over performance are Trauma & Orthopaedics for first attendances ( 123k), Diabetic Medicine for follow-up attendances ( 249k) and Cardiology ( 52k) Newcastle upon Tyne Hospitals Trust Plan Activity (YTD) Actual Variance against Plan Plan 000s (YTD) Actual Variance against Plan POD Summary POD Summary AandE 11,345 11, AandE 1,318 1,277 (41) Critical Care 1,014 1, Critical Care Drugs and Devices Drugs and Devices 3,150 3, Elective 9,243 8,999 (244) Elective 9,176 8,829 (347) Emergency Readmissions Emergency Readmissions (410) (429) (19) Emergency Threshold Emergency Threshold (807) (64) 743 Excess Beddays 3,526 2,042 (1,484) Excess Beddays (354) Maternity Pathways Maternity Pathways Non Elective 4,661 4, Non Elective 9,628 9,591 (37) Other Services 214, ,663 (2,657) Other Services 972 2,194 1,222 Outpatient Diagnostics 8,485 8,455 (30) Outpatient Diagnostics Outpatient First 17,420 15,282 (2,138) Outpatient First 2,810 2,443 (367) Outpatient Follow Up 43,421 40,687 (2,734) Outpatient Follow Up 3,375 3,204 (172) Outpatient Procedures 18,008 17,950 (58) Outpatient Procedures 2,411 2, Ambulatory Care 1,082 1,042 (40) Ambulatory Care (32) Penalties Penalties 0 (175) (175) Challenges Challenges 0 (313) (313) CQUIN CQUIN Flex Month 7 Total 332, ,524 (9,234) Flex Month 7 Total 35,610 36, Estimate for Month 8 47,537 46,206 (1,330) Estimate for Month 8 5,099 4,038 (1,061) Reported Month 8 Position 380, ,730 (10,564) Reported Month 8 Position 40,709 40,311 (398) 5

90 OFFICIAL Data Issues The data represented above is based on the Month 7 Flex data received from the Trust. The levels of un-coded data are reducing but are still significant for Month 7 flex data. Financial Performance The contract is 663k over plan YTD with a forecast of 756k overspend when compared to the contract value. The main areas of variation from plan are: Elective: Activity and costs are performing under the YTD contract plan. The high levels of uncoded activity, 148k mean that these figures could change significantly once the Freeze data is submitted. Currently, the main area that is under plan is Musculoskeletal System. Outpatient First & Follow-up: Activity and costs are performing under the YTD contract plan. The main specialties where this is occurring are Cardiology and Paediatrics for first attendances; and Clinical Psychology, Rheumatology and ENT for follow up attendances. Maternity: Activity and costs are performing over the contract YTD plan. This is mainly in the Standard and Intermediate Antenatal pathways. Emergency Threshold: The level of activity breaching the Emergency threshold is less than was planned for, causing an over spend against this line 2.4 Mental Health The contract with Northumberland Tyne and Wear Foundation Trust is a block contract arrangement with a 0.1% cap. At Month 8 the budget shows a year to date underspend of 1.3m due to an agreed contract reduction. Non-NHS mental health spend predominately relates to jointly commissioned arrangements with North Tyneside Local Authority. These arrangements cover those patients that have been sectioned under Section 117 of the Mental Health Act (1983) and LD patients who require care to be provided out of area (OOA). Whilst LD Out of Area is forecasting a breakeven position Section 117 cases is forecasting a 531k overspend due to an increase in the number of cases. 2.5 Community Services The majority of community services are provided by Northumbria Healthcare Foundation Trust and Newcastle upon Tyne Hospitals Foundation Trust. We are forecasting a break-even position for the Northumbria contract and an underspend of 75k for the Newcastle contract. The largest element of non NHS community contracts are provided by Akari, Marie Curie and St Oswalds. For the Akari contract we are forecasting a 1k overspend and for the Marie Curie contract an overspend of 4k. For the St Oswald s contracts we are forecasting an underspend of 26k. 6

91 OFFICIAL 2.6 Continuing Health Care For Continuing Health Care (CHC) (which includes funded nursing care) we forecast an outturn underspend of 1.1m. The underspend relates primarily to the reduction in CHC ( 1.1m) and shared care ( 201k) cases but has been offset by expenditure pressures including the requirement to expand the CHC case management team ( 131k). 2.7 Primary Care Prescribing The prescribing outturn position has been estimated as a 614k overspend. The estimated overspend on GP prescribing ( 1.04m) has been offset by savings on Nurse prescribing ( 184k) and ONPOS dressings ( 87k). 2.8 Primary Care From 1 April 2017 the CCG has accepted joint responsibility for the management of primary care services. A budget of 27.1m has been delegated to the CCG by NHS England. As at the end of November 2017 the budget is forecast to overspend by 158k. The remaining Primary care budgets include local enhanced services, oxygen services and GP IT costs and for these budgets we forecast an underspend of 440k. 2.9 Better Care Fund The Better Care Fund is a pooled programme of expenditure which spans both health and local government. Its aim is to join up health and social care services so that people can live independently within their communities for as long as possible. This includes re-ablement services, carer s breaks and the implementation of the Care Act. The health elements of the BCF remain within other CCG budgets. The Better Care Fund is forecast to overspend by 2m in 2017/18. The Better Care Fund plan has been submitted to NHS England but the Section 75 agreement between North Tyneside Council and the CCG which governs the operation of the Better Care Fund has yet to be signed for 2017/ Reserves and Contingency In line with NHSE requirements the CCG is holding a 0.5% contingency and a 1% non-recurring reserve. The contingency is available for the CCG to utilise during the financial year. 0.5% of the reserve must be held by the CCG during the financial year. The remaining 0.5% is available for the CCG to utilise to support non-recurring expenditure CCG Running costs The CCG has an annual running cost allowance of 4.7m. An underspend of 423k is forecast for this budget as at 31 March Cash 7

92 OFFICIAL Table 6 outlines the CCG s cash drawings and payments for April 2017 to November Table 6 Cash position to date Actual Actual Actual Actual Actual Actual Actual Actual Forecast April May June July August September October November March 000's 000's 000's 000's 000's 000's 000's 000's 000's Income Balance bfwd DOH Income 27,400 26,700 27,300 25,000 26,500 22,800 24,900 25,600 22,200 Supplementary /Cash Return Prescribing/Home Oxygen Therapy 2,755 3,086 2,781 2,976 2,990 3,005 3,153 2,945 2,865 CHC Risk Pool Better Care Fund Other Income , Total Income 30,541 29,955 30,537 28,390 29,847 26,249 30,249 28,903 25,380 Expenditure Pay (174) (178) (192) (190) (196) (199) (220) (235) (200) NHS Payments including contracts (19,016) (20,396) (21,697) (18,065) (18,740) (18,044) (19,948) (17,029) (17,575) Other Payments - BACS/CHAPS/CHQS (7,859) (5,293) (2,390) (6,058) (5,212) (4,037) (5,924) (5,887) (3,978) Prescribing/Home Oxygen Therapy (2,755) (3,086) (2,781) (2,976) (2,990) (3,005) (3,153) (2,945) (2,865) CHC Risk Pool Better Care Fund (501) (501) (2,997) (501) (2,101) (501) (501) (2,558) (501) Other (132) (210) (220) (290) (293) (213) (213) (213) (211) Total Expenditure (30,437) (29,664) (30,277) (28,080) (29,532) (25,999) (29,959) (28,867) (25,330) BALANCE CFWD Variance against drawdown 0.38% 1.09% 0.95% 1.24% 1.19% 1.10% 1.16% 0.14% 0.23% At the end of November 2017 the CCG holds a cash balance of 36k. At year end it is expected the CCG will meet the planned cash target of a minimum of 50k. 4. Better payments practice code The better payments practice code stipulates that it is good practice to pay 95% of all invoices within 30 days of receipt of the invoice or goods, whichever is later. Table 7 details the number and value of invoices paid from 1 April to 31 November 2017 for both non NHS and NHS suppliers. The CCG has paid 99.3% of the total number of invoices which equates to 99.9% of the total value of invoices. Table 7 Better payments practice code Better Payment Practice Code - 30 Days NUMBER 000's Non-NHS Total Non-NHS Trade Invoices taid in the Year 3,560 49,401 Total Non-NHS Trade Invoices taid Within 30 Day Target 3,534 49,232 Percentage of Non-NHS Trade Hnvoices Paid Within 30 Day Target 99.27% 99.66% NHS Total NHS Trade Invoices taid in the Year 1, ,003 Total NHS Trade Invoices taid Within 30 Day Target 1, ,978 Percentage of NHS Trade Hnvoices Paid Within 30 Day Target 99.26% 99.98% Total Total Trade Invoices taid in the Year 4, ,404 Total Trade Invoices taid Within 30 Day Target 4, ,210 Percentage of NHS Trade Hnvoices Paid Within 30 Day Target 99.27% 99.91% 8

93 OFFICIAL 5. Statement of financial position Table 8 shows the month 8 statement of financial position for the CCG. Table 8 Statement of Financial Position Nov-17 Oct-17 Movement 000's 000's 000's Non Current Assets Property, plmnt Mnd equipment (2) IntMngiNle Assets OtOer FinMnciMl Assets TotMl Non Current Assets (2) Current Assets TrMde Mnd otoer ReceivMNles 2,554 2, PrepMyments & Accrued Income/Provision for NMd dent 1,163 3,076 (1,913) CMsO Mnd cmso equivmlents (254) TotMl Current Assets 3,753 5,834 (2,081) TotMl Assets 3,803 5,886 (2,083) Current LiMNilities TrMde Mnd otoer pmymnles (6,280) (5,991) (289) AccruMls (14,329) (17,417) 3,088 OtOer limnilities Provisions Borrowings TotMl Current LiMNilities (20,609) (23,408) 2,799 Non-Current Assets plus/less Net Current Assets/LiMNilities (16,806) (17,522) 716 Non-Current limnilities OtOer limnilities Provisions Borrowings TotMl Non-Current LiMNilities TOTAL ASSETS EMPLOYED (16,806) (17,522) 716 FinMnced Ny TMxpMyers Equity CMpitMl & Reserves GenerMl Fund (16,806) (17,522) 716 RevMluMtion Reserve OtOer reserves TOTAL TAXPAYERS EQUITY (16,806) (17,522) Efficiency Savings Plan The financial plan for the year is based on the delivery of a 2m in year surplus control total. This control total is predicated on delivering 12.2m efficiency savings. At month 8 it is forecast that 11.7m will be delivered during the financial year. Table 9 Efficiency Savings Plan Scheme Name 17/18 YTD Plan 000's 17/18 YTD Actual 000's 17/18 YTD Variance 000's 17/18 Plan 000's 17/18 Forecast 000's 17/18 Forecast Variance 000's Older People & People with Complex Needs 1,862 2, ,391 3,901 1,511 Prescribing 1,630 1, ,534 2,373 (161) System Pathways 1,524 1, ,231 2, Transactional 665 1, ,705 2,145 (1,560) Urgent Care Access (21) (135) Primary Care Strategy (77) (321) 6,110 7,953 1,843 12,181 11,682 (499) 7. Risks and mitigation strategies Table 10 lays out potential risks and mitigations. The table shows that the CCG has sufficient mitigation to manage the current view of potential risk. 9

94 OFFICIAL Table 10 - Financial risks Risk Value m Risks Acute SLA 2.30 MH SLA 0.00 QIPP underdelivery 1.30 Other Risks 0.00 Total Risks 3.60 Mitigations Contingency Held 1.60 Contract Reserves 2.00 Other mitigations 0.00 Total Mitigations 3.60 Net Risk Recommendations The Governing Body are asked to acknowledge the contents of this report. Report author: Jeff Goldthorpe Head of Finance Report date: 28 December

95 OFFICIAL Governance and Compliance 1. Links to corporate objectives 2017/18 corporate objectives Item links to objectives 1. Commission high quality care for patients, that is safe, value for money and in line with the NHS Constitution 2. Deliver the Financial Recovery Plan, leading to the achievement of the CCG s statutory financial duties and future sustainability 3. Work collaboratively with partners and stakeholders to develop health and social care fit for the future in North Tyneside 4. Continue to develop North Tyneside CCG as a patient focused, clinically led commissioning organisation with a continuous learning culture 2. Consultation and engagement Not applicable 3. Resource implications The CCG has a revenue resource limit, and expenditure needs to be managed within this, however the CCG is reporting a 19.3m deficit. 4. Risks Refer to section Equality assessment Not applicable. 6. Environment and sustainability assessment Not applicable. 11

96 Official Report to: Governing Body Date: 23 January 2018 Agenda item: 11.2a Title of report: North Tyneside Falls Strategy Sponsor: Dr Lesley Young-Murphy, Executive Director of Nursing: Chief Operating Officer, NHS North Tyneside CCG Author: Gary Charlton, Commissioning Development Manager and Dr Alex Kent, GP Commissioning Fellow, NHS North Tyneside CCG Purpose of the report and action required: Ratification of the strategy and the ambitions set within. Executive summary: North Tyneside Fall Strategy sets out the system commitment and plans for reducing the rate of falls and harm from falling in North Tyneside which is led by North Tyneside CCG. It sets out our current situation, strategic priorities, required service developments, ambitions and key actions. Falls have a dramatic impact on individuals, families and the health and social care system. More people are falling in North Tyneside compared with other areas which has remained largely unchanged over the past four years. There are on average of people over 65 admitted to hospital with a fall each month which costs an average of 4.7 million each year. This doesn t include the cost of social care or money that families pay for care or the unnecessary physical and emotional suffering that a fall can cause for the person and their family. Falling is not an inevitable part of growing old and can be prevented by organisations and the public working together. North Tyneside partners from Health, Social Care, Private and Voluntary Organisations, North Tyneside CCG, North Tyneside Council and The Tyne & Wear Fire Service are committed to working together to support people to age well in North Tyneside, to not only to live longer but to extend their lives in good health and maintain functional ability and independence. The impact of the strategy will be measured by a year on year reduction in people being admitted with a fractured neck of femur and a reduction of people falling whilst in Hospital, Nursing Homes or Care Homes. Together we aim to: Ensure that the population understand what they can do to age well and reduce their risk of falls. Prevent frailty, promote bone health and reduce falls and injuries Early intervention to restore independence Respond to the first fracture and prevent the second Improve patient outcomes and increase efficiency of care after hip fracture Together we aspire to create a fall free North Tyneside. Page 1 of 2

97 Official Governance and Compliance 1. Links to corporate objectives 2017/18 corporate objectives Item links to objectives 1. Commission high quality care for patients, that is safe, value for money and in line with the NHS Constitution 2. Deliver the Financial Recovery Plan, leading to the achievement of the CCG s statutory financial duties and future sustainability 3. Work collaboratively with partners and stakeholders to develop health and social care fit for the future in North Tyneside 4. Continue to develop North Tyneside CCG as a patient focused, clinically led commissioning organisation with a continuous learning culture Page 2 of 2

