Governing Body. To be held on Thursday 15 February From 1pm until 4pm. In the Boardroom, Sovereign House, Heavens Walk, Doncaster DN4 5HZ

Transcription

1 Governing Body To be held on Thursday 15 February 2018 From 1pm until 4pm In the Boardroom, Sovereign House, Heavens Walk, Doncaster DN4 5HZ

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3 Governing Body To be held on Thursday 15 February 2018 Commencing at 1pm 4pm In the Boardroom, Sovereign House, Heavens Walk, Doncaster, DN4 5HZ PUBLIC AGENDA Presenter Enc 1. Welcome and Introductions Chair Verbal 2. Apologies Chair Verbal 3. Declarations of Interest Chair Verbal 4. Questions from Members of the Public (See our website for how to submit questions required in advance) Chair Verbal 5. Minutes of the previous meeting held on 18 January 2018 Chair Enc A 6. Matters Arising Chair Verbal Strategy 7. Planning Guidance 2018/2019 Mr Fitzgerald Enc B Assurance 8. Quality & Performance Report Spotlight Report on Mental Health Delivery Plan Spotlight Report on Dementia Delivery Plan Mr Russell & Mr Fitzgerald Enc C 9. Finance Report Mrs Tingle Enc D 10. Corporate Assurance Framework Quarter 3 Report 2017/2018 Mrs Devanney Enc E

4 Standing Items 11. Chair & Chief Officer Report Dr Crichton & Mrs Pederson Enc F 12. Locality Feedback Locality Leads Verbal Items to Note/Receipt of Minutes 13. Receipt of Minutes Audit Committee Minutes from the meeting held on 9 November 2017 Primary Care Commissioning Committee Minutes from the meeting held on 11 January Quality & Patient Safety Committee Minutes from the meeting held on 18 January Executive Committee Minutes from the meeting held on 3 January Engagement and Experience Committee Minutes from the meeting held on 7 December 2017 South Yorkshire & Bassetlaw Sustainability & Transformation Collaborative Partnership Board Minutes of the meeting held on 8 December Primary Care Commissioning Committee Annual Report Chair Enc G 14. Any Other Business Chair Verbal 15. Date and Time of Next Meeting Thursday 15 March 2018 at 1pm in the Boardroom, Sovereign House, Heavens Walk, Doncaster, DN4 5HZ Chair Verbal To resolve that representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest Section 1(2) Public Bodies (Admission to Meetings) Act Chair

5 Verbal Item 1 Welcome & Introductions

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7 Verbal Item 2 Apologies for Absence

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9 Verbal Item 3 Declarations of Interest

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11 Verbal Item 4 Questions from Members of the Public

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13 Enc A Item 5 Minutes of the previous meeting

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15 Minutes of the Governing Body Held on Thursday 18 January 2018 commencing at 1pm In the Boardroom, Sovereign House, Heavens Walk, Doncaster, DN4 5HZ Members Present: Formal Attendees present Dr David Crichton NHS Doncaster CCG Chairman (Chair) Body Miss Anthea Morris Lay Member and Vice Chair of the Governing Mrs Linda Tully Lay Member Mrs Sarah Whittle Lay Member Dr Emyr Wyn Jones Secondary Care Doctor Member Dr Nick Tupper Locality Lead, Central Locality Dr Jeremy Bradley Locality Lead, North East Locality Dr Marco Pieri Locality Lead, North West Locality Dr Niki Seddon Locality Lead, North West Locality Dr Khaimraj Singh Locality Lead, South East Locality Dr Lindsey Britten Locality Lead, South West Locality Mrs Jackie Pederson Chief Officer Mrs Hayley Tingle Chief Finance Officer Mr Andrew Russell Chief Nurse Mrs Lisa Devanney Associate Director of HR and Corporate Services Mr Anthony Fitzgerald Director of Strategy & Delivery Dr Rupert Suckling Director of Public Health Mrs Deborah Hilditch Healthwatch Representative (Attending on behalf of Mr Stephen Shore) In attendance: Mrs Jayne Satterthwaite PA (Taking Minutes) Mr Ian Carpenter - Head of Communications & Engagement Mr Mike Taylor Head of Governance (Item 10 Assurance Framework Quarter 3 Report 2017/2018) ACTION 1. Welcome and Introductions Dr Crichton welcomed everyone to the Governing Body meeting. There were 3 members of the public in attendance at the meeting. 2. Apologies Apologies for absence were received from: Mr Damian Allen DMBC Representative 1

