CCG Governing Body. Room G02A&B, 160 Tooley Street, London SE1 2QH AGENDA. Time Item ENC Presented by

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1 CCG Governing Body Thursday 8 th September 2016, 14:00 17:30 Room G02A&B, 160 Tooley Street, London SE1 2QH AGENDA Time Item ENC Presented by Chair s Welcome Dr. Heaversedge Public Opening Space Dr. Heaversedge OPEN: Southwark CCG Governing Body Meeting in Public Introductions and apologies for absence Dr. Heaversedge Patient story / Southwark showcase Southwark patient story: Cancer and community care at Guy s & St. Thomas Presentation Southwark showcase : Parents and Communities Together Presentation Items for Assurance and Items Recommended to the Governing Body for Decision Part Minutes and action log from the meeting on 14 July 2016 A (i, ii) Dr. Heaversedge Chief Officer s Report B Andrew Bland Report of the CCG s prime committees: June, July & August 2016 Items referred to the Governing Body for decision: i. CCG-commissioned HIV services consultation ii. EPRR self-assessment C C (i) C (ii) Provider presentation and question and answers Amanda Pritchard, Chief Executive, Guy s & St. Thomas NHS Foundation Trust Presentation and discussion Chair: Dr Jonty Heaversedge 1 Chief Officer: Andrew Bland 1 of 269 The best possible health outcomes for Southwark people

2 Standing Items for Assurance Update on the latest CCG position: i. Performance and quality ii. Finance and risk Presentation and discussion Andrew Bland & Kate Moriarty-Baker Malcolm Hines & Jonty Heaversedge iii. Primary care quality Caroline Gilmartin & Emily Gibbs Appended documents for reference: i. CCG Performance Report (M3) ii. CCG Finance Report (M4) iii. CCG BAF and Risk Report (M5) D (i) D (ii) D (iii-a,b) Items for Reference and Information Minutes of CCG committees 11 Integrated Governance & Performance Committee (June & July 2016) Commissioning Strategy Committee (July & August 2016) Primary Care Joint Committee (June 2016) Engagement & Patient Experience Committee (July 2016) E (i - ii) F (i - ii) G (i - ii) H Closing Items Any Other Business: Items to be notified to the secretary at least 48 hours before the meeting in accordance with Standing Orders Dr. Heaversedge Public Open Space Dr. Heaversedge 17:30 CLOSE Items f (To Note) Date of Next Meeting: 2.00pm to 5.30 pm, 10 November 2016 Part III Meeting: In Private Chair: Dr Jonty Heaversedge 2 Chief Officer: Andrew Bland 2 of 269 The best possible health outcomes for Southwark people

3 CCG GOVERNING BODY 14 July Tooley Street, London SE1P 5LX Minutes GOVERNING BODY MEMBERS PRESENT: Dr Jonty Heaversedge (JH) CCG Chair (Meeting Chair) Dr Richard Gibbs (RG) Lay Member, Deputy Chair Andrew Bland (AB) Chief Officer Malcolm Hines (MH) Chief Financial Officer Caroline Gilmartin (CG) Director of Integrated Commissioning Kate Moriarty-Baker Acting Director of Quality and Safety Mark Kewley (MK) Director of Transformation and Performance Robert Park (RP) Lay Member Dr. Noel Baxter (NB) Clinical Lead David Cooper (DC) Healthwatch Representative Dr. Yvonneke Roe (YR) Clinical Lead Michael Khan (MKh) Secondary Care Doctor Member Dr Nancy Kuchemann (NK) Clinical Lead Richard Pinder (RPi) Public Health Consultant Jay Stickland (JS) Director of Adult Social Services, Southwark Council Linda Drake (LD) Practice Nurse Member Professor John Moxam (JMo) King s Health Partners Dr Jacques Mizan (JM) Clinical Lead Joy Ellery (JE) Lay member Dr Jane Cliffe (JC) Local Medical Committee Representative Professor Ami David (AD) Registered Nurse Member Dr Robert Davidson (RD) Clinical Lead (from item 8) IN ATTENDANCE: 1 Adrian Ward (AW) APOLOGIES: Dr. Emily Gibbs (EG) Planning and Assurance Manager (minutes) Clinical Lead 1 *A list of attendees from the public seats are recorded at the end of the minutes. 1 3 of 269

4 Chair s Welcome 1. JH welcomed attendees to the meeting. Public Opening Space JH invited questions from members of the public, advising that questions can also be asked at the open space at the end of the meeting. Bob Skelly thanked the chair for the written answer previously provided on the question asked at the joint committee on Never Events. Elizabeth Rylance-Watson commented that the patient story (item 4) highlights issues that have been known about since the start of SLIC, hence the question is about how solutions are being implemented. She also noted that the themes coming from the governing body reports highlight concerns on A&E, community services and GP services, and asked for confirmation on whether attendance at A&E by Southwark patients had increased in the last year. In the light of this overall picture she asked the governing body to consider how resilient community based services are. 2 AB confirmed that growth in A&E attendances is around 2% (as expected in plans), but this level of growth is much lower than for other CCGs. Whilst the need for improvements across the system is a clear priority it was pointed out that on the measure of delayed transfers of care Southwark remains a top performer and this reflects well on community based services. JMo highlighted that the SLIC evaluation report provides evidence of effective community interventions implemented through SLIC that have helped contain the growth of emergency admissions from local residents. RG highlighted the Better Care Fund non-elective admissions measure on page 31 of the performance report also shows a long term downward trend. DC stated that a Healthwatch report on A&E admissions based on discussions with patients and staff would be presented shortly, highlighting complex issues with no quick fix. JH commented that the resilience of community based services is always a focus of the governing body. Introduction and apologies for absence 3 Introductions were made and apologies received. Members were asked to sign the declaration of interest schedule and declare if any changes. All members reported no change. JM highlighted to the governing body the 2 4 of 269

5 recently declared change that he is now the Medical Director of Instadoc, a start-up company that will provide visiting doctor services for the public. Patient Story A video was shown in which a 92 year old patient described her experience of being discharged from hospital and the subsequent community support for her and daughter. 4 The video had been shown at the recent Going Home conference organised by Southwark and Lambeth Healthwatch and CCGs. It was agreed that the video highlights a number of system weaknesses that could be tackled by having a more joined up and patient centred approach to care. JH formally thanked the CCG and Healthwatch teams on behalf of the board for the useful Going Home event and the video. Southwark Showcase 5 A video was shown highlighting the MyHealthLocker system which is a personalised shared electronic care record for mental health service users. It was agreed that the system has considerable potential as part of a wider local care record approach with which it has interoperability, and the potential for the system to be used for the collection of information on outcomes was noted. The applicability of the model to other care groups was highlighted. Minutes and action log from the last meeting on 12 May 2016 The minutes were agreed to be an accurate record of the meeting on12 May. 6 MK provided a verbal update on the action on the review of Enhanced Primary Care Services for which external support f has been commissioned in order to a) develop an evaluation framework, b) assist with the evaluation. This is at an early stage and it is expected the evaluation framework will be available for circulation over the coming month. Action: MK to circulate evaluation framework for EPCS review. AB provided a verbal update on the allegations against Boots made in the article in the Guardian which are now being reviewed by NHSE as the responsible commissioner. It was confirmed that Southwark Council do not commission NHS health checks from Boots. The action was closed. Chief Officer s Report 7. AB presented the Chief Officer s Report and highlighted the following points: - the Fit for Purpose staff restructure progress - the initial publication of the new Improvement and Assessment Framework assessment of CCGs originally scheduled for early July has been delayed - the Dulwich Health Centre update 3 5 of 269

6 It was confirmed that following the Fit for Purpose process 4 staff had initially been at risk but had been successfully redeployed into new posts. RG requested further information on the reported growth in suspected cancer referrals at KCH leading to pressure on the two week wait target. Action: IG&P to receive report on KCH suspected cancer referral growth and 2 week waits. JMo commented on the need for a small number of high level population health outcome measures to be developed to monitor our success at delivering the 5 Year Forward View prevention agenda. It was pointed out that the new assurance framework includes population health measures such as childhood obesity and smoking so these will be a greater focus in future reporting. LD noted the outcomes measures being developed in the children s commissioning workstream. The difficulty in identifying suitable measures that are timely and meaningful was discussed. JH asked RPi to work with others to propose a short list of key population health outcomes that could be taken to the Health and Wellbeing Board as suitable local measures. Action: RPi RP noted the delay in the 111 procurement in order to align with national approaches and sought assurance that local needs will still be met. CG highlighted the strong clinical input into the process across SE London, providing assurance that the model will meet local needs. MH expanded on the progress being made on the Dulwich Health Centre and the need for a delegated approval process for the business case. The Governing Body noted the contents of the report. The Governing Body agreed to delegate the approval of the business case to the Integrated Governance and Performance (IG&P) Committee on the recommendation of the Dulwich Programme Board (DPB), on the condition that the DPB could confirm that they were satisfied that the project was within the agreed financial envelope. RP suggested that as he is chair of both IG&P and DPB that in governance terms it would be preferable if he did not chair the IG&P for the meeting that endorses the DPB recommendation. It was agreed that RP would not chair IGP for the DPB item. Update on the Latest CCG Position 8 i) Performance AB presented the latest key performance issues, providing the most recent data on A&E, RTT, diagnostics and cancer waits. It was emphasised that although these targets are red lit as the constitutional target is not being met, local recovery trajectories agreed with NHS England are now below constitutional levels in a number of cases. 4 6 of 269

7 For example, on A&E it is important to note that KCH are achieving their trajectory but GSTT are not. On 52 week waiters it is expected that by October all breaches apart from NHSE commissioned neurosurgery will be eliminated. Cancer waits are expected to improve in June giving an overall green light for the quarter. JMo highlighted a number of important non-acute measures in the performance report including: the low result for KCH staff recommending the trust as a place to work in the friends and family test; the IAPT recovery rate; the Quality Premium measures on mental health smoking rates; potential years of life lost and COPD that are not being met. AB confirmed that these are all priorities that are focused on at various forums and on the issue of the KCH staff survey this has been recognised - including by the KCH chief executive when he addressed the CCG board in March. JH suggested that the King s Way transformation programme - and how it aims to improve staff morale - is reported to IG&P. Action: KMB JE observed that looking at the range of measures it appears that secondary care has a serious problem that is worsening, and questioned if the CCG is doing what it can on these issues. AB commented that as commissioners the CCG are taking the right approach in terms of contracting for services, and we are satisfied that trusts are doing the right things to address issues, but in broader commissioning terms there is more to be done in terms of preventing future acute demand, changing patient behaviour etc. JH emphasised that the CCG must seek to own the system problems with the trusts and not put additional pressure on them that can be construed as purely negative criticism of trust staff. ii) Finance and Risk MH presented the key points from the IGP Finance and Risk reports. As at month 2 the financial projections are all on target. The extent to which reserves may need to be utilised to maintain this will be determined during the year but currently in a positive position with contracts and QIPP delivery. DC asked about the CQC GP inspection risk, and whether a report on themes emerging and lessons learnt from the inspections would be provided. KMB confirmed this is in hand with learning on an ongoing basis, and following the current round of GP inspections in December will provide a full report. Action KMB JE commented on the reference to new patient engagement structures to strengthen commissioning, stating these are not yet proven. RG noted that the M2 Finance report contained recommendations that IG&P agreed to fund two of the deferred investment schemes (weight management and dementia pilot) and asked for clarification. MH explained that this had been possible as the financial position following the closure of the accounts had been made more clear. IG&P would 5 7 of 269

8 further review the release of funds from reserves in Q2. JC asked for assurance that the IT transfer risk would be mitigated for GP surgeries. MH set out the controls in place and gave assurance this was a top priority. iii) Quality KMB presented the quality update slides. It was mentioned that some of the learning from the Going Home seminar would be built into protected learning time. The results of the Continuing care deep dive were a good overall and outstanding for fast track palliative care. JH commended this, alongside the recent good result on safeguarding. NB reported back from CQRG on positive improvements made to nasal gastric tube procedures reflecting learning from serious incidents (SI) investigations. JMo asked if this can be shared with GSTT. The problems with inter-trust learning was raised, and the need for more system wide learning events. AD noted that some good inter-trust working on maternity services had been undertaken but sometimes clinicians were an obstacle to joint working. NK commented on mental health SI reporting issues, and the need for more communication between different agencies, perhaps through the Local Care Record. NB said a thematic review of mental health SIs would be undertaken. It was commented that mental health SIs low in number, and some dealt with at contract meetings rather than by quality teams. KMB is recommending all boroughs have a single overarching SI meeting with SLAM as a more effective approach to picking up themes. JE commented on the 6 x12 hour trolley waits linked to mental health patients being picked up as SIs, although it was noted these are PRU cases. RP asked whether different trusts apply different thresholds to trigger serious incidents and never events. JS commented that there have been cases where an SI should have been treated as a safeguarding referral, and that clinicians can be uncomfortable about this. NB agreed and this was discussed at CQRG. The updated position as set out above was noted by the Governing Body. 9. Report of the activities of the CCG s prime committees The governing body noted the report. South East London Sustainability and Transformation Plan (STP) 10 AB presented the report explaining it was a public summary of the plan that has been submitted to NHSE for assurance and previously considered by governing body members. Following this process it will be possible to publish the document in full in July. AB explained that the local preference would have been to publish the document earlier as it contains nothing new or contentious above the public OHSEL plan, but the 6 8 of 269

9 national process prevents full publication at this stage. AB clarified that the governance diagram related only to the governance of the STP, not the governance of the SE London health system. JMo welcomed the way the latest draft embodies mental health alongside physical health, but felt the document is not sufficiently detailed on prevention. JH replied that some of the prevention work is at a local level between councils and local care networks, whereas the STP focuses on those things that are at the south east London level. DC commented that an emerging general concern from public discussions is that the STP will result in a loss of local focus. Healthwatch will seek to articulate these concerns and feed into the process to ensure they are addressed. The Governing Body noted the progress on the South East London Sustainability and Transformation Plan (STP) as set out in the briefing paper. Minutes of CCG committees The Governing Body noted the minutes of the following meetings: a. Integrated Governance and Performance Committee (April and May 2016) b. Commissioning Strategy Committee (May and June 2016) c. Primary Care Joint Committee (April 2016) d. Engagement and Patient Experience Committee (May 2016). e. Audit Committee (April 2016) Any other Business None Public Open Space There were no further public questions Date of the next Governing Body Meeting: 8 September 2016, 2.00pm to 5.00pm. 7 9 of 269

10 Southwark Clinical Commissioning Group Governing Body 12 May 2016 Public Attendance Sheet 1. Bob Skelly Retired and South Southwark PPG member 2. Elizabeth Rylance-Watson Southwark resident 3. Chris Bitterli ABBVIE 8 10 of 269

11 Action Log: Governing Body Meeting July 2016 Outstanding action from last Governing Body meeting Meeting Date Agenda item Action Point Update Date to be completed Lead Status July 2016 Minutes and Actions MK to provide a copy of the evaluation framework to be used for the Enhanced Primary Care Review when it has been developed. Verbal update to be given at next meeting To be agreed MK July 2016 Chief Officer report Public Health to work with others to propose a short list of key population health outcomes that could be taken to the Health and Wellbeing Board as suitable local measures. Verbal update to be given at next meeting September 2016 RPi In progress July 2016 Update of latest CCG position: Quality A full report on the outcomes and lessons learnt from the current round of CQC inspections of GP practices be provided after the current round of inspections. To be provided after current inspections complete in December January 2017 KMB In progress Chair: Dr Jonty Heaversedge 1 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 11 of 269

12 Actions closed since the last Governing Body meeting Agenda item Action Point Update Date completed Lead Status Public Space The CCG is to liaise with NHS England to establish if concerns raised in The Guardian about pharmacy services provided by Boots are an issue in Southwark. AB gave a verbal update. Southwark CCG has written to NHS England as the responsible commissioners requesting that they examine this issue. NHS England have confirmed they are reviewing the matter. Note: It has been confirmed by Public Health that Boots do not provide any NHS health checks in Southwark. July 2016 AB Complete Chief Officer report IG&P to receive report on KCH suspected cancer referral growth and 2 week waits. Report added to the agenda for September IG&P August 2016 CG Complete Update of latest CCG position: Performance The King s Way transformation programme - and how it aims to improve staff morale to be reported to IG&P. Report added to the agenda for September IG&P August 2016 KMB Complete Chair: Dr Jonty Heaversedge 2 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 12 of 269

13 ENCLOSURE B Chief Officer s Report 8 September 2016 CCG DIRECTOR RESPONSIBLE: Andrew Bland, Chief Officer GP CLINICAL LEAD RESPONSIBLE: N/A AUTHOR: Andrew Bland, Chief Officer SUMMARY: The Chief Officer report provides the Governing Body with an update on major developments in local health system and within the commissioning portfolio. This report gives focus to: CCG ratings 2015/16 Fit for Purpose Partnership Commissioning Team Sustainability and Transformation Plan - Our Healthier South East London System Resilience Primary Care Co-commissioning Dulwich Programme Board Better Care Fund Continuing Care KEY ISSUES: As above INVOLVEMENT Each area of the report has been the overseen by the relevant committee of the Governing Body including the Senior Management Team of the CCG. Clinical lead portfolio holders have been involved in each area. RECOMMENDATIONS: The Governing Body is asked to: 1. Note the contents of the report AUTHOR CONTACT: Name: Andrew Bland andrewbland@nhs.net Chair: Dr Jonty Heaversedge 1 Chief Officer: Andrew Bland 13 of 269 The best possible health outcomes for Southwark people

14 Chief Officer s Report 8 September CCG ratings 2015/16 In April 2016 NHS England introduced a new Improvement and Assessment Framework (IAF), which replaced the previous CCG Assurance Framework and separate CCG performance dashboard. On 21 July 2016 our end of year assessment under the 2015/16 framework was released. NHS Southwark CCG is one of only two CCGs in south London to receive the overall rating of good for 2015/16, the other being our neighbours in Lambeth. In particular, we were praised for our vision and leadership, robust approach to planning, contracting and service development across the health and social care pathway. The way we have used our relationships across south east London to develop a nationally recognised Sustainability and Transformation Plan, and our approach to continuing healthcare, involving patients and the public in our work and safeguarding were also highlighted as strengths. There are also areas where we know we need to continue to make improvements. We continue to work closely with King s College Hospital NHS Foundation Trust to address the challenges with referral to treatment and four hour A&E standards. We also need to maintain our focus on our work to deliver IAPT standards and the 62 day wait from urgent GP referral to first treatment for cancer standard. Overall, we are making good progress and continue to strive to make improvements where they are needed. The new IAF will now be used to review CCG performance in the current financial year 2016/17. The IAF draws together in one place NHS Constitution and other core performance and finance metrics, outcome goals and transformational challenges and is structured around the following four areas: Better health: how the CCG is contributing to improving the health of its population. Better care: focussing on care redesign, performance of constitutional standards, and outcomes, including in important clinical areas. Sustainability: focussing on financial sustainability. Leadership: assessing the quality of the CCG s leadership, planning, partnership working and governance. We will receive a rating of either outstanding, good, requires improvement or inadequate in each of these four areas; a rating for our performance in six clinical priority areas; and a headline overall rating. This information, together with detail on some of the key IAF metrics will be published on the MyNHS website over the course of the year. Chair: Dr Jonty Heaversedge 2 Chief Officer: Andrew Bland 14 of 269 The best possible health outcomes for Southwark people

15 2. Fit for Purpose In my last two reports I have updated the Governing Body on our consultation with staff on proposals to make changes to the CCG s management structure, the outcome of that process, and our implementation of those new structures as a Senior Management Team. I am delighted to inform the Governing Body that following the end of consultation and the agreement of our final structures, progress has been rapid in recruiting to new or changed roles, with more than 80% of recruitment completed and the remaining posts being actively recruited to. Our progress in delivering Fit for Purpose team structures is critical in ensuring we are in the best shape to respond to the ambition of our Five Year Forward View and the challenges facing our system now and in the future. Our new structures, once fully implemented, will ensure we live within the required management cost envelop for the CCG and will significantly reduce our reliance on interim or temporary staff. I would wish to place on record my thanks to all members of the team who have contributed to the consultation and shaping our structures and to those who have worked extremely hard to establish new teams at the earliest opportunity. 3. Partnership Commissioning Team NHS Southwark CCG is committed to establishing a Partnership Commissioning Team with Southwark Council that will bring together commissioners across health and social care to work together on improving health and wellbeing for people in Southwark. The team will focus on three key areas of commissioning: children and young people; mental health; and older people/those with complex needs. The creation of this team was agreed by the CCG to form a second and critical phase of our restructure proposals, reported above. We are now jointly recruiting with the local authority for an Assistant Director for Joint Commissioning to lead the Partnership Commissioning team and a staff consultation on the changes needed to establish the new team will commence at the end of September 2016 and will run through October The intention is that following consultation and implementation of resulting changes, the new team will be fully operational in quarter four of 2016/17. The review of the CCG's programme board structures has further prepared us for the joint work of partnership commissioning, with three monthly Commissioning Development Groups now running, focused on the key population groups and attended by representatives from both the CCG and the Council. As agreed by the Governing Body in March, a Joint Commissioning Strategy Committee, co-chaired by Dr Jonty Heaversedge and the Council s Strategic Director for Children s and Adult s Services, David Quirke-Thornton, is being established. This will meet for the first time on 13 October 2016 and then on a quarterly basis. The CCG s own Commissioning Strategy Committee will continue to meet in the intervening months. Chair: Dr Jonty Heaversedge 3 Chief Officer: Andrew Bland 15 of 269 The best possible health outcomes for Southwark people

16 4. Sustainability and Transformation Plan - Our Healthier South East London The draft south east London STP was submitted to NHS England on 30 June The STP was endorsed by boards and governing bodies in south east London to demonstrate commitment to the strategic direction set out. It is intended that the full STP submission will be publically available after it is assured by NHS England, following feedback and an updated submission in October Meanwhile a full summary of our submission is on the OHSEL website and briefing meetings are planned with a number of public engagement groups including Keep Our NHS Public, Save Lewisham Hospital, 38 Degrees and Healthwatch. Current stage of the process We received feedback on our 30 June 2016 submission on 19 August Although STPs are not formally assessed or graded, our submission appears to have been recognised as one of the more advanced. The main themes of the feedback were: strengthening collective leadership towards an implementation focus; further details are required on the programme to release (recurring) productivity improvements by 2020/21; progressing the our orthopaedic programme; agreeing arrangements and process with NHS England and south west London for the South London and South East England specialist services review; development of our oversight and analysis of activity data and how this is utilised to evidence the delivery of the STP plan to include stronger plans for mental health drawing on the recent publication of the Forward View for Mental Health. A further challenge that has been set is that of agreeing contracts for 2017/18 and 2018/19 by the end of December The STP is intended to be the framework within which organisational-level two year operational plans are developed. The programme has coordinated some meetings of provider and commissioner representatives to explore how this might be achieved in advance of the publication of guidance which will not be available until the end of September this year. Next Steps The leadership of the STP (the Quartet ) has been invited to meet with NHS England on 12 September 2016 to discuss the feedback and how it will be incorporated into a revised plan, which is due to be submitted on 21 October The revised plan is expected to include an updated narrative, a set of delivery plans for each transformation work stream and an updated finance and activity plan. 5. System Resilience Accident and Emergency 4 Hour wait Standard In line with the national guidance issued by NHS England and NHS Improvement in July 2016 to help strengthen financial performance and accountability, partners across south east London are in the process of setting up A&E Delivery Boards. These groups are Chair: Dr Jonty Heaversedge 4 Chief Officer: Andrew Bland 16 of 269 The best possible health outcomes for Southwark people

17 successors to System Resilience Groups, and bring together senior representatives from across health and social care to help deliver improvement across the urgent and emergency care pathway. In line with our Sustainability and Transformation Plans, there will be a south east London wide group providing overarching strategic oversight, supported by a Lambeth and Southwark A&E Delivery Board which will focus on local delivery. As part of planning for 2016/17, both Guy s and St Thomas Hospitals NHS FT (GSTT) and Kin s College Hospital NHS FT (KCH) agreed trajectories for performance against the 4 hour standard. Although both Trusts implemented a range of measures to support delivery against these trajectories, neither site achieved planned performance in Quarter one and are likely to deviate from plan in Quarter Two. It is considered that the reasons for underperformance are multi-factorial, but it is notable that both Trusts are currently undertaking significant estate redevelopment programmes which are negatively impacting on capacity and flow in the short to medium term. Whilst we are confident that these projects will ultimately be beneficial and help to improve system resilience, responsiveness and outcomes, commissioners and providers recognise the need to take all possible steps to deliver improved performance throughout the rest of the year. GSTT has been developing and implementing a comprehensive ED Action Plan covering: A review of the medical staffing model and rotas to deliver increased responsiveness to manage surges in demand An expansion in the capacity within the Urgent Care Centre through the use of an additional nurse and ED doctor within the UCC Dedicated vascular ambulatory care beds to improve patient pathways and reduce unplanned admissions A review services to maximize impact on ED performance and to alleviate bed pressures Likewise, KCH have also developed an ED recovery plan, which is supported by the Clean Sheet Redesign programme which focuses on pathways for the first 72 hours of a patients stay in hospital. Actions include: Development of a 24/7 Urgent Care Centre adjacent to the ED which will provide a more appropriate space to manage minors patients, and help reduce breaches in the overnight period. The respecified UCC should go live early in Q4 Bed capacity (increase and reconfigure bed capacity across PRUH, Denmark Hill, and Orpington A focus on discharge planning, and the roll out of criteria led discharge to increase the levels of discharges at weekends. CCG commissioners are working with both Trusts to help relieve pressure within their Emergency Departments, including: Organising a workshop between South London and the Maudsley NHS FT (SLAM), GSTT and KCH to review pathways for mental health patients, with the aim of reducing delays from assessment to placement Chair: Dr Jonty Heaversedge 5 Chief Officer: Andrew Bland 17 of 269 The best possible health outcomes for Southwark people

18 Ensuring that approaches for redirection of patients from A&E are being fully maximised, supported by the development of a new system wide communications campaign Supporting KCH in the planning of a SAFER week in mid-september to focus on reductions in length of stay, and to test winter readiness Referral to Treatment (RTT) Standards The CCG's performance is primarily driven by the position at Kings. In March 2016 the Intensive Support Team reviewed the Trust validation programme and confirmed that the King s PTL was in a position to return to national reporting. As part of Sustainability and Transformation Fund (STF) planning, the Trust agreed an improvement trajectory to get to 88% (Trust wide) by March The Trust met its trajectory throughout Quarter one, with the numbers of patients waiting over 52 weeks reducing to 137 by the end of June 2016, in comparison to a start position of 165 patients at the start of April this year. Whilst delivery on these plans is positive, it is recognised that delivery against trajectories remains high risk, and the CCG continues to work actively with KCH to ensure that all possible steps are taken to improve the position throughout the remainder of the year, including utilising capacity within the independent sector where appropriate. Cancer waits 62 Day Access to Treatment - Performance on 62 Day Access to Treatment standards continues to be impacted by late referrals to GSTT as a specialist provider. However, performance for both GSTT and KCH is in line with STF trajectories, and will be further supported by the development of an Accountable Cancer Network and a south east London wide Cancer Improvement Plan which is being collated ahead of submission to NHS England in September. 6. Primary Care Co-commissioning NHS Southwark CCG has acted as a joint commissioner of local primary care services with NHS England since April This arrangement, referred to as 'Level Two' cocommissioning, provides the CCG with the ability to engage in and take joint decisions with NHS England, the contract holder. CCG's in England are afforded the opportunity to change or deepen their involvement in the commissioning of local primary care services on an annual basis, whereby applications are made in November / December each year for the adoption of new responsibilities at the start of the following financial year. Having begun a discussion with its membership in late June 2016, the CCG will now complete a process of engagement with its members and local stakeholders between September and November 2016 to inform a decision of the Governing Body in November to make an application to enhance its involvement in this area of commissioning as a fully 'Delegated' Commissioner of primary care services (Level Three). Under this arrangement the CCG would have sole responsibility for the commissioning of this area for the borough, under delegated authority from NHS England who will retain statutory responsibility. Chair: Dr Jonty Heaversedge 6 Chief Officer: Andrew Bland 18 of 269 The best possible health outcomes for Southwark people

19 In beginning this engagement, the CCG is clear that its ambitions both for primary care improvement itself; and for commissioning on a population basis, as outlined in Southwark's Five Year Forward View, will be greatly enhanced by the ability to secure locally responsive services through a less fragmented approach to commissioning for our residents. Consequently, we will seek to test the opportunities provided by delegated responsibility for primary care to advance our aims when making a recommendation to this Governing Body later in the year. 7. Dulwich Programme Board The new Dulwich Health Centre will play an essential part in the transformation of primary and community health care, and well-being services across south Southwark. Its development will allow the NHS to leave extremely outdated, inefficient and expensive 19th century premises, the release of much needed land for other public services, the Charter School development, and the creation of a new building that will be fit for purpose as a local health and wellbeing hub. It will support the implementation of NHS Southwark CCG s Primary and Community care strategy, the Five Year Forward View and south east London s Sustainability and Transformation Plan (STP). The plans have been developed through extensive consultation with and the involvement of the local public, patients, clinicians and providers. The business case demonstrates that the scheme described provides scope for a true transformation in the delivery of healthcare, where clinicians from all sectors will work together, sharing central staff and hot-desking facilities and enable boundaries to be porous in response to changing requirements. All of the stakeholders involved in developing this innovative solution are committed to creating a flexible, adaptable facility which will enable services to become more integrated and patient centred. The scheme is shown to be affordable to the CCG, mainly through refocusing resources from an inefficient and little used set of buildings, which are no longer appropriate for modern healthcare, into a facility which will respond to patient needs for the next 25 years and more. The CCG expects to invest a proportion of its growth money into improved services and facilities. The CCG has also bid for non-recurrent costs to be funded through the NHS England Estates and Technology Transformation Fund (ETTF) mechanism. There is a scarcity of public sector capital for the NHS. Following analysis of the options and discussions with the Department of Health, Community Health Partnerships and NHS Property Services, the Department of Health decided that this should be a scheme developed through the NHS Local Investment Finance Trust programme. This stage 1 business case has been produced in the approved format for NHS England assurance purposes, and will now be assessed by NHS England s project Assurance Unit and Capital committee. Moreover, the Southwark Council planning committee will formally look at the planning permission application in October Local approval to submission of the business case was given by the IGP committee in August this, on recommendation from the Dulwich Project Board, and after further clinical discussions at the CSC Committee. Chair: Dr Jonty Heaversedge 7 Chief Officer: Andrew Bland 19 of 269 The best possible health outcomes for Southwark people

20 I am delighted to report this major step forward for this exciting development and would wish to place my thanks on record to the Programme Board and team for their leadership and hard work in getting to this position. 8. Better Care Fund The Better Care Fund is a national policy initiative that requires local areas to agree plans for the integration and transformation of health and care related services. Under these arrangements Southwark Council and the CCG agree plans for the use of a 22m budget, covering a range of health and care related services that effectively support people at risk in the community, reduce hospital and care home admissions and help people to be discharged smoothly and safely from hospital. Our submission for 2016/17 was submitted to NHS England in May 2016, and was rated as being fully assured, one of only four London boroughs to achieve such a rating at the initial review stage. Southwark s plan is now used as a national exemplar which is testament to the hard work and dedication of teams from across the CCG and Council. The BCF has helped us deliver significant improvement across a number of areas including: Low levels of Delayed Transfers of Care (DTOCs), with Southwark one of the top 12 performers nationally, with delays less than a third of the national average Improvements to re-ablement services, with a reduction in the number of patients readmitted to hospital. Over 90% of patients remain at home 90 days after discharge. Care home admissions have been kept at low levels. Thanks to services such as Reablement, Night Owls, more people are being able to be cared for at home, helping rebuild confidence and mobility and reducing need for long-term placements. Work will continue to ensure that these achievements are built upon throughout 16/17 and provide a strong foundation for the development of our Partnership Commissioning Team. 9. Continuing Care As part of the overall assurance of the CCG undertaken by NHS England a deep dive was undertaken into the CCG s continuing health care systems and processes. This required the completion of an assessment template which consisted of 4 key areas: Assessment & Decision Making - lawful, high quality & timely Fast Track Care & Support Planning Previously unassesseed periods of care These four areas were divided into 13 standards and 28 key lines of enquiry. The assurance process also included an assurance meeting with NHS England to examine the CCGs return in more depth. I am delighted to report that the CCG was rated green on all 28 key line of enquiry. The CCG was rate Good overall with Outstanding Chair: Dr Jonty Heaversedge 8 Chief Officer: Andrew Bland 20 of 269 The best possible health outcomes for Southwark people

21 assurance for fast track processes. The CCG was particularly commended on its timely agreement of palliative care fast tracks, work with the wider health economy on supporting people at the end of their lives, implementation of personal health budgets and joint work around end of life care. The CCG has also concluded the work on the 74 previously unassessed period of care appeals received following the Ombudsman s announcement in this area. This work has been concluded in advance of the ombudsman s deadline of 30 September This is an excellent result for the CCG and pays testament to the dedicated and high professional work of our continuing care team. Chair: Dr Jonty Heaversedge 9 Chief Officer: Andrew Bland 21 of 269 The best possible health outcomes for Southwark people

22 NHS Southwark CCG Governing Body ENCLOSURE C Report of the activities of the CCG s prime committees DATE OF MEETING: 8 September 2016 CCG DIRECTOR RESPONSIBLE: Andrew Bland, Chief Officer AUTHOR: Kieran Swann, Head of Governance and Assurance. SUMMARY: 1. The enclosed report of the activities of the CCG s prime committees summarises the activities of the CCG s main committees for the period stated. This report supports the Governing Body to receive assurance that its prime committees are functioning effectively within the governance structure of the CCG and are fully exercising their duties as described in the CCG Constitution and scheme of delegation. 2. The report records the following for each of the prime committee meetings: a. Action taken under delegation by CCG prime committees. The Governing Body should note these actions, which is provided for information. b. Recommendations made by a committee to the Governing Body for decision. Accompanying documents will be referenced as part of the report. The Governing Body will be asked to agree the recommendation received from the prime committee. c. Items of committee business may also be flagged to the Governing Body to note and to further discuss. 3. The most recent minutes of CCG prime committee are also included in Governing Body papers where they have been signed-off by that committee. All minutes and agendas are also available at: Chair: Dr Jonty Heaversedge 1 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people 22 of 269