98 North Tyneside Falls Strategy

99 Contents Foreword Introduction Where are we now? AHSN data Improving Bone Health and Fracture Prevention Current service provision Best practice Community falls Inpatient falls Hip fracture care Fragility fracture Population based strategies Strategy Draft Falls Action Plan References

100 Foreword Falls have a dramatic impact on individuals, families and the health and social care system. More people are falling in North Tyneside compared with other areas which has remained largely unchanged over the past four years. There are on average of people over 65 admitted to hospital with a fall each month which costs an average of 4.7 million each year. This doesn t include the cost of social care or money that families pay for care or the unnecessary physical and emotional suffering that a fall can cause for the person and their family. Falling is not an inevitable part of growing old and can be prevented by organisations and the public working together. North Tyneside partners from Health, Social Care, Private and Voluntary Organisations, North Tyneside CCG, North Tyneside Council and The Tyne & Wear Fire Service are committed to working together to support people to age well in North Tyneside, to not only to live longer but to extend their lives in good health and maintain functional ability and independence. The impact of the strategy will be measured by a year on year reduction in people being admitted with a fractured neck of femur and a reduction of people falling whilst in Hospital, Nursing Homes or Care Homes. Together we aim to: Ensure that the population understand what they can do to age well and reduce their risk of falls. Prevent frailty, promote bone health and reduce falls and injuries Early intervention to restore independence Respond to the first fracture and prevent the second Improve patient outcomes and increase efficiency of care after hip fracture Together we aspire to create a fall free North Tyneside. Dr Lesley Young- Murphy Exec Director of Nursing: Chief Operating Officer North Tyneside CCG Jacqui Old Director of Adult & Childrens Services North Tyneside Council 3

101 1. Introduction Falls and related injuries are a significant problem for older people. Falls are common - 30% of over 65 s and 50% of over 80 s will have at least one fall in a year. 1 Falls lead to physical injuries ranging from cuts and bruises to fractures and head injuries. 5% of falls in older people in the community result in hospital admission, 10-25% of falls in nursing homes and hospital result in a fracture. 1 Falls can also lead to adverse psychosocial outcomes contributing to loss of confidence and independence. Falls can also be a sign of underlying health issues or frailty. Falls in England lead to 255,000 emergency hospital admission per annum and are estimated to cost the NHS 2.3 billion a year. 2 In North Tyneside 1461 patients aged over 65 were admitted due to falls in 2016/17 at a cost of 4.7 million and this figure is increasing. We are a national and regional outlier for falls. Hip fracture is one of the most serious consequences of falls in the elderly. Hip fracture mortality is 10% at one month and 30% at one year. There is also significant morbidity with only 50% returning to their previous level of mobility and 10 20% of patients being discharged to nursing or residential care. 3 Osteoporosis is a common condition affecting 2% of the population at 50 and 25% at 80 years of age. Osteoporosis increases bone fragility and susceptibility to fracture. 180,000 fractures per annum in England and Wales are as a result of osteoporosis and 14,000 deaths result from osteoporotic hip fractures. Direct medical costs from fragility fracture were estimated at 1.8 billion per annum nationally and this is projected to rise. Treatment can reduce the risk of fragility fracture and its complications. 4, 5 Evidence suggests that the number of falls can be reduced by up to 30% through development of a multi-agency falls pathway focussing on early identification and prevention, and multi-factorial assessment and intervention for people at high risk of falling. There is good evidence that a range of interventions can reduce falls and consequent injuries and also provide good return on investment. 1 This strategy sets out how North Tyneside will reduce falls in older people and address known gaps in local services. The strategy is in line with current NICE guidelines, the National Falls Prevention Coordination Group/ Public health England Falls and Fractures consensus statement and the Department of Health National Service Framework for Older People. 4

102 2. Where are we now? The following figures identify admissions due to falls in the over 65+ age group over the past 4 years. Figure 1 Number of admissions due to falls in the 65+ age group. The numbers in falls for over 65 s in North Tyneside has followed a similar pattern over the last four years, averaging between 115 to 140 falls per month with no significant improvements being made. Figure 2 Admissions rate per 1,000 in the 65+ age group 2016/17 When looking at admissions per rate of 1,000 in the 65+ age group, for the period 2016/17, North Tyneside had a highest aggregate in the North East. 5

103 Figure Three Admissions due to falls in the 65+ age group by age and gender The data shows that for the past three years, the majority of admissions from falls has come from those patients aged 80+ and similarly two thirds of fallers have been female. Figure Four Primary reason for admission (65+) 6

104 The data shows that for the past three years, the primary reasons for admission (65+) has not changed with injuries to the head, hip and thigh continuing results in the highest percentage of admissions due to falls. 3. AHSN data Improving Bone Health and Fracture Prevention Analysis of 2015 data from the report AHSN Falls and Fractures Profile suggests that North Tyneside has vast opportunities for improving bone health and fracture prevention. The data in the report highlights the following: What the data is telling us about our providers Surgery: NHCFT significantly better for % of patients undergoing surgery within 48 hours of EA for hip fracture Pre-Op: NHCFT have the 4 th shortest (nationally) for pre-op avg. LOS for hip fracture Admission: NHCFT in top quartile (nationally) for % of cases admitted to an orthopaedic ward within 4 hours of presenting to A&E Discharge: NHCFT in top quartile (nationally) for % not to have developed a pressure ulcer Post-Op: NHCFT and NUTH post-op avg. LOS are both higher than national average Admission: NUTH in lowest quartile (nationally) for % of cases admitted to an orthopaedic ward within 4 hours of presenting to A&E Discharge: NUTH in lowest quartile (nationally) for % not to have developed a pressure ulcer Readmission: NHCFT ratio within 30 days for hip fracture higher than national average and highest in region Mortality: NHCFT significant outlier for mortality (SHMI) for hip fracture North Tyneside Provider Analysis Northumbria The data suggests that hip fracture patients at NHCFT will receive shorter waiting times on admission, a shorter length of stay pre-op, are more likely to undergo surgery with 48 hours and are less likely to develop a pressure ulcer after discharge. This however is countered by the suggestion that a patients post-op stay is likely to be longer and that they are more likely to be readmitted within 30 days. NHCFT is also a significant outlier with regards to mortality for hip fracture. In summary, the data suggests (although not validated) that acute care for hip fracture is excellent although post-op and readmissions concerns suggest that the care in the community may be limited and not of the same quality. Newcastle Issues arising across all elements of care although none of statistical significance. Poor conversion rate from admission to orthopaedic ward is further compounded with longer post-op length of stay and a greater chance of developing a pressure ulcer after discharge. What the data is telling us about our District and Unitary Authority area North Tyneside is a statistically significant outlier for % of physically inactive adults. This is the same for the North East as a whole 7

105 North Tyneside is a statistically significant outlier for emergency admissions for injuries due to falls in people aged over 65, which is also the highest in the North East. Falls in North Tyneside were comparable nationally in 2013/14 but have since risen. North Tyneside is a statistically significant outlier for emergency admissions for injuries due to falls in people aged 65-79, which is also the highest in the North East. North Tyneside is a statistically significant outlier for emergency admissions for injuries due to falls in people aged 80+, and again highest in the North East North Tyneside is a statistically significant outlier for emergency admissions for hip fractures in people aged 65 and over although this has slightly improved, year on year, over the last 3 years (2012/15). North Tyneside is a statistically significant outlier for emergency admissions for hip fractures in people aged and the worst in the region. In comparison to looking at just 65 and over data, this has got worse, year on year, over the last 3 years (2012/15). This is because, emergency admissions for hip fractures in people over 80 is showing improvements. There may be rationale here for the age category (65-79) being the prioritised target group? NHCFT reported a higher percentage of admissions with injuries due to falls (aged 65+) with a secondary diagnosis of dementia and/or delirium than the national average for both 14/15 and 15/16. North Tyneside is a statistically significant outlier for % of patients aged 75+, with a fragility fracture on or after 01/04/14, who are currently treated with an appropriate bone-sparing agent North Tyneside has the greatest spend on prescribing of Osteoporosis medicines by CCG in the North East region. The biggest spend is in Alendronic Acid and we ve spend 38k more than our neighbouring CCGs The expected annual cost of falls in North Tyneside is circa. 5.2 million North Tyneside District and Unitary Authority Analysis North Tyneside is an outlier for bone health and fracture prevention across the board although it may be prudent to prioritise: Focus on the age group for admissions due to falls. This is where the most activity has been. The over 80 s cohort has remained fairly stagnant. Patients aged 75 plus for fragility fracture who are currently treated by an appropriate bonesparing agent. The AHSN Bone Health programme should help with this? Prescribing. In comparison to our peers it looks like we are over prescribing medication. This may be because of the lack of social prescribing available to this cohort of patients. 8

106 4. Current service provision A meeting with stakeholders to look at current service provision found that there are a number of services available for people who had fallen or were at risk of falling. However, there are also a number of gaps in the current falls service provision in North Tyneside and there is a lack of integration of services. In terms of identifying at patients at risk of falling a number of agencies hold data on falls and frailty (GPs, secondary care, Care Call, social care, NEAS, the fire service and community nursing teams) but this information is not being shared and utilised. Northumbria Healthcare trust are also making efforts to screen patients presenting to A+E or Urgent care centres. All patients aged over 65 are asked if they have fallen in the last year and if so referred on to the hospital falls clinic. This clinic has limited capacity and is likely better utilised for more complex patients. For patients who have fallen or are identified as being at risk of falling there are a number of services available. These include Exercise schemes o North Tyneside council have worked alongside Northumbria University on an exercise programme for patients in assisted living/ sheltered accommodation units. o Age UK offer fitness classes. Inpatient falls Northumbria FT has a falls strategy in place for inpatient falls management. This includes a review by a falls nurse for the majority of patients, an MDT assessment and datix completion for every fall. Data from inpatient falls is coded but not always communicated to the GP on discharge. Hospital consultant led falls clinic sees GP referrals and patients referred following admission/ A+E attendance. The community nurses have developed their own brief assessment and intervention. Routine GP workload Care Plus frailty team covering a limited area AART team provide community assessment and therapy input. Community reablement and rehab teams Intermediate care and rehab beds are available. Care homes and domiciliary care agencies in the area have their own tools and strategies for assessing falls risk. Care Call - Council community alarm and telecare service offers a range of telecare options and lifestyle monitoring to help prevent falls and support people who are at risk of falls 9

107 5. Best practice Community falls NICE guideline CG161 published in 2013 sets out current best practice for assessing falls risk and falls prevention in older people. 1 Case/ risk identification o Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and if so the details of the fall/s o Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance. Multifactorial falls risk assessment o Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. o Multifactorial assessment may include identification of falls history assessment of gait, balance and mobility, and muscle weakness assessment of osteoporosis risk assessment of the older person's perceived functional ability and fear relating to falling assessment of visual impairment assessment of cognitive impairment and neurological examination assessment of urinary incontinence assessment of home hazards cardiovascular examination and medication review. Multifactorial interventions o Strength and balance training o Home hazard assessment and intervention o Vision assessment and referral o Medication review with modification/ withdrawal. o Cardiac pacing o Encourage participation of older people in falls prevention programmes o Education and information giving Inpatient falls NICE guideline CG161 recommends: - Consider all patients aged over 65 or aged who are judged by a clinician to be at higher risk of falling because of an underlying condition to be at risk of falling. Consider multifactorial assessment and intervention in the cohort. Ensure that aspects of the inpatient environment that could contribute to falls are identified and modified. 1 10

108 Hip fracture care The Blue Book sponsored by the British Orthopaedic Association and the British Geriatric Association summarises current best practice. 1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation 2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, and during normal working hours 3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer 4. All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of admission 5. All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures 6. All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls Fragility fracture NICE guideline CG146 Osteoporosis: assessing the risk of fragility fracture set out current best practice. This recommends identification of high risk groups of people to assess fragility fracture risk. These include all women over 65 and all men over 75 and also younger individuals who have additional risk factors for osteoporosis. To assess an individual s fragility fracture risk consider using online risk calculators (Qfracture of FRAX) and arrange DXA scan as required. Also assess for vitamin D deficiency and calcium intake. Exclude non- osteoporotic causes of fragility fracture such as metastatic disease, multiple myeloma, osteomalacia, Paget s disease. Following assessment risk is determined to be high, medium or low and drug treatment with bisphosphonate, calcium and vitamin D may be indicated. Patients should also be advised to exercise regularly, eat a balanced diet, stop smoking and drink no more than recommended limits. The NOGG guidelines recommend treatment without assessment for women who have had a previous fragility fracture, people over 70 years of age who are taking high dose corticosteroids. Once started on bisphosphonates annual medication review should include enquiry into adherence and side effects. The ongoing need for treatment should be reviewed after 3-5 years with a repeat DXA scan. For people at high risk of fracture treatment can be continued for up to 10 years. Patients at intermediate risk of fracture should have repeat DXA scanning after 2 years. 6 Population based strategies For the elderly, muscle weakness, physical inactivity and balance impairment increase the likelihood of falling. Environmental risk factors such as poor housing can also contribute towards an increased risk of falling. Being physically inactive, poor work posture, repetitive movements, weak muscles and joints contribute towards MSK conditions. 11

109 Secondary prevention aims to reduce the impact of a disease or injury that has already occurred. This is done by detecting and treating disease or injury as soon as possible to halt or slow its progress, encouraging personal strategies to prevent reinjury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems. The most recent Cochrane systematic review considered the effectiveness of a number of typical fall reducing interventions amongst the over 65s 7. Multiple-component group exercise Multifactorial interventions Home Safety Interventions Withdrawal of Medications Education interventions Conclusions from this systematic review reported that; there is strong evidence that certain exercise programmes prevent falls. Group exercise classes and exercises individually delivered at home reduce rate of falls and risk of falling. The systematic review found that group exercise reduced the rate of falls by 29% and the risk of falling by 15%. Home-based exercise reduced the rate of falls by 32% and the risk of falls by 22%. Multifactorial interventions integrating assessment with individualised intervention, usually involving a multidisciplinary team, are effective in reducing rate of falls but not risk of falling. The Cochrane Collaboration systematic review found that risk assessment followed by a multifactorial intervention reduced the rate of falls by 24%. Home safety interventions reduce rate of falls by 19% and risk of falling by 12%. These interventions are more effective in people at higher risk of falling, and when delivered by an occupational therapist. NICE recommends that older people who have received treatment in hospital following a fall should be offered a home hazard assessment carried out by a suitably trained healthcare professional, such as an occupational therapist, followed by necessary safety interventions/modifications 2. There is limited evidence for the effectiveness of interventions targeting medications (e.g. withdrawal of psychotropic medications, educational programmes for family physicians). The evidence relating to the provision of educational materials alone for preventing falls is inconclusive. There was some, although limited, evidence that falls prevention strategies can be cost-saving. The results indicate that, to obtain maximum value for money, effective strategies need to be targeted at particular subgroups of older people. Public Health England recommends that fall prevention interventions should form part of a whole system approach taking place right across the patient pathway. Commissioners, when designing services should take into account the following 3 : An effective mechanism to respond to fallers and to case find those at risk: Local areas are recommended to agree systems and services for responding promptly to a fall, which help 12