16 3. Declarations of Interest The Chair reminded members of their obligations to declare any interest they may have on any issues arising at meetings which might conflict with the business of NHS Doncaster Clinical Commissioning Group. Declarations declared by members are listed in the CCG s register of Interests. The Register is available either via the secretary to the Governing Body or the CCG website at the following link The meeting was noted as quorate. Declarations of interest from sub-committee/working groups: None declared. Declarations of interest from today s meeting: None declared. 4. Questions from Members of the Public Dr Crichton informed the Governing Body that a question had been received from Mr Doug Wright regarding the Ernst Young Final Report. Dr Crichton explained that our response would be given under Item 7, Ernst Young Final Report. 5. Minutes of the Previous Meeting held on 21 December The minutes of the meeting held on 21 December 2017 were agreed as an accurate record subject to the following amendment: Page 11, Locality Feedback, South East Locality, amend to read Dr Singh. 6. Matters Arising Hospital Services Review Dr Crichton stated that he would liaise with Mrs Stevens to clarify whether it should state a reference to remuneration or payment of expenses. Dr Crichton Health & Wellbeing Charter Mrs Devanney confirmed that she is meeting with Mrs Hilditch to discuss this further on Tuesday 23 January

17 Dr Suckling responded to Dr Crichton s prompt informing the Governing Body that the Health & Wellbeing Charter was originally developed by NHS England and Liverpool however it had now come to an end and all organisations have been asked to discontinue using it going forward. Mrs Whittle asked if the level reached by organisations still stands and Dr Suckling confirmed that this was the case. 7. Ernst Young Final Report Mr Fitzgerald presented the Ernst Young Final Report to the Governing Body for noting and to note the progress made so far to realise the Doncaster Place Plan vision. The Governing Body was also asked to note the arrangements for implementation post November 2017 and the ambition for 1 April It is an all-encompassing report as a partnership to realise the vision of the Doncaster Place Plan and conveys the message of a new approach to Health & Social Care. The Governing Body noted the report and the arrangements for implementation post November 2017 and the ambition for April Dr Crichton informed the Governing Body that the following question has been received from Mr Wright regarding the Ernst Young Final Report, Page 44 Finance and Efficiency Gap: The above states 'The cost of delivering health and care services is increasing and our gap will be 139.5m by 2021 if we do nothing'. Can the Governing Body suggest any possible ways that this gap could be bridged and how this could be done over the next three years? (I will ask the same question to Doncaster Council) I say this because 139.5m was the Doncaster part of the original 571m health and social care gap shown on Page 44 of the original STP in I presume that to date no progress has been made on bridging the Finance and Efficiency Gap. Mr Fitzgerald replied that the 139.5million Gap by 2021 was derived from an exercise undertaken in 2016 by all Health and Social Care Commissioners and providers involved in the Doncaster Place plan partnership. The exercise took into account the gap of each organisation (as known at the time) between perceived income and expenditure over the next 5 years. It also included any provider debt currently in the system. The approach to reducing the deficit in 2017/18 has been the 3

18 individual Quality Innovation Productivity and Prevention (QIPP) and Cost Improvement Plan (CIP) (Savings plans) of individual organisations. As you can see from the finance report later in the meeting NHS Doncaster CCG for instance is currently reporting a 8.5 million saving in 2018/18 financial year. There has always been an acknowledgement however that the extent of the gap by 2021 cannot be bridged by organisations working in isolation. This was one of the initial aims of the Place Plan Approach. The financial savings and contribution to the gap are still being worked through and will emerge over the next financial year through to 2021 (as well as other areas that emerge). Mr Wright highlighted Risk 3.2 Efficiencies within the Assurance Framework Quarter 3 Report 2017/2018 which states that if NHS Doncaster CCG does not achieve the quality and efficiency savings within the Delivery Plans and maximise efficiency opportunities presented by areas such as Prescribing and RightCare, the CCG may be forced to consider decommissioning services from elsewhere in order to achieve the required savings and commented that work should now be undertaken on calculations. Mrs Tingle reported that each organisation was asked to provide their individual control totals for 2017/2018 which was 11.6m for NHS Doncaster CCG and our total expected saving of the 139.5m was approximately 30m. South Yorkshire ACS is also working to a system control total. Mr Wright queried who the CGG would report to? Mrs Pederson stated that we link into the South Yorkshire and Bassetlaw Collaborative Partnership for which there is a Memorandum of Understanding; however NHS England remains the body we currently report to. Mr Fitzgerald introduced Mr Chris Marsh, Interim Director of Transformation to the Governing Body who attended the meeting to give a presentation on the progress and next steps of the Doncaster Place Plan. The Doncaster Place Plan is the strategic framework for the integration of Health and Social Care services across the public, private and community and voluntary sector. It sets an ambitious agenda for reform, integration and delivery, with a strong focus on creating a person centred, whole system, increasingly preventive and localised health and social care system. This is a major undertaking and an urgent one. The aim of the plan is to respond to demand and funding pressures in health and social care but in way that delivers better user experiences, life chances and outcomes for Doncaster people. Delivery is a joint mission for commissioners and providers across all sectors. It has strong support and leadership from the whole health and social care system in Doncaster a critical success factor. The ambition of the Doncaster Place Plan spans all ages from maternity care to support for people in their older years A key focus of the plan is to ensure that a range of health and social 4