23 RATIONALE: 1. For the Governing Body to receive assurance that its prime committees are functioning effectively. 2. To receive recommendations from prime committees to take decisions where this is required under the CCG s scheme of delegation. RECOMMENDATIONS: 1. Review the enclosed report and supporting documents. 2. Agree recommendations proposed by prime committees. PROGRAMME BOARD INVOLVEMENT: All CCG programme board report to the Governing Body via the CCG s prime committees. Their work is reflected as necessary through this report and committee minutes. PATIENT AND PUBLIC INVOLVEMENT: This is not directly applicable to the context of this report. EQUALITIES: This is not directly applicable to the context of this report. CONFLICT OF INTEREST: This is not directly applicable to the context of this report. CCG DIRECTOR CONTACT: andrewbland@nhs.net AUTHOR CONTACT: kieranswann@nhs.net Chair: Dr Jonty Heaversedge 2 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people 23 of 269

24 1. Summary of prime committee meetings since the last Governing Body Committee meetings included in this report Integrated Governance & Performance Committee Commissioning Strategy Committee Engagement and Patient Experience Committee Primary Care Joint Committee South East London Committee in Common Remuneration Committee Audit Committee 28 July July July June July May 2016 Meeting Date 25 August August Chair: Dr Jonty Heaversedge 1 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 24 of 269

25 2. Summary of the principal role of CCG prime committees Committee Principal role of the committee Chair Integrated Governance & Performance Committee Commissioning Strategy Committee Engagement and Patient Experience Committee Primary Care Joint Committee Overarching duty of the committee is to act to oversee governance in an integrated way, with all aspects of commissioning and provider activities are scrutinised using an approach that considers finance, quality, safety and performance together. Assurance of the effective functioning of the CCG and its main contracted providers. Provision of assurance to the CCG Governing Body for safeguarding; information governance; health and safety and equality and diversity management. Responsible for assuring the Governing Body on the monitoring of the CCG s risk management and Board Assurance Framework. Oversees the development and implementation of the CCG s strategic plans and commissioning intentions, taking into account information received from Localities and the Council of Members on commissioning strategy and priorities; scrutinises the ongoing efficacy of commissioned services where service developments are identified; works with Member Practices to implement plans and undertake designated actions in the localities; receives reports from strategic programme boards charged with overseeing major commissioning programmes Responsible for monitoring, advising and providing assurance on patient engagement ensuring statutory duties are met and building on local good practice and report to the Governing Body on progress in implementing the engagement strategy and advising of any major deviation from engagement plans. This is a Joint Committee set up under joint co-commissioning arrangements with NHS England. This committee is responsible for the approval of arrangements for discharging the CCG s responsibilities and duties associated with its primary care commissioning functions. One of the aims of cocommissioning is to help align the commissioning system and to develop better integrated out of hospital services based around the diverse needs of local populations. Robert Park, Lay Member, NHS Southwark CCG Dr. Jonty Heaversedge, Chair, NHS Southwark CCG Joy Ellery, Lay Member, NHS Southwark CCG Joy Ellery for Southwark CCG and rotating chair for SEL meeting Chair: Dr Jonty Heaversedge 2 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 25 of 269

26 Committee Principal role of the committee Chair South East London Committee in Common for Strategic Decision Making Remuneration Committee Audit Committee The Committee in Common will perform the functions delegated to its members by their CCGs in relation to any healthcare service changes (either in hospital or out of hospital) proposed as part of the Our Healthier South East London programme or subsequent programmes, as agreed by the CCGs, which involve public consultation and which have not already or will not be consulted on as part of a separate process. Is a decision-making committee of the Governing Body, makes determinations about the remuneration, fees, payments and other allowances for employees and for people who provide services to the CCG Provides the Governing Body with an independent and objective view of the CCG s financial systems, financial information and compliance with laws, regulations and directions governing the CCG in so far as they relate to finance, and assurance on risk and fraud issues; Paul Minton, independent chair Richard Gibbs, Lay Member, NHS Southwark CCG Richard Gibbs, Lay Member, NHS Southwark CCG Chair: Dr Jonty Heaversedge 3 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 26 of 269

27 3. Recommendations to the Governing Body for decision/approval The Governing Body should review the papers referenced and formally approve the recommendation made by the stated committee. This decision will be recorded in the minutes of the Governing Body meeting. No. Committee name Meeting date Agenda item Recommendation for decision Associated documents 1. Commissioning Strategy Committee 4 August 2016 CCGcommissioned HIV services consultation The committee endorsed the proposed services and made a recommendation that the CCG s Governing Body formally approves this proposal. ENC C (i) 2. Integrated Governance & Performance Committee 25 August 2016 Emergency Preparedness Resilience and Response submission The EPRR was recommended to the Governing Body for approval ENC C (ii) Chair: Dr Jonty Heaversedge 4 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 27 of 269

28 4. Action taken under delegation: Governing Body to note for assurance The Governing Body should note the below items, where a prime committee made a decision under the scheme of delegation as set out in the CCG Constitution. No. Committee name Meeting date Agenda item Action taken under delegation by the committee 1. Integrated Governance & Performance Committee 28 July 2016 CCG IAF Assurance Report (M2) The committee noted the contents of the IAF Assurance Report (M2) and agreed to establish a process for prioritising measures, acknowledging that not all can be addressed in the short to medium term. 2. Integrated Governance & Performance Committee 28 July 2016 CCG Finance Report (M4) The committee agreed: to note the budgets and position for the Programme Budgets and the Running Costs as at end June 2016; to note the Strengthening Financial Performance and Accountability in 2016/17 report. 3. Integrated Governance & Performance Committee 28 July 2016 IAPT progress report The committee noted that it had not been assured by the current report and that a clear action plan is required which addresses the concerns raised. 4. Integrated Governance & Performance Committee 28 July 2016 NHS England guidance on CCG conflicts of interest The committee noted the contents of the guidance and the next steps for incorporating into local policy. 5. Integrated Governance & Performance Committee 28 July 2016 GP practice involvement in co-designing care coordination The Committee noted the availability of funding for the proposal The Committee agreed to proceed in line with the process outlined in the paper. The Committee noted the need for clear mitigations against the highlighted risks. Chair: Dr Jonty Heaversedge 5 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 28 of 269

29 No. Committee name Meeting date Agenda item Action taken under delegation by the committee 6. Integrated Governance & Performance Committee 28 July 2016 CCG Procurement Policy The Committee agreed the updated policy: This will be incorporated into a local policy which will return to IGP for signoff. 7. Integrated Governance & Performance Committee 28 July 2016 Any Other Business The Committee agreed allocation of funding for technical support to the Aylesbury health project for current year and subsequent two years 8. Integrated Governance & Performance Committee 25 August 2016 CCG IAF Assurance Report (M3) & IAF Priorities 2016/17 The committee noted the contents of the IAF Assurance Report (M3) and the IAF priorities document, agreeing that local targets, frequency of data refresh and responsible parties within the CCG should be added. 9. Integrated Governance & Performance Committee 25 August 2016 CCG Risk Report & Board Assurance Framework (M5) The Committee noted that: No new BAF risks were identified during August by directors in their monthly risk review meetings; the current extreme risks for the CCG and BAF risk profile depicted in the Heat Map; movement of risks on the BAF directorate risk registers. 10. Integrated Governance & Performance Committee 25 August 2016 CCG Finance Report (M5) The committee agreed to note: The budgets and position for the Programme Budgets and the Running Costs as at end July 2016; the forecast position for the year for both Programme Budgets and the Running Costs ; and the risks and mitigations. 11. Integrated Governance & Performance Committee 25 August 2016 Emergency Preparedness Resilience and Response submission The committee agreed to: Approve the compliance level, selfassessed by Southwark CCG ahead of submission to NHS England local EPRR team; note the next steps in the assessment process: review meeting and final submission to EPRR central team in December Chair: Dr Jonty Heaversedge 6 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 29 of 269

30 No. Committee name Meeting date Agenda item Action taken under delegation by the committee 12. Integrated Governance & Performance Committee 25 August 2016 Dulwich Business Case The committee agreed to: Note that the anticipated rental falls within the financial envelope previously considered by the IGP; note that the increased rental and clinical costs are included in the five year financial strategy for the CCG; approve the Stage 1 Business case. 13. Integrated Governance & Performance Committee 25 August 2016 Sustainability and Transformation Plan Consultancy Support The committee approved the extension of funding to the project for an additional three months to the end of December Remuneration Committee 14 July 2016 Change to Governing Body membership GP and Lay Member. The committee discussed this and agreed that it would support the increase to four lay members, subject to agreement with the Council Of Members in September. The committee also agreed with the current position of keeping 8 GP members, but not recruiting for the vacant role, until 2017, when other GP roles come to an end. 15. Commissioning Strategy Committee 7 July 2016 CCG Locality Reports The committee noted the Locality Reports from the North and South Localities 16. Commissioning Strategy Committee 7 July 2016 CCG 360 Survey Results The committee agreed that a prioritised proposal for action should be produced to improve some of the areas highlighted in the survey. 17. Commissioning Strategy Committee 7 July 2016 Ann Moss specialist care unit The committee agreed the recommendations included in the paper to ensure that the proposals for change are adequately engaged and consulted on. Chair: Dr Jonty Heaversedge 7 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 30 of 269

31 No. Committee name Meeting date Agenda item Action taken under delegation by the committee 18. Commissioning Strategy Committee 7 July 2016 Update to Governing Body members: National Independent Inquiry into Child Sexual Abuse The committee noted the update. 19. Commissioning Strategy Committee 4 August 2016 CCG Locality Reports The committee noted the locality reports. 20. Commissioning Strategy Committee 4 August 2016 Updates from commissioning development groups The committee noted the reports from the commissioning development groups 21. Commissioning Strategy Committee 4 August 2016 Supporting practices to codesign a common approach to care coordination The committee endorsed the proposal and referred it to the Conflict of Interest Panel to review this decision. 22. Commissioning Strategy Committee 4 August 2016 HIV awareness in primary care The committee approved the proposal, 23. Audit Committee 25 May 2016 Final Annual Report and Accounts The Audit Committee approved the Annual Accounts for submission. 24. Audit Committee 25 May 2016 External Audit Reports The committee accepted the Audit Findings Report. The Committee approved the Annual Security Management Service Report. Chair: Dr Jonty Heaversedge 8 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 31 of 269

32 No. Committee name Meeting date Agenda item Action taken under delegation by the committee 25. Audit Committee 25 May 2016 Southwark Chief Financial Officer s (CFO s) Report: The committee noted the CSU management letter and report for assurance. The committee approved the gifts and hospitality register Items for decisions per Joint Committee: 26. SE London Primary Care Joint Committee 29 June 2016 All SE London CCGs: London Requires Improvement Standard Operating Procedure (SOP) Each Joint Committee chair confirmed that their Joint Committee confirmed their agreement to adopt the final draft of the SOP 27. SE London Primary Care Joint Committee 29 June 2016 Items for decisions reported per Joint Committee: NHS Southwark CCG: Avicenna Health Centre The Joint Committee noted the actions and emergency decision taken by PCJC members (as contained in the paper) as recommended by NHS England (London) to secure emergency arrangements for continuation of the provision of services for the registered patients of Avicenna Health Centre. 28. Engagement and Patient Experience Committee 21 July 2016 CCG Engagement with Children and Young People The meeting was presented with a report of the engagement work that has taken place with children and young people and it was noted that a wide range of work has taken in this area. Chair: Dr Jonty Heaversedge 9 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 32 of 269

33 No. Committee name Meeting date Agenda item Action taken under delegation by the committee 29. Engagement and Patient Experience Committee 21 July 2016 Reviewing the CCG s engagement structures There was a discussion on the CCG governance structures relating to providing advice on assurance and providing the Governing Body on assurance that best practice engagement has been carried out. No decision was reached and the paper will be reframed to ensure that it describes the central role of patients being at the heart of commissioning decisions before being discussed at the September EPEC meeting. Chair: Dr Jonty Heaversedge 10 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 33 of 269

34 Committee items for the Governing Body to discuss The Governing Body should note and discuss the below items. These are items where assurance has been received at a prime committee, but where the Governing Body may wish to seek additional assurance or discuss pertinent issues relating to the business of the CCG. No. Committee name Meeting date Agenda item Recommendation for discussion / to note Associated Documents 1. Integrated Governance & Performance Committee 25 August 2016 CCG Assurance Report (M3) Recommended to the Governing Body for review. ENC C (i) 2. Integrated Governance & Performance Committee 25 August 2016 CCG Finance Report (M4) Recommended to the Governing Body for review. ENC C (ii) 3. Integrated Governance & Performance Committee 25 August 2016 CCG Risk Report & Board Assurance Framework (BAF) (M5) Recommended to the Governing Body for review and approval. ENC C (iii-a,b) Chair: Dr Jonty Heaversedge 11 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 34 of 269

35 Changes to Care and Support for people living with HIV in Southwark July of 269

36 Contents: 1. Introduction 2. HIV in Southwark 3. Work to date 4. Drivers for change 5. Current expenditure on HIV care and support 6. Current proposals 7. Current service usage patterns 8. Recent consultation a. Process b. Responses c. Equalities analysis d. Summary 9. Proposed new pathways 10. Proposed Service model 11. Equalities Impact Assessment 12. Financial implications 13. Transition arrangements 14. Conclusions 15. Recommendations Appendices: 1 Southwark Equalities Impact assessment 2 LSL Consultation Report 3 Transition Action Plan 1 36 of 269

37 1. Introduction Thanks to the success of HIV treatments, and excellent access to these treatments, people living with HIV are now able to live long and healthy lives. The increasing numbers of people living with HIV, although good news, also presents challenges for health and social care. As they age, people with HIV are now more likely to acquire other long-term conditions, such as diabetes. In order to better manage their condition and to live well they also need to access a greater range of social care services to meet a multiplicity of needs not directly related to living with HIV. Southwark has a long and proud history of being at the fore of modernising sexual health and HIV services. This document outlines the next stage in a process of modernising care and support services for people with HIV, a process which started in 2011 with the production of the exhaustive HIV Care and Support Review. The Review noted that the current HIV care and support services were no longer fit for purpose and came up with a detailed plan for change. The process of change was interrupted in 2013 with the transition of public health to local authorities, although started again in This final stage is thus long overdue. 2. HIV in Southwark In 2014, 2,935 adult residents (aged 15 years and older) in Southwark received HIV-related care - 2,195 men and 740 women. Among these, 51.2% were white, 28.6% black African and 4.9% black Caribbean. With regards to exposure, 57% probably acquired their infection through sex between men and 38.4% through sex between men and women. Southwark has a higher proportion of HIV diagnosis in heterosexual men and women compared to London and England rates. 3. Work to date The proposed changes to HIV care and support services, on which the three CCGs are consulting, follow the recommendations of the 2012 HIV Care and Support Review undertaken by Lambeth PCT on behalf of Lambeth, Southwark and Lewisham PCTs with support from Lambeth, Southwark and Lewisham Councils. The project that informed the review included: A review of HIV disease pattern changes over the last 10 years A review of HIV needs and best practice, this involved looking at policies and examples of what has worked well in other places. A review of the HIV care and support services that are commissioned and in place in Lambeth, Southwark and Lewisham Writing of recommendations about future services. The finding of the review (which included extensive engagement with providers and service users) was that the HIV care and support service model was no longer fit for purpose as the natural course of HIV infection had changed radically since the services were set up. The review identified that the success of HIV treatments meant people living with HIV (PLHIV) were living longer and healthier lives and that HIV was an episodic condition, much like other long term conditions. It determined that people with HIV are best served by ensuring they have equitable access to mainstream health and social care services rather than being directed down a specialist pathway for elements of their health and social care needs. To this end, the review recommended ensuring PLHIV have appropriate access to mainstream services and specifically recommended decommissioning certain health and social care services including advice and advocacy, counselling and assessment and signposting. It 2 37 of 269

38 also recommended commissioning a new peer support service and reconfiguring the CASCAID mental health service. The recommendations were slightly delayed by the implementation of the Health and Social Care Act 2012 requiring the setting up of CCGs and the transfer of Public Health functions to local authorities but, post transition, the Lambeth, Southwark and Lewisham Sexual Health Strategy ( ) committed to finally delivering on the recommendations of the review. Since April 2013, the changes recommended in the review have been implemented in a staged approach as follows: Procuring a new LSL-wide peer support and mentoring service which adopts an evidencebased expert patient model and aligns with the local NHS strategy for long-term medical conditions. The new service was procured in 2015 and is delivered by a partnership of local community and voluntary sector organisations. Reconfiguring the CASCAID mental health service, in 2015, delivered by South London and Maudsley NHS Trust (SLaM). Reconfiguration of advice and advocacy, counselling and assessment/signposting services to create new pathways for people living with HIV into non-hiv specialist services in line with the recommendations of the review. This is the stage of the review/strategy that Lambeth, Southwark and Lewisham CCGs are currently seeking to implement. 4. Drivers for Change The drivers for making changes to the HIV care and support services were identified in the 2012 review and remain valid today. They include: Ensuring equitable access to appropriate care and support services for all PLHIV, addressing existing inequalities in access Normalising HIV as a long term condition by ensuring all health and social care services across the three boroughs are capable and competent in working with PLHIV Ensuring PLHIV gain access to services that can meet their holistic needs, which are increasing due to the ageing population of PLHIV as a result of treatment successes Ensuring service provision is sustainable and can respond to the growing numbers of PLHIV Improving service effectiveness and the patient experience Ensuring specialist HIV support continues to be provided as determined by the evidence base and local need, especially where no mainstream services exist that can meet that need In 2013, BHIVA published revised standards of care to inform and support commissioning of services across the system and provide a benchmark for the quality of care: In the three decades since the identification of HIV, progress in treatment and care has been enormous, with substantial improvements in both clinical outcomes and the lives of people living with HIV. Treatment outcomes for people with HIV in the UK are amongst the best in the world, which, despite current financial pressures, must be sustained and enhanced as new structures emerge within an evolving NHS. (Standard 2) People living with HIV should be enabled to maximise self-management of their physical and mental health, their social and economic well-being, and to optimise peer-support opportunities. (Standard 9) Strategically this places the emphasis for the provision of HIV Care and Support services on ensuring people living with HIV have access to sustainable services that promote self-management of their condition. The HIV Care and Support review found that this is best done through a balance of 3 38 of 269

39 reducing the number of HIV specialist services whilst improving access to non-hiv specialist services and retaining a contained range of HIV specialist services. This approach is in line with that that pertaining to other long term conditions and ensures equity of access to services for all those with long term conditions. Given that the commissioning responsibilities for HIV treatment and clinical care and HIV care and support are split between NHS England, CCGs and Local Authorities, there is a need for a systemwide approach to the commissioning services for PLHIV. Public attitudes towards people living with HIV have continued to improve: the percentage of people who believe that people living with HIV deserve the same level of support and respect as people with cancer rose to 79% in 2014, up from 74% in 2010 and 70% in 2007 (National Aids Trust). As testing has increased, the proportion of people living with HIV who are diagnosed, on treatment and virally supressed has continued to improve with almost three quarters of people with HIV in London achieving viral suppression. Viral suppression occurs when antiretroviral therapy (ART) reduces a person's viral load (HIV RNA) to an undetectable level. Viral suppression does not mean a person is cured; HIV still remains in the body but is no longer causing damage and the person ceases to be infectious. The HIV care continuum sometimes also referred to as the HIV treatment cascade is a model that outlines the sequential steps or stages of HIV medical care that people living with HIV go through from initial diagnosis to achieving the goal of viral suppression (a very low level of HIV in the body), and shows the proportion of individuals living with HIV who are engaged at each stage. The London HIV treatment cascade among adults: 2014 (Public Health England) 5. Current expenditure on HIV care and support Medical treatment of HIV, through HIV outpatient services in acute NHS Trusts, is paid for by NHS England and is not affected by these proposals. Southwark CCG also commission a broader package of care and support for people living with HIV to supplement their medical treatment for the virus, some are provided by the NHS e.g. HIV Community Nurse Specialists from GSTT while others are provided by the independent sector and are social or psychosocial in their focus. The combined CCG expenditure on these specialist services has remained largely unchanged since the review of 2012, while the cohort has increased. However, the cost of supporting people living 4 39 of 269

40 with HIV will have increased for both the CCG and the council as people living with HIV increasingly use mainstream services instead of HIV specialist ones. The total value of the CCG spend in this area is 833,455 (see chart below). The combined values of the counselling, advice and signposting services that it is proposed are decommissioned is 128,946 or 16% of the total spend. Southwark CCG expenditure on HIV specialist care and support 6. Current proposals Lambeth Council, in their role as joint sexual health commissioners across Lambeth, Lewisham and Southwark, has completed an 8 week consultation about proposals to change the pathways for care and support services that are available to people living with HIV. These services are funded jointly by Southwark CCG, Lewisham CCG and Lambeth council. The services which are included within the proposals and related consultation are: Counselling provided by the Terrence Higgins Trust Advice and Advocacy provided by the Terrence Higgins Trust First Point (assessment/signposting service) provided by Metro Peer support and mentoring provided by Metro Children and Families services for families affected by HIV provided by Metro/Positive Parenting The proposals which were consulted on are as follows: A continuation of the Children and Families services for families affected by HIV provided by Metro/PPC as is Providing new pathways for people living with HIV to access counselling via IAPT which would lead to the decommissioning of the Terrence Higgins Trust service Providing new pathways for people living with HIV to access advice and advocacy via mainstream advice services which would lead to the decommissioning of the Terrence Higgins Trust service 5 40 of 269

41 An enhanced role for the peer support service to support people recently diagnosed to access the new pathways and to undertake initial assessments which would lead to the decommissioning of the First Point service. 7. Current service usage patterns The services under consideration are working with a shrinking proportion of the cohort of people living with HIV in the borough when compared with earlier years and the number of new referrals to each service are relatively small (eg: just 1% of people living with HIV in the borough referred themselves to the counselling service in the previous year). The characteristics of the service users varies by service type for example, proportionately more gay men use counselling with relatively low take up seen by black African people who are more likely to use the advice and signposting services. This pattern of usage is also reflected through the data on gender. 8. Recent consultation a) Process The consultation on these proposals commenced on 9 th May 2016 and ended on 29 th June The Public Health Commissioning Team made contact with Healthwatch in each borough at the outset and have liaised with them to ensure that service users would feel confident about accessing engagement events and to ensure that people living with HIV who don t use the affected services could provide their views online. User Consultation has included surveys, focus groups, and drop-ins across Lambeth, Lewisham and Southwark. A survey has been made available online (hosted through Lambeth Council website but also included on the CCG website in Southwark) with hard copies made available at events and at service premises. The survey was promoted to relevant agencies and service users. Paper copies of the proposals and feedback form have also been available and these have been delivered to HIV treatment centres HIV clinics and Guys and St Thomas s, Kings and Lewisham Hospital. An engagement event was held at the Harrison Wing at Guys and St Thomas s hospital of 269

42 In addition there have been facilitated engagement events and focus groups with service users across the three boroughs to better understand any potential negative impacts so as to inform the final decision and make recommendations for mitigation where deemed necessary. b) Responses At the close of the extended consultation period, 203 surveys have been completed, of which 30% were Southwark residents. The consultation period was extended by a further four weeks to enable further opportunity for feedback and in recognition of the complexity of the commissioning arrangements across three boroughs. The demographics of respondents to date are broadly in line with the overall profile of people living with HIV in the 3 boroughs: Gender Sexual Orientation Ethnicity Male 68% Heterosexual -35% Black/Black British, African 29% Black/Black British,Caribbean-5% Black British Other 4% Female 31% Gay male 61% White (UK) 34% White Other- 13% Other-1% Bisexual/Other -4% Mixed 8% All other ethnic groups 7% Demographics of participants at engagement events were not formally collected, however these were considered by facilitators of these events to be reflective of those communities most affected by HIV. Respondents to the survey indicated which of the services they currently use and compared with the other boroughs, Southwark respondents were more likely to report using the counselling service and to report using none of the services Respondents current service usage 0 Advice and advocacy Counselling Family support Signposting Peer support None of the above Lambeth Lewisham Southwark Other The proposal receiving strongest support, from Southwark residents, was to maintain the Peer Support Service and this was followed by the proposal to maintain the Families Service. Of the proposals to decommission a current service/provider: a majority of respondents supported the 7 42 of 269

43 proposal concerning the signposting service and more respondents supported the proposal concerning the counselling service than opposed it. Only the proposal to decommission the advice service was opposed by more respondents than supported it, although the opposition did not achieve more than 50%. When compared with responses from respondents from Lambeth and Lewisham, Southwark respondents were less likely to oppose all proposals and more likely to support all proposals, with one slight exception: they were less likely to support the proposal to decommission the signposting service by 1% when compared with Lambeth respondents, although a majority of Southwark respondents still supported this proposal to decommission the service. Support Oppose Unsure/no opinion Peer Support 84% 2% 14% Families 63% 17% 20% Signposting 56% 27% 17% Counselling 43% 35% 22% Advice 38% 50% 12% These results should be considered in light of the campaign to mobilise opposition through social and mainstream media via #stopthehivcuts. Broadly speaking, the majority of respondents did not oppose the proposals and for all but one proposal, support outweighed opposition. Overall, our proposals to keep some services and lose others appear to have received support. The survey s free text boxes did provide people who opposed the proposals with an opportunity to articulate their concerns about losing HIV specific services and using mainstream alternatives, these concerns largely focussed on: Stigma fear of discriminatory behaviour and judgemental attitudes from staff in mainstream services. Confidentiality fear of disclosure of their HIV status (without consent) by the mainstream service to their employer, landlord, other agencies or the wider community. Competency worries that mainstream agencies would have insufficient or outdated knowledge about the impact of HIV and how it affects different communities e.g. Black Africans and gay men c) Equalities analysis of responses Analysis of the responses by key protected characteristics was undertaken at tri-borough level, segmentation at individual borough/ccg level would have involved much smaller numbers, thereby diminishing confidence in our analysis. Gender: Women were more likely than men to support all proposals, this difference was greatest for the proposal to continue the children and families service and it was least so for the proposal to decommission the signposting service. Women generally were slightly less like than men to oppose all proposals and less likely to be unsure. Sexual orientation: Only one respondent identifying as Lesbian, Gay, or Bisexual (LGB) also identified as a female. Heterosexual (or straight) people were more likely to support all proposals when compared with LGBT people, this difference was greatest for the proposals to maintain the Children and families service, which only a minority of LGBT people supported the continuation of. This 8 43 of 269

44 difference was also marked for the proposals to decommission Advice/Advocacy and the Counselling service. LGBT people were more likely to oppose all proposals when compared with heterosexual people and more likely to be unsure. Ethnicity: The headline equality for HIV concerning ethnicity is for Black African communities, since the number of categories for ethnicity are wide responses from Black African communities were considered alongside responses from all other ethnic groups combined. Black African respondents were more likely to support all proposals when compared with other ethnicities, they were also less likely to be unsure on all proposals. This lesser degree of uncertainty meant that Black African respondents were more likely to oppose all proposals while also being more likely to support all proposals when compared with all other ethnicities. The proposal receiving the greatest proportionate level of support, when compared with other ethnicities was the proposal to maintain the children and families service. Age: Differences in responses were analysed for people aged under 45 when compared with those aged over 45. Older people were more likely to support all of the proposals when compared with younger people with the exception for the proposal to decommission the signposting service although his difference was only slight. Older people were less likely to be unsure when compared with young peoples and because of this, older people were more likely to oppose all proposals with the exception of the proposal to continue the services for children and families and the peer support service. Disability: respondents were asked if they identified as having a disability or not and if they did identify as having a disability, the degree to which it limited their daily functioning. Having a disability, and it having a more limiting effect on a person s functioning was associated with lower support and higher levels of opposition to the proposals to decommission the Advice/Advocacy and the Counselling services. Respondents who identified as having a disability that only limited their daily functioning a little, were more likely to support proposals to decommission the signposting service, or to maintain the services for peer support and children and families. This higher level of approval was observed when compared with people whose disability was more limiting and when compared with people who did not identify as having a disability. Respondents who identified with having a disability that limited their functioning a lot were the only equalities group that did not have majority support for the proposal to decommission the Signposting service. d) Consultation conclusions The proposals, generally speaking received higher levels of support from Southwark respondents compared with Lambeth and Lewisham. Support outweighed opposition in all proposals except for the advice service although the opposition to this proposal did not achieve more than 50%. Women, older people and Black African respondents were the all more likely to support the proposal to maintain the service for children and families. Gay/bisexual men and people with a disability which limited their functioning a lot were more likely to oppose the proposals to decommission the services for advice/advocacy and counselling. Many of these differences in support and opposition by equalities groups largely reflects the differences in service usage patterns by protected characteristics. People with a disability that limited their functioning the most indicated a need for additional support more widely. 9. Proposed new pathways and service model The proposed new pathways represent a consolidation and rationalisation of care and support pathways for people living with HIV. They reflect the considerable improvements in service design 9 44 of 269

45 and delivery across LSL since 2012 for talking therapies, advice/advocacy and peer support. As the profile of people living with HIV ages, and the risk of comorbidities increases, it becomes less clinically safe for HIV care and support pathways to sit apart from mainstream ones. The mainstream advice and talking therapy services are better placed to provide seamless referral to the right specialist skills whether it concerns immigration advice or CBT. A move to using mainstream services is not risk free as service users and stakeholders have highlighted through the consultation process. While some activity will be mainstreamed, some pathways will remain specialist (eg: help with charitable applications, family support and urgent care for complex HIV diagnoses). The new pathways will be:- For counselling and mental health support: CASCAID specialist mental health service at South London and Maudsley (SLaM) NHS Trust will see urgent cases e.g. late diagnosis, complex needs. Non-urgent cases will go via the Improving Access to Psychological Therapies service (IAPT) which is provided in all three boroughs by South London and Maudsley NHS Trust. Staff in the individual IAPT services will be supported by CASCAID s liaison function which will include provision of relevant information, assessment support/advice, 2nd opinion and onward referral. Where the Peer Support and Mentoring service has identified mental health support needs through their assessment process they will provide additional peer support to people to more vulnerable people in accessing the IAPT pathway. Where a client has enduring and complex mental health needs that are not appropriate for the IAPT service, the pathway remains unchanged e.g. to Community Mental Health Services and Primary Care who also have access to CASCAID s liaison function. For some clients, reduced price counselling (on a sliding scale according to income) may also be something to be considered. This is provided locally by Metro or THT and can be as little as 5 per session for those who are not working. For those who wish to continue with the specific provider they have got used to this may be an additional option. For advice and advocacy: The Peer Support and Mentoring service will triage the service user and provide a service if it is a simple issue. Where a specialist advisor is required, the Peer Supporters will use their links with local advice service networks Southwark s CAB will triage the service user and provide a service. If the person needs to be seen by a more specialist advisor they will be referred onto the appropriate organisation within the local network of advice agencies eg: Southwark s Local Support Team or Age UK. The advice pathway will cover benefits, immigration, housing, debt and employment. Southwark s Local Support Team - the Council service that provides support to vulnerable residents to receive their full entitlement to welfare benefits (and other help such as budgeting advice and support) will provide a service to PLHIV. This includes the access surgery being piloted at Bermondsey Spa. Support with charitable applications (a key part of the existing advice service s role) will be provided through the Peer Support and Mentoring Service at Metro across all three boroughs. For assessment and signposting of newly diagnosed people: The Peer Support and Mentoring service will provide assessment and signposting for all people newly diagnosed with HIV. This is an expansion to the current service that they are commissioned to deliver of 269

46 Proposed new service model of 269

47 10. Equalities Impact Assessment A detailed equalities impact assessment has been undertaken for Southwark CCG (see appendices) which concludes that the overall impact of the proposals is probably neutral and potentially positive. The assessment was taken to Southwark CCG s Equality and Human Rights Steering Group in July for discussion before final amendments were made in light of the discussion points raised by the Steering Group s membership. HIV continues to have significant equalities dimensions for sexual orientation, ethnicity, and gender. As the cohort of people living with HIV ages due to improved life expectancy, aging with HIV is now a much bigger issue than was the case in the past. The Equality Act 2010 defines disability as a physical or mental impairment that has a substantial and longterm negative effect on a person s ability to do normal daily activities. This has to have lasted for more than 12 months to qualify for protection. However, alongside Multiple Sclerosis and Cancer, protection is immediately afforded for people with a diagnosis for HIV as these are classed as progressive conditions. Across all groups defined by their protected characteristics, the key concern about the changes related to HIV related stigma and how this would manifest itself through discriminatory attitudes or behaviour from staff in mainstream services. For some gay and bisexual men this was compounded by concerns about discriminatory attitudes or behaviour from staff in mainstream services. National research on how stigma affects people living with HIV, recently funded by Public Health England, found that it mostly centred on: Disclosing HIV status within families and communities Experience or fear of sexual rejection Internalised stigma or poor self-image Concerns about the sensitivity and confidentiality of healthcare services remains a concern for people living with HIV but no information was elicited from the research on discriminatory experiences of wider support services. Since specialist advices services for people living with HIV are now the exception rather than the norm, we might conclude that if discrimination in such services was an issue, the research into HIV stigma would have found evidence of it happening and reported it. The experiences of HIV related stigma and discrimination are therefore not a product of the service model for social care and support, and experiences of HIV stigma are most probably not going to be worsened or improved by the proposed changes to the pathways. The transition arrangements proposed will strengthen the mainstream pathways which are being used by increasing numbers of people living with HIV and it is for this reason that the overall assessment has concluded that the changes could potentially have a positive effect. The most damaging inequality for HIV continues to be the relatively late diagnosis rates experienced by Black African communities compared with gay and bisexual men. This inequality impacts negatively on both morbidity and mortality, it also drives the ongoing transmission of HIV. Black African communities are far less likely to undergo HIV testing due to a lack of knowledge about HIV and its treatment this is compounded by judgemental views about human sexual behaviour, faith beliefs and gender norms. Please also see the section on wider commissioning implications for more information on related programmes to tackle HIV stigma. 11. Financial Implications It should be noted that, although today s financial context across health and social care is significantly more pressured than in 2012 when this redesign was initiated, Southwark CCG has not identified any financial savings from these service changes. The intention is that funding freed up of 269