110 the person who has fallen to get up from the floor where appropriate, and ensure assessment and onward referral to avoid hospital attendance and admission if possible. Assessment of fracture risk is considered in all women aged 65 and over, all men aged 70, and for men and women younger than this in the presence of risk factors and that fracture liaison services aim to identify all patients aged 50 and over with a fragility fracture. Older people coming into contact with professionals and organisations which have health and care as part of their remit should be asked routinely about falls. Older people reporting a fall or at risk of falling should be observed for balance and gait deficits and considered for risk assessment and risk reduction interventions ii. Comprehensive evidence based risk assessment should be carried out by a trained healthcare professional for people identified via case finding that are potentially at high risk of falls or fractures. 4 That there is a range of falls prevention services: Including specialist falls services or services that include a component of falls prevention such as frailty services/pathways. A specialist falls service might involve a single point of access for referrals, multifactorial interventions, and strength and balance exercise programmes. It is important to note that services focussing solely on frailty will not necessarily target older people with low to moderate falls risk. Prevention is embedded: Embedded prevention covers case finding, developing workforce competencies in areas such as motivational interviewing and making every contact count, the delivery of brief interventions promoting physical activity, and incorporating strength and balance training into physical activity services. Services that reduce exposure to relevant risk factors such as smoking cessation, alcohol, and dietetic services should be acknowledged as improving bone health and reducing falls risk. Improving quality: Being clear and evidenced based in service specifications for example; all strength and balance programmes should take place for two or more hours per week for a total of 50 hours or more, involve highly challenging balance training and progressive strength training 8, 9. Environmental factors Studies have reported that between 20 and 50% of falls among community dwelling older people are due to environmental causes including poor lighting, slippery floors, degraded pavements and uneven surfaces. 10 In the Highways Act 1980 Section 41 there is a requirement which places a duty on the highway authority to maintain highways maintainable at public expense. Whilst there is no prescriptive description for how the highways should be maintained each highway authority should introduce a highway safety inspection procedure to monitor the performance of the highways. 13

111 6. Strategy Aim To reduce falls and fracture risk and ensure effective treatment, rehabilitation and secondary prevention for those who have fallen. To promote independence and support people to age well in North Tyneside. Objectives Ensure that the population understand what they can do to reduce their risk of falls. Prevent frailty, promote bone health and reduce falls and injuries Early intervention to restore independence Respond to the first fracture and prevent the second Improve patient outcomes and increase efficiency of care after hip fracture 14

112 Key priorities: Prevent frailty, promote bone health and reduce falls and injuries Promote health ageing: Public health campaigns healthy lifestyle choices Promote physical activity Local authority exercise classes Structured approach to case finding/ proactive identification of at risk individuals: AHSN bone health tool Electronic frailty index Screening of all patients over 65 have you had a fall in the last 12 months establish as routine practice in primary and secondary care Direct referral into community falls service by NEAS, fire service, community nursing teams, social care, Care Call, domiciliary workers, patients and their friends or relatives. Proactive management of frailty: Care Plus GP annual review Communications and engagement: Falls prevention/ awareness campaign work with North Tyneside patient forum Falls free North Tyneside campaign Promote self-management of chronic disease Education for healthcare professionals o Primary care staff (clinical and non-clinical) o Secondary care staff include falls prevention in induction and rolling education programmes o High risk environments (care home staff) o Community carers and nursing staff Multifactorial falls risk assessment and interventions. Home hazards: Work with fire service to identify and modify home hazards Exercise: Age UK fitness classes Local authority fitness classes Falling on your Feet Dance Programme Environmental factors 15

113 Additional monies are being invested in North Tyneside by the Mayor and Cabinet to carry out a planned improvement programme of works on the borough s footways. Using local knowledge and intelligence sources illustrated above, we can ensure we target our works to improve the movement of highway users in and around the borough. There is a programme of footway improvements works currently being prepared. Once the programme of improvement works has been agreed the work will commence. Early intervention to restore independence In North Tyneside there is currently no community falls service and no integrated falls pathway. In other areas these have been shown to be a cost effective way of reducing falls in other areas. Develop an integrated falls pathway and community falls service with easy to access multifactorial assessment and intervention: Single point of access for referrals Offer a standardised multifactorial assessment as per NICE guidelines Assess bone health and treat at risk patients as per guidelines Direct referral for multifactorial intervention as per NICE guidelines o Strength and balance training. o Exercise classes o Education and training coordinated falls education programme o Cardiac pacing. o Modification of environmental hazards Fire service, Care Call o Medication review Develop fracture liaison service to identify fragility fractures and ensure appropriate investigation/ prescription/ communication with GP. The North Tyneside Health Economy has 3 ambitions relating to early intervention to restore independence: Ambition 1: 100% of patients seen in the falls clinic within 3 months of first fall Ambition 2: Reduce the number of inpatient falls Ambition 3: Reduction in the number of admissions for falls in patients aged >65 16

114 Respond to the first fracture and prevent the second Ensure robust systems are in place to identify all fragility fracture patients presenting to MIU/ A+E and that this is communicated with GP and the patient. Develop a fracture liaison service to identify patients who have suffered fragility fracture and ensure they have the correct investigations +/- treatment and follow up arrangement. Improve mechanisms for review of patients on bone protection: Develop a template for use in the community when following up patients with osteoporosis Fracture liaison service for advice on bone health Direct referral into the community falls service for patients who suffer fragility fracture. Reduce inpatient fractures. The North Tyneside Health Economy has one ambitions relating to respond to the first fracture and prevent the second Ambition: reduction in % of patients aged >75 sustaining a fracture Improve patient outcomes and increase efficiency of care after hip fracture Follow blue book standards with continual evaluation of service provision against these standards. Develop fracture liaison service to ensure fragility fractures are identified and information on bone protection is communicated on discharge summaries/ fracture clinic letters. Ensure all hip fracture patients are able to access the community falls service and multifactorial assessment/ interventions. Ensure multifactorial assessment and interventions as appropriate. Training for community staff for care post fracture. The North Tyneside Health Economy has one ambitions relating to improve patient outcomes and increase efficiency of care after hip fracture Ambition: increase in % of patients returning to usual place of residence 17

115 7. Draft Falls Action Plan 18

116 Appendix One Falls Pathway 19

117 8. References 1. NICE (2013). Falls in older people: assessing risk and prevention. NICE Clinical guideline [CG161] Public Health England (2017). Falls and fracture consensus statement. Supporting commissioning for prevention. Produced by Public Health England with the National Falls Prevention Coordination Group member organisations 3. Lisk, R., & Yeong, K. (2014). Reducing mortality from hip fractures: a systematic quality improvement programme. BMJ Quality Improvement Reports, 3(1), u w NICE (2012). Osteoporosis: assessing the risk of fragility fracture Clinical guideline CG British Orthopaedic Association (2007). The care of patients with fragility fracture NOGG (2017). Clinical guideline for the prevention and treatment of osteoporosis Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. Interventions for preventing falls in older people living in the community. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2012 Available from: onlinelibrary.wiley.com/doi/ / cd pub3/abstract 8. Sherrington C, Tiedemann A, Fairhall N, Close JCT, Lord SR. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. New South Wales Public Health Bull [Internet] Jun; 22(3 4): Available from: 9. Charters A, Age UK. Falls Prevention Exercise following the evidence [Internet]. Age UK; Available from: Todd C, Skelton D. (2004) What are the main risk factors for falls among older people and what are the most effective interventions to prevent these falls? Copenhagen, WHO Regional Office for Europe (Health Evidence Network report; accessed 14/9/17) 11. Department of Health (2009). Falls and Fractures: Effective interventions in health and social care. Falls and Fractures 20

118 Falls Strategy for: North Tyneside Health and Social Care Economy Developed and published by North Tyneside Clinical Commissioning Group, in conjunction with North Tyneside Local Authority. 12 Hedley Court Orion Business Park Tyne Tunnel Trading Estate North Shields NE29 7ST Contact: Gary Charlton, Commissioning Development Manager or Dr Alex Kent, GP Commissioning Fellow Direct Line: or Version: 4.2 Last amended by: Gary Charlton Date amended: 30 th October 2017 Approval Process Name of Group Date Comments North Tyneside Falls Group 4 th July 2017 Ratified North Tyneside CCG Governing 26 th September 2017 Verbal update Body 23 rd January 2018 Final version to be ratified North Tyneside Local Authority To be confirmed Health & Wellbeing Board To be confirmed 21

119 Official Report to: Governing Body Date: 23 January 2018 Agenda item: 13.1a Title of report: Risk Assurance Framework Sponsor: Dr Lesley Young-Murphy, Executive Nurse and Chief Operating Officer Author: Irene Walker, Head of Governance Purpose of the report and action required: Governing Body is asked to review and receive the Risk Assurance Framework (RAF) Q3 17/18, with a particular focus on extreme and high risks. Executive summary: The Governing Body has overall responsibility for governance, assurance and management of risk. The Governing Body has a duty to assure itself that the organisation has properly identified the risks it faces and that it has controls in place to mitigate those risks to a level consistent with the CCG s risk appetite and that appropriate assurances are in place. The RAF is reviewed by the responsible committees (i.e. Finance Committee, Quality & Safety Committee and Clinical Executive Committee). Audit Committee then receives the RAF for review to enable it to provide assurance to Governing Body that risks are properly identified, assessed and effectively managed and that appropriate sources of assurance exist. The RAF which is aligned to the corporate objectives is attached at Annex 1. Action Governing Body is asked to review and receive the RAF with a particular focus on extreme and high risks (which are highlighted in the Heat Map - Appendix 1 below). Governance and Compliance 1. Links to corporate objectives 2017/18 corporate objectives Item links to objectives 1. Commission high quality care for patients, that is safe, value for money and in line with the NHS Constitution 2. Deliver the Financial Recovery Plan, leading to the achievement of the CCG s statutory financial duties and future sustainability 3. Work collaboratively with partners and stakeholders to develop health and social care fit for the future in North Tyneside

120 Official 4. Continue to develop North Tyneside CCG as a patient focused, clinically led commissioning organisation with a continuous learning culture 2. Consultation and engagement The RAF is presented quarterly to Finance Committee, Quality & Safety Committee, Clinical Executive Committee and Audit Committee for consideration ahead of submission to Governing Body. 3. Resource implications The management of risk is continuous and inherent within day to day management of business. 4. Risks The risk of not identifying and managing risk effectively is failure to deliver statutory requirements and the CCG s corporate objectives. 5. Equality assessment Consideration of equalities issues is inherent as part of the CCG assessing its risks. 6. Environment and sustainability assessment Consideration of environmental issues is inherent as part of the CCG assessing its risks.

121 Risk Matrix Official Appendix 1 Residual Risk Score Impact score Likelihood Negligible Minor Moderate Major 5 Catastrophic 5 Almost Certain 4 Likely 108/109/110/112 3 Possible 106/202/203/ /201/302/406/111 2 Unlikely 101/103/104/105/ /205/401/403/ Rare 206 Target Risk Score Impact score Likelihood Negligible Minor Moderate Major 5 Catastrophic 5 Almost Certain 4 Likely 3 Possible 106/202/ /112 2 Unlikely Rare /104/105/107/109/111/ 204/205/302/401/403/ /108/110/201/404/ 406

122 North Tyneside CCG Risk Assurance Framework Date 16/1/18 Version 3-0 Committee/Date Governing Body 23 January 2018 Note Levels of assurance are indicated in brackets e.g. (1)(2)(3) Date entered Risk Ref Responsible Director/Risk owner Strategic S Corporate C Risk Description Consequence Likelihood Initial Score Controls Detail Gaps in Controls Assurance Gaps in Assurance Actions Consequence Likelihood Residual Score Review Date Target Risk Score Corporate Objective 02/05/ (was 75) Chief Finance Officer/ Performance & Commissioning Manager S Risk of failure to clearly demonstrate compliance with NHS Constitution rights and pledges CCG Constitution reflects NHS Constitution Regular Provider performance management meetings Monthly performance reporting to Clinical Executive, with corrective actions identified and followed up Regular performance reports to Governing Body Annual report of year-end performance against NHS Constitution targets Monthly performance reports to Commissioning, Performance and Finance Committee, to align performance issues with contracting discussion NHS constitution measures included in the penalty schedule within provider contracts No Primary Care Streaming in A&E Comms & Engagement subcommittee minutes covering periodic review of CCG website (1) Notes of Provider performance management meetings (1) Performance reporting to Clinical Executive and minutes of those meetings (2) Performance reports to Governing Body and minutes of those meetings (2) CCG Annual Report and Annual Public Meeting (1) Internal Audit review of Performance Management NTC 1617/10 gave significant assurance (issued Jan 17) (3) Notes of Commissioning, Performance and Finance Meetings (1) Penalty schedule monthly (1) Minutes of QRG monitoring of ECIP action plan (2) Inadequate assurance relating to ECIP action plan Assurance required from A&E Delivery Board NSECH Director to attend Governing Body /3/ /05/ (was 188) Executive Director of Nursing & Chief Operating Officer/ Deputy Director of Nursing, Quality & Safety C Risk of inadequate procedures for Health Care Acquired Infection (HCAI) resulting in a patients contracting an avoidable infection which could prove fatal NTCCG is an active member of the formal control of infection partnership, covering Gateshead and North of the Tyne HCAI is a standard agenda item for Quality Review Groups Robust arrangements evidenced in FTs including FT Infection Protection and Prevention Control meetings and HCAI Action Plans CCG has received and reviewed FT HCAI action plans; HCAI is included in provider contract monitoring meetings CCG HCAI action plan in place, approved by Quality and Safety Committee, refreshed as required HCAI regularly reported to CCG Quality and Safety Committee, escalated to Governing Body as required HCAI included in quality and performance reports to Governing Body NECS producing weekly update reports Overarching action plan in place for e-coli management New e-coli trajectory approved New e-coli trajectory required (targets have been submitted by CCG and FTs awaiting NHSE approval) Agenda and notes of the control of infection Partnership (2) Agenda and notes of Quality Review Groups (2) CCG records of FT Infection Protection and Prevention Control meetings and HCAI Action Plans (1) Agenda and notes of CCG Quality and Safety Committee and Governing Body (2) Quality and performance reports to Governing Body (2) Internal Audit review NTC 1516/13: Quality Assurance and Improvement provided Significant Assurance with no issues of note (issued March 2016) (3) Performance remains within trajectory. (1) /3/ /05/ (was 189) Executive Director of Nursing & Chief Operating Officer/ Deputy Director of Nursing, Quality & Safety S Risk of commissioning services that are not of sufficiently high quality Standard NHS Contracts in place with NHS Providers - joint contract with local authority for domiciliary services & nursing homes Regular Provider performance management meetings CCG is an active member of the Quality Review Groups (QRG) Specific quality issues are actively performance managed (e.g. ambulance handover delays) and reported to QRG and CCG Quality and Safety Committee, escalated as appropriate Regular quality reports to Quality and Safety Contract documentation /17 contracts are currently in the process of being signed, and include quality standards (1) Notes of contract monitoring meetings (1) Notes of Quality Review Groups, received by Quality and Safety Committee (2) Quality and performance reports to Quality and Safety Committee (2) Minutes of Quality and Safety Committee and Governing Body (2) FT Quality Accounts are published and include CCG comments (1) /3/