19 care services work well together at key transition points and events throughout people s lives. This is where we know that good, collective, accessible, person centred work can manage risks and improve physical and mental health as well as social and economic outcomes. We also know that if things do not go well for people at these points, the impacts for them and their families and carers can be huge. This can often lead to high demand and costs for acute health and social care and other public services. The Delivery of the Place Plan will be driven through a new, enhanced level of partnership through an Accountable Care approach and Alliance contracting. This will secure the joint strategic planning and commissioning that is needed to deliver in a joined up way in the key transition points, and in turn enable the integrated delivery between provider partners who will be incentivised to act and achieve our goals together We are building an accountability and operating framework to support this, including an overarching agreement, a Joint Commissioning Agreement and Provider Collaboration Agreement This work is under way and details will be established up to April 2018 There has been seven areas of focus identified: Intermediate Care Complex Lives A deep dive analysis of 57 people undertaken. Starting Well First 1000 days of life. Vulnerable Adolescents Patients can be found in Out of Area high cost or custodial establishments. Urgent and Emergency Care Dermatology Patients can be managed in Primary Care. Learning Disabilities An all age approach. Focus on strategy and transitions to community settings. By the end of April 2018, the formal sign off of agreements will be finalised by Governing Bodies and year 1 of delivery under the new model will take place. Dr Britten queried if the costs relating to Complex Lives were Health & Social Care or if they included policing, prisons and housing. Mr Marsh stated that we have worked closely with the police and some costs included but there was probably an underestimation of potential savings. Dr Jones acknowledged the collaborative working however highlighted that the language used can sometimes be confusing such as the Accountable Care System (ACS) and the Accountable Care Partnership (ACP); one should not be confused with the other. Mrs Pederson recognised that it would be helpful for this to be looked at the names going forward. Dr Suckling stated that part of the next steps should look at what it means for patients and front line staff. Mr Marsh reported that the patient and staff programme will focus on user experience and what needs to be at the centre of it within each area and the workforce 5

20 respectively. Mrs Pederson stated that the focus next year will be on delivery and to have mechanisms in place; front line staff can help with the design and promote delivery. Mrs Tingle informed the Governing Body that CCGs have taken an individual approach to savings across South Yorkshire and Bassetlaw and it is very difficult to achieve savings in isolation; we have to do it together. Dr Pieri queried the evidence to indicate the correct approach. Mr Marsh advised that the best example is the Lambeth approach at scale to Mental Health. Our Intermediate Care model is also a good example of patients accessing services more efficiently. Dr Crichton thanked Mr Marsh for attending the Governing Body meeting. 8. Quality & Performance Report Mr Fitzgerald presented the Quality & Performance report to the Governing Body and stated that overall the report reflected a more positive position. Performance Mr Fitzgerald highlighted the following points: NHS Doncaster Clinical Commissioning Group (CCG) The two Delivery Plan focus areas this month are Learning Disabilities and Intermediate Care. The percentage of patients waiting on a Referral to Treatment (RTT) pathway less than 18 weeks at the end of November increased by 0.5% to 91.73% against the 92% target. The percentage of people receiving a diagnostic test within 6 weeks increased by 0.18% to 99.06% in November achieving the 99% target. A&E performance was 88.57% in December which is below the 95% target but Doncaster Bassetlaw teaching Hospitals NHS Foundation Trust (DBTHFT) achieved 90.86% for Quarter 3 which meets the recovery trajectory of 90.2%. It is worth noting that the Trust was the 32 nd best performing hospital in December Cancer All measures were met during November with the exception of the 62 day wait from urgent GP referral to first definitive treatment for cancer which improved to 83.87% against the 85% target. Quality Mr Russell highlighted the following points: 6