48 through the changes will be made available in the short term for transition, and longer term would be reinvested into Sexual Health as outlined in the 2012 review. The tables below show savings released, costs of current proposed transition plans and areas for potential investment longer term. These still require finalisations, and it is recommended that the final investment proposals are delegated to the LSL Sexual Health Commissioning Board, with relevant CCG officer sign off Efficiencies released (annually) from proposed service changes: Counselling: 48,451 Advice: 33,298 Signposting: 47,197 Total: 128,946 Southwark contribution to LSL investment for Transition Arrangements lasting months: Advice Service QA: 7,000 Overall QA: 2,000 Total 9,000 Southwark increase in annual contribution to LSL investment in augmented peer support: Peer Support Service 10,000 These values are subject to final negotiations with the providers. 12. Transition arrangements The robustness of transition arrangements was identified as a key concern throughout the consultation. The vast majority of stakeholders, specifically the existing providers, recognise and support and direction of travel, however anxiety about both pace of change and assurance that mainstream services can respond to the proposed service changes was evident. Hence, the following transition arrangements are being proposed. a) Capacity The mainstream services that form the proposed new pathway are already providing advice and advocacy and counselling services to people living with HIV. All mental health and advice services commissioned across Lambeth, Southwark and Lewisham are non-discriminatory of people living with HIV and offer the same standard of quality and access to all sections of our communities and all groups with long term conditions. These services have considerable experience of dealing with vulnerable clients and with handling their highly personal information with high standards of professionalism and respect for the client s dignity. The numbers of people who are affected by these proposals are small in comparison to the numbers already being seen by non-hiv specialist services. After analysing the provider s activity data, we anticipate fewer than 200 people a year coming to the mainstream services for advice, one person a fortnight, and we expect that this will generate less than 2 hours a week of additional work for the Southwark advice network. Analysis of the current provider s data for counselling need, we anticipate no more than 30 additional clients a year who will go down the mainstream mental health pathway s, some of the clients who access HIV specialist counselling have enduring mental health problems that are less likely to respond to psychological therapies and therefore we anticipate that of 269

49 some of 30 people will instead be directed by the peer support or CASCAID service to the Community Mental Health Team. b) Capability We intend that advice services across Lambeth, Southwark and Lewisham will provide training for the peer support service on how to best support service users to access advice and advocacy services. CASCAID specialist mental health service at South London and Maudsley (SLaM) NHS Trust will provide a training refresh to IAPT teams and liaison function for staff in all parts of the mental health system who are working with people living with HIV. c) Assurance We are also considering a quality assurance proposal from the advice services that will measure the performance of the new service model during the first year to give us the assurances we need that the change in pathways is working. When decisions have been reached and communicated to all parties, a Transition Advisory Group will be formed comprising of clinicians, stakeholder organisations and service user representatives. This group will: Oversee the development and implementation of the transition plan/s, Develop or identify system wide assurance processes or mechanisms for the overall support system for implementation, and Develop links with CCG programmes for improving the management of long term conditions. Once the decision to decommission a service is communicated to THT and/or Metro we will draw up Succession Plans for each service in line with the standard contract clauses. These plans will ensure clients who access current services, and any new clients wishing to access services in future, are aware of the new pathways. Information and signposting on the new service model would be provided by the peer support service, which currently offers this facility and which will be funded to extend this offer during the transition period. d) Wider commissioning implications The new LSL sexual health promotion service The Rise Partnership delivers community-level HIV prevention interventions to the target communities which are designed to address HIV stigma: this includes the 13 week parenting programme Strengthening Families Strengthening Communities delivered by The Race Equality Foundation and the testing faith initiative designed and delivered by expert positive people of faith to faith leaders in BME communities. Two distinct arms of the local HIV prevention response are therefore designed to improve understanding of HIV and attitudes towards people who are living with the condition. Other priorities requiring investment for consideration: Any further efficiencies released from the decommissioning of the proposed services (following the investment required for transitions) will be reinvested into sexual health in line with LSL Sexual Health & HIV Strategy and as recommended by the LSL Sexual Health programme Board (and agreed by CCG Commissioning lead). Potential areas identified for investment include, in year cost pressures for Termination of Pregnancy, online contraception pilot, and HIV testing in Primary Care 13. Conclusions of 269

50 People living with HIV in Southwark deserve an approach to service provision that is holistic and person-centred, rather than the current model which is driven by diagnosis alone. It is neither desirable nor sustainable for people with HIV to be required to have their needs met through a HIVspecialist pathways only when high quality health and social care services are being providing by a range of excellent non-hiv specialist providers from whose expertise people with HIV would benefit. Indeed many people with HIV are already finding their way into these services, especially in Southwark with its large population of people with HIV. Indeed, less than 10% of the population of people with HIV in Southwark sought a service from the specialist HIV services described in this document last year. Thus, in line with the current Lambeth Southwark and Lewisham Sexual Health Strategy, this document outlines the next stage in a process of modernising services for people with HIV, reflecting what people with HIV are already choosing to do when seeking help. It is also essential that all three borough align their decisions and are consistent in their approach, as exiting contracting arrangements require a co-ordinated approach. 14. Recommendations To this end, the Commissioning Strategy Committee are asked to: 1. Note the proposals and the consultation that has been undertaken to date, led by Lambeth s commissioning team and on behalf of LSL commissioners 2. Consider the findings from the consultation period and how these have been considered in the development of final proposals and transition plans and identify any further areas or approaches for transition. 3. Support the recommendation to decommission existing specialist services for PLHIV for Counselling, Advice & Advocacy and Signposting, and implement new pathway into mainstream services as outlined. This includes the implementation of outlined transition arrangements including establishing a Steering Group to oversee the transition period and provide assurance that mainstream services are meeting the needs of PLHIV. 4. Recommend these proposals are recommended to the Governing Body for endorsement of 269

51 Emergency Preparedness Resilience and Response (EPRR) Annual Self- Assessment Report 1. Introduction As Category 2 responders under the Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005, CCGs are required to ensure suitable and effective arrangements are in place for emergency planning to ensure statutory duties are fulfilled and that there is compliance with NHS England EPRR Framework guidance. CCGs are also required to cooperate and share information with Category 1 responders such as local authorities and NHS England. For CCGs, the implication of the duty to cooperate includes ensuring that its own constituent parts can work together and understand how they would respond in an emergency. This can be achieved by good Business Continuity Management planning (BCM). The duty also applies to outward facing co-operation with other responders, through routine communication activities as well as working together through formal structures such as the Local Health Resilience Partnership (LHRP). This paper sets out the CCG arrangements in place, the self-assessed level of compliance and provides an action plan to meet the outcomes of the assurance process. Following approval by the IGP under delegated authority, the CCG Governing Body is required to note the self-assessed assurance levels that the Chief Financial Officer who is also the Accountable Emergency Officer (AEO) has recommended. 2. NHS England assurance process: Each year, NHS England undertakes an assurance process to ensure that each organisation is compliant with the core standards. The Director-level Accountable Emergency Officer (AEO) and the Governing Body in each organisation are responsible for making sure these standards are met. The assurance process is detailed below: The CCG is expected to complete the first stage and submit its GB-approved self-assessment and evidence to NHS England by 14 September of 269

52 3. The NHS England Emergency Preparedness, Resilience and Response Framework - Core Standards There are 31 core standards in the NHS England Emergency Preparedness Resilience and Response Framework that apply to CCGs. These core standards are in the following areas of assurance: 1. Governance 2. Duty to assess risk 3. Duty to maintain plans emergency plans and business continuity plans 4. Command and Control 5. Duty to communicate with the public 6. Information sharing mandatory requirements 7. Co-operation 8. Training and Exercising For 2016/17 the assurance deep dive is Business Continuity. Recommendation: The Accountable Emergency Officer recommends the selfassessment outlined in Enc. E-i to the IGP and Governing Body: Red No standards were rated as red Amber 2 areas were rated as amber Green All other standards were rated as green The actions identified in 2015/16 have been addressed as follows: Action Lead Progress Finalise SECSU IT Disaster Recovery Plan Malcolm Hines AEO SECSU has completed the plan. It is awaiting final approval through their governance processes early September The CCG has received assurance that a final version will be available before the 14 September If the CSU is not able to finalise their plan, the CCG will declare one section of standard 8 as amber. This will not affect the CCG s overall rating (see section 4 overall rating) of 269

53 Carry out multiagency pandemic flu table top exercise Malcolm Hines AEO Completed in February 2016, CCG represented by Gwen Kennedy. Pandemic flue plan refined and updated as a result. An action plan for 2016/17 has been produced for both the amber-rated standards and also includes actions required to maintain the green status in other standards. It has been signed off by Malcolm Hines, Accountable Emergency Officer, presented in Appendix Self-Assessment overall rating The CCG is asked to state an overall assurance rating according to the classifications below: Compliance Level Full Substantial Partial Non-compliant Evaluation and Testing Conclusion Arrangements are in place that appropriately addresses all the core standards that the organisation is expected to achieve. The Board has agreed with this position statement. Arrangements are in place however they do not appropriately address one to five of the core standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed. Arrangements are in place, however they do not appropriately address six to ten of the core standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed. Arrangements in place do not appropriately address 11 or more core standards that the organisation is expected to achieve. A work plan has been agreed by the Board and will be monitored on a quarterly basis in order to demonstrate future compliance. Recommendation: The Accountable Emergency Officer recommends the CCG declares it has Substantial Assurance where further work is needed on compliance to one or more standards of 269

54 5. Next Steps The next steps are to: Submit the self-assessment and accompanying evidence to NHS England Regional EPRR team by 14 September 2016 Accountable Emergency Officer to represent the CCG at the review meeting with NHS England and a peer reviewer, where final ratings will be agreed. (October-November 2016 Present the final ratings to IGP and GB Submit the final assessment and evidence to NHS England EPRR Central team by 31 December The IGP is asked to: Approve the compliance level, self-assessed by Southwark CCG and agreed by NHS England following review of our plans and self-assessment submission. Recommend the report for Governing Body approval of 269

55 NHS SOUTHWARK CCG NHS ENGLAND EPRR ASSURANCE ACTION PLAN The following action plan lists and describes the actions to be taken by the CCG in order to demonstrate and maintain full compliance to the EPRR core standards 2016/17. Core standard Clarifying information Self- RAG Action to be taken / Action Plan Lead Timescale 2016 Deep Dive on business continuity plans 1. DD1 Organisation has undertaken a Business Impact Assessment Updated Business Impact Assessments All teams within Southwark have completed a BIA in 2015 for all their main activities identifying critical functions, risks, resources, contingency plans and stakeholder interdependencies. Carry out annual update of all Business Impact Assessments Malcolm Hines, AEO Oct 16 Risk Register has EPRR risk which is regularly reviewed and updated by the AEO. 55 of 269

56 Core standard Clarifying information Self- RAG Action to be taken / Action Plan Lead Timescale 2. DD3 There is a plan in place for the organisation to follow to maintain critical functions and restore other functions following a disruptive event. An organisation wide Business Continuity plan that has been updated in the last 12 months and agreed the Board/Governing Body Critical functions and other functions across the organisation are detailed in the Governing Body approved BCP. Annual update Business Continuity Plan utilising updated BIA s Malcolm Hines, AEO Nov 16 Governance key actions needed to maintain green status 2016/ Organisations have an overarching framework or policy which sets out expectations of emergency preparedness, resilience and response. Updated Business Impact Assessments The CCG has an approved EPRR policy which is an overarching framework setting out expectations of emergency preparedness. Annual update of EPRR policy Malcolm Hines, AEO Oct Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs future work Arrangements are in line with NHS England requirements which include a six-monthly communications test, annual table-top exercise and live exercise at least once every three years. Directors on Call training CCGs participate in monthly communications exercises Pandemic flu table top multi-agency exercise successfully completed February Purchase support of expert facilitator Carry out table top exercise with a scenario to test ICT failure leading to loss of information Annual update of Directors oncall training Malcolm Hines, AEO Malcolm Hines, AEO All Directors Sep 16 Jan 17 Awaiting dates from central team 56 of 269 6

57 NHS Southwark CCG Governing Body ENCLOSURE D Update on the latest CCG position DATE OF MEETING: 8 September 2016 CCG DIRECTOR RESPONSIBLE: Andrew Bland, Chief Officer AUTHOR: Kieran Swann, Head of Governance and Assurance. SUMMARY: 1. The Governing Body will receive short presentations covering performance and quality; finance and risk; and a further one on primary care. 2. These will be presented by the appropriate CCG executive director and/or responsible clinical lead. 3. The following documents are provided for additional assurance and for reference in relation to the above presentations. a. The CCG IAF Assurance Report for the most recent month. b. CCG Finance Report for the most recently month. c. The CCG Risk Report and Board Assurance Framework for the most recent month. RATIONALE: 1. For the Governing Body to receive assurance on the latest position on performance, finance, risk and quality. Chair: Dr Jonty Heaversedge 1 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people 57 of 269

58 RECOMMENDATIONS: 1. Review the enclosed report and supporting documents and receive the associated presentations. PROGRAMME BOARD INVOLVEMENT: All CCG programme board report to the Governing Body via the CCG s prime committees. Their work is reflected as necessary through this report and committee minutes. PATIENT AND PUBLIC INVOLVEMENT: This is not directly applicable to the context of this report. EQUALITIES: This is not directly applicable to the context of this report. CONFLICT OF INTEREST: This is not directly applicable to the context of this report. STATUS OF PAPER: SUITABLE FOR SHARING WITH LOCALITIES CCG DIRECTOR CONTACT: andrewbland@nhs.net AUTHOR CONTACT: kieranswann@nhs.net Chair: Dr Jonty Heaversedge 2 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people 58 of 269

59 Assurance Report CCG Improvement and Assessment Framework Month /17 59 of 269

60 2 Approach and contents Approach This report provides the latest performance data and contextual information on each of the performance indicators in the new 2016/17 CCG Improvement and Assessment Framework. It has been written ahead of the publication of national reports on the framework, using the latest data available to the CCG. The self-assessment document is structured to set out the following for each IAF metric: a) A summary of the CCG s current position against delivery of the standard. b) A set of actions completed to date to support / maintain achievement of the standard. c) A set of actions to be taken in the future with deadlines and lead officers noted. Each section begins with a summary of the CCG s self-assessed position. It should be noted that RAG-ratings are indicative only and largely based on comparative data where this is available. This has been completed ahead of the official thresholds for achievement having been made available for all indicators. Contents Page 1 Better Health 3 2 Better Care 19 3 Sustainability 65 4 Leadership 73 5 Appendix 1: supplementary indicators of 269

61 3 Better Health Indicator name Value / RAG 101a. Smoking: maternal smoking at delivery 2.9% 102a. Child Obesity: Percentage of children aged classified as overweight or obese 43.6% 103a. Diabetes: Patients that have achieved all NICE recommended targets 103b. Diabetes: People with diabetes diagnosed less than a year who attend structured education course 104a. Falls: injuries from falls in people aged 65 and over 2, a. Personalisation and choice: utilisation of the NHS e-referral service to enable choice at first routine 27.8% 105b. Personalisation and choice: Personal Health budgets per 100, c. Personalisation and choice: Percentage of deaths in hospital 53.8% 105d. Personalisation and choice: People feeling supported to manage their long term conditions 59.7% 106a. Inequality in avoidable emergency admissions b. Inequality in emergency admissions for urgent care sensitive conditions a. Anti-microbial resistance: appropriate prescribing of antibiotics in primary care b. Anti-microbial resistance: appropriate prescribing of broad spectrum antibiotics in primary care a. Carers : Quality of Life of 269

62 4 Better Health: Smoking 101a. Maternal Smoking at Delivery 2.9% Summary of current position NHS Southwark CCG s has seen a downward trend over the last 5 years in women s smoking status at the point of delivery, and remains low in comparison to other London CCGs seen. However, we know that women do not always honestly report smoking cessation status, especially at delivery, and that this is not an considered an opportune time to clinically intervene. 2015/16 total 2.9%. Actions taken to date Maternity Services were an early implementer of the Health Promoting Hospital 3 Year Contract Incentive that has been in place with KCH & GSTT since 2015/16. This requires all maternity staff to under go training, delivery of brief intervention and onward referral to smoking cessation services. Data on coverage is currently unavailable at DH due to IT systems. KCH Maternity Services and Southwark Primary Care have been piloting CO monitoring of pregnant women, prior to screening for smoking status. Where a women is identified as a smoker or regularly exposed to secondary smoke than a referral is made to Smoking Cessation Services. KCH have made good progress implementing NICE guidance on universal CO monitoring at Booking Appointments., and continue to progress developments Further actions planned in 2016/17 Lead Date Lambeth & Southwark Joint Maternity Commissioning meeting to consider women s continued access to smoking cessation screening across the maternity pathway, with a focus on relapse/starting smoking postnatal and ensuring cessations pre next pregnancy. This will include the development of a meaningful local matrix for system wide implementation. L&S Maternity Commissioning Group Sept 16 KCH to implement Badgernet Maternity IT System in Sept 16 which will allow monitoring of delivery against Health promoting Hospital Contract incentive. CSU Sept 16 Review learning and wider roll out of CO monitoring of women throughout their pregnancy. L&S Maternity Commissioning Group Sept 16 SEL s STP emerging commitments to implement Saving Baby Care Bundle- which includes smoking cessation SEL STP 2017/18 62 of 269

63 5 Better Health: Child Obesity 102a. Percentage of children aged classified as overweight or obese 43.6% Summary of current position Southwark Health and Wellbeing Board has prioritised the development of Everybody s business Southwark Health Weight Strategy which will be presented to the Board in July 2016 for approval. This is based on Southwark Council s commitment to supporting residents achieve a healthy weight as part of their promise to promote a Fairer Future for All. Southwark CCG works in partnership with Southwark Council to develop and implement this strategy to reduce maternal, childhood and adult obesity and continue to drive work already in progress based on available evidence for the prevention and treatment of overweigh and obesity across each life stage. Actions taken to date Drafted Everybody s business Southwark Health Weight Strategy including a 5 year Southwark child obesity ambition to reduce the percentage of children who are obese (percentage reduction to be endorsed by the Health and Wellbeing Board in July 2016) Identified Children and Young People Commissioning Development Group with membership including Council, CCG and public health leads, to oversee implementation of Everybody s business Southwark Health Weight Strategy with senior leadership from Southwark Health and Wellbeing Board. An all age Healthy Weigh Implementation Group will drive the delivery of the strategy with CCG membership 74% of schools are registered to the Healthy Schools London programme (77 out of 104 schools), 44% have achieved accreditation Free Healthy School Meals are offered to all children aged 4-11 (uptake at KS2 92%) and the free fruit scheme offered to children aged 7-11 in all Southwark Schools (100% offered) Implementation of a specialist healthy weight practitioner as part of the school nursing team and specialist Weight Management Service focused on 4-12 year olds who are obese July initial visit by UNICEF confirmed that GST can progress to formal application for initiative and for phase 1 accreditation within 6 months. Further actions planned in 2016/17 Lead Date Implementation of the Everybody s business Southwark Health Weight Strategy working plan JY Q2-Q4 Development of a new integrated early years pathway to ensure health professionals and services are prioritising healthy weight including the introduction or further development of local incentive schemes to fund service focus on healthy weight/exercise advice and signposting Start implementation of the Healthy Child Pathway offering universal and targeted support to families from 0-19 years including healthy weight advice Commissioning of a healthy weigh training programme to be delivered to all health professionals and non health professionals to ensure they feel confident and competent to provide appropriate, up to date, consistent and evidence based lifestyle advice as well as being able to sign post families and children 0-4 and school age) to the appropriate national and local services. JY JY JY October 2016 March of 269 Q4

64 Better Health: Diabetes 103a. Patients that have achieved all NICE recommended targets Summary of current position Actions taken to date The National Diabetes Audit shows a decrease from April 2013 to April 2014 for Southwark people achieving all NICE recommended targets. However, participation rates for practices has been lower locally than nationally. Under 25% participation is being rated as red nationally. Local data analysis indicates that the HbA1c and Cholesterol metrics remained at similar levels to the previous year, with a large fall (4%) in proportion of people achieving the blood pressure target. There is very high variation across practices, in achievement of NICE targets as well as provision of care processes. Support with the management of diabetic patients in primary care is commissioned from the diabetes community service. Practices who are poorer performers against these metrics will be offered additional support from the community service. Contractual levers are in development to support improvement. The metric of children achieving the HbA1c metric has not been collected on a regular basis to date. A mechanism for regular review of this data will be established Downward trend identified and data analysis showing variation across practices in achievement of NICE recommended outcomes as well as care processes. Trend towards poorer blood pressure control identified as contributory factor. Percentage of patients with diabetes, on the register in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmhg or less for patients under 80 years of age or 150/90mmHg for patients 80 years old and over selected by the Clinical Strategy Committee as a local indicator within the Quality Premium Framework in response to identified area of poor outcome. Included as a commissioning intention for inclusion in PMS contract during 2016/17. South East London Blood Glucose Control Management Pathway for Adults with Type 2 Diabetes Mellitus being developed by South East London Diabetes Medicines Working Group as an educational tool for General Practice to improve. Goal setting as part of a collaborative care planning is an evidence based approach to improving biological outcomes for people with diabetes. This approach is in the process of being embedded across primary care. Primary care clinicians were incentivised to attend training, and care planning (and annual review) are included within the population health management contract with primary care. By including within a population based contract (rather than with individual practices), a contractual lever to reduce variation is in place. A number of provider led projects to improve biological outcome are being supported by Southwark CCG. These include Empowering young people with T1 diabetes to manage their own diabetes care, 3 dimensions for diabetes (addressing social and psychological needs of patients) and approaches to improving uptake of structured education for T1 diabetes. Achieving a reduction in HbA1c and blood pressure (when elevated) are KPIs within the community diabetes contract. Reported on a monthly basis to the CCG. Data showing variation across primary care for each of three indicators shared with community team to target support to practices including: undertaking joint clinics, medication review opportunity to attend Community Diabetes Clinics. Work being undertaken with federations to ensure full participation in the National Diabetes Audit to ensure an accurate measure for Southwark is reported nationally Further actions planned in 2016/17 Lead Date Establish mechanism for regular reporting against children HbA1c target and targeted action. CCG working with public health and primary care to establish how this indicator could be report including a review of the current distribution of HbA1c from PDU(s) JY 64 November of

65 7 Better Health: Diabetes 103b. People with diabetes diagnosed less than a year who attend structured education course Summary of current position Participation rates in the National Diabetes Audit for practices has been lower locally than nationally. Under 25% participation is being rated as red. We are committed to increasing the uptake of structured education for people with diabetes as a means of Improving their abilities to manage their health through diet, physical activity and medication. Significant improvements have been seen in referral rates from primary care over the previous four years. The most recent QOF data places Southwark at 31 out of 209 CCGs in England for referrals to structured education. DESMOND and DAFNE are the structured education courses available to the people of Southwark with type 1 and type 2 diabetes, respectively. DESMOND uptake has improved significantly from 2014 to 2015 (7.2% vs 16.0%) however there remains a significant drop off rate from those offered to attended which we are working with providers and local AHSN to address this. A potential data recording issue has been identified as currently the NDA has a value of 0% attending DAFNE. An audit of type 1 patients from 2007 to 2013 puts attendance rates at approximately 30%. Actions taken to date Monitoring and performance management: Uptake of the DESMOND programme is a KPI within the community diabetes service specification. Data submitted and reviewed on monthly basis by the CCG. This is also included in the Health Innovation s structured education dashboard, enabling benchmarking across all boroughs in South London. Referral and uptake rates from all practices are now be reviewed to identify practices requiring targeted support for improvement. Service Improvement: Improvement plan developed by provider to increase uptake of DESMOND, including revising the booking process in line with best practice, increased number of venues and variety of days and times, use of lay educators and development of the self referral option. For people that do not attend DESMOND they are sent a DNA letter with information about other forms of education / information about receiving structured education. Pilots and research: Health Innovation Network Darzi fellow running a project at KHP to investigate the reasons for and improve the uptake of structured education for type 1 diabetes. NIHR funded project across King s College Hospital to develop, implement and evaluate a culturally appropriate diabetes lifestyle intervention Work being undertaken with federations to ensure full participation in the National Diabetes Audit, which will include uptake of DAFNE and DESMOND and ensure an accurate measure for Southwark is reported nationally Further actions planned in 2016/17 Lead Date Review of progress against improvement plan from the DESMOND provider AY Jan 2017 Review recently NICE accredited non-group based structured education for people with T2 diabetes as part of a wider self management review, informing commissioning intentions for 2017/18. AY Dec 2016 Review recommendations from structured education project and incorporate into 2017/18 commissioning intentions if appropriate AY Dec of 269

66 8 Better Health: Falls 104a. Injuries from falls in people aged 65 and over standardised rate per 100,000 population 2,444 Summary of current position NHS Southwark CCG has focused on reducing falls for patients aged 65 and over through the Southwark and Lambeth Integrated Care partnership comprising of local commissioner, provider and citizen representation and collaboration between 2012 and Investment into early identification, primary prevention and reducing the number of falls in our local area was tested and successful initiatives mainstreamed from April Actions taken to date Early identification through full implementation of holistic assessments which aim to identify patients who may develop a risk of falls focusing on patients aged 65 and over. Holistic assessment results in interventions from health and/or social care to pull interventions in place at an early stage (when there is a low risk of falling). Approximately 10-13% of patients receiving a holistic assessment are identified as a falls risk Implementation of community based exercise (primary prevention) groups based on FaME Programme exercises across the borough Implementation of a direct access falls phone help line for patients to seek advice and guidance Reviewed and reduced barriers for patient attending exercise prevention classes through coproduction with our local population resulting in wider promotion through voluntary sector organisations, using buddy schemes to facilitate early class attendance and improving health information strategies Provision of a falls services for patients which ensures all receive the same access to falls assessment and treatment, and are provided with individually tailored falls management programmes to suit their specific needs Further actions planned in 2016/17 Lead Date Increase number of holistic assessments taking place in the community which increases early intervention for patients with a low risk of falls JY/HS Monthly Increase capacity of community based exercise classes to delivery projected demand of primary interventions of patients assessed with risk of falling. The rollout plan enables a significant increase in the primary prevention from 140 individuals per year to 1000 per year by , and a moderate increase in secondary prevention, in line with current demand estimates from 1500 a year to JY Q1-Q4 Review performance of rollout of interventions including holistic assessment and community based exercise classes against plan to deliver a 40% reduction in falls in the at risk population (30% of those aged 65 and over) by 2020 AY/JY Q3/4 66 of 269

67 9 Better Health: Personalisation and choice 105a. Utilisation of the NHS e-referral service to enable choice at first routine elective referral 27.8% Summary of current position Indicator: the percentage of referrals for a first outpatient appointment that are made using the NHS e-referral Service (e-rs). The CCG s performance is at less than 30%. (27.8% April 2016) Actions taken to date We have a well established system of support to help local practices to procure and use ICT products and services. For example, all local services use EMIS Web as their primary care system of choice. We have also implemented a decision support tool (DXS) that works alongside the main clinical system to provide information on local care pathways. It has the ability to automatically populate referral forms and it contains a full directory of services in addition to e-referrals. We began rolling out e-referrals in Southwark in April Further actions planned in 2016/17 Lead Date In partnership with Lambeth CCG we have developed a scheme for the development of training resources and delivery of training to the 91 General Practices in the two boroughs. The funding for this initiative is predicated on a successful bid to the ETTF scheme. Although e-referrals is in use in CCG member practices, we want them to seize the opportunity offered by the Local Digital Roadmap to optimize use of e- Referral and transform access to secondary care. Our secondary care stakeholders, Guy s and St. Thomas s NHS Foundation Trust and Kings College Hospital NHS Foundation Trust have identified a wide range of training issues with local GPs when using e-referral. They are very supportive of this scheme as a way to improve referral management and so make referral management in secondary care more effective and efficient. MH TBC 67 of 269

68 10 Better Health: Personalisation and choice 105b. Personal health budgets rate per 100,000 population 6.3 Summary of current position All Continuing Healthcare service users choosing home care receive a written offer of a personal health budget In , 246 Continuing Healthcare service users were offered a personal health budget Personal Health Budgets extended to Mental Health services users supported by the High Support Needs Team The CCG has 19 personal health budgets across Continuing Healthcare and Mental Health, giving 6.3 per 100,000 CCG patients Actions taken to date PHBs have been mainstreamed within NHS Southwark CCG s continuing healthcare service. PHB are available to everyone eligible for NHS Continuing Healthcare (CHC). This includes both adults and children. Once eligible people are notified of their right to have PHB and provided with written information. PHB are offered in all three options a notional budget, a third party payment or a direct payment. The details of how to access a PHB are on the CCGs public website The CCG has a ratified PHB Policy that sets out the principles and processes for PHB. NHS Southwark CCG and Southwark Local Authority have a ratified joint Personal Budgets Policy (2015) which supports SEND services that cover 0-25 years. Details of PHB for children and young people are included in the Councils Local Offer which is available to access via the Councils website. The CCG and LA have used coproduction to develop our processes for developing PHB for children Personal health budgets have been available from April 2015 for Southwark mental health service users who would otherwise need residential or nursing home care. The CCG MH team working in partnership with the LA and SLaM has developed a scheme to support former inpatients in receipt of accommodation as part of tier on-going care and support. To date 8 PHB have been provided We have developed a variety of roles within the local system to support care navigation and signposting into services run by the voluntary and community sector. The development of these systems provides a foundation upon which to build more formal mechanisms of social prescribing, and to offer practical routes so that people with personal health budgets can access a variety of support services. For example: in partnership with AgeUK, we have implemented the SAIL (Safe and Independent Living) checklist which provides a quick and simple way to access a wide range of local services to support older people in maintaining their independence, safety and wellbeing. Anyone can make a SAIL referral by simply answering the yes/no questions on the checklist below. GPs and district nurses are currently using this checklist, and we have also embedded a SAIL Navigator into some local practices. The SAIL Navigator supports patients by carrying out home visits to create and implement a person centred plan that addresses primarily non-medical needs. Age UK then coordinate and monitor onward referrals and the responses from other services (e.g. the fire brigade). we have also developed a project to up-skill reception, administration or counter staff in 10 GP practices and 10 community pharmacies as primary care navigators (PCNs) across one neighbourhood/locality. PCNs signpost patients to appropriate services and work with SAIL navigators for patients with more complex needs. This will spread the impact of SAIL care navigation and target vulnerable older people. Further actions planned in 2016/17 Lead Date All NHS Continuing Healthcare home care packages notional personal health budgets by default MG September 68 of

69 11 Better Health: Personalisation and choice 105c. Percentage of deaths in hospital 53.8% Summary of current position Southwark has improved significantly on this measure with deaths in hospital falling from 58% in Q3 of 14/15 to current historic low This is supported by the 5 th highest proportion of deaths in people s own homes in London and the highest in the STP area Achievement against this indicator is significantly influenced by the lack of care home provision in the borough, with Southwark having one of the lowest proportions of deaths in care homes in London Southwark was an early adopter of CMC and has the 9 th largest number of patients on the system in London Actions taken to date End of life Care Strategy Group in place which has membership from both commissioning and all relevant providers services. This group has been working to support patient choice of preferred place of death. This has been achieved through the development of; best practice guidance on DNACPR which has been shared and signed up to by LAS, Care Homes, Primary Care and acute palliative care services; development and sharing Recommendations regarding GP input to support the Priorities for Care of the dying adult person in the community (with specific reference to the last days of life); a revised fast track care planning process and training and support for GPs on Difficult Conversations. The Strategy Group has supported the development of the EOLC JSNA 2015 and a set of High Level Outcomes to support commissioning intentions to support patient choice at the end of life. This Strategy Group has also development a single process for the implementation of the 5 Priorities of Care across all community care settings which ensures a consistent approach to end of life care. All applications of NHS Continuing Healthcare fast tracks are agreed by the CCG CHC clinical commissioner on day of receipt. A recent review of fast tracks applications received by NHS Southwark CCGs shows that 94.8% of fast tacks receive care on the day of referral or the day after, 4.6% within 2-3 days of referrals and only one case taking longer. Details of fast-track patients are shared with community nursing teams to ensure immediate follow up. The CCG commissions a range of services to support patients to die at home if this is their preferred place of death. These services include: Marie Curie to provide overnight support for fast track clients this support clients to achieve their preferred place of death., PAL@home specialist palliative care service to provide clinical support to patients in their own homes and 24hr access to specialist palliative care support via both Guys & St Thomas and St Christopher s Hospice. The CCG CHC tam works closely with the community End of Life Nurse Consultant to support transfer of clients from acute to community setting at the end of life. The CCG also commissions a GP Enhanced Services to Care Homes which provides a dedicated GP services to all care home with nursing in Southwark, the commissioned services includes an MDT approach supported by a Consultant Geriatrician, specialist older people's nurses, pharmacy support, two dedicated social workers and palliative care services. This team supports the care homes to manage complex care and support care homes to deliver good end of life care within their homes. Data on admissions to hospital from care homes in Southwark show a 23% reduction in A&E attendances at from care homes since implementation of the new model. The CCG has established a Care Home Network jointly with Lambeth CCG. The Network has attendance from the Care homes, GP providing primary care services to the care homes, plus the multidisciplinary tams working with care homes. The Network has focussed on the initiation of PEACE documents; advance care planning in care homes to support admission avoidance at the end of life and auditing admissions at the end of life to identify learning. The CCG has supported the continued use of Coordinate My Care GP electronic patient register and provided training via protect learning time on the use of the register as a way of support good end of life care and support people to die at home if that is their wish. A clinical commissioner from the CCG CHC team attended the weekly discharge/delayed discharge meetings at KCH to support the transfers for client to the community 69 of 269

70 12 Better Health: Personalisation and choice 105c. Percentage of deaths in hospital (contd.) 53.8% Further actions planned in 2016/17 Lead Date Development of a discharge to assess model to support reduction in the percentage of death in hospital. This will also consider the need for intermediate care beds and will be done jointly with Integrated Commissioning Southwark CCGs Adults Commissioning Development Group has identified EoLC as a priority for consideration for population based health commissioning. This group will identify possible commissioning intentions for EoLC which support a population health approach and test these with the EoLC Strategy Group KMB/CG KMB TBC TBC 70 of 269

71 13 Better Health: Personalisation and choice 105d. People feeling supported to manage their long term conditions 59.7% Summary of current position Actions taken to date Indicator: The proportion of people reporting they have a Long Term Condition (LTC) in the GP Patient Survey who report they receive enough support from local services or organisations to help manage their LTC. July 2016 data 59.7%. We have been developing integrated pathways over several years with support for self-management also available. We are now seeking to make these care processes more systematic, particularly for people with multiple LTCs. The CCG has supported implementation of the Diabetes Modernisation Initiative across the borough, and we have worked closely with partners in KCH, SLaM and GSTT to develop the 3D4D (Three Dimensions For Diabetes) programme to support people with diabetes and severe mental health needs. We have worked with local partners to develop and implement and Integrated Respiratory Team across primary and acute care. This team allows patients to access the team (via a dedicated telephone number) 7 days a week between 9am and 4.30pm. We have worked across the system to test and refine a variety of integrated interventions in relation to the >65s, including the development of care navigation so that people can receive more than medical support in relation to their LTCs We have implemented personal budgets for all people in receipt of continuing care funding. Further actions planned in 2016/17 Lead Date We have embarked upon a whole systems project (underpinned by CQUIN and PMS KPIs) to implement care coordination for people with multi-morbidity (3+ LTCs). The project has a focus on establishing systematic approaches to case finding and holistic needs assessment, named responsible professional, joint care planning, multi-disciplinary working and self-management support. As part of the work we are identifying outcomes that we will monitor over time and our expectation is that this will include person-centred outcomes measures (e.g. the National Voices I Statements) MK / DD Apr-Mar We have successfully applied to access Patient Activation Measure licenses as part of the NHS England programme. Our intention is to implement the use of the PAM as part of our programme of work on multi-morbidity. MK / DD May We are supporting a pilot programme, led by GSTT, to develop an Integrated Heart Failure Pathway GSTT We are supporting the development of a Children and Young Person s Programme aimed specifically at improving the support that children and their families receive in living with long term conditions like asthma and epilepsy CG Apr-Mar 71 of 269