123 North Tyneside CCG Risk Assurance Framework Date entered Risk Ref Responsible Director/Risk owner Strategic S Corporate C Risk Description Consequence Likelihood Initial Score Controls Detail Gaps in Controls Assurance Gaps in Assurance Actions Consequence Likelihood Residual Score Review Date Target Risk Score Corporate Objective Committee and to Governing Body Quality issues in Nursing Homes and other CHC care settings are actively monitored and reported to Quality and Safety Committee CCG sign off annual FT Quality Accounts Working in partnership with Local Authority to monitor and improve quality of care in Nursing Homes Working in partnership with Local Authority to monitor and improve quality of services to people with learning disabilities, including implementing the national programme of work on 'transforming services' Structured approach to capturing and acting on soft intelligence Programme of announced and unannounced visits to all providers arranged Quality of care in Nursing Homes subject of regular reports to Quality and Safety Committee (1) Quality of care for people with learning disabilities subject of regular reports to Quality and Safety Committee, Clinical Executive and Governing Body, including progress on 'transforming services' (1) Systematic approach to capturing soft intelligence includes the patient forum (minute and reported to Governing Body), SIRMS (information collated and reported to Q&S committee), Practice nurse forum (notes), feedback from complaints and MP letters (reported to Q&S committee) (1) Internal Audit review NTC 1516/13: Quality Assurance and Improvement provided Significant Assurance with no issues of note (issued March 2016) (3) CQC inspection reports (3) Serious Incident (SI) review panels (1) Internal Audit 15/16 Service Reconfiguration substantial assurance (3) Internal Audit of Serious Incidents NT1617/03 substantial assurance (August 2016) (3) Internal Audit NTC Quality of Commissioned Services - Substantial assurance (3) 16/11/15 16/11/ (was 538) 105 (was 541) Executive Director of Nursing & Chief Operating Officer/ Deputy Director of Nursing, Quality & Safety Chief Officer/ Director of Contracting & Commissioning C C Risk of unexpected and unacceptable decline in quality of services due to focus on Financial Recovery Plan Risk of short term finance pressures overriding the need to deliver sustainable solutions Quality and Safety Committee has a robust programme of work to maintain a focus on quality of services Q&S committee provide regular reports to the Governing Body, providing assurance on quality matters CCG is an active participant in Quality Review Groups, Safeguarding Boards and other formal and informal quality fora, continuing to give this work a high priority Executive Director of Nursing and Transformation and Medical Director have a continuing commitment to maintaining and where possible improving quality of services In the FRP, QIPP schemes are subject to a Quality Impact Assessment, with an escalation process in place where concerns are raised about quality issues Completion of a Quality Impact Assessment (QIA) for every QIPP Project. PoaP for each QIPP project is signed off by Clinical Sponsor and Executive Director. Permanent Chief Finance Officer appointed CCG Governing Body, Clinical Executive and other key committees balance the imperative to deliver financial recovery alongside longer term sustainable health and social care services CCG meetings with NHS England Team consider both immediate issues, forecast end of year position and development of medium term plans CCG programme of work focused on service Q&S cycle of business, agenda, papers and minutes of Q&S meetings (2) Q&S written and verbal reports to Governing Body meetings (1) Minutes of QRGs, Safeguarding Boards, CHC panels, Health Care Acquired Infection committee, Medicines Optimisation committee (2) Role descriptions in CCG Constitution and Job Descriptions for Executive Director of Nursing and Transformation and Medical Director (1) Completed Quality Impact Assessments for QIPP schemes and follow up actions (1) Internal Audit of NTC 1516/13: Quality Assurance and Improvement gave significant assurance (issued March 16) (3) QIAs to be reviewed and agreed by two of following; Deputy Director of Nursing, Quality and Patient Safety, Executive Director of Nursing and Transformation, Medical Director. (1) Agenda, papers and minutes of CCG Governing Body, Clinical Executive, Finance Committee and other key committees (2) Notes and action plans from CCG monthly meetings with NHS England Team (3) CCG work programme and QIPP project plans (1) CCG commissioning plans (1) Agreement of Intermediate Care Model though Clinical Executive and Older /3/ /3/

124 North Tyneside CCG Risk Assurance Framework Date entered Risk Ref Responsible Director/Risk owner Strategic S Corporate C Risk Description Consequence Likelihood Initial Score Controls Detail Gaps in Controls Assurance Gaps in Assurance Actions Consequence Likelihood Residual Score Review Date Target Risk Score Corporate Objective transformation, with QIPP projects contributing to enhanced quality as well as financial recovery 2 year financial plan in place. Plan to deliver underlying financial balance by end of 17/18 People's Board (1) Internal Audit QIPP Assurance NTC1617/09 - substantial assurance (3) CCG has good assurance rating from NHSE no longer in special measures. (3) Internal Audit Key Financial Controls NTC 1617/15 substantial assurance. (3) 19/11/ (was 543) Executive Director of Nursing & Chief Operating Officer/ Deputy Director of Nursing, Quality & Safety C Risk of inadequate implementation of 'Deprivation of Liberty' (DoL) criteria leading to the required Court Orders not being in place as required CCG employs professional staff with knowledge of DoL regulations and developing DoL case law CCG staff aware of patient group who are the responsibility of the CCG who may require a DoL assessment Process for checking which patients have had or who need a DoL assessment and who have or who need a court of protection order (including Orders that have expired or are about to expire) Detailed plans being put in place to ensure relevant court applications are made The financial impact on the CCG (e.g. the cost of the Court application and associated legal fees) is being calculated Staff attended MCA/DoLs seminar on 24/5/16 at Ward Hadaway to clarify CCG responsibilities CCG staff has a list of CHC patients living at home from NECs Patients who require DoLs identified at panel on Schedule of assessments to be completed for those in the community Safeguarding Teams have briefed the Head of Patient Safety and the Executive Nurse (1) Reports to Safeguarding Committee and to Quality and Safety Committee Local action plans (1) Process for identifying need for DoLs assessor, job description, recruitment and selection process (1) DoLs Assessments included in new CHC specification with Local Authority (1) Joint meeting with LA senior officers re DoLs Action planning and assurance following meeting with the LA Monitor compliance within community assessments and performance manage LA /3/ /05/ (was 544) Executive Director of Nursing & Chief Operating Officer/ Head of Safeguarding: Designated Nurse Safeguarding Children/Deputy Director of Nursing, Quality & Safety S Risk of adult or child safeguarding incident or other significant quality failure incident Adult Safeguarding Board and Local Children Safeguarding Boards in place; CCG an active member Regular performance reports to the CCG from NHS Providers to confirm and evidence that they have robust safeguarding arrangements in place Expertise of designated health professionals and named GP Child and Adult Safeguarding Policies in place (revised November 2015); CCG staff up to date with Safeguarding training Governing Body provided with Prevent and Safeguarding training Serious Incident Management system in place, compliant with NHS England framework Quality and Safety Committee receive regular reports on serious incidents and safeguarding issues) Governing Body receive regular reports on safeguarding issues Minutes of Adult & children Safeguarding Board; Minutes of LSCB (2) Designated Professionals Job Descriptions and work plans (1) Policies in place, on the CCG website and reviewed as appropriate (1) CCG annual report and Governing Body records (1) SI policy documents and notes of SI closedown panels (1) Verbal report to Governing Body (2) Monthly report to Quality and Safety Committee. (1) Internal Audit review of Safeguarding NTC resulted in substantial assurance (issued November 2016) (3) CCG has been rated as fully compliant with all KLOE/Standards set out in the NHS benchmarking/assurance tool 06/04/2016 (3) Internal Audit of Serious Incidents NT1617/03 substantial assurance (August 2016) (3) /3/ /06/ (was 550) Executive Director of Nursing & Chief Operating Officer/ Executive Director of Nursing & Chief Operating C Risk that the delay in Primary Care Support England Services: - Primary care records delayed transfer - Delay in receiving medical NHS England has issued a SOP to all practices Monitored by Primary Care Board (Joint between CCG and NHSE) Incidents reported by practices Gaps in control fall to NHSE Updates from NHS England (3) As reported to the CCG on 25/07/17 NHS England has, to date, held two risk summits, chaired by Dr David Levy, Regional Medical Director, NHS England Midlands and East, to review the risks and mitigations associated with the PCSE contract delivery. Following the last summit on 17/5/17 a briefing has been Process is not working as anticipated following delays Continue to embed process Monitor via practices Continue to raise to NHSE /3/

125 North Tyneside CCG Risk Assurance Framework Date entered Risk Ref Responsible Director/Risk owner Strategic S Corporate C Risk Description Consequence Likelihood Initial Score Controls Detail Gaps in Controls Assurance Gaps in Assurance Actions Consequence Likelihood Residual Score Review Date Target Risk Score Corporate Objective Officer supplies causes delays in treatment and safeguarding incidents prepared to provide CCG Governing Bodies or Quality Forums with reassurance and confidence that the recovery of PCSE services is nearing completion. It also provides detail on the next steps and plans for transformation. The briefing report taken to Q&S 5/9/17 and PCC 12/10/17. (3) Reduction in negative reports from GPs (1) Minutes of Primary Care Board (2) 04/08/ (was 551) Executive Director of Nursing & Chief Operating Officer Executive Director of Nursing & Chief Operating Officer C Intermediate Care - level of system resilience, delayed discharges, and not realising their potential for rehabilitation Transition plans in place Model previously signed off by CCG, NHCFT and LA Part of older people's board Operational team Assurance and Operational meetings in place to monitor progress System Risk Register in place Detailed operational plan and service specifications developed Bed occupancy monitored daily Operational meeting minutes (1) Assurance meeting minutes (1) Under occupancy provides assurance (1) Ongoing monitoring /3/ /08/ (was 552) Director of Contracting & Commissioning/ Commissioning Manager C Risk that delayed ambulance handovers impacts negatively on patient safety and patient flow Regular director level meetings with NHCFT and NEAS Action plans developed and implemented ECIP (national expert team for urgent care) appointed to review NSECH process and recommend improvements - report supplied Dec 16 Local A&E Delivery Board overseeing response to ECIP report CCG working collaboratively with Northumberland CCG to reduce walk in activity at NSECH to increase capacity for ambulance conveyed patients. Sitreps from whole system during winter. CCG has regular meetings with ECIP and NHSFT. Daily updates on delays and diverts from NESCH (1) Daily updates fed up to director level meetings and NHSE (1) Regular reports to Quality & Safety Committee (1) Daily sitreps from NEAS (1) Minutes of QRG s monitoring of ECIP (2) Inadequate assurance relating to ECIP action plan Assurance required from A&E Delivery Board regarding delivery of ECIP report/action plan NSECH Director to attend Governing Body /3/ /07/ (was 560) Executive Director of Nursing and Chief Operating Officer/ Executive Director of Nursing and Chief Operating Officer C CCG IT systems at risk of cyberattack, jeopardising day to day operations and impacting on service delivery and patient safety Business Continuity Plan v3.1 approved by Quality & Safety Committee 2/5/17 Business Impact Assessment (BIA) undertaken for IT date 24/4/17 Monitoring by IM&T Sub Committee NECS IT Contingency Plan (as per BIA) NECS IT Disaster Recovery Plan (as per BIA) Service Auditor Reports (3) Monitoring of Business Continuity Planning incidents, responses and lessons learned by Quality & Safety Committee (2) NECS IT Director attended Audit Committee on 17/11/17 to provide update on system assurance (2) Audit Committee is unclear the extent and source of assurances received Obtain assurances from providers (NECS, NEAS, NuFT, NHCFT, NTW) via contracting process /3/

126 North Tyneside CCG Risk Assurance Framework Date entered Risk Ref Responsible Director/Risk owner Strategic S Corporate C Risk Description Consequence Likelihood Initial Score Controls Detail Gaps in Controls Assurance Gaps in Assurance Actions Consequence Likelihood Residual Score Review Date Target Risk Score Corporate Objective 18/12/ New Executive Director of Nursing and Chief operating Officer/ Deputy Director of Nursing, Quality & Patient Safety C Nursing homes are rated inadequate by CQC and/or are in organisational safeguarding, resulting in reduced availability of beds in nursing homes to meet demand Action plans following CQC Inspections 15 Steps review Scheduled quality monitoring visits with LA CCG unannounced visits with LA to monitor implementation of CQC action plans CCG is part of organisational safeguarding meetings (led by LA) Joint forum meetings with providers (& LA) CCG & LA meet CQC to share intelligence Nursing home forum System wide action plan to mitigate emerging risks CQC Reports (3) 15 Steps reports (1) Reports from monitoring visits (1) Quality & Safety Committee papers (1) Minutes of meetings (2/3) System wide assurance CCG/LA to meet with directors to discuss system wide quality issues /3/ /09/ (was 536) Executive Director of Nursing & Chief Operating Officer/ Primary Care Development Manager C Risk of not being able to implement New Models of Care (now Care Plus), with the consequent risk of services not being fit to meet the needs of the ageing population Key stakeholders engaged in the planning and delivery of New Models of Care, including Foundation Trusts, LA, Healthwatch, Patient Forum and LMC Council of Practices, as key clinical decision making CCG committee, committed to this development and the clinical benefits its will bring Clinical Blueprint clearly set out and articulated Programme of work to included phased implementation, to enable continuous learning and improvement Expected benefits of New Models of Care clearly articulated and implementation monitored against KPIs Workforce fully staffed with Geriatrician, Nurse Practitioner, OT and Physiotherapist Service live across North Shields and Whitley Bay Localities from June 2017 Project Plan in place Revised model agreed with GP Federation and member practices New revised model requires testing to ensure delivery of logic outcomes New Models of Care Project Board in place, inclusive of key stakeholders, reports to North Tyneside Integration Board. (1) Patient Forum involved in design of New Models of Care, informing its development and enhancing understanding of and commitment to (1) Council of Practices briefed and involved; this discussion minuted (1) Clinical Blueprint facilitated by NHS IQ complete (2) 4 localities signed up as pilot sites and Whitley Bay implementation work streams in place (1) New Models of Care programme part of QIPP work, with supporting documents in place, including KPIs (2) Project Plan and finances signed off by QPAC 27/06/2016. (2) New Models of Care Project Board monitors performance (1) Weekly updates on activity of new service (1) Internal Audit 1516/12 Service Reconfiguration substantial assurance (3) Monthly Programme to oversee progress (1) Secondary care activity data and the impact on patient care and financial management Roll out to 4 localities within existing resource to reach target numbers for RDI evaluation. Plan for increase capacity based on above in line with Future Care /3/