21 The Clinical Quality Reporting Group (CQRG) held a discussion regarding the performance for patient access to the stroke unit and diagnostic waiting time. NHS Doncaster CCG has discussed this with the Trust and actions have been implemented to improve patient flow to the unit. Early indications are that improvements are being noted. An increase in access to the Speech and Language Therapy (SALT) has been noted. CAMHS - The percentage of children starting a treatment plan within 8 weeks of referral improved significantly during November by 32.1%, a performance notice has been issued to CAHMS. The new reporting standards have now been published by the Yorkshire Ambulance Service (YAS). Of the 4 new categories (ranging from Life Threatening to Less Urgent) 3 were not met during December 2017 and one has not been reported by YAS. We will look at how data for Doncaster is reported. Continuing Healthcare (CHC) NHS England has requested how many initial assessments are undertaken within the Acute Trust. NHS Doncaster CCG is well below the threshold set by NHS England for CHC assessments completed in the Acute Trust. This demonstrates ongoing good performance. A Domestic Homicide has been initiated and NHS Doncaster CCG will be involved as necessary. Mrs Tully commented that, since March 2017, reductions into CAMHS have been noted which recover quickly and queried the reason for this. Mr Russell stated that the reason was unclear but could be due to clinical capacity issues. Mr Woodcock, Support Manager, Performance confirmed that it was related to capacity issues as a result of both short and long term sickness. Dr Crichton raised the cancer performance and queried if we may expect a dip in performance due to the Christmas Bank Holidays. Mr Fitzgerald stated that, although he had not seen the data, Bank Holidays are known to affect performance as patients choose to wait for their appointments. Spotlight on the Learning Disabilities Delivery Plan. Mrs Butcher attended the Governing Body to give an update on the Learning Disabilities Delivery Plan: The Transforming Care Partnership (TCP) (covering Sheffield, North Lincolnshire, Rotherham and Doncaster CCGs) trajectory of moving people to community is below target. The focus is on getting patients out of hospital but there is no infrastructure in place due to time restraints. Work is ongoing to understand why patients are going into hospital. A provider event is scheduled to take place on Wednesday 24 January 2018 and good attendance is anticipated. The Enhanced Community team is working on training with providers to support patients so they do not go into crisis. 7

22 A review of Physical Health checks is being undertaken to look at the Local Enhanced Service (LES) with Primary Care. We need to make the connection with the cancer strategy and Public Health to screen more patients with learning disabilities. Work is being undertaken with the Local Authority to include a safe step-up facility in Doncaster. We need to understand why patients are accessing the A&E department and we are approaching a number of trusts to share their data. We are developing a data set to identify those patients accessing A&E on multiple occasions Mrs Whittle asked how many learning disability patients are in Doncaster and whether they all have access to a GP. Mrs Butcher reported that the intention is to get uniformity across Doncaster and we are working on the premise that residents in Doncaster have a GP. We are also looking to include at dentistry and optometry in this. Mrs Whittle also asked how many patients were coming of age. There have been two who have now transferred to the adult list and we are now starting to understand the number of this cohort of patients and their complexities and we will work closely with patients and their families. Spotlight on the Intermediate Care Delivery Plan Mrs Aitchison gave a presentation on the Intermediate Care Delivery Plan and the progress to date and highlighted the following points: Our aim is to support more people in their own home when it is safe to do so and enable people to retain their independence for as long as possible by: o Simplifying access to intermediate care. o Increasing step up support to prevent admission. o Growing the community Intermediate Care (IC) offer- more responsive, more flexible. o Redesigning the IC bed base. o Integration of physical, mental health and social care support to meet complex needs. o Partnership approach to delivery and joint commissioning- more joined up. The Intermediate Care Delivery Plan actions are mostly on track with the exception of developing joint commissioning and provision model and associated financial modelling which has taken longer than anticipated as it has been dependent on progress of wider Doncaster Place Plan and the Accountable Care Partnership (ACP) work. The key achievements for 2017/2018 are as follows: o The model was launched on 25 January o 400 people were accepted onto the pathway by the end of December 2017 (updated since dashboard produced). o 77% of patients were supported at home. o 107 follow up calls have been conducted, very positive feedback was received and 86% of the people contacted said they felt safer at home as a result. 8