72 14 Better Health: Emergency admissions 106a. Inequality in unplanned hospitalisation for chronic ambulatory care sensitive conditions 1149 Summary of current position Indicator: the reduction over time of within-ccg variation in unplanned hospitalisation, based on the relationship at Lower Super Output Area (LSOA) level between unplanned hospitalisation for chronic ambulatory care sensitive conditions per 100,000 population and deprivation, measured by the Index of Multiple Deprivation. ACS conditions include a range of respiratory diseases, heart failure, neurological disorders (including epilepsy) and diabetes related conditions. Have high rate of this type of admission and risk that inequality slop high within the borough. Actions taken to date We have previously undertaken the Diabetes Modernisation Initiative to improve diabetes control, in part to reduce unplanned admissions, and we have commissioned an integrated respiratory team which provides 7 day a week access for patients who need additional support to avoid exacerbations and associated unplanned care. We have also launched a pilot project in partnership with GSTT which will develop a Heart Failure pathway, again to improve people s disease management and to reduce avoidable unplanned care. Commissioned a new Extended Access Primary Care Service which provided an additional 87,343 face to face appointments for urgent and same day appointments, based on triage, and available 8am-8pm, 7-days-a-week. This allows rapid access to a GP (with full access to the care record) and allows local practices to provide more focused care to people with chronic conditions. We have changed our approach to commissioning enhanced services in primary care. We have grouped the enhanced services into a Population Health Management contract to reduce the variability in access to services across the borough. By reducing this variation in access we are explicitly attempting to reduce the variation in outcomes for people living in the most deprived parts of the borough. Services included in the PHM contract include holistic assessments of need, case management for the elderly, and ambulatory blood pressure monitoring. This more preventative approach should reduce the exacerbation of chronic conditions that often result in unplanned care. Further actions planned in 2016/17 Lead Date We have embarked upon a whole systems project to implement care coordination for people with multi-morbidity (3+ LTCs). The project has a focus on establishing systematic approaches to case finding and holistic needs assessment, named responsible professional, joint care planning, multi-disciplinary working and self-management support. Our analysis shows that multi-morbidity is unequally distributed across our local population, with the highest prevalence in the areas of highest deprivation. Our analysis also points to the relationship between uncontrolled risk factors (smoking, obesity, alcohol, blood pressure, HbA1c) and unplanned admissions. Again these are not equally distributed throughout the population. Our focus on case management for people with multi-morbidity, and our more intensive support to people with 3+ LTCs and 2+ uncontrolled risk factors is intended to reduce unplanned admissions, and we believe that it will consequently help to reduce the existing inequality in unplanned admissions. MK/DD Apr-Mar Expert Reference Group has agreed the EMIS search algorithm for use with the cohort above. MK/DD May 72 of 269

73 15 Better Health: Emergency admissions 106b. Inequality in emergency admissions for urgent care sensitive conditions 2004 Summary of current position Indicator: The proposed indicator will measure the reduction over time of within-ccg variation in emergency admissions for urgent care sensitive conditions, based on the absolute gradient of the relationship at Lower Super Output Area (LSOA) level between emergency admissions for urgent care sensitive conditions per 100,000 population and deprivation, measured by the Index of Multiple Deprivation (2015). UCS conditions include COPD, acute mental health crisis, non-specific chest pain, falls, non-specific abdominal pain, DVT, cellulitis, pyrexial child, blocked tubes and catheters, hypoglycemia, UTI, angina, epileptic fit, minor head injuries. Actions taken to date We have commissioned a new falls pathway focused on reducing the risk of falls in people who are at high risk (>75s). This is being developed alongside an e-frailty index tool that can help to identify people who would benefit from this additional support. We have developed and commissioned additional admission avoidance services (Enhanced Rapid Response and teams) from GSTT which work alongside the LAS to respond quickly to urgent need, but to provide a suitable level of support for high acuity patients without resulting in an admission. Through our Southwark and Lambeth Integrated Care partnership we have supported the development of a catheter passport system to reduce the incidence of UTIs, alongside a Geriatrician hotline (TALK) which gives GPs instant access to consultant opinions to support out of hospital management of patients who are >65. We have also begun to develop a Locality Geriatrician outreach model to provide more responsive care in the community. In addition we have worked with KCH and GSTT to implement Hot Clinics which address some of the ACS conditions, alongside more focused frailty and elderly care services to provide an alternative to unplanned admissions. Further actions planned in 2016/17 Lead Date We have embarked upon a whole systems project to implement care coordination for people with multi-morbidity (3+ LTCs). The project has a focus on establishing systematic approaches to case finding and holistic needs assessment, named responsible professional, joint care planning, multi-disciplinary working and self-management support. Our analysis shows that multi-morbidity is unequally distributed across our local population, with the highest prevalence in the areas of highest deprivation. Our analysis also points to the relationship between uncontrolled risk factors (smoking, obesity, alcohol, blood pressure, HbA1c) and unplanned admissions. Again these are not equally distributed throughout the population. Our focus on case management for people with multi-morbidity, and our more intensive support to people with 3+ LTCs and 2+ uncontrolled risk factors is intended to reduce unplanned admissions, and we believe that it will consequently help to reduce the existing inequality in unplanned admissions. MK/DD Apr-Mar Expert Reference Group has agreed the EMIS search algorithm for use with the cohort above. MK/DD May Through the Children and Young People s Health Programme (CYPHP) we will be developing a paediatric hotline and outreach model to give GPs instant access to consultant opinions to reduce the need for onward referral to hospital. The main areas of focus is on epilepsy and asthma. GSTT TBC 73 of 269

74 16 Better Health: Anti-microbial resistance 107a. Appropriate prescribing of antibiotics in primary care Summary of current position Antibiotic items/star PU 2015/16 = Southwark CCG met the national Quality Premium target for 2015/16 (target 0.93). The national target for 2016/17 has been set as and so the CCG is currently achieving this indicator. Actions taken to date Prescribing Guideline Southwark Primary Care Antibiotic Guideline was updated May 2015 to align with PHE prescribing recommendations. The guideline includes a no/delayed antibiotics strategy for acute self-limiting respiratory tract infections and mild urinary tract infection symptoms to discourage inappropriate antibiotic prescriptions. Prescribing Incentive Scheme (PIS) 2015/16 Antibiotic indicator (antibiotic items/star PU) was included as part of the Prescribing Incentive Scheme 2015/16. Essential antibiotic audit (part of the PIS) This gave practices the opportunity to improve the quality of their antibiotic prescribing through a review of their current prescribing practice against the updated guideline. Two audits were available - one of which focussed on reducing the overall number of antibiotic prescriptions. Practices were allocated the audit by the Medicines Optimisation Team based on an analysis of their prescribing data. Medicines Optimisation Protected Learning Event A presentation on appropriate antibiotic prescribing was given by the CCG s lead GP for Quality. This focussed on learning around a medication incident involving poor antibiotic prescribing in primary care providing GPs with an opportunity to reflect on their own prescribing. GP Clinical Associate The CCG has recently recruited a GP Clinical Associate for Antimicrobial Stewardship started in post early June 2016 Further actions planned in 2016/17 Lead Date Prescribing Incentive Scheme (PIS) 2016/17 Antibiotic items/star PU has been included as part of the PIS for 2016/17. MOT March 207 Antibiotic Prescribing Campaign The South East London Area Prescribing Committee is working on a collaborative antibiotic prescribing campaign that will run across the 6 member boroughs CCGs and acute trusts. This is being led by Lewisham and Bromley CCGs, and will be developed and agreed by September 2016, in readiness for the European and World Antibiotic Awareness campaigns. Essential Antibiotic Audit results Results from the audit work carried out In 2015/16 will be fed back to practices to provide learning and areas for improvement. Prescribing Guideline PHE guideline has recently been updated (May 2016) the Southwark antibiotic guideline will be revised to reflect changes MOT MOT MOT Autumn 2016 Autumn of Not 269 yet known

75 Better Health: Anti-microbial resistance 107b. Appropriate prescribing of broad spectrum antibiotics in primary care 10.9 Summary of current position Broad spectrum antibiotic prescribing data 2015/16 = 10.9%. Southwark CCG met the national Quality Premium target for 2015/16 ( 11.5%). The national target for 2016/17 has been reduced to 10.2%. The CCG will be required to reduce prescribing of these agents further. Actions taken to date Prescribing Guideline Southwark Primary Care Antibiotic Guideline updated May 2015 to align with PHE prescribing recommendations - broad spectrum antibiotics feature for a limited number of infections. Furthermore, due to recent increase in resistance to cefixime in gonorrhoea, GPs have been informed to change prescribing from cefixime to ceftriaxone and azithromycin combination in line with CMO s recommendations to amend guidance. Prescribing Incentive Scheme 2015/16 : Percentage broad spectrum antibiotic prescribing included as part of the Prescribing Incentive Scheme (PIS) 2015/16 Essential antibiotic audit (part of the PIS): This gave practices the opportunity to improve the quality of their antibiotic prescribing through a review of their current prescribing practice against the updated guideline. Two audits were available - one of which focussed on reducing broad spectrum antibiotic prescribing. Practices were allocated the audit by the Medicines Optimisation Team based on an analysis of their prescribing data. Focussed audit in top 5 prescribers of broad spectrum antibiotics The top 5 practices identified with the highest proportion of broad spectrum antibiotic prescribing were audited further by a member of our team, which involved review of their total 2015/16 broad spectrum antibiotic prescribing data to assess compliance with the local guideline and provide feedback. The average for the 5 practices decreased from 26.5% (Q4 2014/15) to 13.5% (Q4 2015/16). GP Clinical Associate: The CCG has recently recruited a GP Clinical Associate for Antimicrobial Stewardship started in post early June 2016 Further actions planned in 2016/17 Lead Date Prescribing Incentive Scheme 2016/17 Percentage broad spectrum antibiotic prescribing has been included as part of the PIS for 2016/17. This indicator has a GP Federation level target as well as a practice level target. 100% practice achievement of this indicator will be based on: (1) The practice achieving the practice level target AND (2) The Federation making an overall improvement in prescribing This is to encourage practices to work collectively within their Federation for delivery of this indicator. This could be achieved through sharing good practice, sharing data, having a Federation level champion for antibiotics and through peer review groups. MOT March 207 Antibiotic Prescribing Campaign The South East London Area Prescribing Committee is working on a collaborative antibiotic prescribing campaign that will run across the 6 member boroughs CCGs and acute trusts. This is being led by Lewisham and Bromley CCGs, and will be developed and agreed by September 2016, in readiness for the European and World Antibiotic Awareness campaigns. MOT September 2016 Essential Antibiotic Audit results - Results from the audit work carried out In 2015/16 will be fed back to practices to provide learning and areas for improvement MOT Autumn 2016 Prescribing Guideline - PHE guideline has recently been updated (May 2016) the Southwark antibiotic guideline will be revised to reflect changes MOT 75 of Not 269 yet known 17

76 18 Better Health: Carers 108a. Quality of Life Summary of current position Indicator: The directly standardised average health status (EQ-5D ) for individuals reporting that they are carers, measured based on responses to a question from the GP Patient Survey. 21,000 people in Southwark (more than one in 14 of the local population) care on an unpaid basis for friends and members of their family who are ill, frail or disabled. More than 2,300 of them are 24 or younger. One in four care for more than 50 hours per week and 40-50% provide more than 20 hours per week. Actions taken to date Recognising that carers may need advice and support to help them in their caring role and to support them to look after their own health and well-being, the council and the CCG have continued to invest resources in a range of services. These include commissioning Southwark Carers to provide a range of services that: ensure carers have access to advice, information and a single point of contact for support; ensure services for carers are personalised, including the allocation of personal budgets; carers can get outcome-based assessments of their needs and support with planning around how to meet their needs; promote carer self help and peer support with the focus on carers maintaining their independence; support carers to have a life outside of the caring role. We published our Carers Strategy in 2013 setting out our priorities to: identify and reach more carers, early in their caring role, offering the right information and support in the right way; support carers physical and mental health and wellbeing; help carers to have fulfilled lives beyond their caring responsibilities; make sure carers have choice and control over the services they use; support young carers and protect them from caring which harms their wellbeing and development. Carer health development workers have been recruited to support the identification of carers in primary and secondary health settings. They help us train our health and social care staff to better identify carers and start those conversations with them regarding their support needs. Carer Health Development Workers also ensure effective liaison between services and signposting carers to the services they need. Create an online support pack and alert for GPs so that they can signpost carers to relevant services. Further actions planned in 2016/17 Lead Date Review how personal budgets and direct payments are offered to local carers, to make sure there is a strong focus on more choice and control and support to maintain or improve their wellbeing. KMB Mar of 269

77 19 Better Care (1 of 2) Indicator name Value / RAG 121a-c Care Ratings: use of high quality providers TBC Cancer 122a Cancers diagnosed at early stages b 62 days waits 83.3% 122c. One year survival rates for all cancers d. Cancer patient experience 85.9 Mental Health 123a IAPT recovery rate 38% 123b Early access to psychosis treatment standard 60% (June) 123c Children and young people s mental health services transformation 123d Crisis care and liaison mental health services transformation 123e Out of area placements for acute mental health inpatient care transformation Learning Disability 124a Learning Disability: reliance on specialist inpatient care for people with a learning disability/autism 49 per million 124b Learning Disability: proportion of people with a learning disability receiving an annual health check 31% Maternity 125a Neonatal mortality and still births b Women s experience of maternity services c Choices in maternity services of 269

78 20 Better Care (2 of 2) Indicator name Value / RAG Dementia 126a Estimated diagnosis rate for people with dementia 76.9% 126b Dementia care planning and post-diagnostic support 80.7% Urgent and emergency care 127a Achievement of milestones in the delivery of an integrated urgent care service TBC 127b Emergency admissions for urgent care sensitive conditions c Percentage of patients admitted, transferred or discharged from A&E within 4 hours 83.5% 127d Ambulance waits 70.0% 127e Delayed transfers of care attributable to the NHS per 100,000 population f Population use of hospital beds following emergency admission 0.71 Primary medical services 128a Management of long term conditions : emergency admissions chronic ambulatory care sensitive conditions 1, b Patient experience of GP services 78.6% 128c Primary care access TBC 128d Primary care workforce a Elective access: patients waiting 18 weeks or less from referral to hospital treatment a 7 day services: achievement of clinical standards in the delivery of 7 day services TBC 131a NHS continuing care: People eligible for NHS Continuing Healthcare of 269

79 Better Care: Care ratings Overall a. Use of high quality providers Hospital services Hospitals 55 Primary Medical Services 55 Adult Social Care 60 Hospitals King s College Hospital NHS Foundation Trust South London and Maudsley NHS Foundation Trust Guy s and St Thomas Community Services (Adults) Guy s and St Thomas Community (Children s) Requires Improvement Good Requires Improvement Good Summary of Action plans are in place to address CQC inspection recommendations; CCG attended Quality Summits at Acute Trusts following CQC inspections; implement actions current plans are monitored through the CQRGs position Actions taken to date The CCG led/contributed to CQC submission for 3 Trusts. Prior to the SLaM CQC Southwark led on the development of a framework was created to co-ordinate the 4 CCGs quality concerns to inform the CQC inspection We actively participate in 4 CQRGs and see this as a vital tool to improve quality. The CQRGs are regularly attended by Medical Director, DoN, and specialty leads. Continuity of attendance enables robust tracking of on-going and emerging issues. A tight spec is agreed in advance regarding each agenda item to direct the Trust to areas of concern or interest. The CQRGs are reported to our Quality & Safety sub-committee of our Integrated Governance & Performance and via this to our Governing Body. Good relationships with other local CCGs and regular contact enable shared learning across patch and co-ordinated approach to providers Clinical site visits; 7 were undertaken at KCH in 15/16, we plan for alternate months in 16/17. Feedback and recommendations are feedback to the providers and presented at our Quality & Safety Committee. At SLaM a number of monthly Clinical visits and shadowing on the wards and services to ensure quality of care for patients are meeting required standards. We take a Critical friend approach to providers which has shown results in improved transparency, openness. Increased reporting of NE/SI at GSTT enabling learning. We track themes from incidents and prompt providers for action and monitor the implementation of actions plans for never events via CQRGs. We are leading discussion to move SI reviews at SLAM to a consolidated meeting covering all SIs rather than the current borough based system. This will be easier to identify themes and enable wider learning across the Trust. We have undertaken a detailed review of the contract quality schedule and revised it for 16/17. Items are tracked through CQRGs Four deep dive investigation/audits were carried out by the CCG to improve identified areas for improvements that have significant impact on services and patient outcomes within SLaM. An assessment of quality issues 4 CCGs members, Southwark Local Authority, GPs and service users ensuring quality issues across all organisations was raised and collecting and collate evidence to support the assessment and develop a plan with SLaM to address the issues raised As a joint initiative the CCG instigated weekly ward rounds of senior staff from community services, social care and continuing care of a number of wards at KCH to help troubleshoot issues related to discharge and offer support and guidance. The learning helped inform the content for a pan-lambeth and Southwark workshop (see below), and the creation further guidance on continuing care checklists and HNAs to help support wards in the discharge planning process The CCG, ECIP, GSTT and KCH co-sponsored an event in June across the health and care economy to identify a number of high impact changes that could help reduce delays in discharges, improve patient flow, and support better joint working between organisations. The event focussed on improving the utilisation of seven day services and opportunities to adopt discharge to assess and trusted assessor models. Work is on-going with GSTT and KCH to ensure learning is fed in to overarching trust plans. 79 of 269 Event held for over 120 people with Lambeth CCG, Lambeth and Southwark Healthwatch to focus upon improving people s experience of discharge from hospital. All main providers, LA, LCS present, plus patient representatives. Initial report presented to and well-received by Strategic Partnership Group. 21

80 22 Better Care: Care ratings Overall a. Use of high quality providers Hospital services (contd.) Hospitals 55 Primary Medical Services 55 Adult Social Care 60 Hospitals King s College Hospital NHS Foundation Trust South London and Maudsley NHS Foundation Trust Guy s and St Thomas Community Services (Adults) Guy s and St Thomas Community (Children s) Requires Improvement Good Requires Improvement Good Further actions planned in 2016/17 Lead Date We are running an event for over 120 people with Lambeth CCG, Lambeth and Southwark Healthwatch to focus upon improving people s experience of discharge from hospital. All main providers, LA, LCS will be present, plus patient representatives. The objectives are to highlight issues and good practices, the objective is an action plan agreed across the area to improve Going Home JF July 16 A number of CQUINs and Key performance indications has been developed and implemented via the NHS contract - continued to monitoring to ensure improve quality of care JF/RA/DS On-going Evaluation of the Clinical Site Visits programme to inform continued roll out in 16/17 KMB/JF August 16 Monitoring of SLaMs action plan to support recruitment of staff to address staffing numbers RA On-going Agreement and roll out of quality deep dive programme at SLaM which will include a deep dive in the quality of physical health provision in residential setting. RA On-going 80 of 269

81 Better Care: Care ratings Overall b. Use of high quality providers Primary Medical Services Hospitals 55 Primary Medical Services 55 Adult Social Care 60 Primary Medical Services Outstanding Good Requires Improvement Inadequate Previous Inspection Framework (All standards met) Not yet inspected Summary of current position Overall CQC inspections that have taken place have rated services as good. The CCG is working in partnership with NHSE to address quality concerns for practices rated as inadequate Actions taken to date The Primary and Community Strategy outlines a number of principles which guide the CCG s approach to improving primary care services. Delivery of this strategy is supported by a Primary Care Quality Improvement Framework developed to improve primary care quality in GP Practices. A Primary Care Dashboard in within this framework and allows member practices and federations to identify, benchmark and oversee work to improve patients outcomes and quality in priority areas The CCG held a workshop to support CQC inspection readiness. The CCG The CCG held a workshop to support CQC inspection readiness. The CCG offers focussed support to all practices following CQC inspections this includes infection, medicines optimisation, clinical leadership for nurses, safeguarding, engagement and comments on overall practice action plans. The CCG Quality Team run an effective Quality alert system, acting upon feedback and requesting action where needed. Feed back is provided at primary care locality meetings and GP newsletters ( You said we did ). The team have received some QA from secondary care highlighting issues in primary care. QAs reported have resulted in a review of some services in primary care for example follow ups from virtual clinics and launched the discussion regarding the issuing of fit notes in secondary care The CCG supports a monthly protected learning event (PLT) for primary care and provides SELDOC cover in order to support attendance from every practice. The PLTs have a clinical focus and support learning and improvement in the delivery of quality care. Where possible the CCG seeks to show the systemic implication of actions what could have been done in primary care to prevent something worsening. The CCG Quality Team have introduced a quality story to start each monthly PLT and to encourage discussion and reflective learning. The CCG is working with practice managers and Southwark Healthwatch to support practices to implement service improvements following Healthwatch s patient engagement work which focused on patient experiences of primary care services in the borough. Patient experience feedback is a key indicator of quality. This can be collected from a number of patient experience sources including the quarterly GP Practice Survey, Friends and Family Test completed in GP practices and local surveys. Patient Participation Groups (PPGs) will be key in highlighting systematic quality issues to commissioners and the CCG supports 81 a of robust 269 structure of Locality PPGs across Southwark. 23

82 24 Better Care: Care ratings Overall b. Use of high quality providers Primary Medical Services Hospitals 55 Primary Medical Services 55 Adult Social Care 60 Primary Medical Services Outstanding Good Requires Improvement Inadequate Previous Inspection Framework (All standards met) Not yet inspected Further actions planned in 2016/17 Lead Date The CCG Quality Team is recruiting to a Band 7 quality manager. This post will have a focus on primary care quality. KMB Sept 16 Implement and monitor the Primary Care Quality Assurance Process focusing on the improved experience of GP services from our local population JY Monthly Continue to support practices following CQC inspection assessment s JY/KMB On-going Delivery of the CCG s Five Year Forward View ambition to establish primary care federations delivering at scale MK On-going 82 of 269

83 25 Better Care: Care ratings Overall c. Use of high quality providers social care Hospitals 55 Primary Medical Services 55 Adult Social Care 60 Adult Social Care Domiciliary Care Nursing Homes Residential Homes Outstanding Good Requires Improvement Inadequate Not inspected Summary of current position Good quality of Residential Care provision in the borough with all residential homes rated Good and one rated as Outstanding by CQC 8 out of 17 Domiciliary Care services inspected, with 7 rated as Good and only one rated as Inadequate The CCG commissioned Domiciliary Care services is rated as Good Of 3 nursing homes in the borough one rated as Good and two rated as Requires Improvement Nursing homes rated as Requires Improvement have improved from previous Inadequate rating Actions taken to date The CCG has commissioned a GP Enhanced Care Home Contract. This provides primary care support to all care homes with nursing in Southwark from one GP Practice. The model includes clinical oversight from a Consultant Geriatrician who undertakes ward rounds in the care homes alongside the GPs on a weekly and leads a monthly MDT at each of the care homes. The enhanced services is supported by two dedicated social workers, older peoples nurse specialists, care home pharmacist, specialist palliative care and allied health professionals. An evaluation of this services is being planned and will support commissioning discussions regarding the role out of the model to residential homes The CCG Continuing Care clinical commissioner undertakes joint quality monitoring visits with the LA and provides clinical nursing advice with regards the quality of health care including recommendations for improvement. The CCG also commissions a Care Home Support Team which undertakes 3 monthly and annual reviews of all clients in the care homes within 83 of 269 Southwark.

84 26 Better Care: Care ratings Overall c. Use of high quality providers social care Hospitals 55 Primary Medical Services 55 Adult Social Care 60 Adult Social Care Domiciliary Care Nursing Homes Residential Homes Outstanding Good Requires Improvement Inadequate Not inspected Actions taken to date The CCG and LA have a monthly Senior Managers Quality and Safety Meeting which reviews all safeguarding and quality alerts from care homes and domiciliary care providers in the borough. This group provides a report to the Quality & Performance Sub-group of the Southwark Safeguarding Adults Board which agrees strategic actions based on information provided. Serious issues of concerns are escalated to the Director of Quality & Chief Nurse within the CCG and Director of Adults Social Care in the LA for agreement on appropriate actions which may include decisions to embargo homes. Care Home quality is reported and monitored at both the CCG Safeguarding Executive Committee and the CCGs Senior Management Team The CCG has commissioned a domiciliary care service to provide care for all client sin Southwark who meet the criteria for CHC. This services is based in Croydon and so their CQC rating is not included in the figures above but was Good when inspected earlier this year. Further actions planned in 2016/17 Lead Date Evaluating the GP enhanced Care Home Service with a view to procure in 16/17 RD/MG Aug 16 To scope the model of primary care support to residential homes using the evaluation of the GP care home enhanced service KMB/JY Sept Continued joint working with the LA to support he continued improvement of quality particularly in care homes with nursing. KMB/JY 84 of Nov 26916

85 Better Care: Cancer 122a. Cancers diagnosed at early stages 50.6% Summary of current position Southwark CCG diagnoses patients at an early stage in line with the National Average (50.7%), and above the London-wide average (48.2%). Based on a part year effect (Quarters 1 3, ) Southwark achieved the target (93%) for 2ww referrals seen within the time-frame. Southwark will continue to focus on ensuring patients are diagnosed at an early stage via a range of initiatives and networks (outlined below); supported by a Cancer Locality Network Group. Actions taken to date Lambeth & Southwark CCG agreed to pilot Multi-disciplinary Diagnostic Centre (MDC) pilot provided by GSTT, the pilot aims to ensure that unspecific symptoms are managed effectively through access to multiple diagnostics. This approach has been found to increase cancer early detection rates. The Cancer Locality Group (includes membership from Lambeth, Bromley, Southwark and the CSU) has developed action plans with GSTT and KCH and continues to review at by-monthly meetings. These are also presented to CQRG, along with CCG and Trust monthly reports. Action plans have informed a review of local diagnostics provision (in particular imaging services), and how these services are accessed by GPs, in order to understand how these align with the best-practice (i.e. NICE). Dialogue is also underway with providers where its deemed that provision is not in line with best-practice. Patient information on the two week wait pathways has been shared with Primary Care for use at the point of referral, to give a clear understanding of the timeliness of referral and investigation for suspected cancer, in line with NG12 guidance. Borough-wide training provided in November 2015 included a range of Cancer Pathway related workshops Talk Cancer, a Cancer Research UK training programme designed to help Primary Care Clinicians to feel more confident talking to people about ways to reduce the risk of cancer and spotting cancer early, has been rolled out across SE London. A new stream-lined colorectal pathway has been mainstreamed KCH & GSTT - designed to improve the number of patients being diagnosed/ treated in the right place first time. A guide to cancer screening has been produced locally and includes information on bowel, breast and cervical cancer screening including read codes and a list of on-line resources Further actions planned in 2016/17 Lead Date Review and on-going monitoring of 2WW referral quality L&S Locality Group On-going Mobilisation of the MDC Pilot in North Southwark, involving training for Primary Care GSTT Q3 Monitoring development of Transforming Outcomes & Health Economics through Imaging (TOHETI) project in order to inform further local pathway enhancements GP direct access to gastroscopy tests for the investigation of specific upper GI symptoms to be measured as part of NHSE quality premium in order to decrease mortality rate from gastrointestinal disease for under 75 years. Maximum of 2 weeks for urgent (2ww) requests by end of 2016/17. Deployment of two funded sessions of Macmillan GP time to support General practice in early intervention and diagnosis. L&S Locality Group IGP/CG Q4 85 of 269 Q4 27

86 Better Care: Cancer 122b. Treatment within 62 days from urgent GP referral 82.1% Summary of current position KCH April performance is in line with the STF 62 day trajectory performance of 87.3% compared to plan of 85.3%. May performance has however deteriorated trajectory and target will be breached, noting figures are currently being validated. Inter Trust Transfers (ITTs) remain an issue with late KCH referrals impacting on GSTT rather than KCH performance. GSTT April performance is in line with the STF 62 day trajectory performance of 70.9% compared to plan of 67.7%. Internal performance is slightly below trajectory % compared to plan of 85%. ITTs remain the significant driver of GSTT s Trust wide performance. Actions taken to date Significant focus on 62 day performance in 2015/16 with work undertaken to establish processes and systems to support a system wide approach to cancer delivery (relaunched 62 day group and the establishment of the Accountable Cancer Network) alongside key on going work streams sector PTL, Patient Choice work stream, demand and capacity planning, agreement and implementation of timed pathways. Recovery Plans and trajectories agreed by Trust for 2016/17, including overall Trust 62 day performance plus ITT performance improvement. The trajectories and underpinning assumptions have been reviewed in detail by NHS England and signed off by NHSE and NHSI. Additional resource agreed by CCG commissioners for KCH to provide: an inter trust transfer coordinator post working across KCH and GSTT, enhanced administrative capacity to address process issues, tackle administrative delays and improved real time monitoring and pathway management and a service redesign post to support the Trust s pathway redesign in key challenged tumour groups (immediate focus urology, then lung and GI). Action with Southern Region to support ITT improvement from Southern Region Trusts a NHSI secondee has been working for GSTT to address ITT issues - model to be rolled out to KCH to support improved ITTs in to KCH. Further actions planned in 2016/17 Lead Date A Cancer Improvement Plan for SEL is being collated for submission to NHSE in September. This will consolidate the existing trust and CCG plans and will demonstrate how the system will deliver the already agreed STF trajectories. The following key actions will be reflected in the plan: Sector PTL prototype enabling an automated SEL PTL to be maintained and managed over 2016/17. Existing recovery plan actions reviewed to ensure they are fit for purpose - recognising that current performance remains challenged. Key additional actions agreed are: Self assessment gap analysis against lung and urology timed pathways and GP straight to test pathway, plus a patient level audit against the timed pathways for the last 10 patient treated by Trust for each of urology, lung and GI straight to test. This will inform required tumour specific actions to support performance improvement. Implementation of a pan provider ITT RCA process. Accountable Cancer Network to take forward key areas of work to support 62 day delivery, focused on the following two key immediate objectives: Care pathway redesign at a tumour group level, to ensure timed pathways can be delivered and sustained across SEL tranche one focus on urology, lung and GI with a whole pathway focus from day 1 to 62. Work programme currently being developed. Agreement of ITT referral criteria and supporting minimum data set. To include requirements in relation to diagnostic work up. Caroline Gilmartin & Andrew Eyres Sep 2016 Two week waits understanding of actual demand compared to planning assumptions for 2WW referrals to test D&C planning requirements and inform training and education of primary care in relation to the use of the new 2WW referral forms, patient information and communication prior to referral. 86 of

87 Cancer Waiting Time Standards 2 weeks GP referral (target 93%) - % patients seen within 2 weeks of an urgent GP referral for suspected cancer 31 days treatment (target 96%) - % patients receiving first definitive treatment within 31 days of a cancer diagnosis 62 days treatment (target 85%) - % patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer SCCG Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2 weeks days days May CCG performance on 62 days relates to 5 breaches.(all GSTT). 2 of the breaches were categorised as avoidable, both administrative errors 62 Day Target by trust Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun King s GSTT of

88 30 Better Care: Cancer 122c. One year survival rates for all cancers 68.9% Summary of current position Southwark CCG one year cancer survival rates (68.9) are below both the national (69.6%) and London (70.3%) average. Commissioners continue to focus on improvement in specific tumour groups i.e Lung. This includes working with MacMillan to improve management of patients and improve early diagnosis (see 122a) as strategies to raise the survival rates above the national average. Actions taken to date GSTT & KCH contracts require Best practice pathways to improve access to Lung Surgery. MacMillan guidance including top tips for improving 1 year survival has been shared with Primary Care. Programme of support to Primary Care including training, practice visits, and support tools delivered across Practices Further actions planned in 2016/17 Lead Date Continuation of the Macmillan GP lead to improve screening & management of cancer within Primary Care CG Q1 Review of local provision for Living with & Beyond Cancer TCST Q2 Geriatric Oncology Liaison service (GOLD) to optimise older patients in preparation for oncology treatment (Macmillan funded 1yr pilot) to go live GSTT Q2 Stratified follow-up in the community of stable or low risk prostate cancer patients who are under watchful waiting GSTT & KCH Q4 88 of 269

89 31 Better Care: Cancer 122d. Cancer patient experience (Overall satisfaction positive) 85.9% Summary of current position The National Cancer Patient Experience Survey results are due shortly, which will provide information to shape, identify and prioritise future quality improvements and inform where further local engagement could support pathway enhancements. Limited learning to date from previous survey due to short time frame between publication and subsequent learning. Previous results highlighted lack of support of Primary Care through Cancer treatment. Actions taken to date OHSEL led needs assessment of Primary Care to understand where quality can be improved. This will inform further training, local guidance and pathway enhancement initiatives. A number of practice visits have been made by CRUK facilitators to support better diagnosis and treatment provision in Primary Care, this has included safety netting of practice systems to ensure smooth pathway from pathway to 2WW clinic. Colorectal 2 week wait referrals now sent to a Colorectal Telephone Assessment / Straight to Test Service. GSTT encourage this route as the clinicians can access the clinical information immediately and assign patients to the most appropriate clinic or test, avoid an administrative delay and reduce the risks of inappropriate or unnecessary appointments as the patients is given their appointment date / time when the arranged over the phone. Programme of PLT cancer visits covering importance of the cancer register and cancer care reviews have been carried out across Primary Care. Patient leaflet produced to support patients who are referred on 2WW pathway Further actions planned in 2016/17 Lead Date The national cancer patient experience survey will be published in July. Results will come out for responses at acute trust level and also be reported on at CCG level. These will steer service improvement work-streams. L&S Locality Meeting Nov CNS and AHPs in cancer MDTs will attend advanced communications training and Level 2 psychological assessment skills training, and will have access to ongoing psychological support supervision. This has been the focus of Provider Reponses to previous survey results KCH & GSTT Q4 89 of 269