127 North Tyneside CCG Risk Assurance Framework Date entered Risk Ref Responsible Director/Risk owner Strategic S Corporate C Risk Description Consequence Likelihood Initial Score Controls Detail Gaps in Controls Assurance Gaps in Assurance Actions Consequence Likelihood Residual Score Review Date Target Risk Score Corporate Objective 16/11/ (was 539) Chief Officer/ Head of Governance S Risk of insufficient clinical input into the work of the CCG if clinical leaders and member practices CCG are not effectively engaged CCG Committee membership includes Clinicians - Council of Practices, Quality and Safety Committee, Clinical Executive, Audit Committee, Finance Committee CCG Chair is a GP, supported by Medical Director (GP), 3 Clinical Directors (GPs) and a range of Clinical Leads CCG Governing Body members include an experienced executive nurse and secondary care specialist doctor Practice Managers are members of Quality and Safety Committee and the Clinical Executive Committee CCG Constitution sets out matters reserved to Members, enacted through a structured programme of meetings of the Council of Practices Practice Nurse Forum facilitated by CCG Quality team Monthly newsletter to all practices highlighting commissioning issues Development of locality working actively supported by CCG Clinical Chair and Chief Officer programme of joint practice visits Practice facilitators in post, working into Practices to support local implementation of FRP Changes to constitution and remit of Council of Practices and Clinical Executive Committee, resulting in improved clinical insight CoP actively involved in development of CCG QIPP PMO/CFO scheduled to attend locality meetings Appointment of New Clinical Director 1 Locality Director posts unfilled. Governing Body and Committee Terms of Reference, meeting papers and minutes (2) CCG Constitution and papers and minutes of the meetings of the Council of Practices (1) CCG annual report (1) Practice Nurse Forum notes (1) Monthly newsletters (1) Locality Group meeting notes and reports to the Clinical Executive (1) Clinical Chair and Chief Officer programme of joint practice visits, with follow up actions (1) Practice facilitators work programme and achievements (1) Internal Audit review of Clinical Engagement 2014/15 NTC4806 provided Significant Assurance with one issue of note (issued Feb 2015). Issue of note has been addressed (3) 360 Stakeholder Survey (2) CoP minutes and agendas (2) Secondary Care Doctor recruited commences 1 st Jan 18 (1) Recruit 1 Locality Director (Whitley Bay) Development of practice engagement plan /3/ /11/ (was 540) Director of Contracting & Commissioning/ Planning & Commissioning Manager S Risk that the CCG fails to focus on the needs of patients and fails to commission the right, cost effective services to meet those needs Lay Member for Patient and Public Involvement in post Active Patient Forum, Chaired by Lay Member and facilitated by CHCF, with programme of work and effective sub groups; Patient Forum reports to Governing Body CCG planning predicated on Joint Strategic Needs Analysis, which documents the health needs of North Tyneside CCG population Active public and patient engagement in planning, commissioning and service review Clinical Leaders bring direct experience of patient contact to CCG decision making Mechanisms in place for patients to contact the CCG formally and informally North Tyneside Health and Wellbeing Board priorities inform CCG plans Quality Review Groups in place, joint with other CCGs, to support the delivery of high quality healthcare services Service planning and service redesign, including QIPP plans, based on clinical evidence Referral Management System being implemented to support adherence to good clinical practice Role of Lay Member for Patient and Public Involvement set out in CCG Constitution and evidenced in her work in the CCG (1) Patient Forum work programme, meeting notes and reports to CCG Governing Body (1) Communications and engagement strategy in place, supported by specific plans for identified work streams (1) CCG operational plan and Commissioning Plans prepared, approved by the Council of Practices and published (1) Value Based Commissioning Policy on CCG website; Medical Director identified as CCG decision maker; reported at Clinical Executive (1) Reports from public and patient engagement in major service reviews (e.g. maternity services review, urgent care review) (1) Committee reports and minutes show that Clinical Leaders - nurses and GPs - are involved in all aspects of CCG decision making (1) CCG website shows a number of ways to contact the CCG including 'contact us', complaints and compliments, opportunity /3/

128 North Tyneside CCG Risk Assurance Framework Date entered Risk Ref Responsible Director/Risk owner Strategic S Corporate C Risk Description Consequence Likelihood Initial Score Controls Detail Gaps in Controls Assurance Gaps in Assurance Actions Consequence Likelihood Residual Score Review Date Target Risk Score Corporate Objective Communication and Engagement group within Patient Forum which provides a direct link with Governing Body CCG Patient Forum Comms & Engagement Group working with Save the Children to engage with children and young people and their parents to develop healthcare fit for the future Healthwatch input and feedback into CCG commissioning plans CCG actively engages with stakeholders, public and patients, including commissioning the Community Health Care Forum to facilitate the patient forum. to meet Governing Body members informally prior to meetings (1) Internal Audit review 2014/15 of Patient Experience NTC4805 provided significant Assurance with no issues of note (issued May 2015) (3) Minutes of Quality Review Groups and reports to Quality and Safety Committee (2) Plans for service redesign, including QIPP plans, maternity services, urgent care, include reference to available clinical evidence (1) Advice of Clinical Senate sought on paediatric care pathway and on urgent care plans (2) Internal Audit review of Strategic Planning NTC 1617/02 provided significant Assurance with no issues of note (3) External assurance from Andy Mills, Consultation Institute on urgent care process (at Governing Body ) (3) 30/11/ (was 545) Chief Finance Officer/ Director of Contracting & Commissioning C Risk of activity or contract performance increasing over contracted or formally planned levels, bringing additional, unplanned financial pressures Contract management meetings with variances against planned contract activity scrutinised forecast out turn summaries updated Finance Committee to oversee investigation into priority areas, supported by QIPP Programme Assurance Committee (QPAC) Detailed finance and contract report and quality and performance report presented to Clinical Executive, Finance Committee and Governing Body to enable triangulation of information Medicines Optimisation Services purchased from NECS - Medicines Optimisation Committee in place Robust CHC assessment processes in place, benchmarked against other CCGs nationally, robust CHC decision making processes and budget forecasts High cost CHC packages remain under close scrutiny CHC Policy approved by Clinical Executive February 2015 sets out CCG's role in commissioning CHC Metrics and KPIs agreed for each scheme in the BCF BCF Board in place to oversee monitoring against plan and initiate corrective action if required Referral Management System in place Discussions with NHCFT regarding risk mitigation of specific activity increases in Accident and Emergency Provision of suitable financial reserves in the plan. Appointment of Director of Commissioning and Contracting. Regular contract meetings with all providers where activity and pressures discussed. s256 agreements not in place Notes of contract management meetings and 14 Day reviews and actions arising from those (1) Minutes of Finance Committee and QIPP Programme Assurance Committee (QPAC), including deep dives (2) Finance and contract reports and quality and performance reports to Clinical Executive, Finance Committee and Governing Body with exceptions highlighted and actions reported (2) Minutes of Medicines Optimisation Committee, medicine optimisation SLA with NECS and medicine optimisation QIPP schemes (1) CHC assessment processes and reports to Clinical Executive and Finance Committee (1) CHC Policy BCF s75 agreement; signing reported to Governing Body (1) BCF Board ToR and meeting papers (2) Review by Internal Audit NTC16/17/1 Medicines Management provided substantial assurance (3) Review by Internal Audit NTC16/17/12 Contract Monitoring Substantial assurance (3) NTC 1617/15 Key Financial Controls - substantial assurance (3) Review by Internal Audit NTC16/17/09 QIPP Assurance gave substantial assurance with no issues of note (3) Review by Internal Audit NTC 1617/10 Performance Management gave substantial assurance with no issues of note (3) Reduction in elective activity (1) Contractual agreement with NHCFT (1) Internal Audit NTC 1617/06 CHC good assurance (3) Demand management paper submitted to Governing Body - 25 June 17 (1) National assurance on BCF agreement not received s256 agreement to be signed Escalation to NHSE /3/

129 North Tyneside CCG Risk Assurance Framework Date entered Risk Ref Responsible Director/Risk owner Strategic S Corporate C Risk Description Consequence Likelihood Initial Score Controls Detail Gaps in Controls Assurance Gaps in Assurance Actions Consequence Likelihood Residual Score Review Date Target Risk Score Corporate Objective Contract meeting notes escalated by exception. (1) 09/11/ (was 554) Chief Finance Officer/Head of Finance C QIPP plans, including target contract values, are not delivered and/or there is increased expenditure, causing the CCG to breach its control total QIPP Projects developed with support of Business Intelligence and Finance to test the robustness of assumptions made. PMO assurance of QIPP projects PMO fortnightly monitoring, reporting and escalation of QIPP progress QPAC receives QIPP monitoring reports and directs remedial actions (where appropriate) Finance Committee receives regular reports of QIPP and challenges underperformance Each QIPP project has a project plan, savings target, KPIs, Quality and Equality Impact Assessments Monthly monitoring of CCG FRP implementation by NHS England Team Monthly contract management meetings Contracts with Acute Trusts include QIPP within value. System wide STP (Sustainable Transformation Plan) being developed that includes N CCG, NT CCG and NHCFT to identify joint QIPP programme - 5 year plan. 13 work streams identified NTW contract signed. NUTH contract agreed risks and mitigations being tracked on an ongoing basis to inform position Financial expenditure controls QIPP schemes (including block contracts) Joint cost reduction approach with NHCFT. Minutes FRP refreshed during 16/17 Urgent care procurement process Identification of further QIPP schemes to address risk in FRP STP requires completion and implementation QIPP plan monitored by the QIPP Programme Assurance Committee; QPAC formally reports to Clinical Executive and provides updates to the Finance Committee. (1) Signed contract with providers (1) Minutes of monthly meeting with NHS England Team to scrutinise and validate credibility of QIPP across NCCG and NTCCG (2) Reports to Finance Committee and Clinical Executive Committee (1) QPAC Tracker/QPAC minutes (2) Internal Audit QIPP Assurance NTC1617/09 substantial assurance 16/17 (3) NECS/ Deloitte review of QIPP arrangements and subsequent action plan (3) Joint cost reduction approach with NHCFT. Minutes (1) Further work on STP to determine how plan will be delivered /3/ /07/ (was 559) Chief Finance Officer/Head of Finance S Fraud undermines the financial position/reputation of the CCG Overall financial control environment including: specific system controls; budgetary control system; internal audit; counter fraud services; external audit review of financial statements; and CCG policies as outlined below: HR07:Disciplinary Policy HR35: Whistleblowing policy CO06:Anti-Fraud Policy CO13:Procurement Policy CO19:Standards of Business Conduct Internal audit reports and opinion (3) Counter fraud updates and annual report (3) External audit opinion (3) CCG Policies (1) Budget reports (1) Reconciliations (1) Internal Audit NTC Financial & Strategic Planning substantive assurance (3) /3/ /06/ (was 558) Director of Contracting & Commissioning/ Commissioning Manager C Risk that the delay in the launch of the new Urgent Care Centre Service creating system uncertainty, potential pressure on other services, reputational damage and Model designed in collaboration with Clinical Senate, which involved extensive consultation, and engagement at Chief Officer level with key stakeholders and Legal advice In collaborative dialogue with stakeholders (current contract holders) to ensure continuity service provision post September 2017 Legal challenge from Northumbria Healthcare NHS FT has resulted in the contract award being delayed. Current contracts come to an end NHCFT has indicated they would not support Consultation process audited by The Consultation Institute and found to be consistent with recognised standards of best practice (3) Seek agreement from current contract holders to extend contracts in order to ensure continuity of service provision. Work with providers to coproduce a service solution which takes account of system changes including GP extended hours, streaming /01/

130 North Tyneside CCG Risk Assurance Framework Date entered Risk Ref Responsible Director/Risk owner Strategic S Corporate C Risk Description Consequence Likelihood Initial Score Controls Detail Gaps in Controls Assurance Gaps in Assurance Actions Consequence Likelihood Residual Score Review Date Target Risk Score Corporate Objective 22/12/ New Director of Contracting & Commissioning/ Commissioning Manager C financial risk. Closed 22/12/17 Risk that urgent care procurement does not result in contract award Existing contract for Battle hill Walk in Centre & GP Out of Hours services extended to October 2018 Procurement process followed Review & revision of specification & financial envelope following market feedback and consultation Contract documentation & specification approved by Governing Body Active and reactive press statements & correspondence to inform key stakeholders & public another provider utilising the Rake Lane site and therefore the public preferred option is not secure at this time. Complexity of stakeholder management Potential legal challenge Communications agreed Minutes of Clinical Executive and Governing Body Minutes of Overview & Scrutiny Committee Procurement Reports at NSECH and is in line with clinical model and is cognisant with procurement law. Meet with MPs and Mayor Review comms re urgent care to improve understanding Respond to any further letters re factual inaccuracies Press releases /3/ /05/ (was 138) Executive Director of Nursing and Chief Operating Officer/ Deputy Director of Nursing Quality and Safety S Risk of the work of the CCG and its partners not improving the health of the population in line with statutory duties Commissioning Plans informed by JSNA to ensure focus on health needs and health improvement Regular reports to Clinical Executive and Governing Body on progress against health outcomes data set Regular Performance Reviews with the NHS England Area Team Joint working with CCG and Local Authority Public Health department, including Consultant Public Health (Medical) working within the CCG 2 days per week Progress on health improvement reported year-on-year in CCG Annual Report Commissioning Plans developed and published (1) Regular integrated quality and performance reports to Clinical Executive and Governing Body; minutes of those meetings and results of 'deep dives' (2) Notes of Quarterly Performance Reviews with the NHS England Area Team (3) Public Health work plan (2) CCG Annual Report against CCG health outcomes data set (1) Review by Internal Audit of Performance Management (NTC 1516/08) gave significant assurance with no issues of note (issued Jan 16). (3) /3/ /05/ (was 193) Executive Director of Nursing & Chief Operating Officer/Head of Improvement & Development S Risk of failure to engage with partners and stakeholders in line with CCG statutory duties, resulting in misalignment of plans across the health economy CCG an active partner in the North Tyneside Health and Wellbeing Board CCG attends the Overview and Scrutiny Committee, as required, to present and discuss the work of the CCG CCG has regular formal and informal meetings with North Tyneside Council, local NHS Foundation Trusts, HealthWatch, local MPs Stakeholder engagement plan in place, as part of communications and engagement strategy, with specific targeted plans for identified initiatives CCG complies with formal duty to consult There are regular communication channels between CCG and Voluntary Sector Process designed for the development of Commissioning Intentions Operational Plan 16/17 complete and available of CCG website CCG has engaged with the NTW Sustainable Transformation Plan governance arrangements and are planning system wide financial control targets for 17/18 Communications and engagement services Failure to agree funding for the Local Authority in 17/18 (difference of circa 750k between budget and LA expectation) results in potential decommissioning of social care services to that value. North Tyneside Health and Wellbeing Board and Overview and Scrutiny Committee meeting papers and minutes (2) Minutes and papers of committees of the Health and Wellbeing Board, Integration Board, Turnaround Board, Urgent Care Board, Primary Care Commissioning Committee and meetings with MPs (2) Communications and engagement strategy (1) Communications and engagement plan for key pieces of work including for example, FRP, commissioning plan, urgent care (1) Reports to CCG Governing Body on plans to consult and outcome of consultation, including, for example, maternity services and urgent care (2) Formal agreement with the Community Health Care Forum (1) Internal Audit review of Strategic Planning NTC 1617/02 provided significant assurance with no issues of note (issued May 2016) (3) Internal Audit review of Partnership Arrangements - Governance NTC 1516/04 National request to revise baseline Meetings between LA/NTCCG to align spending and planning assumptions Discuss in assurance meeting with NHSE /3/