23 o Feedback from YAS is positive, although would like the hours to be extended. o AGE UK is now offering low level social support as part of the response and rapid access to handy person about to be tested with St Ledger. o We are working with care homes to identify support required following a fall to help reduce ambulance conveyances. o Most step-up support can now be accessed via the RDaSH Single Point of Access (SPA). o Plans to bring access to step-up beds in line next. o Joint triage for health and social care reablement and plans to further integrate are being progressed. o Integrated Doncaster Care Record (idcr) proof of concept is due to go live on 23 March o Integrated health and social care dashboard for IC services. o Joint Multi-Disciplinary Teams (MDTs) with Geriatrician input (daily and weekly), monthly inter-agency case reviews and joint CPD event- Different conversations. Patient Story A short video was played which related to this month s spotlight report on the Intermediate Care Delivery Plan. It featured Mrs June Watkinson who fell on 23 December 2017 and subsequently sustained an injury to her back and required access to services which enabled Mrs Watkinson to remain in her own home. Mrs Tully queried if the 400 patients accepted onto the pathway was the total demand and if we have community geriatricians in place. Mrs Aitchison advised that several referrals are received per day and work is needed to address capacity issues. We are currently liaising with GPs for them to access patients thereby releasing geriatrician capacity into the community. The use of telehealth and Telecare would also be advantageous. Mrs Pederson informed the Governing Body that the Better Care Fund invested money into Intermediate Care and we now need to revise the model and invest more into community. Mrs Whittle acknowledged that the Intermediate Care model had proved to be invaluable and suggested that the Voluntary Sector could also be instrumental in providing help and support for patients and professionals going forward. Mrs Aitchison reported that Age UK were present at some of the MDTs. Dr Seddon informed that Governing Body that she has found the referral process to be seamless. Dr Cheng Looi who is a Geriatrician is very pro-active and has visited a number of practices and care homes. Mr Fitzgerald advised the Governing Body that Mrs Aitchison would be leaving NHS Doncaster CCG in March 2018 and thanked Mrs Aitchison and Mrs Tooley for their tenacity and enthusiasm. Dr Crichton thanked Mrs Butcher and Mrs Aitchison for attending the Governing Body meeting. 9

24 9. Finance Report Mrs Tingle stated that the report is for noting by the Governing Body and provides the financial position for NHS Doncaster CCG for 2017/18 as at the end of November NHS Doncaster CCG is forecasting to achieve all of its financial targets for 2017/18 and although pressures are emerging at pace they are being managed. Financial risks are as follows: Doncaster and Bassetlaw Teaching Hospital NHS Foundation Trust (DBTHFT) The Acute contract over performance remains a key risk as providers are undertaking additional activity to meet Referral to Treatment (RTT) targets. The November monitoring information from DBTHFT indicates significant overtrading ( 4.8m) relating to both a drive to deliver the 92% Trust wide RTT target and the phasing of the demand management schemes in place across the system. The activity variance has been shown at a high level but it is important to note that there are variances at individual specialty level. There are also case mix variances due to moving to HRG4+ and changes in the complexity of patients, again this varies by individual specialty. The Maternity variance is purely related to case mix due to an issue with the original costing of the contract. There are also national coding issue related to Sepsis which is awaiting national guidance and how this should be treated. The variance on Paediatric Assessment Activity is related to more patients being discharged from the Assessment Ward rather than being admitted as Non Elective patients. NHS Doncaster CCG has met with colleagues from the Trust on a number of occasions to discuss affordability and contract totals and we continue to work closely with the Trust to achieve a suitable outcome and commissioning for 2018/2019. Efficiency Savings Programme NHS Doncaster CCG has an ambitious efficiency plan equating to 11.6m. The main contracts with DBTHFT and Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) were negotiated net of the agreed efficiency targets of 4.5m and 0.5m respectively. To the end of Month 8, 5.3m of actual savings have been delivered with a forecast of 8.5m, the achievement against the majority of schemes can now be quantified. Each scheme has a Red Amber Green (RAG) rating in terms of the current and forecast delivery, there are a large number of schemes that are rated Amber as, although progress is being made through the delivery plans, the savings are slow to materialise and the annual target is unlikely to be met. The reporting assumptions have now been reviewed and productivity savings are also being identified although they need quantifying. Work is underway to identify the recurrent and non-recurrent impact of the schemes to feed into the 2018/19 budget setting and contracts. Prescribing - There are now some clearly identifiable savings in terms of the impact of Optomize Rx, rebates and medicines optimisation and these have now been further quantified through 10