90 32 Better Care: Mental health 123a. IAPT recovery rate 35% Summary of current position A newly procured Talking Therapies Service to deliver IAPT standards commenced from 1 April Improvement of the recovery rate, maintaining good access to service and reducing waiting times will be focussed on during 2016/17. Recovery rate April 35.8%,May 37.9%. Current recovery rate is impacted by the transition to new service, staff turnover and increased waiting times for treatment. The TUPE process has been completed and the service is working to fill all vacancies. Actions taken to date a) In the CGG retendered the psychological therapies services to deliver a more enhanced model with a focus on increasing access and reaching difficult to engage populations as well as increase self referral s who are more likely to complete treatment therefore achieving recovery. b) A CQUIN has been agreed for to improve the recovery in improving access to psychological therapies, with greater focus on ensuring that people finishing a course of treatment move to recovery. C) Participation by commissioner and provider in Demand and Capacity Modelling workshops and sessions run by IAPT Intensive Support Team, (IAPT IST) with plans to implement learning in practice in Southwark. d) Commissioners have identified that resources may need to be commissioned to reduce waiting lists and times that may have developed, due to lost capacity during 2015/16 and during transition to new service. Evidence provided by IAPT IST suggests that reducing waiting lists and times is positively correlated to improved recovery rates. e) Monthly monitoring and review of service developments in the new model commissioned to measure the achievement and delivery of contracted outcomes as specified. Further actions planned in 2016/17 Lead Date a) In order to increase the number of people moving to recovery it has been suggested by IAPT Intensive Support Team that reducing waiting times and list will improve recovery rates in Southwark. The CCG will review the current demand and capacity and develop case for change, identify any additional resource required and seek to address this on a non recurrent basis. b) Tight tracking and monitoring of the service KPI reporting against trajectory, with a clear action planning to address short falls in performance c) Apply for new IAPT funding earmarked to increase access target to 25%, work on long term conditions and digital technologies. For Southwark this will mean an increase in resources to achieve an additional 8% to increase the access target from 17% to 25%. The service is already targeting people with long term conditions and using digital technologies, any additional funding will therefore be to enhance these areas of work. Rabia Alexander Carol-Ann Murray Carol-Ann Murray September 2016 On-going monthly When announced 90 of 269

91 Improving Access to Psychological Therapies (IAPT) Month Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Ma y Jun Monthly 1 st contacts to equal 15% trajectory Number of first contacts Recovery rate (target 50%) Reliable Improvement (%) of

92 34 Better Care: Mental health 123b. Early access to psychosis treatment standard 28.6 Summary of current position EIP services are provided by South London and Maudsley NHS Foundation Trust (SLaM) to four local boroughs (Lambeth, Southwark, Lewisham and Croydon). Recruitment of staff by provider has been challenging, with the complete staff complement expected to be in post by August 2016 following national and local recruitment processes. In April % or 5 out of 6 referrals achieved the waiting time standard. In May 57% or 4 out of 7 referrals achieved the standard, June 3 out of 5 (60%).- against national target of 50%. Actions taken to date a) EIP service developments are included in the Service Development and Improvement Plan (SDIP) in the 16/17 contract with SLaM and builds on the previous years work to ensure the successful implementation of the standards from April b) Additional recurrent commissioner investment into EIP services from 2015/16 to ensure appropriate workforce can be recruited. c) Four borough commissioners have been meeting together since January 2016 to monitor and review the systems EIP preparedness. Monthly meetings and teleconferences to continue during 2016/17 to review and test data submissions before sign off d) SLaM actively engaged in the London EIP Clinical Reference Group (CRG) and in the process of implementing the recommendations of the CRG to ensure that the best practice guidance is adhered to. Further actions planned in 2016/17 Lead Date a) Continue to monitor and review performance monthly using established process of teleconferences and meetings; with built in capacity to respond to unexpected data trends. Rabia Alexander On-going 92 of 269

93 35 Better Care: Mental health 123c. Children and young people s mental health services transformation Summary of current position The Southwark Children and Young People s Mental Health and Wellbeing Transformation Plan was assured on 18 December 2015 and is published on the NHS Southwark CCG and Southwark Council websites. Local stakeholders are working together to implement the transformation plan across health, social care, education and local third sector. The plan has provided an opportunity to develop and pilot new ways of working as well as enhance existing services.. Actions taken to date a)the CCG has worked with partners to publish the local transformation plan (LTP ) including the baseline data as required for assurance. Commissioners review changes and developments in the local economy especially around budgets, to ensure that new and existing services are sustainable. b) A dedicated community eating disorder service has been commissioned from a provider cited in the commissioning guidance as an example of good practice and against a model recommended in the guidance. The children and young people s eating disorder team is a member of the quality assurance network as required to be compliant. c) The CCG commissions specialist community outpatient CAMHS at tier 4 and have comprehensive tier 3 services. These arrangements are reviewed across the SE London sector with NHS England participating and seek to reduce the number admitted to inpatient care whatever the setting. Collaborative commissioning plans, that are required to be fully compliant, will be reviewed in July 2016 to consider services enhanced and developed as a result of the LTP. d) Joint agency workforce plans have been published and the provider contributes to building capacity and capability across CAMHS services to implement and embed CYP IAPT transformation objectives. e) The CCG has increased its' spend on Mental Health Services for Children and Young people by at least their allocation of baseline funding for 2016/17. Implementation of the LTP is monitored regularly with providers to ensure that all spend allocated is utilised Further actions planned in 2016/17 Lead Date a)continue to monitor and review the deliverables and outcomes agreed in the LTP. This will be done via existing mechanisms and project groups established for implementation of the LTP. b) The CCG and LA will develop commissioning intentions for children and young people s mental health and wellbeing via joint commissioning development group and use local arrangements in place for delivering the Southwark Children and Young People s Strategy to oversee the implementation of the LTP. Rabia Alexander Rabia Alexander On-going On-going 93 of 269

94 36 Better Care: Mental health 123d. Crisis care and liaison mental health services transformation Summary of current position The CCG currently commissions a core 24 /7 psychiatric liaison service and a 24/7 crisis response. Services have been fully mobilised as of 1 st June There has been significant investment and service re-design within psychiatric liaison, & crisis response services. There is a public consultation about to take place with respect to redeveloping the place of safety service for 4 boroughs to ensure the system continues to meet the required standards. Actions taken to date Liaison mental health services (for adults, older adults children and young people) a) November 2015 the CCG invested an additional 137,717 with South London& Maudsley FT (SLaM) to ensure that the adult component of the Kings Health Trust (Denmark Hill site) liaison mental health service is staffed to deliver a Core 24 liaison service provides on-site 24/7 service which will provide a 1 hour response time following an Emergency Department referral and 24 hour response time following a ward referral. b) Southwark has a well-established paediatric liaison service based at King s. This is the mental health service for under 18s and their families presenting for children and young people presenting to emergency departments, in wards and community settings which includes provision for a response across extended hours etc. Additional youth worker support roles have been identified as a potential service improvement for out of hours to improve patient experience and reduce time spent in ED and we are planning to pilot this with non-recurrent 15/16 transformation plan money. Crisis resolution home treatment teams (adults): Southwark CCG agreed an adult transformation plan which focusses on inpatient, community and crisis care. As part of the transformation the CCG an agreed and funded service development and improvement plans to ensure the Home Treatment Team is operating effectively and in line with recognised best practice offering more treatment in extended hours, providing faster responses to new referrals and providing a 24/7 gatekeeping function for acute MH inpatient beds. Crisis line and street triage was commissioned in to work in connectively with the HTT to ensure 24 hour crisis response is offered and all patients receive face to face assessments within four hours of referral. The CCG has a CQUIN within the contract to develop and collect outcome measures across all crisis services. Places of safety (for people of all ages): a) Southwark CCG commissions 24/7 accessible health-based places of safety to prevent people of any age having to undergo a Mental Health Act section 136 (s136) assessments in police custody b) A full review of the s136 suites across Southwark, Lewisham, Lambeth & Croydon (SLLC) was carried out in c) All section 136 admissions has been reviewed and data is collected and investigated whenever someone detained under s136 is refused access to a health-based place of safety and/or taken to police custody?. This data collected over the last year highlighted issues gaps in the current service and an improved service model has been developed. d) In 2015 a street triage service and crisis line was commissioned which give police officers urgent access to mental health specialist clinical advice. The CCG has invested in an MHOA additional liaison worker to reduce the DTOC from acute services Full implementation of the Crisis Care developments is fully mobilised. Further actions planned in 2016/17 Lead Date The CCG is currently in the process of developing and enhanced Place of Safety with SLaM and SLLC. An operational policy is currently being developed with the Directors of social care across SLLC and a public consultation will need to take place. Rabia Alexander October 94 of

95 37 Better Care: Mental health 123e. Out of area placements for acute mental health inpatient care transformation Summary of current position The CCG currently do not have any out of area inpatient acute mental health placements, a robust plan and data base has been created to monitor all out of area placements including non-acute placements. We will be focusing on further reduction of out of area placements for residential care placements in Actions taken to date a) A joint review of all out of area placement for mental health inpatient care was carried with South London & Maudsley Trust in Quarter 1 of to establish trends, length of stays and why placements took place. And an action plan was put in place to ensure all placements would be monitored on an individual basis repatriation achieved as soon as possible if appropriate. b) The financial implications and activity figures are monitored monthly and a cap on activity has been agreed with SLaM. The CCG is currently collecting data on a monthly basis which allows robust monitoring of all out of area placements which is broken down by patient level, type of placement, provider, length of stay, costing's, reasons for placements as well as alternative provision within borough. c) The CCG commissioned additional bed capacity in quarter 3 of and to prevent overspill to the private sector and out of area. d) The CCG reviewed all residential placement in with a focus on out of area placements repatriation and have establish a plan with SLaM and Southwark Local Authority to repatriate as many people as possible within the borough. e) The CCG has a plan in place to reduce the use of acute mental health bed out of area placements in 2016/17. The Southwark AMH Transformation Plan is key to eliminating out of area placements by 2020/21, The plan focusses on better crisis response and enhanced community services to prevent admission and reduce the length of stay creating more capacity in the system to prevent patients having to be place out of area. Additional capacity has been commissioned for to allow for full mobilisation of the plan. Further actions planned in 2016/17 Lead Date The CCG have a robust plan to generate more capacity within the borough by retendering current block provision which currently do not meet the need of the patients and commission a new model that will meet the needs of this cohort. A number of people have already been repatriated back to the borough and we will continue to work-in partnership with the Local Authority and SLaM to continue this work. A project group has been set up to oversee this, and processes have been put in place to ensure all patients are being reviewed regularly and identifying any risk to the CCG not achieving the set targets. Rabia Alexander On-going 95 of 269

96 38 Better Care: Learning disability 124a. Reliance on specialist inpatient care for people with a learning disability/autism 49 per million Summary of current position The CCG HSCIC data show s 8 patients meeting the TC cohort Working closely with Specialised commissioning to reconcile their cohort data with CCG cohort data The CCG achieved the trajectory set to achieve 5 discharges against November 15 reporting of 9 clients in assessment and treatment beds NHS Southwark CCG has very robust processes in place to support the timely discharge of patients from assessment and treatment and to prevent where appropriate admission to assessment and treatment for both children and adults so reducing reliance on specialist in patient care Actions taken to date Transforming Care Steering Group is well established and has representation from CCG, LA, MH providers, community LD teams, children's social care and Specialised Commissioning. Risk registers are in place to track - all clients in assessment and treatments both adult and children and adults and children at risk of admission to assessment and treatment.. CCG Governance and Internal Escalation process is in place. CCG governance includes daily escalations to the Chief Officer and the Director of Quality & Chief Nurse, and 2 weekly reporting to the CCG SMT/Governing Body. The CCG achieved the trajectory set to achieve 5 discharge against November 15 reporting of 9 clients in assessment and treatment beds. The CCG currently has 8 clients meeting the criteria. CTRs have been undertaken for 7 of these clients with review CTR dates in place. A date is set for the CTR for the 8 client. Each of the 8 clients is assigned to a commissioning lead to monitor and track compliance with CTR recommendations and actions and to support discharge planning. Each client also has a case manager within A&T and are linked to a community team to support discharge planning. The CCG currently has 8 clients meeting the criteria. CTRs have been undertaken with review CTR dates agreed. Each of the 8 clients is assigned to a commissioning lead to monitor and track compliance with CTR recommendations and actions and to support discharge planning. Each client also has a case manager within A&T and are linked to a community team to support discharge planning. The CCG is very engaged with the SEL TCP and the CCG Director of Quality & Chief Nurse is the Deputy SRO. The SEL TCP has established 3 work streams to support its three year programme. Southwark CCG is leading with Lambeth CCG on the Partnership Commissioning Framework across SEL TCP. SEL TCP have been allocated year 1 funding which is match funded by CCGs Further actions planned in 2016/17 Lead Date Continued work of the development and proactive use of risk registers this will be through the Southwark Transforming Care Steering Group KMB On-going Joint work with the LA to agree how dowries are agreed and administered KMB Sept 16 Supporting the implementation of the SEL TCP priorities to ensure a reduction in the reliance on inpatient beds KMB 96 On-going of 269

97 39 Better Care: Learning disability 124b. Proportion of people with a learning disability receiving an annual health check 31% Summary of current position Significant progress has been made on the number of people with an LD receiving an annual health check, This has increased from 27% in 14/15 to 47% in 15/16 Actions taken to date The CCG commissions a community LD team who support GP practices to implement the requirements of the DES. This team support practices to identify their cohort of people with an LD and offer an annual health check. This team ensure that health action plans are shared with GP practices. Community LD team, LD PLT, LD Primary Care Support Pack, Governing body lead for LD, big health check up The CCG held a PLT in October 2015 which provide data on annual health checks, support to undertake these and provided three workshops. These focussed on Communication and Reasonable Adjustments, Learning Disabilities Referral Pathways and Atypical signs & symptoms (common diagnostic pitfalls) The CCG has a Governing Body lead for Learning disabilities who actively support primary care compliance with the DES The CCG working in partnership with the LA holds a LD Big Health Check Up day to consult with people with LD, carers and providers on how we could better serve the needs of this population. JSNA for Learning Disability Further actions planned in 2016/17 Lead Date Reconcile LA data on people with LD with GP practice, this will be managed through the Transforming Care Steering Group KMB On-going The SEL TCP focus is all people with an LD or Autism and this will drive development of services to support clients at all levels of need KMB On-going 97 of 269

98 40 Better Care: Maternity 125a. Neonatal mortality and still births (per 1000) 7.5 Summary of current position Neonatal Mortality & Still Births have both reduced in Southwark over a number of years, however this continues to be a local concern, with higher rates than national and London averages. There is an acknowledgement that that this may partly reflect the demographics of local women, learning from the neonatal death panel s have identified a theme of late booking, particularly for women who have recently moved to the UK. Actions taken to date Both local acute trusts 2016/17 contracts contain the new London Strategic Clinical Network Maternity Services Specification. One of the KPIs within the Service Specification relates to reducing perinatal mortality. This is being monitored closely through our monthly contract monitoring processes. Commissioners meet regularly with acute trusts to discuss a wide range of maternity performance via the Southwark & Lambeth Joint Maternity Group (clinically led by SCCG) and the two Trust Clinical Quality Review Groups (CQRGs), which regularly discusses Maternity as a main agenda item and picks up key areas for action. Commissioners review Maternity KPI performance including rates of Neonatal deaths and still births on a monthly basis at CQRGs - and agree a response with the provider Early Booking continues to be a local concern and focuses on discussions at the Southwark & Lambeth Joint Maternity Group. Poster Campaign carried out in Primary care to raise awareness amongst women of the importance of early booking Rates of maternal smoking cessation continues to be an area of focussed intervention Further actions planned in 2016/17 Lead Date In light of the publication of the national Saving Babies and Better Births guidance, SE London commissioners and Trusts have committed to work inyear to work up a more granular local service specification, which reflects the requirements of the new national guidance. Continued challenge by commissioners via relevant quality forums SEL Maternity Clinical Network CQRG & L&S Maternity Commissioning Group Sept 2016 Sept 2016 SEL STP are agreeing trajectories for 20% reduction in neonatal deaths by 2020, which will include the intention to contract for the Saving Babies Lives Care Bundles in 2017/18. SEL STP 17/18 98 of 269

99 41 Better Care: Maternity 125b. Women s experience of maternity services 81.1% Summary of current position Awaiting published data from CQC National Maternity Survey to confirm. KCH & GSTT operate various existing mechanisms for collecting women s experience, which includes the Maternity Services Liaison Committee which conducts walk abouts and open dialogue with women across the maternity pathway, Friends & Family test, and Maternity How are we doing? Survey. KCH have failed to meet Friends & Family Indicator, on further exploration this has predominately been due to technical issues and improvement plans have been initiated. Actions taken to date Provider dashboards track maternity experience and are monitored at CQRG and the Southwark & Lambeth Joint Maternity Group. The Southwark & Lambeth Joint Maternity Group was set up in 2015, as a subgroup to the CQRGs. This is a clinically led forum with good engagement across commissioners and providers and provides an opportunities for discussing quality issues across the pathway that impact on women s experience. SEL Maternity Network has assessed and agreed provider improvements against the London Quality Standards Provider action plans in response to London s Whose Shoes Maternity Network in progress. Improving Perinatal Mental Health is significant issue for improving women s experiences of maternity services locally. Work is underway to ensure that commissioning for perinatal mental health services is integrated with the Children & young People s agenda and women have timely access to high quality services. The Chair of SEL Perinatal Mental Health Network sits on the Maternity Governance Structures. Further actions planned in 2016/17 Lead Date Continued monitoring of provider dashboards through CQRGs and S&L Joint Commissioning Meeting helps commissioners to understand variation and agree improvement plans. CQRG & L&S Maternity Commissioning Meeting 16/17 The implementation of Badgernet IT system at KCH will improve real time data and enable further quality improvements. KCH Sept 16 OHSEL Maternity Programme has strengthened over last 12 months, and is developing the strategic case for change as a foundation for SEL STP. SEL work plan will be signed of by November SEL STP Nov 2016 SCCG progressing review of Perinatal pathway. SCCG April of 269

100 42 Better Care: Maternity 125c. Choices in maternity services 69.5% Summary of current position Awaiting data from CQC Maternity Survey to confrim. In terms of provision KCH & GSTT both provide midwife lead units, offer home births to Southwark women and provide antenatal care in various community settings. At KCH, 5.5% of women (April 16) choose to have their baby at home, and is recognised locally as a best practise model of care. Capacity issues continue to be a significant challenge locally in delivering greater choice. Actions taken to date London Maternity Service Specification (adopted April 2015) promotes women s choice of type and place of birth and includes Better Birth recommendations for consistent information on birth settings. SEL Maternity Network deliver a workstream on post and neo natal care which promotes choice, and specifically focuses on supporting mothers in their decisions how to feed their baby. Further actions planned in 2016/17 Lead Date Take local learning from King s model of providing home births and share learning across SEL SEL Maternity Network April 16 SEL STP will review capacity and choice across SEL, including ensuring access and provision of maternity services interface with Local Care Networks SEL STP 2017/18 Develop consistent information on birth settings across SEL SEL Maternity Network April 16 Better understand tensions between women s choice and c-section rates. Ami David April of 269

101 43 Better Care: Dementia 126a. Estimated diagnosis rate for people with dementia 76.9% Summary of current position The CCG is currently meeting the diagnosis target and currently performing at a rate of 75.4%. A number of initiatives has been put in place to ensure the CCG continues to improve the diagnosis rate and achieving the target. Actions taken to date a) Additional capacity was built in the Southwark memory service to manage the increased number of referrals, stabilise waiting times, and address the continued predicted growth in referral numbers and free up consultant time to carry out more assessments. b) A training an awareness campaign for GPs and professionals to was carried out to help them recognise the early signs of Dementia and thus referring them for an assessment c) There have been various forms of awareness raising information provision through local publicity campaigns, websites, leaflets and other various community initiatives, and voluntary sector groups. d) Dementia Community Navigation pilot has been operating for 12 months in Southwark and has focussed on pre-diagnosis support to support GPs in providing support for complex patients who may not otherwise have family to support them to access their acute appointments. The post also liaises with hospital discharge teams to bolster the dementia specific understanding needed to ensure smooth transition back into the home/care home environment. e) The SLMS was commissioned to have a greater role in diagnosing dementia in primary care and supporting GPs to identify dementia early, do diagnostic work up and refer to SLMS for memory assessment. A new role was created to provide training to the wider primary care and community sector and will make links with social care and voluntary sector funded organisations that provide access to support for the patient and their families, enabling them to live well with dementia in the community. Further actions planned in 2016/17 Lead Date a) Mental Health Commissioners are currently working with GP Lead for Learning disabilities to identified best ways to identify early diagnosis of dementia with people with Learning Disabilities during they annual health check. Funding has now been agreed to support this, with recruitment to be undertaken for October 2016 Rabia Alexander Oct of 269

102 Dementia Diagnosis Rate 2016/17 estimated prevalence = 1,499 (65+_) Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar April May June Trajectory diagnoses Actual number diagnosed ,156 1,180 1,176 1,189 1,178 1,176 1,156 1,151 1,160 1,168 1,130 1,140 1,153 Trajectory - % diagnosed Actual % diagnosed Data extracted from HSCIC monthly dementia registers publication. Green = above target; Amber = <1% below target; Red = >1% below target. Reported Performance Position In June 2016, there were 1,153 patients on dementia practice registers which means the CCG is meeting the national two thirds diagnosis target and is performing at a rate of 76.9% with an additional 346 people who remain undiagnosed. 102 of

103 45 Better Care: Dementia 126b. Dementia care planning and post-diagnostic support 80.7% Summary of current position The CCG have implemented a number of initiatives to improve care planning, post-diagnostics support and better outcomes for patients who have been diagnosed with dementia to ensure they are supported and stay well for longer in the community. We will continue to monitor the outcomes of the new pathways to ensure the best outcomes are achieved. Actions taken to date a) A shared care protocol has been developed with the dementia services at SLAM and primary care. b) An older adult mental health specialist integrated care team has been commissioned to support, diagnosis and manage older vulnerable people to remain at home, support care homes and nursing homes with residents presenting with challenging behaviour with a diagnosis of dementia. c) We have developed, with the local authority, a stronger dementia pathway from pre- and immediate post-diagnostic support through to end of life, to facilitate people living with dementia and their families/carers to continue to live as independently as possible within the community (that is, as dementia friendly as possible) and subsequently reducing the need for hospital and long term care. d) A number of post diagnostic support services have been commissioned Alzheimer s Society all new diagnoses made via Southwark & Lambeth Memory Service are referred into the single point of access at the locally commissioned Alzheimer s Society. A dementia advice service has been commission to offer support for up to 10 weeks post diagnosis to provide the patient with information and advice about the disease and will provide some support in terms of coping and what to expect, how they might need to make adaptations to live well with the condition as they deteriorate. Dementia support workers have been commissioned to work with families to ensure they understand the diagnosis and how to cope going forward, providing advice that will enable them to care for their loved one as their condition deteriorates. Information, advice, signposting and an assessment at home will be carried out to understand any adaptations that need to be made. Further actions planned in 2016/17 Lead Date a) CCG/Council to develop an integrated dementia pathway 6 months engagement with voluntary sector Alzheimer s Society, social care teams, GSTT community teams, district nursing, SLaM, King s, patients, carers, GPs. Sophie Gray Quarter b) CCG will pilot an integrated pathway support within GP practices. Phase 1 stage of the pilot will support the development of an integrated pathway to support primary care based assessment, diagnosis, initiation of treatment and a holistic post diagnostic support offer. Phase 2 - The pilot will be extended to practices in Southwark during the 2016/17 financial year to test the efficacy of the primary care pathway developed and implemented during 2015/16 and to test patient outcomes Sophie Gray Quarter of 269

104 46 Better Care: Urgent and emergency care 127a. Achievement of milestones in the delivery of an integrated urgent care service 50% Summary of current position SEL CCGs are making good progress towards achieving the eight key elements of an Integrated Urgent Care Service. Four elements are met in full. Two are partially met and all are expected to be met by October 2017 when SEL s Integrate Urgent Care service launches. Actions taken to date Joint 111 and GPOOH governance arrangements have been established in shadow form The capacity for 111 and GPOOH is jointly planned The Summary Care Record is available to 111 clinicians Care plans are shared with 111 Data can be sent between providers SEL 111 service is currently piloting direct booking of GP hub (primary care extended access networks) appointments Further actions planned in 2016/17 Lead Date Joint 111 and GPOOH governance structure to be formally adopted CG October 2016 Direct booking of GP hub appointments to be expanded CG Oct 2016 Oct 2017 Clinical Hub to be established - containing GPs and other healthcare professions - enabling a single call to get an appointment out of hours CG October 2017 Interoperability to be established to allow the Clinical Hub to view and edit primary care records CG October 104 of

105 47 Better Care: Urgent and emergency care 127b. Emergency admissions for urgent care sensitive conditions 2834 Summary of current position Indicator: Rate of unplanned hospital admissions for urgent care sensitive conditions, per 100,000 registered patients. UCS conditions include COPD, acute mental health crisis, non-specific chest pain, falls, non-specific abdominal pain, DVT, cellulitis, pyrexial child, blocked tubes and catheters, hypoglycemia, UTI, angina, epileptic fit, minor head injuries. Actions taken to date Commissioned a new Extended Access Primary Care Service which provided an additional 87,343 face to face appointments for urgent and same day appointments, based on triage. This allows rapid access to a GP (with full access to the care record) and allows local practices to provide more focused care to people with chronic conditions. We have changed our approach to commissioning enhanced services in primary care. We have grouped the enhanced services into a Population Health Management contract to reduce the variability in access to services across the borough. By reducing this variation in access we are explicitly attempting to reduce the variation in outcomes for people living in the most deprived parts of the borough. Services included in the PHM contract include holistic assessments of need, case management for the elderly, and ambulatory blood pressure monitoring. This more preventative approach should reduce the exacerbation of chronic conditions that often result in unplanned care. We have commissioned a new falls pathway focused on reducing the risk of falls in people who are at high risk. This is being developed alongside an e-frailty index tool that can help to identify people who would benefit from this additional support. We have developed and commissioned additional admission avoidance services (Enhanced Rapid Response and teams) from GSTT which work alongside the LAS to respond quickly to urgent need, but to provide a suitable level of support for high acuity patients without resulting in an admission. Through our Southwark and Lambeth Integrated Care partnership we have supported the development of a catheter passport system to reduce the incidence of UTIs, alongside a Geriatrician hotline (TALK) which gives GPs instant access to consultant opinions to support out of hospital management of patients who are >65. We have also begun to develop a Locality Geriatrician outreach model to provide more responsive care in the community. Further actions planned in 2016/17 Lead Date We have embarked upon a whole systems project to implement care coordination for people with multi-morbidity (3+ LTCs). The project has a focus on establishing systematic approaches to case finding and holistic needs assessment, named responsible professional, joint care planning, multi-disciplinary working and self-management support. MK/DD Apr-Mar Go live of Urgent Care Centre new specification should be in place from October 2016, with the UCC moving to its new location in January 2017 DS Oct 16 Recommissioning of the NHS 111 service CG TBC Implementation of Demand Management initiatives Roll out of active redirection of patients upon presentation at ED (in accordance with the BHRUT model) to redirect patients to primary and community services or to self care. Both GSTT and KCH are developing models for implementation by Q3 DS Oct 16 Through the Children and Young People s Health Programme (CYPHP) we will be developing a paediatric hotline and outreach model to give GPs instant access to consultant opinions to reduce the need for onward referral to hospital. The main focus of this is epilepsy and asthma. GSTT 105 of Apr-Mar 269

106 48 Better Care: Urgent and emergency care 127c. Percentage of patients admitted, transferred or discharged from A&E within 4 hours 83.5% Summary of current position KCH Bipartite agreed recovery trajectory for 2016/17. The Trust met the performance trajectory in April - performance of 83.5% (2.1% over plan) and May - performance 84.7% (0.9% over plan). However 87% June target breached (3.2% below plan) and significant challenge for months GSTT - Bipartite agreed recovery trajectory for 2016/17. The Trust has breached the trajectory YTD with April performance of 91.9% (2.5% under plan),may performance of 89.1% (6.2% under plan) and June performance of 89.8% (.5.7% under plan) Recovery and delivery of August to March trajectory represents a significant challenge. Actions taken to date KCH - site specific in hospital Recovery Plans in place, with a six point internal KCH plan focused on: ED capacity, minor injuries/ucc, emergency/acute care pathway clean sheet redesign, additional bed capacity (Business Case completed, engagement and implementation process commencing), frailty pathway, discharge. Whilst Recovery Plan is being progressed key high impact actions have yet to be implemented, with Quarter 1 and 2 primarily focused on the recovery planning process. GSTT - Recovery Plan agreed and in place, with YTD actions implemented, however performance has been significantly below plan. April and May performance drivers assessed to inform refreshed actions key issues have been overall demand, noting rebuild space constraints compounded by issues in relation to outflow from A&E. Out of hospital care action plans agreed and in place for both GSTT and KCH. Focused on local initiatives to support demand management, A&E diversion, mental health interfaces and escalation, the optimal utilisation of admission avoidance and supported discharge services, noting these services have been expanded and enhanced for 2016/17 and a continued focus on addressing discharge, repatriation and rehabilitation delays. A continuing challenge relates to non local emergency flows and interfaces. Further actions planned in 2016/17 Lead Date KCH: Urgent Care Centre new co-designed CCG/KCH service in place from October 2016, with the UCC moving to its expanded location in February Clean sheet emergency acute care pathway redesign programme launched in June 2016, pathway changes to impact on performance from Quarter 3. Bed Capacity increased bed capacity (63 beds Trust wide, 43 of which will be at Denmark Hill) due to open in January This will close the Trust s bed gap and allow for reduced bed occupancy and improved flow. Implementation of effective standard operating procedures and improved productivity and efficiency important if performance benefit of additional beds is to be realised. On going delivery of the overall Recovery Plan including frailty pathway/unit and discharge/7 day working. Andrew Bland See narrative GSTT: On going delivery of the overall Recovery Plan, plus new initiatives being piloted to further support improved performance medical staffing model and rotas, senior lead and revised processes to focus on UCC breaches, refreshed internal escalation processes, electronic live bed state, dedicated vascular ambulatory care beds, enhanced capacity and focus on discharge, including process redesign. Review and rephasing of elements of the rebuild programmed to mitigate impact of rebuild and maximise available space to manage demand. Review rapid response services to ensure they are being targeted to maximise impact on A&E performance/alleviating bed pressures Andrew Eyres End Quarter 2 System wide work:implementation of demand management initiatives including roll out of enhanced active redirection of patients (BHRUT model) across KCH and GSTT. Implementation of a joint Mental Health breach reduction plan between KCH, GSTT and SLaM CCG/ECIP facilitated workshop to support this process. System wide communications campaign developed and delivered to raise awareness of service options and sign post patients appropriately. System wide review and implementation of nationally mandated U&EC initiatives, where there are current provision gaps. Agreed utilisation of winter funding to support resilience over the winter months. Andrew Eyres (UCWG Chair) End Quarter of 269

107 Urgent care performance A&E waits A&E waits all types (target 95%) - % of patients who spent 4 hours or less in A&E before treatment or admission Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun KCH (all sites) KCH (Denmark Hill) GSTT A&E waits type 1 (target 95%) - % of patients who spent 4 hours or less in A&E before treatment or admission Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun KCH (all sites) KCH (Denmark Hill) GSTT of

108 50 Better Care: Urgent and emergency care 127d. Ambulance waits 73.5% Summary of current position Performance against the 75% Cat A target was slightly below target for Q1, but has improved month on month. Performance for the month to date is 83.2% which meets the national standard and is the highest performance in London. Actions taken to date Development of the LAS@home service which enables LAS to refer to GSTT community service teams for patients suffering falls, or who need care that would otherwise require admissions to hospital. This service has agreed SLAs where a response is guaranteed within 2 hours. The service has been well utilised with LAS promoting it as a recommended model for other parts of London. Access to Urgent Care Centres. LAS has confirmed that appropriate ACPs are in place for Denmark Hill, St Thomas and Guy s UCCs, with direct access available to all units. This reduces pressure on majors departments and helps ensure rapid handovers for crews Work with neighbouring CCGs to reduce offload waits. It is recognised that there are relatively high delays from arrival at hospital to patient handover at other hospitals within SE London notably PRUH and QEH. We recognise that these delays can compromise the ability of LAS to respond to new calls, and can cause crews to be pulled out of area. Through the Our Healthier South East London programme, all sites and commissioners are reviewing offload delays and ensuring appropriate ACPs to community services and UCCs are in place to reduce reliance on EDs and help lower offload delays and conveyance rates. Ensuring presence of LAS at all key forums and contributing to the development of a London wide LAS strategy. LAS play a key role at SRGs, Urgent Care Working Groups and at KCH s Emergency Care Board. They are therefore able to help shape strategy and influence key stakeholders. All providers and commissioners have committed to working collaboratively with LAS to improve system wide performance. The SRGs are working with HLP and London wide commissioners of the service to develop a strategic approach to ambulance services for London, which inform STP development and ensure that LAS become an integrated element of UEC transformation Further actions planned in 2016/17 Lead Date Focus on high volume callers to LAS. Meetings have been held with LAS local area teams and with the Head of Quality and Darzi Fellow for LAS to discuss a joint action plan on providing support for high volume callers. An MDT involving community nursing, mental health nursing, as well as colleagues from housing, benefits and social care will case manage high volume callers, alongside frequent attendees to ED, to develop bespoke care plans to reduce demand on both ambulance and hospital services. David Smith 01/10/16 Review of ED assessments of ambulance borne patients. It is noted that both GSTT and KCH have an average handover time above the 15 minute handover. Whilst both departments receive high volumes of ambulance borne patients, and have low levels of 60 minute handover breaches, we are keen to understand from LAS whether they feel processes could be optimised to reduce wait times further. A report is expected back to the next SRG meeting Phil Powell (LAS) 29/8/16 Further promotion of LAS@home. Whilst pleased with the impact of the service to date, work is on-going with both GSTT and LAS to see how utilisation of the service can be increased yet further. This involves continually publicising the ACP to crews and distributing case studies to demonstrate positive impact and clinical efficacy. David Smith/ Phil Powell On-going 108 of 269

109 London Ambulance Service Trust Performance 8 minutes red 1 (75%) - May be life threatening and the most time critical conditions - emergency response within 8 minutes 8 minutes red 2 (75%) - May be life threatening, but less time critical than Red 1 - emergency response within 8 minutes 19 minutes (95%) - May be life threatening - receive an ambulance response at the scene within 19 minutes LAS Trust Performance % Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 15/16 Apr May Jun A 8 mins red 1 (75%) A 8 mins red 2 (75%) A 19 minutes (95%) LAS Trust Southwark Performance % Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 15/16 Apr May Jun A 8 mins red 1 (75%) A 8 mins red 2 (75%) A 19 minutes (95%) of