131 North Tyneside CCG Risk Assurance Framework Date entered Risk Ref Responsible Director/Risk owner Strategic S Corporate C Risk Description Consequence Likelihood Initial Score Controls Detail Gaps in Controls Assurance Gaps in Assurance Actions Consequence Likelihood Residual Score Review Date Target Risk Score Corporate Objective from NECS to support the work of the CCG Agreement with CCG & LA in respect of previous years QIPP (joint) from closure of Cedars Report to CCG and Council on service implications of spending plans Joint letter from CCG/LA supporting FYE QIPP (BCF) sent to NHSE/LGA provided significant assurance with issues of note (issued Nov 2015) (3) Operational Plan 16/17 signed off by Clinical Executive, Governing Body and Council of Practices, available on CCG website. (2) STP (final version submitted (21/10/16) (1) Internal Audit NTC Stakeholder Engagement substantial assurance (3) 13/08/ (was 534) Director of Contracting and Commissioning/ Commissioning Manager/Head of Governance S Risk of inadequate operational resilience, or organisational capacity and infrastructure, leading to a failure to respond to local healthcare needs Robust organisation processes in place, including suitably qualified and trained staff, a range of policies and procedures, clear work plans, agreed HR processes and agreed IG processes CCG Constitution in place, with Scheme of Delegation and clear governance structures Service Level Agreement with Commissioning Support Unit in place CCG capacity to deliver FRP and maintain all other essential business reviewed and staff team strengthened and adjusted CCG Major Incident & Business Continuity Management Plan in place CCG complies with Emergency Planning, Resilience and Response (EPRR) requirements under Civil Contingencies Act Urgent Care Working Group/System Resilience Group in place to monitor capacity and direct investment as required. Membership of Urgent Care Group includes all relevant Commissioners and Providers Winter plans in place Clinical Executive reviews capacity plans as necessary; plans also subject to review by partners and by NHS England System to monitor capacity and pressure in place. Daily teleconference between Commissioners, Acute Providers and NEAS to manage pressures over winter period Report received from ECIP (Dec 2016) with recommendations how to improve system resilience and urgent care system. Response being co-ordinated by Local A&E Delivery Board. Establishment of meetings of A&E Delivery Boards for the NNT footprint Reported results of 17/18 EPRR selfassessment to Governing Body (full compliance) Appointment of Director of Commissioning and Contracting Regular reviews of CCG capacity and competency. Clear staff reporting arrangements; job descriptions, appraisal processes, objectives and work plans, Staff statutory and mandatory training up to date, monitoring arrangements for the SLA with NECS including HR and IG (1) CCG Constitution is current and on CCG website; committee ToR regularly reviewed and reported in Annual Governance Statement (1) CSU service user reports received by Audit Committee and referenced in the CCG Annual Report (2) IG toolkit level 2 attained in 2013/14, 2014/15, 15/16 and 16/17 reported to Q&S committee. (1) Internal Audit review 2013/14 NTC3816 Emergency Planning gave significant assurance (29 July 2014) (3) Internal Audit review 2013/14 NTC3817 Business Continuity Planning gave significant assurance (29 July 2014) (3) 2015/16 EPRR self-assessment completed (1) Local A&E Delivery Board (2) Clinical Executive papers and minutes (1) Lifting of special measures reflecting the strengthening leadership. (3) Internal Audit Risk Management & Assurance Framework 1617/3; Information Governance 1617/14; Conflicts of Interest 1617/11 - all substantial assurance (3) Winter plans including documented system to monitor capacity and pressure (1) Notes of Daily teleconference over the winter period (1) A&E Delivery Boards minutes to Clinical Executive (2) NHS England CCG assurance (Amber Feb 17) (2) /3/ /08/ (was 535) Chief Officer/Head of Governance S Risk of a lack of confidence in the CCG as a result of reputational damage, inhibiting the CCG s role as a system leader Standards of Business Conduct policy in place, with clear conflict of Interest management arrangements in line with current guidance and good practice Deloitte review of QIPP Robust contracting and procurement process in place Standards of Business Conduct policy, quarterly review of conflict of interest declarations, over seen by Audit Committee (2) PMO arrangements identified as best practice (2) Minutes of Governing Body where Legal Directions removed 12/1/2018 Deliver FRP 17/ /3/

132 North Tyneside CCG Risk Assurance Framework Date entered Risk Ref Responsible Director/Risk owner Strategic S Corporate C Risk Description Consequence Likelihood Initial Score Controls Detail Gaps in Controls Assurance Gaps in Assurance Actions Consequence Likelihood Residual Score Review Date Target Risk Score Corporate Objective CCG has access to legal advice NHS England actively supporting the CCG to consider and develop sustainable options for the future Robust consultation and engagement processes Proactive media relations to promote openness and transparency on financial position and actions being taken NHSE approved changes to constitution November now v13. Improvement Plan in response to Directions completed procurement decisions made and recorded (2) Reference to legal advice in committee reports (1) Governing Body Meetings held in public, with papers posted in advance of the meeting (2) Internal Audit report NTC 1516/14 on Governance Structures gave Significant Assurance (issued 17 March 2016) (3) CCG Annual Reports and Annual Governance Statements published for 2013/14, 2014/15 and 2015/16 (1) Internal Audit report NTC 1516/05: Primary Care Co-Commissioning gave Significant Assurance (issued 3 Nov 2015) (3) CCG removed from special measures (3) 16/11/15 06/06/ (was 542) 406 (was 557) Chief Officer/ Executive Director of Nursing and Chief Operating Officer Executive Director of Nursing and Chief operating Officer/ Commissioning and Performance Manager S C Risk of the CCG lacking capacity to provide system wide leadership Capacity in Primary Care and system support for new ways of working challenges the delivery of sustainable Primary Care Services Governing Body members maintain both an external and internal focus, working with key stakeholders and partners CCG Directors and Senior Managers participate in region wide groups and fora CCG chairs and leads meetings, acting as system wide leader Permanent appointments to Chief Officer and Chief Finance Officer post. Tripartite Primary Care Strategy developed and agreed by CCG GP Federation and LMC. Monitoring of progress again Tripartite Primary Care Strategy by Primary Care Committee Primary Care Quality Committee 2 Locality Directors in post Council of Practices CCG has 3 Clinical Directors, Medical Director and Chair who are Primary Care Practitioners Support from NHS England in the management of primary care issues CCG working with NHSE (HENE) to mitigate system risks by collective workforce planning and recruitment 1 Further Locality Director required GP Capacity risk Minutes of Health and Wellbeing Board, CCG Accountable Officers and Chairs meeting, Primary Care Commissioning Committee, Integration Board (2) Terms of Reference, papers and minutes of Professional meetings e.g. health care acquired infection partnership (2) Terms of reference for Urgent Care working group, practice nurse forum, QRGs, Medicines Optimisation (2) Joint CCG Committee for the Cumbria & North East established & approved by Governing Body 28/11/17 (1) Primary Care Strategy approved by Governing Body May 16 (1) Primary Care Committee ToR and minutes to Governing Body (1) NHS England approval of Level 3 submission. (3) Quarterly assurance meetings with NHS England (3) Urgent Care/Primary Care changing landscape has introduced uncertainty to discharging of previously agreed plans. Appointment of a further 1 Locality Director Directors to agree strategy to manage impact of changing landscape Update PCC on progress of HENE work /3/ /3/ /18 Corporate Objectives 1. Quality& Safety Committee: Commission high quality care for patients that is safe, value for money and in-line with the NHS Constitution. 2. Finance Committee: Deliver the Financial Recovery Plan, leading to the achievement of the CCG s statutory financial duties and future sustainability. 3. Clinical Executive Committee: Work collaboratively with partners and stakeholders to develop health and social care fit for the future in North Tyneside. 4. Clinical Executive Committee: Continue to develop North Tyneside CCG as a patient focused, clinically led commissioning organisation with a continuous learning culture. Three lines of defence 1. The first line of defence functions that own and manage risk (assurance from functions that own and manage risk) 2. The second line of defence functions that oversee or specialise in risk management compliance (e.g. PMO, CCG financial and performance reporting, Governing Body, Audit Committee, external organisations e.g. QRG, LSCB, A&E Board, Health and Wellbeing Board) 3. The third line of defence functions that provide independent assurance (e.g. internal audit, external audit CQC, NHSE) Risk Assurance Framework Definition Strategic Risk is a risk that undermines the CCG s ability to meet its statutory duties. These are defined as strategic risks on the Risk Assurance Framework. They will remain on the Risk Assurance Framework permanently to provide assurance the risks are effectively managed. Corporate refers to a risk that is transient in nature and once managed to an acceptable level will be closed. These are identified as corporate risks on the Risk Assurance Framework. Risk Assurance Framework is a document which consolidates the Corporate Risk Register (see corporate risks) and Assurance Framework (see strategic risks) into one document. Source: Chartered Institute of Internal Auditors (brackets by CCG) 11

133 Notes of the meeting of the North Tyneside CCG Patient Forum held on 16 November 2017 held at The Linskill Centre, Linskill Terrace, North Shields, 11am 1pm Present: The meeting was chaired by Eleanor Hayward Practice Representatives: Beaumont Park Priory Medical Group Wellspring Practice Whitley Bay Health Centre Lane End Surgery Park Road Medical Practice Park Parade Northumberland Park Swarland Avenue Surgery Nelson Medical Group Monkseaton Medical Practice West Farm Surgery Collingwood Medical Group Battle Hill Health Centre In attendance: Community & Health Care Forum Community & Health Care Forum NHS North Tyneside CCG Not in attendance: West Farm Surgery Nelson Health Group Portugal Place Health Centre Spring Terrace West Farm Surgery Bewicke Medical Centre Apologies for absence: NHS North Tyneside CCG NHS North Tyneside CCG NHS North Tyneside CCG NHS North Tyneside CCG Whitley Bay Health Centre Victoria Mayes Susan Dawson Sandra Gillings Anne Carlile Val Telfer Gillian Bennett Anne Lawson Heather Carr Steve Manchee Colin Thomson George Mitchell CBE Ray Calboutin David Hall Steve Cattle Sylvia Hall John Tanner Andrew Fothergill Wendy Johnson Peter Maitland Dean Stewart Michele Spencer Carole Reed (Note taker) Jon Connolly Patsy Lemin Linda Scott Tina Trowbridge Gillian Rayne Grace Foggin Sonia Bradley Lesley Young-Murphy Wally Charlton Anya Paradis Mathew Crowther Philip Lowe PhD 1

134 Beaumont Park Mark Hoggan 49 Marine Avenue Pat Bottrill MBE Earsdon Park Medical Practice Ann Appleby Battle Hill Health Centre Anne Baxter Forest Hall Medical Group Judith McSwain Village Green Surgery Bill Critchlow Collingwood Medical Group Phil Howells 49 Marine Avenue Hazel Parrack Lane End Surgery Steve Roberts Marine Avenue Jon Routledge 1. Welcome and introductions: Mrs Hayward welcomed members to the Patient Forum and thanked everyone for taking the time to attend. 2. Apologies: Apologies for absence were received as above. 3. Confirmation of quoracy: The meeting was confirmed as quorate. 4. Declarations of interest: There were no declarations of interest but everyone was encouraged to declare if relevant. 5. Notes of the previous meeting dated 14 September 2017: The notes were agreed as a true record. Actions were discussed, concluded or to follow. 6. Any Other Business (this was brought forward on the agenda as there wasn t time at the last meeting). A member drew the groups attention to the amount of Did Not Attends (DNAs) at his GP surgery and asked if there was any advice available on how to combat this problem. It was agreed this should be discussed further on a separate occasion. 7. Urgent Care Jon Connolly (on behalf of Mathew Crowther) Jon showcased his presentation The future of urgent care services in North Tyneside please see attached. This prompted a lengthy discussion with the members. Jon confirmed that the new urgent care treatment centre would be up and running in North Tyneside by 1 October He explained that urgent care did not include emergencies like heart attacks or strokes for example; these cases would be sent to Northumbria Specialist Emergency Cramlington Hospital (NSECH) or the Royal Victoria Infirmary (RVI) urgent care covers minor injuries, strains, sprains, and cuts, conditions that require basic but immediate attention. Under the new system the urgent care treatment centre will offer a GP-led service from 8am to 10pm. An out of hours home visiting service at evenings and weekends to be accessed via NHS 111. Also GP Practices in North Tyneside will offer an additional 1,000 primary care appointments per week at evenings, weekends and bank holidays throughout the Borough. This will be made sustainable by using an extended access programme. Instead of being triaged, patients will use a streaming service and this will be a national requirement. There will also be a new regional clinical hub to increase telephone based appointments with health care professionals. The members agreed that this should be publicised. When asked why the service is being changed Jon explained that the present system is not making the best use of the NHS. The walk-in centres night time services have been suspended since December 2016; this is because it wasn t cost 2

135 effective to have medical staff on duty 24/7 when only a handful of patients used it. They are better deployed to NSECH. A member explained that the critical success of the service depended on five factors to monitor its impact. It was suggested that the members look at these factors within the forum so they can be challenged and reviewed. It was generally agreed that a large number of North Tyneside residents did not know about these proposed changes and are shocked and disappointed about the decisions. Jon informed the members that the urgent care patient survey is available on the NHS CCG website. On the other hand it was suggested that there was a general apathy among the public although not everyone agreed. The members thought the public should be more positive and trust the people they have elected to make the right decisions. Everyone is so used to the NHS just being there that it is sometimes taken for granted. Jon confirmed that the Care Quality Commission will have a responsibility to monitor the quality of this new service. 8. Working Groups Briefing Caring for Older People Working Group Care Plus Update The North Tyneside Care Plus Service has now moved out of Rake Lane Hospital into the Appleby Surgery and although there have been a few teething problems it is working well and has a good atmosphere. Members will meet again in six months, rolling out of the service to other surgeries in the North West of the Borough and Wallsend is underway. The September and November newsletters have been shared with the members. Royal Quays Intermediate Care Rehabilitation Unit Update Two members visited the unit again and found this very useful. The service is working much better than before. There have been a few small problems with I.T. but the staff are highly trained and developed. Another visit is planned in six months. The unit is GP-led and all referrals come from hospitals. The unit is run by Akari who also own the building and the service is financed by the CCG. Falls Strategy Gary Charlton has been working closely with Dr Alex Kent on a new primary care model. The falls poster, leaflet and bookmark have been distributed around the Borough. The final strategy will be shared with members in due course. End of Life Working Group Nothing to report but the next meeting will be in January Self Care and Well Being Working Group The back pain workshops have been successful with more people attending, they have now been extended to next year every six weeks in North Shields, Killingworth and Wallsend and the feedback is good. Eddy s Walk is still continuing every Thursday morning from Tynemouth Haven Car Park; Eddy s son also still attends. Everyone is welcome. Mental Health Working Group Anya Paradis has now changed her role; she was on the agenda today to discuss mental health services but unfortunately had to send her apologies. 3