25 work with the Medicines Management Team. Dr Pieri queried how an overtrading position had been reached by the Trust. Mrs Tingle explained that we were requested by NHS England to have contracts for 2017/2018 signed by the 31 December 2016 and as a result we were not in full possession of all information. The new electronic system GooRoo within the Trust should give an indication of the position to date and going forward. HRG4+ has also created complexities within the system. Miss Morris asked at what point overspend will be referred to the Governing Body. Mrs Tingle reported that it would be within the Scheme of Delegation. It is difficult to land exactly on the year-end figures; we have included mitigation which is being held in reserve if this is exceeded it would then be referred to the Governing Body. Dr Jones asked how the 24m for the Better Care Fund was being used. Mrs Tingle explained that it was always the intention that it be established as a pooled budget, the largest contribution is from the NHS. The money is used for transformation with some also used for the benefit of patients and staffing however we need to re-visit how we can adopt a different approach. Dr Suckling advised that the Fund is monitored closely and our current plans have been submitted and supported nationally. The fund is overseen by the Health and Wellbeing board and a high level report has been provided to Governing Body in the past. Some additional funding is in relation to Delayed Transfers of Care (DTOC) which is a particular concern to the Local Authority. Dr Seddon congratulated Mrs Tingle and the Finance team on the achievements to date. Mrs Tingle stated that it its testament to the hard work invested on the Delivery Plans. There are challenges across South Yorkshire and Bassetlaw however Doncaster is maintaining its financial responsibilities. The Governing Body noted the report. 10. Assurance Framework Quarter 3 Report 2017/2018 Mr Taylor presented the Assurance Framework Quarter 3 Report 2017/2018 for noting by the Governing Body however wished to highlight the following points: 2.2 Urgent Care - The action to remediate against the A&E target continues to be tracked through the monthly Quality & Performance Report at Governing Body and subsequently the target to achieve by March 2018 has been revised to 92.35%. The A&E Delivery Board and System Resilience Group continue to oversee the actions against the 9 nationally recognised key elements to improve 4 hours access. The Urgent Care Delivery Plan has also been reviewed to ensure that the range of elements is fully covered. 11

26 3.1 Transformation - The Quality, Innovation, Productivity and Prevention (QIPP) Programme Board has been established, chaired by the Chief Officer and has met twice in the quarter. Work has focussed on clarifying assumptions and identifying further in year opportunities. QIPP delivery has improved and there is no change in risk rating at this stage. Mr Taylor stated that the Audit Committee had initiated a Deep Dive and discussed the interdependencies of risks. A process to develop a revised template to gain a clearer understanding of the report will be undertaken. The Governing Body noted the Assurance Framework Quarter 3 Report 2017/ Chair and Chief Officer Report Dr Crichton stated that the Chair and Chief Officer Report was for noting by the Governing Body however wished to highlight the following points: NHS Doncaster CCG 360 Stakeholder Survey - The CCG s 360 Stakeholder Survey 2017/18 is underway the results of which are being collated by Ipsos Mori on behalf of NHS England with the survey due to conclude by 23 rd February. Dr Crichton requested that Locality Leads encourage completion by member practices within their respective Locality meetings. Planning Guidance 2018/ The publication of the Planning Guidance 2018/2019, which was expected on 19 January 2018, has been delayed. Application to move locality Dr Crichton stated that no objections have been raised by either the South East or North East localities for the request of The Village Practice to move to the North East locality and requested that the Governing Body approve the application. The Governing Body approved the application for the practice to move localities. The Governing Body noted the report. 12. Locality Feedback Locality Leads gave the following feedback from their Locality meetings: North East Locality Dr Bradley reported that the following items were discussed: Mr Taylor, Head of Governance attended the meeting to discuss the 12

27 proposed changes to the Locality model. North West Locality Dr Seddon reported that the following items were discussed: Dr Crichton attended the meeting to discuss the Doncaster Place Plan, the Accountable Care System and the 360 Stakeholder Survey. Mr Taylor, Head of Governance attended the meeting to discuss the proposed changes to the Locality model. The following feedback from the North West Locality meeting was received: o Sickness within the Medicines Management Team. o It was felt that electronic referrals were not working effectively. o Askern Medical Practice has requested Church view surgery to join the North West Locality from South West Locality once they take ownership of the contract. South East Locality Dr Singh confirmed that no meeting had taken place. South West Locality Dr Crichton attended the meeting to discuss the Doncaster Place Plan, the Accountable Care System and the 360 Stakeholder Survey. Central Locality Dr Tupper reported that the following item was discussed: Mr Taylor, Head of Governance attended the meeting to discuss the changes to the Locality model. 13. Receipt of Minutes The following draft minutes were received and noted by the Governing Body: Primary Care Commissioning Committee Minutes from the meeting held on 14 December Executive Committee Minutes of the meeting held on 6 December South Yorkshire & Bassetlaw Sustainability & Transformation Collaborative Partnership Board Minutes from the meeting held on 10 November Any Other Business Mr Fitzgerald informed the Governing Body that emergency cover for GP practices has been arranged for the Doncaster Wide Primary Care Event taking place on 1 February The Governing Body acknowledged that Mrs Jackie Daniel, Ex-Chief 13