110 52 Better Care: Urgent and emergency care 127e. Delayed transfers of care attributable to the NHS per 100,000 population 4.4 Summary of current position It is fully recognised that delays in transfers of care negatively affect patient outcomes and result in beds being blocked thus reducing hospital flow and negatively impacting on ED and RTT performance. Southwark has one of the lowest DTOC rates in the country (12 th nationally, 4 th in London) with DTOCs at 37% of the national average. Our focus is to maintain or better this position, and seeking opportunities to work with neighbouring boroughs who have higher DTOC rates which affect performance at local trusts. Actions taken to date Agreed Better Care Fund Plans - Reducing DTOCs are the key measure of BCF plans in 16/17. Our BCF plan has been rated as Fully Assured by NHSE, one of only 4 plans in London to achieve this rating at the first checkpoint. Investment in re-ablement services We have invested significantly and re-ablement services through the BCF to ensure that patients can be discharged to home for further care or assessment without needing to stay in hospital. Community Service and Social Care teams are working with the CCG to improve access further and move to a single point of access to reduce response times and reduce duplication Reducing delays due to patient/family choice - From analysis of DTOCS in 15/16, it is noted that 20% of DTOCs stem from patient and family choice, particularly where patients and their families have not made, or been supported in making, decisions about care arrangements post hospital. To help reduce these delays, in 16/17, a new choice policy has been rolled out across GSTT and KCH. This policy gives clearer advice to patients and their carers and families about what support the patient is likely to need post-discharge to aid forward planning. Underpinning this, a Care Home Selection Service is in place which will work proactively with families to help choose a care home for their relative. Extra Care Flats Through the BCF, 2 step down flats are now operational for patients who are medically fit for discharge, but require intensive support and re-ablement before returning home. This cohort of patients would otherwise have longer stays in hospital or require care-home placement. Initial evaluations of the scheme have shown that over 80% of patients are able to return to independent living, post their stay in the extra care facilities. Further actions planned in 2016/17 Lead Date Review of intermediate care provision As a CCG we have consciously tried to reduce demand on physical beds by investing heavily in community services to ensure patients are assessed and cared for in their own place of residence wherever possible. However, we are keen to investigate whether there are any further opportunities to develop more step up/step down beds, for those that are too unwell to stay at home, but no longer require acute care. A project manager has been appointed to conduct a review with clear recommendations, which will report back by November 2016 Platinum calls with SLaM it is recognised that whilst the level of DTOCs within Southwark are low, DTOC levels at SLaM regularly exceed those at both acute trusts. We have instigated weekly calls with SLaM and Southwark LA to discuss all current cases where Southwark patients are ready for discharge in order to ensure senior level escalation is in place and that solutions are rapidly sought. Caroline Gilmartin & Jay Stickland Caroline Gilmartin & Rabia Alexander/ Mike Conlon Nov 16 On-going Pro-active support to acute trusts The CCG Continuing Health Care team attend weekly discharge review meetings at KCH to provide advice and support on discharge. Where necessary these staff will troubleshoot and ensure that all external providers are delivering the appropriate support to ensure that discharges can be expedited Kate Moriarty- Baker On-going 110 of 269

111 Better Care: Urgent and emergency care 127f. Population use of hospital beds following emergency admission, standardised bed days rate per 1000 population Summary of current position Actions taken to date Reducing length of stay in hospitals is a key tenet of 16/17 plans for both GSTT and KCH, and the CCG is working collaboratively with both trusts to explore all potential options for improving discharge management, reduce delays in transfers of care, as well as maximising efforts to avoid admissions entirely through community services or ambulatory care. The CCG has recently led a pan- Lambeth and Southwark workshop with ECIP to bring together partners to examine how we can spread best practice, improve processes and make full use of the range of 7 day services in place across the borough Mainstreaming of Night Owls service The Night Owls service is commissioned through the BCF, and which provides intensive over-night home care support to prevent the need for patients to remain in hospital or be admitted to care homes. The service provides support for up to 50 patients at any time, helping ensure that hospital beds can be used more appropriately. Implementation of Choice Policy The CCG have led the development of a local 'Choice Protocol' to reduce delays as a result of patient/family choice. The protocol ensures that patients and their families are informed at the earliest possible stage of their admission of the likely impact of their condition on their ability to live independently, and helps support families in the identification and selection of care homes to avoid delays once patients are medically fit for discharge Mobile Platinum As a joint initiative the CCG instigated weekly ward rounds of senior staff from community services, social care and continuing care of a number of wards at KCH to help troubleshoot issues related to discharge and offer support and guidance. The learning helped inform the content for a pan-lambeth and Southwark workshop (see below), and the creation further guidance on continuing care checklists and HNAs to help support wards in the discharge planning process ECIP/CCG High Impact event on Discharge The CCG, ECIP, GSTT and KCH co-sponsored an event in June across the health and care economy to identify a number of high impact changes that could help reduce delays in discharges, improve patient flow, and support better joint working between organisations. The event focussed on improving the utilisation of seven day services and opportunities to adopt discharge to assess and trusted assessor models. Work is on-going with GSTT and KCH to ensure learning is fed in to overarching trust plans. Further actions planned in 2016/17 Lead Date 0.71 Roll-out of SAFER bundle both KCH and GSTT are actively working to ensure the SAFER bundle is used as discharge planning tool. The CCG has been active in advocating the use of the bundle through the Mobile Platinum work with KCH, and it has been successfully piloted on surgical wards. The CCG will support both Trusts in the rollout of SAFER across all wards, in line with the national push to have this completed in-year Greater use of seven day services Southwark and Lambeth CCGs and LAs have invested heavily in a range of seven day services over the last few months, but there is significant scope for higher utilisation. As part of planning for winter we are working with KCH to ensure that criteria-led discharge processes are in place to maximise weekend discharges and thus maintain flow throughout the week. GSTT community services and the Local Authority are reviewing the management of re-ablement and rehabilitation pathways to create a joined up service, and GSTT are about pilot the Bertzog community nursing model Kate Moriarty- Baker/ David Smith Kate Moriarty- Baker/ David Smith/Caroli ne Gilmartin Nov 2016 Nov 2016 Increasing utilisation services service is now fully operational, with palliative care and services now also onstream. A key focus of the run-up to winter will be to maximise utilisation of these services to both avoid admissions, but also to ensure that patients who present to ED or are admitted are being referred wherever clinically appropriate. The CCG will work with both acute trusts, and team to ensure that all clinicians and ward staff are clear on the range of patients that can be supported in the community, as well as being sent regular case studies to demonstrate efficacy. This will be supported by GSTT and Southwark LA moving to a single point of access for both social care and community services to improve responsiveness and reduce duplication. Kate Moriarty- Baker/ David Smith Oct of

112 54 Better Care: Primary medical services 128a. Management of long term conditions unplanned admissions for ambulatory care sensitive conditions 1,108 Summary of current position Indicator: The rate of unplanned hospitalisation for chronic ambulatory care sensitive conditions, per 100,000 registered patients (age and sex standardised). ACS conditions include a range of respiratory diseases, heart failure, neurological disorders (including epilepsy) and diabetes related conditions. Actions taken to date We have changed our approach to commissioning enhanced services in primary care. We have grouped the enhanced services into a Population Health Management contract delivered on a population basis to reduce the variability in access to services across the borough. By reducing this variation in access we are explicitly attempting to reduce the variation in outcomes for people living in the most deprived parts of the borough. Services included in the PHM contract include holistic assessments of need, case management for the elderly, and ambulatory blood pressure monitoring. The PHM contract also includes collective quality incentives for the identification and management of LTCs. This more preventative approach should reduce the exacerbation of chronic conditions that often result in unplanned care. The CCG has supported implementation of the Diabetes Modernisation Initiative across the borough, and we have worked closely with partners in KCH, SLaM and GSTT to develop the 3D4D (Three Dimensions For Diabetes) programme to support people with diabetes and severe mental health needs. We have worked with local partners to develop and implement and Integrated Respiratory Team across primary and acute care. We have worked across the system to test and refine a variety of integrated interventions in relation to the >65s, including the development of care navigation so that people can receive more than medical support in relation to their LTCs. And we have in place a Geriatrician hotline (TALK) which gives GPs instant access to consultant opinions to support out of hospital management of patients who are >65. We have also begun to develop a Locality Geriatrician outreach model to provide more responsive care in the community. Commissioned a new Extended Access Primary Care Service which provided an additional 87,343 face to face appointments for urgent and same day appointments, based on triage. This allows rapid access to a GP (with full access to the care record) and allows local practices to provide more focused care to people with chronic conditions. We have changed our approach to commissioning enhanced services in primary care. We have grouped the enhanced services into a Population Health Management contract to reduce the variability in access to services across the borough. By reducing this variation in access we are explicitly attempting to reduce the variation in outcomes for people living in the most deprived parts of the borough. Services included in the PHM contract include holistic assessments of need, case management for the elderly, and ambulatory blood pressure monitoring. This more preventative approach should reduce the exacerbation of chronic conditions that often result in unplanned care. Further actions planned in 2016/17 Lead Date We have embarked upon a whole systems project to implement care coordination for people with multi-morbidity (3+ LTCs). The project has a focus on establishing systematic approaches to case finding and holistic needs assessment, named responsible professional, joint care planning, multi-disciplinary working and self-management support. MK/DD Apr-Mar Through the Children and Young People s Health Programme (CYPHP) we will be developing a paediatric hotline and outreach model to give GPs instant access to consultant opinions to reduce the need for onward referral to hospital. GSTT 112 of 269

113 Better Care: Primary medical services 128b. Patient experience of GP services 79% Summary of current position In the latest GP Patient Survey (January 2016), on average 79% Southwark patient s rate their experience of their GP surgery as good, ranging between 50% and 94%. This is slight a reduction since Dec 2013 and Jan 2015, 83% and 80% respectively. Nine percent of patients rated their surgery poor, above the national average of 5%. Of the 20 practices below the CCG good experience rating, these mainly correlate with lower rates of satisfaction of patient experience of booking appointments (access) in patient s GP practice.. Rate is in lower national quartile hence red lit. Actions taken to date NHS Southwark CCG has developed and agreed a Quality Assurance Process to improve primary care quality in GP Practices the Primary Care Dashboard and a programme of practice visits focusing on improving local areas of performance are within this framework. The practice visits includes both Clinical lead and senior officer attendance The CCG works with practices through Health Watch and PPG structure to improve patient experience as monitored by the CCG through the GP Patient Survey. The survey is included in the CCG s Primary Care Dashboard is a set of patient focused outcome indicators. It has been developed to allow member practices and federations to identify, benchmark and oversee work to improve patients outcomes in priority areas. It is local tool for identifying unwarranted variation to support practices reduce inequalities. The dashboard also identifies practices who are achieving highly under certain priority areas and allows for opportunities to share best practice and peer challenge. The CCG has provided a programme of receptionist training and organisational development for GP practice staff including coaching support to improve GP practice services resulting in improved patient experience. The CCG has also provided non-recurrent funding to GP Federations to support signposting and navigation skills development of Health Care Assistants (HCAs) and reception staff, and embedding Age UK care navigators in general practice. The CCG supports the Patient Participation Groups (PPGs) including the management of 2 locality (one north and one south) PPGs. The CCG attends these monthly meeting and works with the PPG leads to develop their role in working with their GP practice to feedback their experience of services and how these can be improved locally. Patient experience of the CCG s Extended Primary Care Service (EPCS) 7 days a week 8am to 8pm has high satisfaction rates from patients. The EPCS provides up to 87,000 annual appointments Further actions planned in 2016/17 Lead Date Implement and monitor the Primary Care Quality Assurance Process focusing on the improved experience of GP services from our local population JY Monthly CCG to work with the providers of the EPCS ( GP federations) who receive high satisfaction rates, to assist them to share best practice with their member practices JY Q2-Q4 CCG reviewing impact of training programme for receptionists and organisational development on reported patient experience of GP services KMB Q4 CCG non-recurrent investment in GP Federation Business Plans to support a wide range of initiatives aimed to support at scale models of primary care and improved patient experience of GP services. This will include investment in a Service and Quality Improvement programme focused on the 10 high impact areas in the GPFV, deploying general practice based pharmacists, and enabling initiatives to support the effective delivery of Federation population based contracts (Population Health Management and Extended Primary Care Services) and Local Care Network initiatives (e.g. a standardised approach to deliver person centred coordinated care for a cohort of people with 3+LTCs) HS Q1-Q4 113 of

114 56 Better Care: Primary medical services 128c. Primary care access TBC Summary of current position Indicator: Percentage of practices within a CCG where patients have the option of accessing pre-bookable appointments outside of standard working hours Monday to Friday; that is on (i) weekday evenings (usually after 6.30pm), (ii) on a Saturday, (iii) on a Sunday. We have now commissioned a service that is fully compliant with this indicator. NHS Southwark CCG commission 2 Extended Primary Care Services (EPCS) from the south of the borough starting November 2014, and the north of the borough starting April Since this time the CCG has funded up to 3300 additional monthly appointments for Southwark registered population to access at the beginning of this financial year. The initial focus of this service is to ensure patients receive the appropriate access to same day appointments through clinical triage allowing practices to free up capacity for access to more complex patients requiring continuity of care. This service is open 7 days a week 8am to 8pm and provides up to 87,000 annual appointments Actions taken to date We successfully bid to be part of the PM Challenge Fund. As a result we have worked closely with our local practices to develop a new Extended Access Primary Care Service which provided an additional 87,343 face to face pre-bookable appointments for urgent appointments, based on triage, and available 8am-8pm, 7-days-a-week. This allows rapid access to a GP (with full access to the care record) and allows local practices to provide more focused care to people with chronic conditions. The service has been commissioned in both the north and south of the borough. It is provided by two GP federations, respectively Quay Health Solutions and Improving Health Ltd. All local GP practices are covered by this service, and consequently all registered patients in the borough have the ability to access the services. EPCS has initially focussed on same day appointments but both federations have service improvement plans to include both routine nurse care and GP appointments. The additional capacity within these services both frees up capacity in individual practices to offer more time with complex registered patients and on both same day/next day access and pre bookable appointments and the EPCS offers the ability for all patients to access appointments outside core hours i.e. after 6.30pm and at weekends. Local A&E is able to refer and directly book patients into available appointments for this service without waiting. KCHFT is able to refer with plans for GSTFT A&E and UCC to implement later this year. We have changed our approach to commissioning enhanced services in primary care. We have grouped the enhanced services into a Population Health Management contract to reduce the variability in access to services across the borough. By reducing this variation in access we are explicitly attempting to reduce the variation in outcomes for people living in the most deprived parts of the borough. Services included in the PHM contract include holistic assessments of need, case management for the elderly, and ambulatory blood pressure monitoring. This more preventative approach should reduce the exacerbation of chronic conditions that often result in unplanned care. 114 of 269

115 57 Better Care: Primary medical services 128c. Primary care access (contd.) TBC Further actions planned in 2016/17 Lead Date We have adopted the London specification as part of our commissioning intentions for PMS, which includes direct incentives for online access to GP services. CG/JY TBC We are working closely with the federations to support the continued increase in utilisation of the EPCS, and the development of the service model so that it can provide a broader range of general practice services (e.g. wound dressings etc.). CG/JY Ongoing Plan to roll out routine appointment access to nurse care in both north and south EPCS sites JY/HS Q3 EPCS evaluation to review effectiveness and appropriateness of the service model, contract model and provider delivery, including impact on patient satisfaction MK/CG Q4 CCG to support GP Federations in implementing a telephony overlay system that will support more effective demand management and utilisation of the EPCS (included in ETTF bid) JY/HS Q3 CCG non-recurrent investment in GP Federation Business Plans to support a wide range of initiatives aimed to support at scale models of primary care and improved primary care access. This will include enabling initiatives to support the effective delivery of the EPCS contract HS Q1-Q4 115 of 269

116 58 Better Care: Primary medical services 128d. Primary care workforce - number of GPs and Practice Nurses (FTE) per 1,000 weighted patients 0.81 Summary of current position Southwark has a comparatively young population of GPs with 20% of GPs under the age of 35 compared to 13% nationally, and a median age of practice nurses in the range, meaning that national medium to long term challenges around workforce reductions due to retirement are less marked locally Southwark does face challenges with smaller practices which are disproportionately staffed with professionals approaching retirement age Measure is bottom quartile nationally but not far below London average. Actions taken to date The Southwark Community Education Provider Network (CEPN) has been established to support the delivery of both the Southwark Five Year Forward View and GP Forward View in Southwark. Delivery of both plans will require new ways of working and the CCG is working with the Federations and LCNs to develop population health management. This will require the prioritise service developments to support the delivery of coordinated care to people with complex needs and the workforce to develop new ways of working which will be supported via the CEPN. The CCG is working with Federations and LCNs to further develop the culture within Southwark that attracts and retains a primary care workforce. This will be achieved through supporting recruitment practices, common terms and conditions and equitable access to training and development opportunities and exploring opportunities for joint working across practices. The CEPN is working with Federations and LCNs to create a primary care workforce database to support better understanding of workforce capacity, in all designations. This database will support the identification of workforce training and development needs to support both core services and new skills and competencies. The CEPNs across SEL are exploring ways of working at scale across the sector. This will include for example exploring the opportunity of having a pre-registration nursing course based in the community rather than an acute setting. Working collaboratively with Health Education England, the CCG have recruited 2 Urgent Care Fellows to work across General Practice and the Urgent Care Centre at Denmark Hill. The Fellows will undertake 4 sessions in General Practice per week and will work collaboratively with colleagues in GP Federations and KCH to help integrate urgent care pathways, reduce demand on Emergency Departments, and provide additional support to General Practice in south Southwark. The CEPN is supporting the recruitment and retention of the practice nurse workforce through equitable access to learning and development opportunities, development of a mentor workforce and creating pre-registration nurse placements in general practice. The CCG is committed to the development of a strong nursing workforce within Southwark and provides nurse leadership to this workforce through the CCG Chief Nurse role, CCG PN Board Member and CCG Nurse member of the board. The Chief Nurse is exploring opportunities for developing emerging leaders within the nursing workforce and the development of nurse clinical associates in order to raise the nursing profile and support the recruitment of nurses into Southwark. Working in partnership with Health Education England and NHS Lambeth CCG, we have established a Population Health Improvement Fellowship for newly qualified GPs to undertake a two year long programme with a specialist population health focus. This initiative aims to make the general practitioner role a more attractive career choice, develop a workforce targeted to population health need, and support the release of clinical leadership capability within GP Federations to deliver quality improvements and population based health services locally. In Southwark, we have recruited 3 Population Health Improvement Fellows. This initiative supports a number of workforce pressures facing primary care and aligns with the joint 10 point action plan described by NHS England in conjunction with Health Education England, the Royal College of General Practitioners, and the British Medical Association as part of the implementation of the Five Year Forward View and New Deal for Primary Care. It has also formed the basis for a broader discussion between Federations and their member practices around the development of both joint and portfolio roles to encourage both recruitment and retention in general practice locally. CCGs and Federations are implementing a number of schemes to support workforce retention including development programmes for practice managers, developing HCAs and receptionists as care navigators, backfill to support newly recruited PN to undertake a PN Development Programme, exploring GP Portfolio roles, clinical associate roles to harness local talent, share good practice and provide clinical leadership and lead nurse roles within Federations and development programmes for receptions, practice nurses and practice 116 managers. of 269 The CCG has appointed a pharmacist as a Darzi Fellow. The Darzi Fellow is developing a model for pharmacists in general practise which will create additional capacity and support to GPs

117 59 Better Care: Primary medical services 128d. Primary care workforce (contd.) 0.81 Further actions planned in 2016/17 Lead Date Identifying the core skills and competences required of the workforce to deliver population health management DK Deliver against the CEPN Operation Plan Agreeing workforce objectives with Federations and LCNs and through this informing CEPN activity. This will be through the Primary Care Development Group and will support both core services and the development of population health management KMB/HS Sept 16 Mapping of all current workforce development and training opportunities currently commissioned that will support agreed workforce objectives KMB Sept 2016 Creation and population of the workforce database MG Sept 16 Implementation of clinical pharmacists in primary care A-D K August 17 Roll out year 2 of the Population Health Fellowship AS October of 269

118 60 Better Care: Elective access 129a. Patients waiting 18 weeks or less from referral to hospital treatment 85.1% Summary of current position CCG performance driven by a combination of KCH and GSTT performance. KCH above trajectory for April, May by 0.2% and 0.3% respectively actual performance of 80.7% and 80.9%. and on trajectory for June. Performance position masks an underlying increase in the overall PTL, over 18 week backlog and non neuro over 52 week waiters, noting that Trust wide activity is below plan. GSTT above trajectory for April and May by 0.2% and 0.3% respectively actual performance of 80.7% and 80.9%. and on trajectory for June. Performance position masks an underlying increase in the overall PTL, with referrals to GSTT continuing to increase. Actions taken to date KCH: 2015/16 waiting list validation exercise to support a clean PTL and a return to national reporting after 11 months of non reporting in March /17 demand and capacity planning to provide assurance that activity plans reflect backlog clearance trajectory requirements and that capacity is in place to support delivery. KCH start year plan includes assumed outsourcing for neurosurgery, general surgery and orthopaedics. 2016/17 Recovery Plan in place. Plan covers 6 key work streams RTT policy and procedures, RTT monitoring and reporting, RTT education and training, RTT validation, RTT backlog clearance, demand and capacity modelling. External support being provided by the IST RTT validation, monitoring and reporting plus demand and capacity planning. On going work to determine an agreed whole systems strategy for securing a sustainable neurosciences service. GSTT: 2015/16 Recovery Programme to support waiting list management and delivery of the Trust s activity plan, focused on key challenged specialties and robust waiting list validation. 2016/17 demand and capacity planning to provide assurance that activity plans reflect backlog clearance trajectory requirements and that capacity is in place to support delivery. Quarter 1 targeted validation programme covering over 5000 patients. Outsourcing arrangements put in to place for adult ENT services, focused on non admitted activity. ENT accounts for 20%of the Trust s backlog. Further actions planned in 2016/17 Lead Date KCH: RTT refresh exercise to review the robustness of Trust s current plans in the context of month 1 and 2 trends and the outcome of the Quarter 1 demand and capacity plan outputs. Neurosurgery and neurology refreshed forward plan reflecting end May performance position, system decision on catchments/london wide waiting list approach, implementation of referral gateway initiative, potential further outsourcing for complex cases. External support a further external support offer from MBI is being discussed and scoped. Demand management - enhanced focus on demand management in line with national demand management initiatives. GSTT: Quarter 1 refreshed RTT sustainability plan. Internal outpatient toolkit launched focus on reducing variation and inconsistency across directorates. Concerted focus on reviewing clock stops and closing appropriate pathways. Enhanced performance management approach for challenged specialties, combined with enhanced support to directorates e.g. booking parties, Elective Assurance team training, outsourcing. Implementation and launch of a Planned Care Board to focus on demand management Programme Manager post being recruited, clinical leads identified. SEL wide - SEL wide outsourcing scoping exercise, with plans now being developed to take a SEL system approach to outsourcing for all SEL providers priority focus orthopaedics and ENT. NHSE outsourcing lead supporting this work. Andrew Bland Andrew Eyres Andrew Bland Ongoing All actions underway/ completed. 118 Ongoing of 269

119 Referral-to-Treatment: 18 Weeks Performance Referral-to-Treatment Incomplete (target 92%) The % of patients waiting to start treatment who have been waiting less than 18 weeks. % Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Southwark CCG* KCH (Trust wide) GSTT (Trust wide) % The CCG's performance in June is primarily driven by the position at KCH, and this is expected to be the case for the duration of 16/17, and has been reflected in the CCG s trajectory. The Trust returned to reporting its RTT incomplete position in March 16. Southwark performance at KCH was at 79% for the month. GSTT met the target as a Trust in June. KCH - had been implementing a RTT recovery plan over the whole of 2015/16. In March 16 the IST reviewed the KCH validation programme and confirmed that the KCH PTL was in a position to return to national reporting for the March submission. For March data KCH had validated all over 18 week waiters both admitted and non-admitted. Trust wide the reported position in March was 80.4%. In June this has continue to improve to 81%. The Trust has submitted an improvement trajectory to get to 88% (trust wide) by March 2017, and is currently above this trajectory. The Trust has also submitted an over 18 week backlog reduction trajectory; the Trust is behind this at 15,495 against a target of 14,506. This highlights that whilst performance is on track the backlog has not reduced to the level expected, this points to the performance improvement being linked to a reduction in the level of activity and or an increase in new referrals rather than backlog clearance. The Trust continues to work to an agreed RTT action plan to improve performance and reduce backlog over the year. GST although the Trust met trust wide performance, the Trust has highlighted an increase in referrals which will affect its ability to keep track with increased activity and therefore is likely to affect their incomplete performance in coming months. The Trust has already flagged this issue to the commissioners and their regulator NHSI. 119 of

120 Referral-to-Treatment: 52 + week waits RTT - Patients Waiting 52+ Weeks (target 0) The number of people waiting over 52 weeks to commence treatment. There is a zero tolerance policy for any RTT waits of more than 52 weeks Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Southwark CCG KCH (Trust wide) GSTT (Trust wide) CCG position: 36 of the breaches were associated with KCH; 14 T&O, 7 Neurosurgery, and the remaining 15 across a number of specialties. KCH position: The validation process over 15/16 identified a number of over 52 week waiters at KCH. KCH reported 137 Trust wide in June. KCH has produced an over 52 week trajectory. The Trajectory for June was 177 breaches; the Trust is therefore ahead of its target; with Neuro specialties being 68 ahead of plan and non-neuro specialties being 28 behind (with the most notable specialty behind being Orthopaedics). The agreed trajectory shows all non Neuro long waiters reduced to 0 by October The Trust is working with NHSE, NHSI and Commissioners to implement further actions to reduce long waiters in Neuro specialties, and are exploring additional outsourcing options for non-neuro specialties. An additional assurance process had been put in place for clinical review of the additional long waiters identified. This has had input from CCG clinical leads. GSTT: 1 ENT patient with a lengthy patient initiated delay and with a confirmed TCI date, 4 paediatric ENT - 2 are no longer waiting (I treated in July, the other declined treatment) and 2 have TCI dates in September. The CSU is investigating the other two cases: 1 in Urology at Imperial, and 1 in ENT at Aspen Parkside. 120 of

121 63 Better Care: 7 day services 130a. Achievement of clinical standards in the delivery of 7 day services TBC Summary of current position Both GSTT and KCH have a high level of compliance against the seven day services clinical standards, though both have some areas where improvement is necessary. It is understood that the submissions by all trusts in April 2016 is currently undergoing national review and as such, the updates below relate to compliance at the baseline assessment in September Commissioners have included the requirement for both KCH and GSTT to make progress towards compliance, particularly in the four priority standards (2, 5, 6, 8) in contracts for this year, and monitoring will overseen by both trusts Clinical Quality Review Groups. Actions taken to date Standard 2 Time to Consultant Review Both GSTT and KCH were compliant with the standard for high risk patients. For targets for assessment by Consultant following an emergency admission, both Trusts showed a high level of compliance, with the majority of specialities 100% compliance. However, there are a number of areas, such as general medicine, where it was assessed that the target was only being met at both trusts 80% of the time. Whilst, initial scores are positive, both trusts acknowledge further work is required to ensure full compliance with standards. Standard 5 Access to diagnostics. GSTT were fully compliant on all 7 day diagnostic standards. KCH were compliant on the vast majority of standards with the exception of ECGs where weekend cover was not consistently available and Bronchoscopy where there were gaps in both weekday and weekend provision. Standard 6 24 hour access to consultant-directed interventions Both GSTT and KCH were fully compliant on all measures Standard 8 On-going review Both GSTT and KCH had significant variability on how these standards were being delivered. Whilst the majority of standards were being met, both Trusts require improvement on areas such as consultant led review of all patients every 24 hours, 7 days a week. Whilst it is encouraging that both trusts are compliant in the majority of areas, and perform well relative to their peers, the monitoring of progress will be a focus of commissioners throughout 2016/17 Other Standards Whilst the standards above are the national focus for 16/17, work is on-going to deliver compliance with all 10 standards. As an example, in relation to Standard 9 Transfer to community, primary and social care, we have invested significantly in the provision of 7 day services for primary, community and mental health services and social care services to ensure that 7 day care and support is available, and that all parts of the system are able to accept referrals and manage discharge from hospitals at weekends. Further actions planned in 2016/17 Lead Date The requirement for both trusts to make progress towards compliance against the clinical standards has been included as part of Service Development and Improvement Plans for 16/17. This will include both Trusts completing a stock take assessment of compliance against standards to inform a prioritisations process and related action plan for the CQRGs Rob McCarthy Q In additional to the national clinical standards, both trusts are working towards delivery of the London Quality Standards on 7 day working. Both trusts, working via the Urgent and Emergency Care Network, will agree the timeframes for designation of urgent and emergency care facilities in line with LQS standards Rachael Crampton Dec of 269

122 64 Better Care: NHS Continuing Healthcare 131a. People eligible for NHS Continuing Healthcare (per 50,000 population weighted) 23.2 Summary of current position Measure is bottom quartile but the CCG would challenge a negative rating Number of people eligible for NHS Continuing Healthcare in Southwark are low due to demographic and service factors NHS Continuing Healthcare decision-making in Southwark is based on best practice including Local Authority involvement in all decisions Recent NHSE deep dive suggested high levels of assurance for NHS Continuing Healthcare in Southwark Actions taken to date NHS Southwark CCG was rated green on all key lines enquiry on the recent CHC assurance deep dive. The CCG has worked in partnership with the LA to develop a joint protocol for the implementing CHC. The CCG has provided training on NHS Continuing healthcare for district nursing and social workers. The CCG is working proactively with district nursing to support the identification of clients on DN caseloads that should have an NHS CHC checklist completed. The CHC clinical commissioners are attending the weekly discharge meetings at Kings to identify clients who should have a continuing healthcare assessment. The CCG CHC team have provided a flow chart outlining the CHC assessment process and documentation needed to the wards at KCH to support staff to identify patients that should have a CHC assessment completed. The CCG CHC team actively encourage relevant acute and community staff to observe the CHC Panel to better understand the CHC process and to support quality assessments. The CCG CHC clinical commissioner or CHC Manager attends the LA Funding Panel every week and through this identifies clients that should be assessed for CHC eligibility. All CHC assessment where the recommendation is not for CHC eligibility are reviewed at the CCG CHC Panel to ensure that the recommendation supports the evidence. The CCG continuing healthcare panel sees all assessments and reviews completed and will commonly overturn an MDT recommendation of ineligibility where the panel feels that the individual has a primary health need. Assurance on previously unassessed period of care The CCG taken steps to ensure that numbers of previously unassessed periods of care are reported accurately to NHSE and reflect current position In common with all CCGs there is a risk of a late transfer of a case from another area, however the CCG is confident that the cases it currently has do belong to Southwark Southwark has two cases remaining, the assessment are complete and we are making arrangements with families for local resolution, these will take place before the September deadline Further actions planned in 2016/17 Lead Date Developing an discharge to assess model for CHC assessment this will include intermediate care scoping and will be work done jointly with Integrated Commissioning To work proactively with the hospital discharge teams to support appropriate discharge planning including providing resources and information to support quality discharges. KMB/CG KMB 122 On-going of 269

123 65 Sustainability Indicator name Value / RAG 141a. Financial sustainability 141b. In-year financial performance 142a. Allocative efficiency: outcomes in areas with identified scope for improvement TBC 142b. Allocative efficiency: Expenditure in areas with identified scope for improvement TBC 143a. New models of care: adoption 144a. Paper free at point of care: local digital roadmap in place TBC 144b. Digital interactions between primary and secondary care 61.2% 145a. Estates Strategy: Local Strategic Estates Plan (SEP) in place 123 of 269

124 66 Sustainability: Financial sustainability 141a. Financial Sustainability Summary of current position The CCG has developed a robust 5 year plan, maintaining a surplus throughout the 5 year period of over 1% (1.30% at its lowest in 2020/21). The CCG has held 3,937k 1% non-recurrent spend budget uncommitted, and also has a 2,150k 0.5% contingency budget held in reserves. The CCG is not relying on the use of drawdown of prior year surpluses in order to achieve its plan in 2016/17. The plan meets the business rules in that management costs do not exceed the CCG admin allocation, Mental Health Minimum Investments and Better Care Fund contributions are met etc. The plan is credible in terms of achievement, but is stretching when taken in the context of the local health economy with Kings recovery plan, the support and investment we are making with local trusts in service redesign, and transformation including GP federations. The CCG has invested significantly to ensure that it has purchased activity at a realistic level for 2016/17. In doing so, the contracts with King s and Guy s trusts, have been agreed as a semi block arrangement with agreed 2.5% tolerance for reopeners. This reduces the CCG s in year risk by c. 4-5M. Actions taken to date The CCG has been, and continues to be, an active partner in OHSEL, which as a partnership, is developing the Sustainability and Transformation Plan (STP) for local services through work jointly carried out by south east London clinical commissioning groups (CCGs), hospitals, community health services and mental health trusts, with the support of local councils and members of the public The CCG has a comprehensive finance reporting structure as part of its governance process, with a monthly report being produced to go to the Integrated Governance & Performance Committee, which details year to date and forecast performance against statutory financial duties, all areas of expenditure (including the CCG admin allocation and Better Care Fund) and QIPP as well as highlighting potential risks and mitigations, cash position and aged debt, all helping to increase the visibility and monitoring of the CCG s current and forecast financial position. Most of the CCG s QIPP programme is guaranteed and embedded in contract agreements with King s and Guy s, means the CCG is then low risk in year, and can guarantee delivery to this level. The CCG s other QIPPs are in place to deliver as well, e.g.. Prescribing. The CCG is forecasting 100% QIPP achievement in line with previous year s successful delivery of the QIPP programmes. The balance of the programme is also embedded in agreed budgets and work programmes, e.g.. For prescribing and mental health schemes. Further actions planned in 2016/17 Lead Date The CCG will be starting the annual planning process earlier in 2016/17 for the 2017/18 financial year. Work has already begun on updating the 5 year financial plan, taking into account Southwark s Five Year Forward View of Health and Social Care 2016/17 to 2020/21 and detailed work and preparation for the 2017/18 QIPP programme has begun. Further work across SEL on the five year strategic financial plan, with all providers involved to achieve financial sustainability by Continued work both within the CCG, and with partners and providers such as Southwark Council and King s College Hospital and Guy s & St Thomas as well as SLaM and other local providers including GP Federations to plan and to transform the way health is delivered to ensure sustainable services for Southwark people. This will inform the 5 year financial plan to ensure robust and achievable plans continue to be delivered and achieved by the CCG. Malcolm Hines Malcolm Hines July/ August On-going On-going 124 of 269