136 Comms Working Group Issue nine of the newsletter is nearly complete, all members are welcome to have some input into the newsletter and are also being encouraged to join the working group. It was suggested that the newsletter could be used to circulate information about public meetings but as it is for patients only it should not been seen to advocate CCG business alone. Shared Decision Making (SDM) Working Group This was a time limited group and there have been no further meetings planned. It was agreed it is important to make sure the SDM leaflets are in GP surgeries and a follow up review will be arranged. Tripartite Primary Care Strategy A smaller group meeting took place last month with Hugo Minney and some of the members Working Group thought it was beneficial. The next one will take place in January More information can be found on the briefing, available by and at the meeting. Jon Connolly Finance Update We are now into the seventh month and the pressure is on, the target is to deliver the 2m surplus. Jon said he remains reasonably confident that the CCG can deliver the target and maintain a sustainable footing. The service is out of Special Measures and he hopes the next step will be to come out of Legal Directions. Jon was asked if this success is due to the interim staff having left and now all employees are permanent including himself; he replied that things have got better but the interims did start getting the service onto the right track in the first place. Jon confirmed that Dr John Matthews is standing down as Clinical Chair from the CCG at the end of March 2018 and permission has been granted to appoint someone else. Dr Martin Wright is also standing down as Medical Director and will be replaced by Dr Ruth Evans. Jon gave thanks to both clinicians for their input into the service as they have done a really good job in their respective posts. Mrs Hayward suggested inviting Mark Adams, Chief Officer of Gateshead and Newcastle CCG to the Forum to discuss the Sustainable Transformation Plan. Date and time of next meeting Thursday, 11 January am to 1.00pm Linskill Centre Linskill Terrace North Shields NE30 2AY 4

137 North Tyneside CCG Patient Forum Action Log Date Action No. Action Person Responsible Target Date Status Liaise with Dr Alex Kent re Falls Presentations for the Parkinson s Group List of efficiencies to be shared with members Michele Spencer Lesley Young- Murphy Top ten reasons for hospital admissions to be shared with members Copies of Falls Strategy and Mental Health in Later Life to be shared with members when complete Lesley Young- Murphy Michele Spencer 5

138 Primary Care Committee Minutes of the Primary Care Committee Meeting held on Thursday, 11 May 2017, 2.30pm 4pm, at Hedley Court Present: Mary Coyle CCG Deputy Lay Chair, NTCCG (Chair) Lesley Young-Murphy Chief Executive Director of Nursing and Chief Operating Officer, NTCCG James Martin Commissioning & Performance Manager, NTCCG John Matthews Clinical Chair, NTCCG Jeff Goldthorpe Head of Finance, NTCCG Jenny Long Primary Care Assistant Contract Manager In Attendance: Shelagh Cockburn Tracy Charlton Apologies: Ruth Evans Christine Keen Tracy Johnstone Denise Jones Wayne Kirkham Programme Management Officer Minute Taker Clinical Director Director of Commissioning, NHS England Head of Primary Care, NHSE Deputy Head of Contract Management Primary Care Transformation Support Manager NTPCC/17/022 Agenda Item 1 Welcome & Apologies for absence Mary Coyle (MC) welcomed all to the Private Primary Care Committee and apologies were noted as above. Introductions were provided. MC highlighted the importance of ensuring the committee had the correct representation. It was agreed that Martin Wright (MW) be invited to future Primary Care Committee meetings. Action: Tracy Charlton to invite MW to future Primary Care Committee meetings. NTPCC/17/023 Agenda Item 2 Confirmation of Quoracy The meeting was confirmed to be quorate.

139 NTPCC/17/024 Agenda Item 3 Declarations of Interest The Register of Interest was checked for up-to-date accuracy. John Matthews (JM) confirmed a conflict of interest in relation to Item 8 on the agenda. MC advised that this was item to note and no decision was required. NTPCC/17/025 Agenda Item 4 Minutes of the previous meeting The minutes from the meeting held on 23 February 2017 were agreed to be a true record. NTPCC/17/026 Agenda Item 5 Actions from the previous meeting 1. NTPCC/17/017 JMt and LYM to meet with TJ to develop project plan within the timescales to implement these decisions. Complete. 2. NTPCC/17/019 LYM to Denise Jones for an update on progress and advise that an MP enquiry has been raised. LYM reported that she is still awaiting a response from Denise Jones. LYM advised that if a response wass not received, she will follow up. Outstanding. NTPCC/17/027 Agenda Item 6 - Local Enhanced Service (LES) VfM Review JMt reported progress to the Primary Care Committee and requested approval of the continuation of the Local Enhanced Services (LES). JMt provided the background in terms of responsibility and funding for LES which had been devolved from NHS England to the CCG and explained the aims of the services were to: 1. Maintain and enhance the quality of care for the residents of nursing and residential homes through the provision of coordinated and regular health care cover. To ensure each nursing and residential home was linked to a GP practice, thereby offering consistent, efficient and a high quality of care. 2. Provide a pro-active, preventative approach to caring for all patients registered with the practice who reside in a care home.

140 3. Adoption of a multi-disciplinary approach that aims to deliver a tailored package of care involving the practice lead GP as the reference point for the patient and their carer. JMt explained that the paper reported the activity whilst identifying if there is value for money. LYM highlighted that it is important for the Primary Care Committee to note that the new National Diabetes Audit specification which would need to be considered as well as ensuring the NTCCG has practices aligned to the relevant care homes. LYM suggested a comparator be devised within the context of a wider care home framework to enable the CCG and other providers consider specific requirements within a care home. This would enable the Quality team, NECS and Catherine Hall (Clinical Lead, End of Life) to become involved. Following discussion, MC thanked members for considering the content of the review and that whilst members agreed that the LES continued, they recognised that additional work was required. Action 1. JMt to review the Nursing Home LES to enable further improvement NTPCC/17/028 Agenda Item 7 IM&T Strategy Group Terms of Reference Members were provided with an Executive Summary and asked to consider and approve the Terms of Reference for the IM&T Strategy Group. Members approved the IM&T Strategy Group Terms of Reference. NTPCC/17/029 Agenda Item 8 Wallsend Primary Care Development JMt provided the committee with information on the CCG funding of revenue implications of Wallsend Primary Care Development. JMt explained the development of a new health centre in Wallsend. The building would host two GP Practices (Portugal Place and Park Road) and provide accommodation for Northumbria Healthcare NHS Foundation Trust community teams. JMt advised that the CCG recognised the benefits to the local population and had approved the application on the understanding the development would be revenue neutral to the CCG. LYM reported that a lengthy discussion had taken place within the Extra Ordinary Clinical Executive Committee relating to conflict of interest. MC advised that this was officially referred to the Audit Committee to confirm that the correct process had been

141 undertaken. It had been agreed by the Audit Committee members it was inappropriate to include a GP in the process. It was also agreed that the process undertaken had been satisfactorily followed. NTPCC/17/030 Agenda Item 09 Primary Care Committee Terms of Reference JMt provided the committee with the Primary Care Committee Terms of Reference for information. NTPCC/17/031 Agenda Item 10 - Operational Issues Bridge Medical Centre Jenny Long (JL) presented an additional paper relating to the Application to Add Additional Premises as Part of Administrative Merger; Monkseaton Medical Centre and Bridge Medical. JL explained the purpose of the report was to approve a contract variation to allow patients to be seen at both practice premises, whilst they progress an application to fully merge the two practices. JL advised the committee that she appreciated, in light of the short notice, additional time may be required prior to making a decision. MC thanked JL for recognising this may be short notice. The committee briefly discussed the pros and cons of the change whilst taking into consideration the importance of the patient need. The committee members agreed to accept the recommendation subject to the actions outlined in 5.2. Battle Hill JMt advised the committee that the contract for Battle Hill Walk-in Centre would be finalised on 30 September JMt explained that agreement had been reached in February 2017 to begin the process to change surgery s status to a branch. To ensure patient feedback on the proposed change, letters and leaflets have been printed and were to be posted to patients within the next few days. LYM confirmed that a meeting with Newcastle Hospitals, Freeman Clinics had been arranged to address any concerns relating to changes to the service. The committee considered taking additional time to further consider the implications of the change Action: JMt to contact NHSE to confirm the cost/financial implication and any risks regarding the likelihood of an extension to the contract

142 NTPCC/17/032 NTPCC/17/033 Agenda Item 10 Any Other Business There were no items of any other business raised. Agenda Item 11 Date and time of the next meeting 2.30 pm 4.00 pm on Thursday, 13 July 2017 NTCCG, Hedley Court

143 Primary Care Committee (Public) Minutes of the Primary Care Committee Meeting held on Thursday, 15 June , 2.30pm - 4pm, at Hedley Court, NTCCG Present: Mary Coyle CCG Deputy Lay Chair, NTCCG (Chair)(MC) Jon Connolly Chief Finance Officer (JC) Lesley Young-Murphy Executive Nurse and Chief Operating Officer, NTCCG (LYM) In Attendance: James Martin Tracy Johnstone Wayne Kirkham Iain Kitt Martin Wright Tracy Charlton Commissioning & Performance Manager, NTCCG (JMt) Head of Primary Care, NHS England (TJ) Primary Care Transformation Support Manager (WK) Board Member, Healthwatch Medical Director, NTCCG (MW) PA, Interim Director of Commissioning and Contracting, Medical Director (TC) Apologies: Shelagh Cockburn Ruth Evans Margaret Hall Christine Keen John Matthews Irene Walker Programme Officer, NTCCG (SC) Clinical Director, NTCCG (RE) Cabinet Member, Member of Health and Wellbeing Board, NTLA (MH) Director of Commissioning, NHS England Clinical Chair NTCCG (JM) Head of Governance (IW0 Agenda item, Discussion & Agreed Actions Action NTPCC/17/014 Welcome & Apologies for absence: Agenda Item 1 Mrs Mary Coyle (MC) welcomed all to the Primary Committee and apologies were noted as above. MC stressed to members the importance of beginning the meetings on time. It was also highlighted that all members inform Tracy Charlton, (TC) of their attendance/non-attendance prior to the meetings. MC warmly welcomed Dr Martin Wright (MW) and Wayne Kirkham (WK) to the committee. Page 1 of 5

144 NTPCC/17/015 Confirmation of Quoracy: Agenda Item 2 The meeting was confirmed to be quorate. NTPCC/17/016 Declarations of Interest: Agenda Item 3 The Register of interest was checked for up-to-date accuracy. There were no declarations of interest. NTPCC/17/017 Minutes of the previous meeting : Agenda Item 4 The minutes from the meeting held on 30 March 2017, were agreed as a true record. NTPCC/17/018 Actions from the previous meeting : Agenda Item 5 JMt reported that all items have been successfully completed. There were no other actions arising. NTPCC/17/019 Operational Update: Agenda Item 6 JMt reported the cycle for the Primary Care Committee is held quarterly in public with private meetings in between. JMt advised that in the time since the previous Primary Care Committee held in public there has been a need to make a decision on the following 2 items: Local Enhanced Services Value for Money (VfM) Review; Application to Add Additional Premises as part of Administrative Merger; Monkseaton Medical Centre and Bridge Medical. The committee were requested to note the recent decisions highlighted in the accompanying paper. Page 2 of 5

145 NTPCC/17/020 Locality Working : Agenda Item 7 JMt advised members to review the proposal. JMt provided the committee with a background to the accompanying paper in terms of the need to mobilise member practices to engage with the implementation of national policy such as the GP forward view, CCG priorities, the local Tripartite Primary Care Strategy, and the development of new models of care. JMt explained the work that had been undertaken to date in relation to the elements of funding. JMt raised the key points and explained the accompanying paper set out the process. With regards to investment of transformation funding highlighted in the GP Forward View, JMt explained the proposal to invest it in 2 ways to increase clinical leadership and project support to localities. This would provide the structure and resource to support practices to make the changes identified in the GP Forward View and Tripartite Primary Care Strategy. The funding could provide additional sessions for the Locality Directors or other GPs in the locality to be a clinical lead on specific projects. A Locality Project Support Officer would be appointed for each locality to support the delivery of a locality work plan. In addition to the Locality Project Support Officer there would need to be specialist support from other functions within the CCG to support the development of projects and any business cases. JMt progressed to explain in detail the need for the CCG to make a decision on the investment of funding released into primary care budget by the transfer of a number of practices from PMS contracts to GMS contracts. JMt advised that the reduction in funding for former PMS practices is taking place over a 7 year period of which 2017/18 is year 4. The level of funding that has been released is 240k. JMt highlighted that this funding be split between 4 localities to be used nonrecurrently to pump prime projects aligned to the Tripartite Primary Care strategy that will improve sustainability and resilience in local practices. JMt explained that the use of the funding will remove some of the risk to practices to try new projects and encourage innovation. Lesley Young-Murphy (LYM) approved the proposal in principle. Martin Wright (MW) felt the importance to raise the suggestion for the Practice Activity Scheme to be fitted in. Page 3 of 5

146 Iain Kitt (IK) questioned the relationship between the Locality Working project and New Models of Care and queried the expectation that over time the localities will take on additional responsibilities. JMt explained that the purpose of the project is to provide a better service and for the practices to work collaboratively in making decisions. Jon Connolly commented that whilst this project will be a challenge it made sense to be consistent with the strategy. MW agreed that this gave an opportunity to move forward but that caution be taken in the process of measure and outcomes. MW highlighted the importance of ensuring a clear plan in terms of how this links in with plans to advance Primary Care home. To conclude JMt advised that all project proposals put forward by localities needed to be presented for agreement through the Primary Care Committee before commencing to ensure they align with the Tripartite Primary Care strategy, have reasonable and appropriate costing, and can be evaluated. The committee agreed to this proposal. NTPCC/17/021 Strategy Update: Agenda Item 8 JMt asked the committee to note the progress being made in implementing the Tripartite Primary Care Strategy. JMt requested members make reference to the accompanying report/paper and provide an overview on the following: Strategy update DVT pathway Menorrhagia pathway Care Navigators Online GP Consultations Extended GP access Members were provided with the opportunity for discussion. NTPCC/17/022 Quality Update : Agenda Item 8 JMt lead the discussion and explained the accompanying report outlined the business which was discussed at the Primary Care Quality Group (PCQG) meeting on 16 May The committee was requested to note the contents, of the accompanying paper, for information. JMt explained that the PCQG reviewed the data provided by NHS England. It was agreed amongst the committee Page 4 of 5

147 members that the level of data quality remained difficult to interpret. It was also agreed amongst the members that action for improvement has been identified. NTPCC/17/023 Any Other Business: Agenda Item 9 There was no other business to discuss. NTPCC/17/024 Date and time of the next meeting - Agenda Item pm 4.00 pm on Thursday, 14 September 2017 NTCCG, Longsands Meeting Room, Hedley Court Page 5 of 5