28 Nurse, Doncaster and Bassetlaw Teaching Hospital NHS Foundation Trust has been awarded Dame Commander of the Order of the British Empire. 15. Date and Time of Next Meeting 1:00pm on Thursday 15 February

29 Verbal Item 6 Matters Arising

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31 Enc B Item 7 Planning Guidance 2018/2019

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33 Meeting name Governing Body Meeting date 15 th February 2018 Title of paper Refreshing NHS Plans for 2018/19 - Planning Guidance Executive / Clinical Lead(s) Author(s) Anthony Fitzgerald Director of Strategy & Delivery Anthony Fitzgerald Director of Strategy & Delivery Purpose of Paper - Executive Summary The NHS already has two-year contracts and improvement priorities set for the period 2017/19. These were based on the NHS Operational Planning and Contracting Guidance published in September 2016 and reflected in the March 2017 document Next Steps on the NHS Five Year Forward View The DCCG Governing Body approved the Commissioning & Contracting Intentions in November 2016 and the 12 Focussed Delivery Plans in March The attached document is guidance received by NHS England and NHS Improvement in regard to refreshing these plans for the 2018/19 financial year. Page 3 and 4 of this summary shows the timetables that local teams in the CCG are working toward, including Governing Body sign off of refreshed plans on 15 th March There is also a requirement for the DCCG refreshed Commissioning and Contracting intentions to align with the South Yorkshire & Bassetlaw Integrated Care System operative plan narrative. A summary of some of the main points within the guidance are shown below Financial framework for Commissioners Resources available to CCGs will be increased by 1.4 billion, reflecting realistic levels of emergency activity, additional elective activity to tackle waiting lists, universal adherence to the Mental Health Investment Standard and a commitment to reaching standards set for cancer services and primary care. Additional investment will be made through: o removing the requirement for CCGs to underspend 0.5 per cent of their allocations for 2018/19, releasing 370 million, and removal of the requirement for a further 0.5 per cent to be spent non-recurrently o an additional 600 million for CCG allocations in 2018/19, distributed in proportion to target allocations o creation of a new 400 million Commissioner Sustainability Fund to enable CCGs to return to in-year financial balance. National tariff The two-year tariff remains in place for next year. 1

34 Underlying assumptions Local systems are expected to continue to implement the priority efficiency programmes within the ten-point efficiency plan. CCGs will receive the remaining period of temporary benefit from changes made to Category M generic drug prices. Emergency care Clarity on control totals, as well as additional sustainability funding for providers and commissioners, are intended to enable health systems to plan for activity in a way that enables improved A&E performance. Allocations also allow for a 2.3 per cent growth in non-elective admissions and a 1.1 per cent growth in A&E attendances. It is expected that government will roll forward the goal of ensuring aggregate performance against the four-hour target of 90 per cent for September 2018, with the majority of providers achieving 95 per cent for March 2019 and a return to overall adherence to the 95 per cent standard during Plans should demonstrate how commissioners and providers will complete the implementation of the integrated urgent care strategy. All providers and commissioners should work together to reduce length of stay. Community providers will be invited to participate in a new local incentive scheme where savings from acute excess bed day costs can be reinvested to expand community and intermediate care. 210 million CCG Quality Premium incentive funding will be contingent on performance on moderating demand for emergency care. Referral to treatment times Allocations now allow for improvements in the volume of elective surgery and improvements in waits over 52 weeks. Commissioners and providers are asked to plan on the basis that their RTT waiting list will be no higher in March 2019 than March 2018, and should aim to reduce it. National numbers of patients waiting over 52 weeks should be halved by March Provider plans will need to consider the capacity required to deliver growth in elective and non-elective activity. Integrated system working Integrated care systems (previously known as accountable care systems) will continue to be rolled out voluntarily. The existing ICS areas should prepare a single system operating plan narrative, rather than individual organisational narratives, and NHS England and NHS Improvement will focus their assurance on these system plans, not organisational ones. There will be a further, non-recurrent, allocation within each STP to support its leadership. 2