125 67 Sustainability: Financial performance 141b. In-year financial performance Summary of current position The CCG is currently meeting and forecasting to achieve all of its statutory financial duties under the NHS Act 2006 (as amended). This includes expenditure not to exceed income, revenue resource does not exceed amount specified, and Revenue administration resource use does not exceed the amount specified. The ytd position is currently slightly ahead of plan 37k due to an underspend on Running Costs. QIPP monitoring shows the programme being achieved, with the majority of the plan is guaranteed and embedded in contract agreements with KCH and GSTT. The CCG is holding 3,937k which is the 1% non-recurrent spend required to be uncommitted. The CCG has assessed the risks over and above the current forecast likely position and has identified mitigations that would enable the CCG to continue to achieve delivery in line with plan in even the worst case scenario Actions taken to date The contracts with King s College Hospital and Guy s & St Thomas s trusts have been agreed as a semi block arrangement with agreed 2.5% tolerance for reopeners. This reduces the CCG s in year risk by c. 4-5M, and helps to give the CCG confidence that the plan will be delivered. We have bought 4-7% additional acute activity for estimated in year growth this year. SLAM mental health contract includes agreed risk shares on all significant activity areas. We expect our maximum exposure across all these contracts to be below 3m this year. The CCG has a comprehensive finance reporting structure as part of its governance process, with a monthly report being produced to go to the Integrated Governance & Performance Committee, which details year to date and forecast performance against statutory financial duties, all areas of expenditure (including the CCG admin allocation and Better Care Fund) and QIPP as well as highlighting potential risks and mitigations, cash position and aged debt, all helping to increase the visibility and monitoring of the CCG s current and forecast financial position. The CCG has maintained both the 1% uncommitted non-recurrent spend budget and a 0.5% contingency reserve and has also held back investments to create a deferred investment reserve to ensure that there are enough potential mitigations available to cover any issues arising in year. The majority of 2016/17 QIPP programme is guaranteed and embedded in contract agreements, which means the CCG are then low risk in year, and can guarantee delivery to this level. Our programme at c 1.6% represents a level of QIPP that we feel can be guaranteed as above, and it should be noted the level of reinvestment we have been able to make in services this year at c. 10m, including supporting recovery of local Trust positions. The CCG has completed a consultation on the organisation s structure to ensure that the structure is fit for purpose, delivers against the CCG s priority areas and remains within the financial affordability envelope. Following this, the CCG has reviewed all posts currently filled by interim staff and has progressed a recruitment programme to ensure these posts are filled with substantive staff to further reduce the costs to the CCG and to ensure that these costs remain under control Further actions planned in 2016/17 Lead Date The CCG continues to monitor both its financial position (through the reporting structure) and will only release the deferred investment reserve when it is in a position to ensure affordability The CCG will only release the 1% non-recurrent spend budget as and when advised by NHSE. Continued QIPP and provider monitoring to ensure savings are being delivered in line with plan and that any financial pressures are identified and addressed at an early stage. Malcolm Hines Malcolm Hines Malcolm Hines On-going Unknown On-going 125 of 269

126 68 Sustainability: Allocative efficiency 142a&b. Outcomes & Expenditure in areas with identified scope for improvement TBC Summary of current position Southwark CCG is committed to the primary objective for the NHS Right Care programme to maximise value. This includes the value which individual patients derives from their care and treatment as well as the value which the whole population derives from the investment in their healthcare. Head of Primary and Community Care, Head of Planning and CCG Assurance, and Service Redesign Manager have attended Regional Right Care Events. We are in Wave 2 for RightCare national roll out. The where to look packs and focus packs have been reviewed in detail by clinical and officer leads. These packs and the wider approach to systematically identifying priorities are being embedded within the CCG s strategic planning and commissioning cycle as part of a wider Programme Budget Marginal Analysis approach. Actions taken to date Review of indicative data highlights value opportunities across the following programmes: Gastro-intestinal, Neurological, Cancer, Genito Urinary, Mental Health, Musculoskeletal, Respiratory, Circulation, Endocrine, nutritional & metabolic, Trauma and injuries Commissioning for Value where to look pack reviewed to identify key opportunities for improvement, and mapped against current reform activity and improvement plans. Complex patient analysis from the Integrated Care pack has informed the selection of the patient cohort as part of a local care coordination shared incentive across providers Local measures for Quality Premium have been identified from the opportunities for improvement in the Commissioning for Value Packs. These were reviewed and selected by Commissioning Strategy Committee in April Local contractual levers and mitigating actions have been identified for improvement in year. The following metrics were agreed: Percentage of people on the diabetes register for whom their last blood pressure reading is <140/80 mm/hg (patients under 80) and <150/90 (patients 80 and over) IAPT referrals with a wait <28 days Proportion of COPD patients with an FEV1/FVC ratio recorded and consistent with COPD; and a record of diagnostic spirometry that shows the test was of adequate quality. Right care principles and commissioning for value approach integrated into Southwark s Adults Commissioning Development Group business process and are central to the development of the CCGs commissioning intentions and QIPP planning for 2017/18. This will also steer longer term planning in line with the local STP and five year forward view. Further actions planned in 2016/17 Lead Date Monthly Adults Commissioning Development Group, chaired by the Director of Integrated Commissioning, to lead the process through 2016/17. CG On-going Mapping of high value opportunities against populations, as defined in South East London STP, and local needs assessments CG Aug 2016 Utilise commissioning for value focus packs, in depth SPOT analysis and other local and national data sources to identify quality improvement opportunities for programmes Develop business cases for 2017/18 which shift spend to higher value early action interventions, and away from low/zero value interventions. To include reform approaches, such as contractual levers, shared incentives, contract management and policy development CG Sep of 269 CG Dec 2016

127 69 Sustainability: New models of care 143a. New models of care adoption Summary of current position Indicator: At what stage are you in implementing and contracting with a new model of out of hospital care which has all of the core components of an MCP or a PACS, as set out in the relevant frameworks for these models? 1. Minimal thinking; 2. There is a strategic intent to implement a new model of care; 3. CCG has had initial discussions with potential partners; 4. Concrete plans exist to implement a new model of care, but implementation has not yet started; 5. Implementation is underway. Our work is well progressed in this area with a clear strategy, partnership engagement, and the beginnings of contractual alignment to implement integrated care. Actions taken to date We have set out our strategic intent to move towards an MCP model in both a local Southwark Five Year Forward View publication, and in our STP. Our MCP model (referred to locally as a Local Care Network) is based on formal federations of GPs working at scale, and entering into commercial / contractual relationships with local foundation trusts. We have formally established two GP federations in the borough, both of which are legally incorporated (one as a CIC the other Ltd), and both of which hold significant contracts for service delivery. All 44 of our local practices are members of a federation. In addition we have established a formal programme of LCN development which is underpinned by LCN Programme Boards in the north and the south of the borough. These boards have senior representatives from each FT, the GP federations, alongside the local authority and the VCS. These boards have been meeting on a monthly basis with consistent nominated attendees and have begun to discuss governance models and practical issues in relation to co-located working. Oversight of the development of the five LCNs across Southwark and Lambeth is provided by a Partnership Board comprising the local chief officers and chairs of the CCGs, councils, federations and FTs. To give focus, and a contractual underpinning, to the LCN development programme we have established a common CQUIN-PMS incentive based on co-designing and implementing the coordinated care specification set out in the London Primary Care Strategic Commissioning Framework. All FTs have agreed the CQUIN as part of 16/17 contracts; the PMS KPIs are formally agreed as commissioning intentions but are still subject to consultation with the LMC as part of the on-going PMS Review. Further actions planned in 2016/17 Lead Date We are exploring options for further partnership arrangements, for example sharing back-office functions, and supporting training and development (using the CEPN to encourage joined up approaches). MK / KMB We have embarked upon a whole systems project to implement care coordination for people with multi-morbidity (3+ LTCs). The project has a focus on establishing systematic approaches to case finding and holistic needs assessment, named responsible professional, joint care planning, multi-disciplinary working and self-management support. MK / DD Apr-Mar We have identified > 1m for investment in 2016/17 so that federations can be supported to develop as organisations that support at scale working in general practice. Allocation of the funding is based on the federations respective outline business plans, with project-by-project draw-down based on specific agreed plans / SLAs. MK / HS Apr-Mar 127 of 269

128 70 Sustainability: Paper-free and digital 144a. Paper free at point of care: local digital roadmap in place TBC Summary of current position Under the auspices of the OHSEL programme, there has been an established group working across SEL, including all organisations, health and social care, working to develop a joint digital roadmap. The original footprint for this work was separate boroughs, but this was joined together from February A series of workshops wit circa 30 representatives and clinicians, have been held including London and national programme leads. The work stream is led by the Southwark CFO as SRO. A joint LDR has been submitted on 30 June, and bids made at borough and SEL level for ETTF funding. Actions taken to date Project management in place, and workshops held to advance common thinking on solutions for SEL. Production of Digital maturity assessments, and sharing of these to facilitate solutions. Hands on working with Trust and Council IT directors. Workshops to explore the state of systems in SEL, and those needed to support new models of commissioning services. Getting agreement to work as one roadmap across SEL, and greater engagement with HLP digital programme. Productivity work with PWC support to look at the opportunities that exist for rationalisation, and improved patient care through new and linked systems Further actions planned in 2016/17 Lead Date Moving into implementation of some of the initiatives that have been identified to rationalise systems across SEL. MH / OHSEL On-going Taking forward the preparatory work from existing local solutions, to move into readiness for the London and national solutions that should be ready within months to link across all care settings, and create a Customer based access to all records held on an individual. MH/ OHSEL Summer 2017 Further links to other OHSEL initiatives, in order to maximise the benefit from transformation of care pathways. OHSEL On-going Implement the schemes across SEL that are currently bids against ETTF for the next three years. MH /OHSEL On-going 128 of 269

129 71 Sustainability: Paper-free and digital 144b. Digital interactions between primary and secondary care 61.2% Summary of current position Indicator: a composite of four underlying metrics, including - Use of EPS2 (Electronic Prescription Service release 2) (% use of EPS2 by GP practices in a CCG, HSCIC report) Use of NHS e-referral system (ers) (% of elective referrals made electronically through the ers by GP practices, HSCIC report) Accessing GP summary information across Ambulance, 111 and A&E (proportion of ambulance, 111 and A&E setting accessing Summary Care Records (SCRs) or local systems to access GP summary information across each CCG) (HSCIC report) At discharge, % of care summaries shared electronically with GPs (captured through Digital Maturity assessments at provider level) Actions taken to date We have a well established system of support to help local practices to procure and use ICT products and services. For example, all local services use EMIS Web as their primary care system of choice. The Patient Demographic Service (PDS) is well used across the borough which means that information in the summary care record is up to date. We have also implemented a decision support tool (DXS) that works alongside the main clinical system to provide information on local care pathways. It has the ability to automatically populate referral forms and it contains a full directory of services in addition to e-referrals. We began rolling out e-referrals in Southwark in April 2015, and the e-prescribing service is also available across the borough. In addition we have worked closely with Lambeth CCG, KCH, GSTT and SLaM to develop and implement the Local Care Record which provides point of care access to up to date information across care settings i.e. a clinician in the ED can see up to date primary care data and vice versa (including hospital test results). Currently this system allows a view only of the data and it is restricted to primary and acute data. We have rolled this system out across 91 practices in Southwark and Lambeth. The development of this system represented > 1m investment with recurrent costs of circa 100k per borough. Further actions planned in 2016/17 Lead Date In partnership with Lambeth CCG we have developed a scheme for the development of training resources and delivery of training to the 91 General Practices in the two boroughs. The funding for this initiative is predicated on a successful bid to the ETTF scheme. Although e-referrals is in use in CCG member practices, we want them to seize the opportunity offered by the Local Digital Roadmap to optimize use of e- Referral and transform access to secondary care. Our secondary care stakeholders, Guy s and St. Thomas s NHS Foundation Trust and Kings College Hospital NHS Foundation Trust have identified a wide range of training issues with local GPs when using e-referral. They are very supportive of this scheme as a way to improve referral management and so make referral management in secondary care more effective and efficient. MH TBC We are scoping the expansion of the Local Care Record. This is to allow the transfer of structured data between primary and secondary care (rather than view only), and to incorporate community care and social care in the system. This is the subject of an ETTF bid. As part of the Healthy London Partnership we are developing a framework of standards and requirements for interoperability. This includes the development of a data controller service, an online account service, and a record locator service. MH TBC 129 of 269

130 72 Sustainability: Estates 145a. Local Strategic Estates Plan (SEP) in place Summary of current position The CCG has a draft Local Strategic Estates Plan (SEP) in place, and is a partner in the production of the OHSEL wide estates strategy as well. Southwark has an excellent track record of working with the council on regeneration schemes, and the new Dulwich health centre scheme, which is currently at the planning committee stage. New developments are planned at key sites, as hubs, to assist the delivery of our local care networks model. Actions taken to date The CCG has developed a Local Strategic Estates Plan (SEP) in draft, which will have been through full governance in Summer The CCG has also been very active in the OHSEL estates strategy group, where all organisations are represented, and that group has also produced a broader SEL draft strategy, which has been submitted as part of the STP. In Southwark this has been developed through a series of workshops involving commissioners, local acute, community and mental health providers, Southwark Council, the GP Federations and LMC representation. This group has proposed a set of criteria which would underpin the prioritisation of potential projects which recognises not only the transformation challenges set out in the Five Year Forward View, but also the population increases resulting from extensive regeneration in the north of the borough. The proposed criteria for prioritising ETTF or estates related bids are, in summary: Support the development of services provided by Local Care Networks, Need to support the delivery of services operating at scale, Be able to manage some areas of significant population increase within regeneration areas, Be accessible well spread out and have good transport access; Be as efficient as possible ; Be fit for purpose- statutorily compliant, flexible for the future and meet the needs of a redesigned workforce The workshops also looked in detail at each locality, considering the future service needs, and pooling information about service and estates changes. This will result in a plan which can identify the parts of the borough where there are most likely to be gaps in suitable estate for the provision of services in the future Further actions planned in 2016/17 Lead Date Implement all schemes currently underway, and that are successful in bids submitted for ETTF funding. MH / RS On going CCG s board to approve the SEP and confirm its alignment with the CCG s current commissioning plans MH/RS August 2016 The SEP is informed by a CCG-led Local Estates Forum (LEF) under the local leadership of one or more CCGs MH/RS On going The SEP reflects CCG engagement with each of the providers it commissions services from in respect of their own estate strategies MH/RS On going 130 of 269

131 73 Leadership Indicator name Value / RAG 161a. Sustainability and Transformation Plan 162a. Probity and corporate governance 163a. Workforce engagement - Staff engagement index b. Workforce engagement - Progress against workforce race equality standard a. Effectiveness of working relationships in the local system a. Quality of CCG leadership 131 of 269

132 74 Leadership: STP 161a. Sustainability and Transformation Plan Summary of current position Final STP submitted to NHSE on 30 June Awaiting the evaluation and feedback from NHSE, but confident that plan is relatively advanced and well developed. We forecast a green rating ( the STP that the CCG is part of is meeting all the requirements of the KLOEs and demonstrating progress in designing and implementing their STP ).The STP will be further refined based on feedback and formal implementation will commence in October. Actions taken to date STP developed building on previous work programme of OHSEL programme in line with STP guidance issued in December STP submitted to NHSE 30 June Further actions planned in 2016/17 Lead Date Further refinement of STP based on NHSE assessment and other feedback. ME July+ Implementation phase of STP plan. Procurement of support contract for the next phase of implementation work. Current PWC contract end September ME ME October 2016 August of 269

133 75 Leadership: Corporate governance 162a. Probity and corporate governance Summary of current position This indicator assesses CCGs compliance with a number of requirements of the revised statutory guidance on managing conflicts of interest for CCGs, to be based on a self-certification process to be introduced from Sept The CCG self-assessment at this stage is that the CCG will be in a 100% compliant position (green). Actions taken to date The CCG has a clear policy for the management of conflicts of interest (in line with the statutory guidance on managing conflicts of interest for CCGs) and that the policy includes a robust process for the management of breaches. The CCG runs annual mandatory training on conflict of interest for all Governing Body members. The CCG has a long established Conflict of Interest Panel in place and has also undergone significant external scrutiny on conflicts of interest. The CCG has a minimum of three lay members. This includes confirmation of the number of CCG lay members and how many days they are employed per month. The CCG s audit chair has taken on the role of the conflicts of interest guardian, supported by a senior CCG manager(s). The CCG has processes in place to ensure individuals declare any conflict or potential conflict of interest as soon as they become aware of it, and within 28 days, ensuring accurate, up-todate registers are complete for: conflicts of interest; procurement decisions; and gifts and hospitality. Any breaches will be published on the CCG s website, along with a summary of how they have been managed and communicated to NHS England Further actions planned in 2016/17 Lead Date A minimum of 90% of CCG staff have completed the mandatory conflicts of interest online training as of 31 January each year. MH Jan 17 Preparation for Quarterly return from Sept 16 MH Sep 16 Registers to be available on the CCG s website and, upon request, at the CCG s headquarters. 133 of 269

134 76 Leadership: Workforce engagement 163a. Staff engagement index (providers measure from NHS staff survey mapped to CCG) 3.93 Summary of current position The CCG monitors workforce engagement through a number of regular indicators at its monthly CQRGs Actions to address recommendations are reviewed by the CCG Actions taken to date Workforce indicators are reviewed regularly at our provider CQRGs (KCH, SLaM, GSTT and LAS) and workforce is taken as a main agenda item at least once per year. A spec is given covering an entire gambit of strategic indicators including recruitment, retention, absence, staff survey results and resultant action plans and the Workforce Director or senior rep presents. KCH have recently appointed a new Executive Director of Workforce. KCH CQRG in June we discussed the impact of the Trusts on-going management restructure, particularly the impact on staff motivation and therefore impact on quality and productivity. We are aware that this uncertainty, plus a big CIP programme, is challenging staff. We have not yet seen a negative impact on workforce but we continue to monitor this through the CQRG process. CCG is concerned that there is a low number of responders to staff surveys at KCH and are working with the trust to identify ways to increase numbers. GSTT staff survey showed a high level of staff recommending their trust as a place to work or receive treatment. Further actions planned in 2016/17 Lead Date KCH planning to survey their entire workforce this year. KCH are seeking to improve the response rates to survey and will achieve this through the use of 2-way communication and feedback mechanisms to listen and involve staff in the decisions that affect them as part of the strategy and the ODD work. Staff engagement will be key as part of KCH s vision/strategy and organisational design and development (ODD) work. The CCG will monitor the impact of this within the CQRGs JF December of 269

135 77 Leadership: Workforce engagement 163b. Progress against workforce race equality standard composite measure from provider staff survey 0.22 Summary of current position Measure covers questions on harassment, bullying, abuse, equal opportunities for career progression and discrimination. The CCG has taken steps to assure itself that its providers (GSTT, KCH and SLaM) are implementing the workforce race equality standard (WRES) with clear action plans to address any shortcoming in relation to the four indicators in WRES. Discussions, scrutiny and progress reports on how providers are implementing the WRES have taken place at the clinical quality review group (CQRG) meetings. In addition, the CCG has also taken steps to ensure that it is also paying due regard to WRES as required for commissioning organisations. Actions taken to date KCH has published baseline data in relation to its workforce. At the April 2016 CQRG, workforce equality was a main discussion item, and as part of this, KCH presented its annual workforce report. In their published WRES reporting template, they have agreed to continue to monitor and review outcomes of the four WRES indicators, develop and implement action plans to tackle issues where identified. it was agreed at the CQRG that KCH would bring an annual workforce report including progress against the WRES as well as thematic equality issues on a quarterly basis. In July 2016, KCH s Education and Workforce Development Committee (Board sub-committee) has signed off the Trust s equality objectives, which includes implementing the WRES. GSTT is reviewing its equality workstreams, and their draft equality objectives were presented at the June 2016 CQRG, where assurance was given that there is an plan with a number of actions to improve BME staff experience notably reducing the gap between those who report significantly poorer experiences regarding whether they feel they have equal opportunity for career progression, and whether they have been subject to discrimination in past 12 months. GSTT s WRES will also be published in due course after the board review in July. In August 2016, SLaM met with the CCG to share information about how the Trust is implementing the WRES. To this end, the Trust has published its initial WRES baseline data (July 2016), and some actions to address some of the identified gaps The CCG has conducted a comprehensive self-assessment in relation to workforce equality using the equality delivery system (EDS2) goal three is about, a representative and supported workforce. The CCG rated itself as achieving (green) against this goal. In the 2015 NHS staff survey 27% of the respondents reported themselves as coming from a non-white background. 19% of the respondents reported bullying in the survey but had not reported this formally. There was no discrimination reported in the staff survey from any source in relation to any protected groups, including race. Further actions planned in 2016/17 Lead Date SLaM to be requested to present baseline data to the CQRG in relation to its workforce and how WRES is being implemented. HB Q2 Outside of CQRG, the CCG is arranging meetings with GSTT, KCH and SLaM to discuss the findings in the 2015 WRES data analysis report for NHS Trusts, and how these are being taken forward. HB Q3 Annual reports by all providers on progress against WRES to be presented at CQRG. HB Q4 KCH to present thematic equality issues at CQRG periodically. HB Q4 135 of 269 The CCG will be carrying out a staff survey in 2016/17 and the results of this will also inform the baseline of its WRES indicators HB Q4

136 78 Leadership: Local system relationships 164a. Effectiveness of working relationships in the local system 75.1 Summary of current position Indicator: This metric is taken from the annual CCG stakeholder 360 survey and would draw on the responses to 2 questions [stakeholders] are be asked to provide an overall rating of their working relationship with the CCG, and to rate the CCG as an effective local system leader in the categories very effective, fairly effective, neither effective nor ineffective, not very effective, ineffective. Actions taken to date Through focused efforts from the engagement team the CCG has continually achieved an extremely high response rate to the 360 stakeholder survey. Southwark also has the third highest response rate nationally for the second year running the national average is 59% across all stakeholder groups and 56% nationally for member practices. Southwark s member practice response rate has risen from 80% last year to 86% this year. As a system leader we have worked closely across SEL to develop the OHSEL strategy, and latterly to support the refinement of OHSEL governance structures to support a broader STP planning process. We host the OHSEL/STP support team and provide continued leadership to fundamental work strands, including the financial modelling and productivity work, and the Community Based Care (MCP) strands. The CCG is also a founding member of the Southwark and Lambeth Strategic Partnership which brings together CCGs, councils, GP federations and FTs to establish local delivery plans in relation to the Community Based Care strand of the STP (and incorporating parts of the digital roadmap). As coordinating commissioner for KCH we have worked closely with the Trust, associate CCGs, Specialised Commissioning, NHSE, and NHSI to support the development and assurance of the 1 year, 2 year and 5 year Financial Recovery Plans. Further actions planned in 2016/17 Lead Date We are exploring options to strengthen our relationship with Southwark Council through the formation of a Partnership Commissioning Team CG Sept of 269

137 79 Leadership: Leadership quality 165a. Quality of CCG leadership TBC Summary of current position Indicator: Four key lines of enquiry will be assessed to determine how robustly the senior levels of a CCG are performing their leadership role. Indicators focus on a) Robust culture and leadership sustainability; b) quality; c) governance; d) engagement and involvement. The CCG is committed to the continuous development of its leadership team and management staff. A number of evaluative and developmental programmes have been run over the last year with others planned for 2016/17. The CCG has embedded strong processes to support the effective running of the organisation. The leadership The leadership actively promotes and develops strong relationships within its local system. Actions taken to date A series of staff development and education sessions/workshops were run as part of the process of the CCG s development of its Five Year Forward View strategy in 2015/16. Over the last two quarters the CCG has run a bespoke leadership development programme for members of the CCG Governing Body and SMT. The CCG has also allocated resources to fund 360 reviews and coaching for GB members. All CCG staff have been encouraged to apply for funded coaching/mentoring and programmes run by the NHS Leadership Academy, with a number of staff currently also on these developmental programmes. The CCG has clinical and managerial leadership with additional support resource to undertake robust quality assurance of commissioned providers. This includes attendance at all CQRG meetings with providers. Reporting regularly goes through a dedicated Quality & Safety Group, through the Integrated Governance & Performance Committee and to the Governing Body. The CCG s governance structure ensures that responsibilities are clear, regular review is built in, and that quality, performance, and finance risks are understood and managed. CCG fully assured following NHS England deep-dive review of PPI, May Patient representatives and/or Healthwatch Southwark sit on all CCG committees. Engagement Programme Board provides clinically-led operational leadership with the aim of broadening our engagement work, to advise on engagement for the CCG s programmes of transformation, and to take advantage of new techniques and technology to do this. Over the last year we have concluded major pieces of patient and public engagement on obesity; for a number of mental health services and for extended primary care access. In December 2015 our work to involve local people in creating a new healthy weight service was recognised by Guy s and St Thomas NHS Foundation Trust. We won the Involvement to Impact award for the way we worked with people who have been struggling with losing and maintaining a healthy weight, to design a new support service. Further actions planned in 2016/17 Lead Date The CCG will review its current OD plan to ensure that it focuses on talent management and which will develop clinical and nonclinical leaders to meet current and future operating challenges. KS Q3 The CCG will initiate developmental work to look at how we improve engagement with seldom heard group s. We will additionally review the way in which we feedback to patients involved in CCG engagement exercises. RW Q2 137 of 269

138 Appendix 1: Supplementary metrics Page 81: Diagnostics Page 83: Mental Health CPA 7 day follow up on discharge Page 84: Serious Incidents and Never Events Page 85: MRSA and C Difficile Page 86: Family and Friends Test Page 88: Better care Fund Targets Page 90: Quality Premium 2016/17 Page 91: Acute Constitutional actuals against trajectory 138 of 269

139 81 Better Care: Diagnostics Achievement of the national diagnostic standard 5.7% Summary of current position Actions taken to date CCG performance driven by a combination of KCH and GSTT performance. KCH above trajectory for April by 0.2% (performance of 5.8%), below trajectory for May by 4% (performance of 8%), and below trajectory in June by 6.4% (performance of 8.4%). KCH trajectory was informed by a Quarter 4 deterioration in performance and the planned pace of 2016/17 recovery. Performance has however further deteriorated on the Denmark Hill site - consequently the risk associated with delivery of the July trajectory for a return to compliance is now material. GSTT below trajectory for April by 0.2% (performance of 1.5%), above trajectory for May by 0.1% (performance of 1.2%) and below trajectory in June by 0.4% (performance of 1.5%) KCH 2016/17 Recovery Plan in place with diagnostic test specific actions noting this plan was based on the known end March performance position. 2016/17 demand and capacity planning to provide assurance that activity plans reflect assessed demand and capacity requirements. Outsourcing of non obstetric ultrasound has commenced, although pace and scale of impact remains unclear at this point. Phase 1 of the TCST led diagnostic demand and capacity planning exercise completed further work required to validate KCH data and assumptions. GSTT 2016/17 Recovery Plan in place with diagnostic test specific actions. MRI outsourcing contract in place, pending additional internal capacity coming on stream when the Guy s Cancer Centre opens. 2016/17 demand and capacity planning to provide assurance that activity plans reflect assessed demand and capacity requirements. Phase 1 of the TCST led diagnostic demand and capacity planning exercise completed further work required to validate KCH data and assumptions. Further actions planned in 2016/17 Lead Date KCH Trust have confirmed that the current trajectory can still be delivered and to provide further assurance in relation to additional recovery actions, risk and mitigations. This will subject to ongoing review, noting that significant performance improvements needed to resume trajectory TSCT phase 2 diagnostic demand and capacity work with a need to link this to a review and assessment of sustainability requirements post recovery. Outsourcing further testing of the scope to outsource key diagnostic tests, through the SEL outsourcing initiative, to provide additional risk mitigation and contingency against further staffing or equipment failure risks. Wider performance improvement work diagnostics within the cancer timed pathways and elective demand management work will provide a focus on diagnostics as part of overall care pathway planning and delivery. Andrew Bland On going. GSTT Additional MRI capacity is coming on stream in 2016/17 when the Guy s Cancer Centre opens. Process related service improvement work to reduce monthly breaches and timely treatment alongside specific work in urology and cystoscopy. TSCT phase 2 diagnostic demand and capacity work with a need to link this to a review and assessment of sustainability requirements post recovery. Outsourcing further testing of the scope to outsource key diagnostic tests, through the SEL outsourcing initiative, to provide further risk mitigation. However for some tests where demand is increasing there is limited alternative provision e.g. GA paediatric MRI and paediatric sleep studies. Wider performance improvement work diagnostics within the cancer timed pathways and elective demand management work will provide a focus on diagnostics as part of overall care pathway planning and delivery. Andrew Eyres On going. 139 of 269

140 Diagnostic Waits Diagnostic waits exceeding 6 weeks (target <1%) - The % of patients waiting 6 weeks or more for a diagnostic test % Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Southwark CCG KCH GSTT KCH - represents the biggest proportion of the underperformance, Trust wide performance was at 9.4% in June a deterioration from May; Denmark Hill 10.5 %, PRUH 7.9% The two biggest issues are with Ultrasound and Neuro MRI. Ultrasound has had staffing and capacity issues. The Trust has increased agency staffing levels on sonographers and has agreed to increase capacity to reduce the backlog this will include both external outsourcing and additional staffing using the KCH facilities. Neuro MRI was driven by staff vacancies reducing capacity; Inhealth has also been unable to provide additional days on site. KCH has a recovery trajectory to be at 1% in from August 2016, despite the deteriorating performance the Trust have restated this commitment. GSTT performance Trust wide is at 1.45%, the Trust s trajectory was delivering the target by July, they are now forecasting that performance will be static at the current level until October. 140 of

141 Mental health: Patients on CPA followed up within 7 days of discharge from psychiatric inpatient care 2015/16 target 95% Number of patients on CPA who were followed up within 7 days after discharge from psychiatric inpatient care Total number of patients on CPA discharged from psychiatric inpatient care Proportion of patients on CPA who were followed up within 7 days after discharge from psychiatric inpatient care (Southwark) London benchmark 15/16 Q % 96.9% 15/16 Q % 97.4% 15/16 Q % 97.8% 15/16 Q % 97.1% 16/17 Q % 97.0% This is an operating plan standard which is now being reported on as compliance has recently declined. Performance is monitored through the monthly contract monitoring mechanism. 141 of

142 Serious Incidents & Never Events requiring investigation Provider SIs KCH All SIs at Denmark Hill Serious Incidents (notified) 2016/17 (Southwark patients in brackets) 2015/16 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 65 (21) 4 (1) 8 (2) 8(3) 6(5) KCH All SIs at PRUH 100 (1) 8 (0) 6 (0) 9(0) 3(0) GSTT Acute & Community All Sis 85 (18) 9 (0) 14 (2) 7(0) 11(2) SLaM All SIs 89 (14) 7 (2) 11 (3) 5 (0) 10(3) LAS All SIs 61 (4) 6 (0) 4(0) 6(0) TBC Other - Southwark patients only London Ambulance Service (LAS) monthly SI figures will be provided during 2016/17. Due to reporting timeframes, these sometimes may be provided in arrears of 2 months The data represents when serious incidents (SIs) were reported to commissioners, not when they actually occurred. KCH reported 6 SIs at Denmark Hill in July SIs were notified at the PRUH. SIs logged at the PRUH are reviewed and assured by NHS Bromley CCG. The Southwark CCG Quality Team actively manage the assurance process to ensure robustness of investigations, action plans and implementation of lessons learnt. GSTT reported 11 SIs in June 2 of these involved Southwark residents. Southwark CCG support the lead commissioner, Lambeth CCG, in management of SIs at GSTT. SLaM reported a total of 5 SIs in July and 3 of these affected Southwark residents. All incidents are assessed case by case on level of significant harm outcome & significance for learning 1 SI was notified by Southwark CCG in July, this involved a Southwark resident in a funded placement within a Croydon care home. 142 of 269

143 Healthcare Acquired Infections MRSA / c.difficile MRSA MRSA Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar April May Jun SCCG MRSA target is zero for year. Case in May assigned to KCH. Case in June assigned to CCG C Difficile C Diff Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar April May Jun SCCG C Diff target is 45 for 16/17. The CCG is slightly over the expected C Difficile level ytd, 8 of the 12 cases were assigned to a nonacute setting. 143 of

144 Friends & Family Test Response Rates and recommending care A&E patient response rate Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Den. Hill 20% 20% 16% 19% 16% 17% 17% 15% 14% 12% 8% 3% 9% GSTT 13% 16% 13% 18% 15% 13% 14% 15% 17% 13% 12% 14% 18% Inpatients - patient response rate Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Den. Hill 14% 15% 16% 13% 11% 15% 15% 12% 13% 13% 13% 14% 15% GSTT 33% 31% 30% 30% 31% 29% 28% 30% 29% 29% 26% 26% 26% A&E - % recommending care Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Den. Hill 80% 79% 82% 82% 81% 80% 81% 83% 77% 74% 79% 75% 69% GSTT 86% 85% 86% 84% 85% 83% 87% 86% 84% 82% 83% 85% 86% Inpatients - % recommending care (no target) Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Den. Hill 95% 96% 95% 95% 94% 94% 95% 95% 91% 96% 96% 93% 95% GSTT 95% 95% 96% 95% 96% 96% 96% 95% 95% 97% 96% 97% 97% In June the London average A&E recommendation was 86% (on an average response rate of 16%) hence Denmark Hill is below average with 69% recommending (on a 9% response). The London average inpatient recommendation was 95% (on an average response rate of 27%, hence both Denmark Hill and GSTT are on par, or above average. 144 of

145 2015/ /16 Friends & Family Test Staff The Work question asks how likely staff would be to recommend the NHS service they work in to friends and family as a place to work. The Care question asks how likely staff are to recommend the NHS services they work in to friends and family who need similar treatment or care. Q4 2014/15 KCH 54% 66% 64% Recommended to work at Q1 2015/16 Q2 2015/16 Q3 2015/16 Q4 2015/16 Staff FFT not conducted in Q3 because the NHS Staff Survey takes place GSTT 71% 77% 76% 79% SLaM 62% 65% 65% 63% London 62% 65% 61% 62% 48% Recommended to get care at Q4 2014/15 Q1 2015/16 Q2 2015/16 Q3 2015/16 Q4 2015/16 KCH 73% 85% 86% Staff FFT not conducted in Q3 because the NHS Staff Survey takes place GSTT 91% 91% 92% 79% SLaM 71% 71% 71% 71% London 76% 77% 76% 76% 78% Note: Response rate staff Q4: Kings 8.6% (increase from 1.9% in Q2). GST 9.5%, SLaM: 27%, London average 11%. 145 of