148 OFFICIAL 1 Agenda Item 4 Quality and Safety Committee Part 1 Minutes of the Quality and Safety Committee Meeting held on Tuesday 03 October 2017, 9am 11.30am, at Hedley Court Present: Mary Coyle Maureen Grieveson Anne Foreman Dr James Lunn Steve Rundle Dr Martin Wright CCG Deputy Lay Chair Deputy Director of Nursing, Quality & Patient Safety Designated Nurse Looked After Children Nominated GP Head of Planning and Commissioning Medical Director In Attendance: Julie Bee Clinical Quality Manager, NECS Gregor Miller Senior Clinical Quality Manager, NECS (Arrived 09.15) Andrea Ormond Team Secretary (Minute Taker) Michelle Douthwaite Team Secretary (Training Purposes) NTQS/17/084 Agenda Item 1 Welcome and apologies for absence Ms Coyle welcomed everyone to the meeting, apologies were given from Mrs Southern, Mrs Hemingway, Mrs Walker and Dr Young-Murphy. The committee noted that Mrs Foreman was attended on behalf of Mrs Hemingway. The committee welcomed Mrs Douthwaite who is to attend future meetings as minute taker, and therefore full introductions were made. Introducaton were made. NTQS/17/085 Agenda Item 2 Declarations of Interest Ms Coyle reminded the committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of North Tyneside CCG. Declarations declared by members of the Quality and Safety Committee are listed on the CCG s register of interest and attached to the committee papers. Declarations of interest from sub committees - Not applicable. Declarations of interest from today s meeting - No additional declarations were noted. NTQS/17/086 Agenda Item 3 Confirmation of Quoracy The committee was confirmed to be quorate. NTQS/17/087 Agenda Item 4 Minutes of the previous meeting 05 September 2017 Page 1 of 5

149 OFFICIAL The minutes were reviewed and agreed to be a true record with the minor typing error on page 5, action 14 queries should read queried. NTQS/17/088 Agenda item 5 Actions from previous meeting: 05 September 2017 NTQS/17/073 Action 14 Mrs Bee to produce an SI Thematic Report Update Mrs Bee advised the report should be available for the December meeting. Status Ongoing - Action log to be amended to December NTQS/17/073 Action 15 A more detailed Q1CQUIN Report to be provided. Update Mrs Bee is not in full receipt of all information to compile report therefore this item will be defer the report until December Status Ongoing Action log to be amended to December NTQS/17/075 Action 16 Mr Miller to make enquiries to identify if the CQC notify NHS England regarding concerns identified in CQC visits. Update Mr Miller has contacted NHS England no response and this should be carried forward to next meeting. Patient, Quality and Safety Status Ongoing Action log to be amended to December NTQS/17/089 Agenda Item 6 Integrated Governance Report Mrs Bee presented the report to the end of August Mrs Bee highlighted the following:- 4 Serious Incidents (SIs) were reported relating to North Tyneside CCG (NTCCG) patients. There were no never events reported. A total of 4 complaints and four concerns and 27 Freedom of Information Act requests were received. Mrs Bee advised that the only QRG that has taken place since the last meeting relating to Northumbria Healthcare NHS Foundation Trust (NHCFT) which took place on the 12 September. The main points covered:- Page 2 of 5

150 OFFICIAL Falls: a presentation was given which provided an update on incidences of falls, harm caused and on the initiatives being implemented to reduce the risk of falling in NHCFT premises. Mrs Bee confirmed that regular updated will continue to be provided at the QRGs. Central Alerting System (CAS) compliance The Trust provided detail on its current non-compliance with Restricted use of open systems for injectable medication (NHS/PSA/D/2016/008) alert. The committee raised concerns with non-compliance and Mrs Grievson advised that a number of trust are no compliant with this and the Trust have been advised to contact other trust who are compliant for advice. Dr Wright and Mrs Grieveson confirmed to the committee that this issue will continue to be monitored through other avenues including the QRG group. Oncology Peer Review and it was reported that an oncology lead was now in post and an update was provided on the work being undertaken to recruit into vacant and new oncology posts. The Committee was informed that a formal response from the review had not yet been received. Excellence in Quality and Safety Report The Trust provided an update report and was congratulated on the executive summary and content. Discussion took place on compliance with the reporting of SIs within 2 days and subsequent provision of the 60 day report. Dr Wright advised the committee that the report is very comprehensive and therefore exception reporting may be considered. Complaints an update was provided which indicated that complaints figures were in line with last year s figures. It was reported than over 95% of responses were now being provided within the timescale negotiated with the complainant or family Friends and Family Test: Response rates continue remain well below the national and regional average for A&E and inpatients for both NHCFT and NuTHFT NuTHFT A&E response rate has reduced significantly to 4.5% (June s score 10.9%). Mrs Grieveson advised that the trust has introduced new ways of obtaining better feedback and this may have impacted on the FFT response rate. NTWFT reported a slight reduction to 86% (88% in June) in its recommendation rate Healthcare Acquired Infections: NTCCG reported four cases of C-Difficile in August NuTHFT reported 11 cases of C-Difficile in August The committee noted that this figure is high. Mrs Grieveson advised that a rapid review has Page 3 of 5

151 OFFICIAL taken place and occasionally there is a cluster of cases. Mrs Grieveson confirmed to the committee that this will be monitored through the QRG to ensure there are no trends. NHCFT reported two cases C-Difficile in August 2017 NHS Safety Thermometer (July s data): NHCFT has continued to rise to above national average for all pressure ulcers. An upward trend in reporting of these types of incidents has been seen in the last 12 months. NTWFT has risen to slightly above national average in the area of falls with harm. Mrs Coyle asked if the committee had any further questions to raise. Mrs Grieveson raise awareness to the 62 day wait for urgent GP referrals being 80.7% against a standard of 85%. There were no further questions raise by the committee. NTQS/17/090 Agenda Item 7 CQC Reports 2 reports have been published by the CQC. The report rate for Coble House was overall good for the past 3 inspections and going to pilot mock CQC inspections being developed by Transformation Team. Mrs Coyle ask if good 3 times why not outstanding Mrs Grieveson advised this is why the transformation team is going in to give an extra push to obtain this. Stephension Court was rated overall good. It previously required improvements. They recruited a new manager last year who has made significant improvements. The committee had no further comments or questions. Corporate, Quality and Safety NTQS/17/091 Agenda Item 8 Information Governance Mrs Grieveson presented the Information Governance report in Mrs Walker s absence. The IG Strategy and the IG Management Framework have been amended to include reference to the implementation of the General Data Protection Regulation issued in July The IG Management Framework and IG Strategy documents were for review and approval by the committee. Mrs Coyle asked the committee if it was happy to approve both documents or if there were any questions. Page 4 of 5

152 OFFICIAL For Information The committee agreed to approve the documents with the slight amendment to a typing error. The committee approved the Information Governance Strategy. NTQS/17/092 Agenda Item 9 Any Other Business There was no other business and the meeting was closed. Date and time of the next meeting 07 November :00 11:30 Hedley Court Page 5 of 5

153 OFFICIAL 1 Agenda Item 4 Quality and Safety Committee Part 1 Minutes of the Quality and Safety Committee Meeting held on Tuesday 07 November 2017, 9am 11.30am, at Hedley Court Present: Mary Coyle Jan Hemingway Dr James Lunn James Martin Steve Rundle Alice Southern Dr Martin Wright Dr Lesley Young-Murphy In Attendance: Julie Bee Michelle Douthwaite CCG Deputy Lay Chair Head of Safeguarding Nominated GP Performance and Commissioning Manager (Arrived 9.15am) Head of Planning and Commissioning Nominated Practice Manager Medical Director Executive Director of Nursing / Chief Operating Officer Clinical Quality Manager, NECS Team Secretary (Minute Taker) NTQS/17/093 Agenda Item 1 Welcome and apologies for absence Ms Coyle welcomed everyone to the meeting; apologies were given from Mrs Grieveson, Mrs Walker and Mr Miller. NTQS/17/094 Agenda Item 2 Declarations of Interest Ms Coyle reminded the committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of North Tyneside CCG. Declarations declared by members of the Quality and Safety Committee are listed on the CCG s register of interest and attached to the committee papers. Declarations of interest from sub committees - Not applicable. Declarations of interest from today s meeting - No additional declarations were noted. NTQS/17/095 Agenda Item 3 Confirmation of Quoracy The committee was confirmed to be quorate. NTQS/17/096 Agenda Item 4 Minutes of the previous meeting 03 October 2017 The minutes were reviewed and agreed to be a true record with the minor typing error on page 4, update should read Mr Miller and not Mr Gregor. NTQS/17/097 Agenda Item 5 Actions from previous meeting: 03 October 2017 Page 1 of 5

154 OFFICIAL NTQS/17/073 Action 14 Mrs Bee to Produce an SI Thematic Report, this is to be produced by December NTQS/17/073 Action 15 A more detailed Q1 CQUIN report to be provided. Mrs Bee advised this will be discussed as agenda item NTQS17/075 Action 16 Mr Miller to make enquiries to identify if the CQC notified NHS England regarding concerns in the Vocare CQC report. Mr Miller did not attend the meeting therefore the action has been carried forward to December 2017 Patient, Quality and Safety NTQS/17/098 Agenda Item 6 Integrated Governance Report Mrs Bee presented the report with regards to the activity in September. Mrs Bee highlighted the following: 5 Serious Incidents (SI s) were reported in September 2017 relating to North Tyneside CCG (NTCCG) patients. There were 2 never events reported in September and October 2017 by Newcastle upon Tyne NHS Foundation Trust. Mrs Bee advised that the only QRG that has taken place since the last meeting was with Newcastle upon Tyne NHS Foundation Trust (NuTHFT) and this took place on 05 October The main discussion covered: Surgical Safety: an update was provided on the Sign up to Safety initiative and it was reported that the improvement plan now expanded the scheme beyond the theatre area to incorporate consent information and Local Safety Standards for Invasive Procedures. Medication Update: a presentation was given on progress as part of the Sign up to Safety initiative specifically in relation to the dispensing of medication. Incidents were examined and learning from the incidents was reported to have made improvements. Never Events update on the action plan: an update was provided on the action plan developed as a result of the recent independent review. It was noted that many of the actions identified had been implemented. Patient experience: the results of the A&E survey were discussed and the Group acknowledged them as being positive and an improvement on the previous year s results. Page 2 of 5

155 OFFICIAL Mrs Bee advised that a QRG had taken place on 29 September with North of England Ambulance (NEAS). The main discussion covered: Training update: A report on the quality of training covering September 2016 to March 2017 was presented and it was recognised that more evaluation of training is needed. The Vocational Training Services (VTS) induction program provided by NEAS for Care Homes was commended. Safer Staffing update: it was confirmed that there is currently no safer staffing tool in place and the Trust has undertaken a rebuild in order that information can be extracted. Serious incident occurrence and compliance with timescales: It was reported that there had been18 SIs reported for 2017/18 all of which occurred in the south region and there was none for North Tyneside area. It was reported that several SIs had not been reported within 2 days. Ambulance booking arrangements: the issue of diverts to Newcastle Hospital rather than Patient Transport Services (PTS) was discussed. It was agreed further discussions need to take place to address the difficulties being encountered. Friends and Family Test: Response rates continue to remain well below the national and regional average for A&E and inpatients for both NHCFT and NuTHFT NuTHFT A&E response rate has reduced again to 3.9% NTWFT reported a slight increase to 87% from 86% in July). Healthcare Acquired Infections: NTCCG reported two cases of C-Difficile in September NuTHFT reported 7 cases of C-Difficile in September 2017 NHCFT reported one case of MRSA in September 2017 NHS Safety Thermometer (August s data): NHCFT has fallen below the national average for all pressure ulcers, reversing the upward trend since March NuTHFT reported a spike to above the national average in new pressure ulcer occurrence. NHCFT has reported an increase in VTEs since April 2017 taking it above the national average. NTWFT also shows an increase to above the national average. Dr Young-Murphy raised that NEAS have changed their ambulance response program to ensure the correct vehicle and cover is sent in Page 3 of 5

156 OFFICIAL response to calls, rather than just focusing on meeting the response times. Ms Coyle asked the committee if they had any areas of concern to be picked up. Dr Wright asked if we would get more information with regards to the Never Events. Dr Young-Murphy advised this was discussed at the QRG meeting and a copy of the report can be requested. NTQS/17/099 Agenda Item 7 Never Events Policy and Framework Review 2016/2017 Mrs Bee advised in April 2017 the response to the consultation was published. There were 574 responses received and of these 386 were from individuals and 188 from organisations. The 188 organisations were made up of providers (53.29%), commissioners (20.36%), others (including patient organisations), (13.17%), professional (11.38%) and not known (1.80%). Removal of financial sanctions and supporting learning more effectively 66% of respondents identified the option of continuing to have a Never Events policy and framework, removing the financial sanctions and working with commissioners, regulators and organisational leaders to improve response to Never Events, with an increased focus on learning and improvement. 39% of organisations and 19% of individual respondents suggested that sharing the learning from Never Events within and between organisations is not consistent and this needs to be addressed. Never Event Name 9% of organisations and 5% of individuals identified the term as misleading because it suggests that this group of SIs will not occur under any circumstances. It was suggested that a change in terminology should be considered to support learning rather than blame. This was notable as this question had not been asked as part of the consultation. Mrs Hemingway commented that she thought they were called Never Events because they should never of happen. Dr Lunn and Ms Coyle agreed with Mrs Hemingway s comments. Dr Young-Murphy advised that the main issue is the root cause analysis. Ms Coyle asked if there a system for learning between trusts. Dr Wright advised that there is a meeting set up to discuss the issues. Page 4 of 5

157 OFFICIAL NTQS/17/100 Agenda Item 8 Serious Incident Management Policy summary of revisions For Information Mrs Bee advised the following amendments have been made to the Serious Incident Policy: Mrs Bee also confirmed that appendix 3 and 9 have been added to the policy. Ms Coyle asked the committee if they approved of the amendments to the policy. The committee approved all amendments. NTQS/17/101 Agenda Item 9 Any Other Business There was no other business and the meeting was closed. Date and time of the next meetings 05 December :00 10:30 Hedley Court 16 January :00 11:30 Hedley Court Page 5 of 5

158 OFFICIAL North Tyneside CCG Clinical Executive Meeting (Part One) Wednesday, 08 November 1.30 pm 2.15 pm Hedley Court Present: Mark Adams Jon Connolly Ruth Evans Philip Horsfield Shaun Lackey Anya Paradis Martin Wright Lesley Young-Murphy In Attendance: Tracy Charlton Apologies: John Matthews Irene Walker Chief Officer (Chair) Chief Finance Officer Commissioning Clinical Director Practice Manager, Village Green Surgery Clinical Director Director of Contracting & Commissioning Medical Director Executive Director of Nursing & Chief Operating Note Taker Clinical Chair Head of Governance Agenda Item, Discussion & Agreed Actions Action NTCE/17/101 Welcome & Apologies: Agenda Item No. 01 Mark Adams (MA) welcomed committee members to the meeting and apologies were noted above. NTCE/17/102 Register of Interest: Agenda Item No. 02 The standard Register of Interests form was attached to the agenda. NTCE/17/103 Quoracy: Agenda Item No. 03 The meeting was confirmed quorate. Page 1 of 5