146 Better Care Fund Indicators Non-elective admissions 3.5% reduction in emergency admissions in 2015 (calendar year) data refreshed May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Target 2,538 2,656 2,385 2,560 2,635 2,684 2,961 2,538 2, tbc tbc tbc Admissions 2,782 3,000 2,592 2,602 2,748 2,596 2,634 2,591 2, tbc tbc tbc Delayed transfers of care Delayed transfers of care from hospital (delayed bed days) Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar April May Jun Target Delayed transfers Care home admissions Permanent admissions of older people (aged 65 and over) to residential and nursing care homes (number) (refreshed February) Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar April May Jun Target Admissions of

147 Better Care Fund Indicators performance position Non elective admissions No longer a formal target for the BCF, but we will continue to monitor. Work is underway to refresh data collection and reporting process, to ensure that appropriate inclusions and exclusions are made, and will be reported in future months. Delayed Transfers of Care Southwark had the 16 th lowest rate nationally of patients delayed per 100,000 population in 2015/16 (Adult Social Care Outcome Framework measure) and the 5 th in London. Performance continues at this level but is slightly below the challenging target. In June 247 of the 306 delayed days were in non-acute settings. Care Home Admissions The 2015/16 target for reducing new permanent care home admissions for older people has been hit, with 128 admissions compared to the target of 155. Performance continues to be strong in 16/17, with the target met in every month of Q1. GP Survey data people feeling supported to manage long term conditions Last published data (July 16) shows an improvement to 59.7% (from the January figure of 57.2%) and is above the London average of 57.9%. However this remains below the stretch target of 62% Local measure on patient experience of integrated care (new) Local areas were required under the BCF to develop a local measure on service user experience of integrated care. In Southwark it was agreed to add a local question to the annual adult social care user survey targeted at people receiving health and social care services. Do all the people treating and caring for you work well together to give you the best possible care and support?. Two years data are now available on this. In the 2016 survey 81% said yes (419 responses, excluding don t knows). In 2015 the figure was 78%, hence a measurable improvement has been achieved. Re-ablement 91.1% of the cohort discharged in Q1into reablement/rehab were still at home after 91 days without having re-attended hospital, against the BCF target of 90.4%. 147 of

148 Quality Premium Targets 2016/17 Quality Premium target Target Max Value Baseline 2016/17 Note Cancers diagnosed at early stage 2015 plus 4% 290, % (2014) n/a 2015 data not released Increase in the proportion of GP referrals made by e- referrals Overall experience of making a GP appointment (GP survey) Antimicrobial resistance (AMR) Improving antibiotic prescribing in primary care Local target 1: Diabetes controlled blood pressure140/80 mmhg or less for patients <80 yrs or 150/90mmHg for patients > 80 yrs March 2016 performance plus 20% points = 46.1% July % = 70.2% a) Primary care: <0.904 b) Broad spectrum: < 10.2% 290, % (March 16) 27.8% (April 2016) 290,000 July 67.2% n/a January publication 145,000 a) 0.81 b) 11.8% (Apr-Dec 15) a) b) 10.5% April % 145,000 March 16: 72.0% 1 July: 67% Downward trend Local target 2: IAPT referrals with a wait of less than <28days. 75% 145,000 March 16: 69% n/a April data published 26 July Local target 3: COPD management: FEV1/FVC and a record of diagnostic spirometry 50.1% 145,000 April 16: 47.6% 1 July: 47.5% Total* 1,450,000 Constitutional target penalty forecast (RTT, Cancer, A&E, LAS for Qtr 4) 725,000 Forecast 50% based on OP trajectories Quality Premium payment 725, of

149 91 Acute constitution standards latest position vs plan KCH Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 A & E RTT Cancer 62 days Diagnostics Actual 83.5% 84.7% 83.8% Nat target - 95% Plan 81.4% 83.8% 87.0% 88.1% 87.4% 91.4% 91.0% 89.8% 90.3% 91.4% 91.4% 91.4% Diff 2.1% 0.9% -3.2% Actual 80.7% 80.9% 81.3% Nat target - 92% Plan 80.5% 80.6% 81.3% 82.0% 82.7% 83.3% 84.2% 85.0% 85.8% 86.5% 87.3% 88.1% Diff 0.2% 0.3% 0.0% Actual 87.3% 80.8% 89.8% Nat target - 85% Plan 85.3% 85.3% 85.3% 85.1% 85.1% 85.3% 85.4% 85.2% 85.5% 85.3% 85.0% 85.6% Diff 2.0% -4.5% 4.5% Actual 5.8% 8.0% 8.4% Nat target - 1% Plan 6.0% 4.0% 2.0% 1.7% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% Diff 0.2% -4.0% -6.4% Note latest month may not be based on published data. GSTT Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Actual 91.9% 89.1% 89.7% A & E Plan 94.4% 95.3% 95.4% 95.3% 95.1% 94.7% 93.3% 93.3% 92.8% 92.8% 93.3% 94.7% Diff -2.5% -6.2% -5.7% Actual 92.1% 92.6% 92.1% RTT Plan 91.3% 91.8% 92.1% 92.1% 92.1% 92.1% 92.1% 92.1% 92.1% 92.1% 92.1% 92.1% Diff 0.8% 0.8% 0.0% Actual 70.9% 70.7% 63.4% Cancer 62 days Plan 67.7% 69.7% 71.6% 75.6% 78.6% 80.6% 81.6% 81.1% 82.1% 81.6% 82.1% 81.1% Diff 3.2% 1.0% -8.2% Actual 1.5% 1.1% 1.5% Diagnostics Plan 1.3% 1.2% 1.1% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% Diff -0.2% 0.1% -0.4% Note latest month may not be based on published data. 149 of 269

150 92 Southwark constitution standards latest position vs plan Southwark CCG Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Actual 84.7% 84.7% 85.1% Nat target - RTT Plan 85.0% 85.5% 86.0% 86.4% 86.8% 87.2% 87.6% 88.1% 88.5% 88.9% 89.4% 89.8% 92% Diff -0.3% -0.8% -0.9% Diagnostics Nat target - 1% Actual 2.9% 5.7% 5.7% Plan 3.3% 2.4% 1.5% 1.3% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% Diff 0.4% -3.3% -4.2% Cancer Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Actual 93.4% 90.1% 91.6% Nat target - 2ww Plan 93.1% 93.1% 93.0% 93.1% 93.0% 93.1% 93.1% 93.1% 93.1% 93.1% 93.1% 93.0% 93% Diff 0.3% -3.0% -2.4% 2 ww breast symptomic 31 day 1st def treatment (diagnosis to treatment) 31 day subs surgery 31 day subs drugs 31 day subs radiotherapy 62 day 1st def treatment (from GP urgent referral) 62 day 1st def treatment (from screening) 62 day 1st def treatment (from cons upgrade) Nat target - 93% Nat target - 96% Nat target - 94% Nat target - 98% Nat target - 94% Nat target - 85% Nat target - 90% No national target Actual 82.1% 90.0% 96.3% Plan 93.1% 93.1% 93.0% 93.1% 93.0% 93.1% 93.1% 93.1% 93.1% 93.1% 93.1% 93.0% Diff -11.0% -3.1% 3.3% Actual 97.1% 100.0% 97.6% Plan 97.1% 97.1% 97.2% 96.9% 96.0% 97.1% 96.9% 96.9% 97.1% 96.9% 96.7% 96.0% Diff 0.0% 2.9% 0.4% Actual 81.8% 80.0% 100.0% Plan 94.4% 94.4% 94.7% 94.1% 95.0% 94.4% 94.1% 94.1% 94.4% 94.1% 94.1% 95.0% Diff -12.6% -14.4% 5.3% Actual 97.6% 100.0% 95.7% Plan 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Diff -2.4% 0.0% -4.3% Actual 100.0% 100.0% 95.8% Plan 96.3% 96.3% 96.4% 96.0% 96.6% 96.3% 96.0% 96.0% 96.3% 96.0% 95.8% 96.6% Diff 3.7% -3.7% -0.6% Actual 85.7% 83.3% 82.1% Plan 85.3% 85.3% 85.7% 87.5% 86.5% 85.3% 87.5% 87.5% 85.3% 87.5% 87.1% 86.5% Diff 0.4% -2.0% -3.6% Actual 100.0% 75.0% 75.0% Plan 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Diff 0.0% -25.0% -25.0% Actual 100.0% 87.5% 75.0% Plan 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Diff 0.0% -13.5% -25.0% 150 of 269

151 CCG Finance Report 2016/17 Month 4 (Period to end of July 2016) 25 August of 269

152 Financial Performance Duties Duty YTD Target YTD Performance RAG Annual Target Forecast Performance RAG Achieve planned surplus (Expenditure not to exceed income) Capital resource does not exceed the allowance Revenue resource does not exceed the allowance Capital Resource use on specified matters does not exceed the allowance Revenue resource use on specified matters does not exceed the allowance Revenue administration resource use does not exceed the allowance 2,558k 2,868k 7,673k 7,673k N/A N/A N/A N/A 132,961k 130,094k 411,212k 403,539k N/A N/A N/A N/A N/A N/A N/A N/A 2,129k 1,819k 6,387k 6,387k Notes: 1. The above duties correspond to those reported in Note 41 of the 2015/16 Annual accounts, and represent the statutory duties of NHS Southwark Clinical Commissioning Group ( the CCG ). 2. To support the delivery of the above, an in-year QIPP programme of 7,259k has been established. However, in order to achieve the plans, an investment of 600k has been made. This leaves the net QIPP value at 6,659k. QIPP monitoring information is included later in this report of 269

153 Summary of Position (1 of 2) The CCG was underspent at the end of Month 4 by 2,868k for the year to date (ytd). This is marginally above the planned pro rata effect of 2,558k, and is mainly a result of an underspend on running costs. The CCG has utilised 128k of reserves to achieve this ytd position. This is to offset small adverse variances in the reported position. There are partially offsetting favourable and adverse variances in Acute, Transformation and Prescribing (favourable), Client Groups, Primary Health Services and Corporate (adverse). The CCG is forecasting to meet the annual target surplus of 7,673k. This is equivalent to the brought forward surplus from 2015/16, which has been returned to the CCG in the form of a nonrecurrent allocation, in line with national process. The CCG is currently holding 10,215k of earmarked budgets and reserves. This has increased since Month 3, due to the return of non-recurrent transformation funds from NHS England. The Month 3 report highlighted that this allocation adjustment was expected. However, the amount received was higher than had been agreed and therefore 2,000k will be returned to NHSE in Month 5. 3,937k of the reserves relate to the 1% non-recurrent expenditure reserve, which national guidance has required CCGs to set aside and which is not currently available to the CCG to utilise of 269

154 Summary of Position (2 of 2) There is currently 10,100k of reserves uncommitted in the likely forecast position as at Month 4 (though this is artificially inflated by the inclusion of the 2m allocation issue reported on the previous page). This is calculated as 10,215k total earmarked budgets and reserves, less forecast 114k variance shown in the table on page 5. The 114k is committed to enable the CCG to reach the target surplus of 7,673k. In the worst case projection, we would need to utilise 3,791k of reserves. This is the remainder if the 10,214k after deducting the 3,937k not available for CCG s to commit, a reserve to fund Winter Resilience schemes, and the return of the 2m allocation. In Month 4, this shows as 6,423k reserve not being utilised to improve the worst case position. These amounts are not utilised as they are not available to be utilised or are earmarked for specific use. Data available for this report: Acute data is available for 3 months. GP Prescribing data is available for 2 months. Continuing Care information is available for 4 months. Southwark CCG Running Costs are treated as a separate allocation so shown as separate in the summary. Cross subsidisation of Running Costs by underspend on Programme Budgets is not permitted of 269

155 CCG Programme Budget Summary 2016/17 - Month 4 Programme Budget Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Acute 216, ,622 Client Groups 74, Community & Primary Health Services 40, Transformation 2, Prescribing 33, Better Care Fund (excluding schemes totalling 5.14m reported elsewhere: total BCF 20.68m) 15, Corporate Costs 4, Earmarked Budgets & Reserves 6, ,791 1% Non-recurrent reserve (uncommitted) 3, Planned Surplus 7,673 2,558 7,673 7,673 7,673 Total 404,825 2,557 7,673 8,449 7,616 Reserves not yet utilised in above position 10,100 10,214 6,423 Reserves not yet utilised in above position (Mth 3 for comparison) 6,886 6,886 4,423 Drawdown of prior yr surpluses supporting 2016/17 position Note: a red negative sign indicates budget overspend of 269

156 CCG Running Costs Summary 2016/17 Month 4 Running Costs Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Running costs 6, Month 3 (for comparison) 6, Notes: 1. The running costs allocation is separate from the Programme budget and should be monitored separately. 2. The running costs budget has decreased in 2016/17, due to the national requirement to reduce the amount spent on this area. 3. In line with national requirements, the running cost allocation per head of population has reduced from 25 in 2013/14, to in 2016/17. The above budget represents 70k less than the initial allocation due to the collaboration between London CCGs, for which NHS Islington CCG holds the budget. Other London CCGs have passed the relevant amount of programme and running costs allocation to Islington CCG to create the budget. 4. The variance as at Month 4 has increased due to the release of a provision made during the 2015/16 financial year. The CCG made a provision for redundancy costs that may have been incurred as part of a proposed restructure. No redundancies resulted from the restructure and therefore the provision has been released unused. Note: a red negative sign indicates budget overspend of 269

157 Acute Financial Position 2016/17 Acute Contract Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) King's College Hospital NHS Foundation Trust Guy's and St Thomas NHS Foundation Trust (excluding Community contract) 86, , Lewisham and Greenwich NHS Trust 3, University College London Hospital 1, London Ambulance 11, Other contracts and non-contracted activity 18, ,097 Total Acute 216, ,622 Month 3 (for comparison) 216, ,131 Note: a red negative sign indicates budget overspend of 269

158 Notes on Acute Budgets The year to date position is based on Month 3 information adjusted where appropriate for areas where reporting doesn t yet reflect contractual arrangement or doesn t yet include agreed challenges. The Month 3 position is then pro-rated up to Month 4. The position at Month 3 shows a 82k favourable variance. Within this, there are adverse variances relating to St George's Healthcare NHS Foundation Trust, Royal Brompton and Harefield NHS Foundation Trust, Barts Health NHS Trust, BMI Healthcare, Lewisham & Greenwich NHS Trust and Homerton University Hospital NHS Foundation Trust, as well as other, smaller contracts. These adverse variances are currently offset by underspends against Acute reserves. King s College Hospital NHS Foundation Trust the ytd position shows performance in line with plan. There is an underlying overspend position, driven by overspends on the following PODs: emergency (- 290k), outpatient follow-up (- 378k), critical care (- 279k), and other (- 537k). The overspends are partially offset by significant favourable variances on elective ( 808k), maternity ( 222k) and outpatient procedure ( 324k). At the current time, the value of the underlying underspend after being adjusted for various contractual adjustments is within the contract tolerances, and therefore the reported position is break-even. The expectation is that the underlying position will not exceed the contract tolerances and on that basis, the year-end likely forecast position is breakeven of 269

159 Notes on Acute Budgets Guy s & St Thomas NHS Foundation Trust the ytd position shows performance in line with plan. There is an underlying overspend position, driven by overspends on the following PODs: Other (- 366k), emergency (- 244k), outpatient follow up (- 178k), maternity (- 166k) and outpatient procedure (- 149k). These overspends are offset by significant underspends on elective ( 536k), and critical care ( 128k). At the current time, the value of the underlying overspend is within the contract tolerances, and therefore the reported position is break-even. The year-end likely forecast position is breakeven. The predicted year end position is based on the year to date position and forecast forward taking into account expected seasonality and expected growth in activity as the year progresses. The worst case scenario assumes that the outturn for King s College Hospital NHSFT and Guy s & St Thomas NHSFT will exceed the contract tolerance and will therefore result in a adverse variances of 269

160 Client Group Financial Position 2016/17 Programme Budget Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Mental Health Contracts (excl. IAPT) 54, IAPT 3, Learning Disabilities 2, Older Adults 2, Palliative care 2, Children Services 1, Young Persons with Disability (YPD) 6, Other Client Groups Total Client Groups 74, Month 3 (for comparison) 74, Note: a red negative sign indicates budget overspend of 269

161 Notes on Client Groups Budgets The SLaM contract for 2016/17 has been agreed and signed. QIPP savings of 854k have been applied to the South London and Maudsley NHS Foundation Trust (SLaM) contract and the CCG and the Trust are working closely to ensure effective delivery of the savings. There is a further 310k of QIPP savings allocated to other Client Groups budgets and as at Month 4, the full QIPP target of 1,200k is forecast to be met. As at Month 4, there is an adverse variance on Client Groups of 172k, which is mainly due to: Learning Disabilities - 93k due to recognising the increase in CCG funded caseload. 5 cases have been agreed as CCG or joint funded with the Council creating an annual cost pressure of 279k. The CCG has budget set aside to fund this cost pressure so this will be applied for future months. Children Services - 60k due to higher activity than planned. Residential placement costs are currently causing an element of concern and as a result, are being monitored closely by both the Commissioning and Finance teams. SLaM have advised that the placement services that they manage are currently overspending and are forecast to continue to do so throughout the year. Funded Nursing Care budgets have not yet been uplifted to reflect the cost pressure caused by the increase NHS-funded care rate for 2016/17 which was notified to CCGs in mid-july, but backdated to the beginning of the financial year. This cost pressure is estimated at 300k for the CCG of 269

162 Community & Primary Care Health Services 2016/17 Programme Budget GSTT Community Contract (including BCF) Extended Primary Care Services Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) 31, , Quality Standards Other Primary Care Health Services 5, Total 40, Month 3 (for comparison) 40, Community & Primary Care Health services are currently performing broadly in line with plan. The overspend in Other Primary Care Health Services relates to practice related expenditure and is expected to come into line with budget as the year progresses. Note: a red negative sign indicates budget overspend of 269

163 Transformation 2016/17 Programme Budget GP Federations Business Plans Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) 1, Population Health Fellows Staffing Costs Total 2, Month 3 (for comparison) 2, As at Month 4, there is a favourable variance of 61k within staffing which is due to budget being allocated for posts which are newly created and which have not yet been recruited to. Note: a red negative sign indicates budget overspend of 269

164 Prescribing Financial Position 2016/17 Programme Budget Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) North Southwark 16, South Southwark 14, Other Prescribing (including clinics) Prescribing Incentive Scheme Drugs held centrally Admin and Other Prescribing Total 33, Month 3 (for comparison) 33, Note: a red negative sign indicates budget overspend of 269

165 Notes on Prescribing Budgets From Month 3, the prescribing report has changed format and has moved away from reporting 3 sections based on a borough split, and has moved to reporting on two geographical segments North and South. Both North and South segments are reporting slightly above budget as at Month 4 and this is forecast to continue to the year end. However, it is anticipated that the North s position will improve over the coming months while the South s adverse financial performance will not continue at the same rate seen in the first 4 months. Practice prescribing budgets have been set in accordance with historical expenditure and list sizes. The budget formula based on list size is set in accordance with national guidance and therefore there is likely to be some variance as it uses national averages rather that Southwark specific assumptions. At month 4 only two months expenditure information is available to base expenditure forecasts on. Practice prescribing expenditure will continue to be monitored closely as more information is available. The Medicine s Optimisation team have identified further in year cost pressures and these will be discussed in the coming months. At present, these stand at an additional funding requirement of 180k and the CCG has funding earmarked to cover this potential requirement of 269

166 Better Care Fund 2016/17 (1 of 2) The Better Care Fund (BCF) is a pooled budget between the CCG and Southwark Council and is hosted by the Council. The CCG s contribution to the BCF in 2016/17 is 20,679k. This funds a number of schemes, some of which are led by Southwark Council, and some are led by the CCG. Under the pooled budget arrangement, there is no requirement to physically transfer cash to the host for the pooled budget to exist. On that basis, the CCG only transfers the proportion of its contribution needed to fund the Council led schemes. On that basis, the reporting of the BCF is split into two segments: the amount paid to the Council, and the CCG led schemes which are reported as part of the relevant directorate. The CCG led schemes have also been included as part of the BCF section of this report to provide transparency with regard to how the full CCG BCF contribution is spent. Programme Budget Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Better Care Fund: CCG Contribution to Southwark Council led Schemes 15, Total 15, Month 3 (for comparison) 14, The BCF figure of 15,539k on page 5 of this report comprises the 15,336k CCG contribution to council led schemes (above) and 204k for consultancy and contingency. Council led schemes increase d by 1,035k in Month 4 due to agreement on the lead organisation for 2 schemes. Note: a red negative sign indicates budget overspend of 269

167 Better Care Fund 2016/17 (2 of 2) BCF schemes reported as part of other expenditure areas Community GSTT schemes: Admission Avoidance, Hospital at home, Enhanced Rapid Response Primary Health Services schemes: Self management, Enhanced primary care access Corporate/Running Costs schemes: Change management capacity Mental health schemes (lead organisation yet to be agreed) & BCF Contingency Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) 3, , Total 5, Month 3 (for comparison) 6, Total CCG contribution to BCF Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Total CCG Contribution to BCF 20, Note: a red negative sign indicates budget overspend of 269

168 Corporate Costs 2016/17 Programme Budget Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) GP IT Development Costs for Dulwich Health Centre and Other Projects Estates Costs 1, Medicines Optimisation Other Corporate 1, Total 4, Month 3 (for comparison) 4, Note: a red negative sign indicates budget overspend of 269

169 Notes on Corporate Costs 2016/17 These costs are not counted against the CCG Running Costs allocation. There is no longer a budget for 1.337m for Payments to Southwark Council m related to Public Health and 300k related to GUM. The CCG has had a reduction in allocation in order to make the adjustments to both the CCG s and the Council s baseline funding in 2016/17. The overpsend is mainly due to costs relating to the Dulwich project. The CCG is currently reviewing the allocation for Development Costs for Dulwich Health Centre and Other Projects and it is likely that this figure will increase in future months. Note: a red negative sign indicates budget overspend of 269

170 Primary Care Co-commissioning 2016/17 As of the 1 April 2015, the CCG entered into Level 2 co-commissioning of primary care with NHS England. There were 3 levels available to CCGs with regard to co-commissioning: Level 1: Greater involvement in primary care decision-making Level 2: Joint Commissioning enables decisions Level 3: Delegated Commissioning enables decisions. Level 2 enables one or more CCGs to assume responsibility for jointly commissioning primary medical services with NHS England via a committee arrangement. This model is designed to give CCGs and NHSE an opportunity to more effectively plan and improve the provision of out-of-hospital services. However, within Level 2, the CCG and NHSE remain accountable for meeting their own statutory duties with regard to Primary Care Commissioning. On this basis, NHSE retains the financial budget and any associated risk of overspends against that budget. The CCG remains at Level 2 for the 2016/17 financial year. Note: a red negative sign indicates budget overspend of 269

171 Primary Care Co-commissioning 2016/17 NHS England - London Region Primary Care Services - South London (Southwark) Medical Services Financial Summary - 3 Months to 30th June 2016 Description Annual Budget YTD Budget YTD Actual Expenditure YTD Variance Forecast Outturn Forecast Variance 2015/16 Outturn 000's 000's 000's 000's 000's 000's 000's Additional and Essential Services 32,712 8,178 8, , ,899 QIPP Savings Enhanced Services 1, , ,862 Quality and Outcomes Framework (QOF) 2, , ,821 Premises Payment 4,608 1,152 1, , ,581 Seniority Other Administered Funds (Maternity etc) Personally Administered Drugs Other Medical Services Prior Year Accruals Total 42,327 10,581 10, , ,132 NB: The figures above are included for information only. As explained on the previous page, NHS England retains financial responsibility in 2016/17 for Level 2 co-commissioning. Note: a red negative sign indicates budget overspend of 269

172 Earmarked Budgets and Reserves 2016/17 Programme Budget Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) General Contingency (0.5%) 1, ,544 Non-Recurrent Expenditure (1%) 3, Deferred Projects Reserve Winter resilience Local Activity/ Risk Reserve 3, ,377 Total 10, ,791 Month 3 (for comparison) 6, ,463 Reserves not yet utilised in above position 10,100 10,214 6,423 The CCG received an allocation adjustment of 4m from NHSE in Month 4. This will enable the Contingency and Local Activity / Risk reserves to be built back up to the planned level. The allocation was calculated incorrectly and therefore 2m will need to be returned in Month 5. Planned Surplus 7,673 2,558 7,673 7,673 7,673 Month 3 (for comparison) 7,673 1,918 7,673 7,673 7,673 Note: a red negative sign indicates budget overspend of 269

173 Running Costs 2016/17 (Separate Allocation) Budgets Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000) Staff Costs 3, CSU Recharge 1, Office Accommodation Other 1, Total 6, Month 3 (for comparison) 6, This is the separate allocation of per head of population for running costs. The budget decreased in Month 3 due to transferring non-recurrent allocation to NHS Islington CCG to fund Southwark s share of London levies that are classed as running costs. The CCG has implemented a plan to move towards filling all vacancies with substantive staff and thereby reduce the dependence on temporary staffing solutions. The Other costs include the CCG s share of Office costs and Audit Fees. The reason for the favourable variance is the release of a restructuring provision made in the 2015/16 financial year, which has not been required as no redundancies resulted from the restructure. Note: a red negative sign indicates budget overspend of 269

174 Capital 2016/17 (Separate Allocation) Capital Projects Annual Budget ( 000s) Variance to Month 4 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000) SWK Refresh endpoint devices CCG led SWK Refresh backend infrastructure CCG led SWK Virtualisation and Online Backups CCG led Total Month 3 (for comparison) The CCG has had 3 capital Business as Usual Project Initiation Documents approved by NHS England. As at Month 4, the projects had not started and as yet, no funding has been allocated to these projects. Once the projects commence, they will be reported on a monthly basis in this section of the report. The CCG is awaiting the approval of a number of GPIT capital projects for which NHSE would hold the budget. Note: a red negative sign indicates budget overspend of 269

175 QIPP Monitoring SOUTHWARK CCG QIPP Annual Plan Year to Date Forecast QIPP Target (Post-RAG-Rating) ( 000s) YTD Plan ( 000s) YTD Actual ( 000s) YTD Variance ( 000s) YTD RAG Outturn ( 000s) Acute 4,500 1,500 1, ,500 0 Mental Health 1, ,200 0 Primary Care Prescribing Community Services Corporate Running Costs Southwark CCG QIPP Target 2015/16 Variance ( 000s) 6,659 2,220 2, ,659 0 Ytd Shortfall from plan: 0.0% Forecast shortfall from plan: Total QIPP savings plans of 7,259k are in place for 2016/17. However, in order to achieve the plans, an investment of 600k has been made. This leaves the net QIPP value at 6,659k. NHS England has assessed that the QIPP programme could be more stretching. The CCG has stated that there a number of circumstances in the local health economy that meant achieving higher QIPP savings would not have been realistically possible and therefore the QIPP programme was set at a realistic level. The CCG is forecasting to deliver the QIPP programme in full in 2016/ % Note: a red negative sign indicates budget overspend of 269

176 Financial Risks & Mitigations (1 of 2) Risks Full Risk Value ( m) Probability of risk being realised (%) Potential Risk Value ( m) Commentary Acute SLAs % 1.50 Overperformance & RTT Community SLAs 0.00 Mental Health SLAs % 0.25 Excess bed usage Continuing Care SLAs 0.00 QIPP Under-Delivery 0.00 Performance Issues % 0.25 Volume issues on key target areas Primary Care 0.00 Prescribing % 0.25 Price variations Running Costs 0.00 Other Risks % 2.00 Repayment of NR Transformation Fund - allocation error - to be returned in M5 TOTAL RISKS Mitigations Full Mitigation Value ( m) Probability of success of mitigating action (%) Expected Mitigation Value ( m) Uncommitted Funds (Excl 1% Headroom) Contingency Held % 1.54 Contract Reserves % 4.73 Investments Uncommitted 0.00 Uncommitted Funds Sub-Total Actions to Implement Further QIPP Extensions 0.00 Non-Recurrent Measures % 0.19 Delay/ Reduce Investment Plans 0.00 Other Mitigations 0.00 Mitigations relying on potential funding 0.00 Actions to Implement Sub-Total Commentary TOTAL MITIGATION NET RISK / HEADROOM 2.21 Forecast Outturn Surplus/Deficit 7.67 RISK ADJUSTED CONTROL TOTAL of 269

177 Financial Risks & Mitigations (2 of 2) The value of the potential risks reported on the previous page is in addition to the forecast outturn position. The purpose of this table is to report on risks and mitigations that are not included in the forecast i.e. to illustrate anything that puts the reported forecast outturn at risk. The best case impact is 6.28m: no risks materialise and funds remain uncommitted. However, please note that this calculation is artificially high in month 4 due to the 2m held in reserve that will be returned to NHS England in Month 5. The more realistic figure is 4.28m, which has increased from the amount reported in Month 3. The worst case impact is that the current forecast would be adversely affected by 0.22m: all risks occur, further actions are unsuccessful and uncommitted funds all used to mitigate risks. Contract Reserves reported in the Mitigations table on the previous page exclude the 1% nonrecurrent headroom that CCGs are required to plan for and at the current time are not permitted to commit expenditure against of 269

178 Cash Position 2016/17 The Maximum Cash Drawdown (after payments made on behalf of NHS Southwark CCG by NHS Business Services Authority PPA & HOT, and the CHC Risk Pool Contribution) is 370,909k. The actual and forecast drawdown of cash is shown in the table below. Cash drawdown Monthly Drawdown 000s Cumulative Drawdown 000s Proportion of Annual Cash Resource Limit KPI % of cash balance as drawdown 000s Month end cash Bank Balance 000s ACTUAL Apr-15 32,500 32, % May-15 31,500 64, % Jun-15 26,000 90, % Jul-15 34, , % Forecast Aug-15 28, , % 356 Sep-15 31, , % 389 Oct-15 31, , % 389 Nov-15 31, , % 389 Dec-15 31, , % 389 Jan-16 31, , % 389 Feb-16 31, , % 389 Mar-16 31, , % 389 Annual Total 370,909 Achievement The cash KPI was not achieved in Month 4 due to a payment to Southwark Council being rejected by the Council s bank. This was due to the account not accepting the type of payment mechanism that the CCG was using to make payment for an invoice of 269

179 Better Payments Practice Code (BPPC) 2015/16 Jun-16 NHS NON-NHS TOTAL NHS NON-NHS TOTAL NUMBERS FOR THE MONTH Total number of invoices paid in the month , Number of invoices paid within target , Numbers percentage for the month % 99.57% 99.64% 99.61% 98.29% 98.70% VALUES FOR THE MONTH ( 000s) Total value of invoices paid in the month 21,494 5,072 26,567 27,450 7,493 34,943 Value of invoices paid within target 21,494 5,007 26,502 27,450 7,431 34,880 Value percentage for the month % 98.72% 99.76% % 99.17% 99.82% CUMULATIVE NUMBERS TO THE MONTH Total number of invoices paid YTD 754 2,595 3,349 1,013 3,179 4,192 Number of invoices paid within target 749 2,573 3,322 1,007 3,147 4,154 Numbers percentage cumulative 99.34% 99.15% 99.19% 99.41% 98.99% 99.09% CUMULATIVE VALUES TO THE MONTH ( 000s) Total value of invoices paid YTD 78,075 15,472 93, ,524 22, ,489 Value of invoices paid within target 76,177 14,953 91, ,626 22, ,011 Value percentage cumulative 97.57% 96.65% 97.42% 98.20% 97.47% 98.07% Jul-16 95% <95% Under the Better Payments Practice Code (BPPC), CCGs are expected to pay 95% of all creditors within 30 days of the receipt of invoices. This is measured both in terms of the total value of invoices and the number of invoices by count. The CCG missed the target for value in Month 2, but Month 3 and 4 show a return to target achievement of 269

180 Aged Debtors (Receivables) 2016/17 Customer Account Group Current Debt 1-30 amount AR Ageing amount AR Ageing amount AR Ageing amount AR Ageing amount AR Ageing 181+ amount Total AR due amount NHS 345, , , , , , Non-NHS , , Total 345, , , , , , % 19% 4% 0% 34% 5% 100% The overall level of debt owing to the CCG has reduced by 533k in Month 4 Southwark Council were reported as owing 661k in Month 3. This has now been cleared has been paid. The 225k NHS debt in AR Ageing relates mainly to Guy s & St Thomas NHS Foundation Trust and relates to the SLIC programme which has now finished. Over a third of the reported debt is current and this is a healthy position for the CCG in terms of outstanding debt of 269

181 Financial sanctions imposed by the CCG As part of the NHS standard contract, the CCG is required to report quarterly on financial fines and penalties imposed on providers for failure to achieve national standards. The sanctions are routinely calculated and form part of regular monitoring of contracts, recognising the national requirements against each indicator. The standards are split into 2 main categories: Operational Standards: include requirements for 18 weeks referral to treatment, A&E waiting times, Cancer standards, mixed sex accommodation, cancelled operations. National Quality Standards: include requirements for MRSA, C-Diff, over 52 week waiters, Ambulance handovers, duty of candour, required data, trolley waits in A&E. Please note: the full list of standards is not included in the financial sanctions tables. Only those standards that have incurred financial sanctions are reported. The CCG will report on these when information from the first quarter is available of 269

182 Revenue Resource Limit (1 of 2) Admin ( m) Programme ( m) Total ( m) Initial CCG Programme Allocation 2016/ Running Costs Allowance 2016/ Brought forward surplus from 2015/ /17 Opening Allocations In year Allocations: Eating Disorder Service Q1 non-recurrent (Month 3) TB Allocations Q1 non-recurrent (Month 3) Epsom and St Helier - recurrent (Month 3 contract variation) /17 HLP and Levies non-recurrent (Month 3) London Transformation Fund Allocation non-recurrent (Month 4) Total Confirmed Allocation at Month of 269

183 Revenue Resource Limit (2 of 2) There has one change to the Start Allocation in Month 4. Return of NR transformation funds from NHSE ( 4m incoming) Adjustments are expected in future months for: Correction of NR transformation funds from NHSE ( 2m outgoing - Month 5) Primary Care OD - HLP ( 400k incoming) Adjustments are not reflected in the table on the previous page until such time time as they have been agreed and confirmed through the NHSE standard process. Note: a red negative sign indicates budget overspend of 269

184 Recommendations 1. To note the budgets and position for the Programme Budgets and the Running Costs as at end July To note the forecast position for the year for both Programme Budgets and the Running Costs. 3. To note the risks and mitigations and to note the artificially high mitigation value in Month 4 and that this will reduce by 2m in month 5 due to the return of the incorrect allocation. Malcolm Hines Chief Financial Officer NHS Southwark CCG 12 August of 269