35 The existing ICS areas should prepare a single system operating plan narrative, rather than individual organisational narratives, and NHS England and NHS Improvement will focus their assurance on these system plans, not organisational ones. All ICSs will work within a system control total, with flexibility to vary individual control totals. All ICSs will be required to operate under system control total incentive structures by 2019/20, but there will be some flexibility on this in 2018/19. Systems adopting this structure will have a more autonomous regulatory relationship with NHS England and NHSI. Winter demand and capacity There will be no additional winter funding in 2018/19. Systems will need to demonstrate that winter plans are embedded in both system and individual organisation operating plans. There is a requirement for each system to produce a separate winter demand and capacity plan. Guidance for these plans will be available by March 2018 Process and timetable Commissioners and providers should update the 2018/19 year of their existing twoyear plans to take account of these changes. Where changes need to be reflected in finance, activity or other schedules, a contract variation should be agreed and signed no later than 23 March

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37 Recommendation(s) Governing Body are asked to Note the NHS England and NHS Improvement Refreshing NHS Plans for 2018/19 Guidance Note the National and CCG Planning Timetable Approve the approach taken by the CCG prior to Governing Body sign off of refreshed plans on 15 th March 2018 Impact analysis Quality impact Equality impact Sustainability impact Financial implications Legal implications Management of Conflicts of Interest Consultation / Engagement (internal departments, clinical, stakeholder & public/patient) Report previously presented at Risk analysis [Identify any quality impact] [Identify any equality impact positive, negative or neutral] [Identify any sustainability impact including nil] [Identify any financial impact cost, saving or nil] [Identify any legal impact including nil] [Include details of any conflicts of interest declared] [Where declarations have been made, include details of the conflicted individual(s) name, position; the conflict(s) details, and how these have been managed in preceding meetings] [Confirm whether the interest is recorded on the register of interests if not list the agreed course of action] [Identify any prior consultation/engagement] [include engagement with internal departments (e.g. finance, medicines management, contracting, quality), clinical engagement, stakeholder engagement and public/patient engagement] [List any other meetings which have discussed the paper, and the outcomes] [Identify any risks arising from the paper not otherwise covered in the Executive Summary and how the paper mitigates risks] 5

38 Assurance Framework [List the Assurance Framework risks to which the paper relates] 6

39 Meeting name Governing Body Meeting date 15 th February 2018 Title of paper Refreshing NHS Plans for 2018/19 - Planning Guidance Executive / Clinical Lead(s) Author(s) Anthony Fitzgerald Director of Strategy & Delivery Anthony Fitzgerald Director of Strategy & Delivery Purpose of Paper - Executive Summary The NHS already has two-year contracts and improvement priorities set for the period 2017/19. These were based on the NHS Operational Planning and Contracting Guidance published in September 2016 and reflected in the March 2017 document Next Steps on the NHS Five Year Forward View The DCCG Governing Body approved the Commissioning & Contracting Intentions in November 2016 and the 12 Focussed Delivery Plans in March The attached document is guidance received by NHS England and NHS Improvement in regard to refreshing these plans for the 2018/19 financial year. Page 3 and 4 of this summary shows the timetables that local teams in the CCG are working toward, including Governing Body sign off of refreshed plans on 15 th March There is also a requirement for the DCCG refreshed Commissioning and Contracting intentions to align with the South Yorkshire & Bassetlaw Integrated Care System operative plan narrative. A summary of some of the main points within the guidance are shown below Financial framework for Commissioners Resources available to CCGs will be increased by 1.4 billion, reflecting realistic levels of emergency activity, additional elective activity to tackle waiting lists, universal adherence to the Mental Health Investment Standard and a commitment to reaching standards set for cancer services and primary care. Additional investment will be made through: o removing the requirement for CCGs to underspend 0.5 per cent of their allocations for 2018/19, releasing 370 million, and removal of the requirement for a further 0.5 per cent to be spent non-recurrently o an additional 600 million for CCG allocations in 2018/19, distributed in proportion to target allocations o creation of a new 400 million Commissioner Sustainability Fund to enable CCGs to return to in-year financial balance. National tariff The two-year tariff remains in place for next year. 1

40 Underlying assumptions Local systems are expected to continue to implement the priority efficiency programmes within the ten-point efficiency plan. CCGs will receive the remaining period of temporary benefit from changes made to Category M generic drug prices. Emergency care Clarity on control totals, as well as additional sustainability funding for providers and commissioners, are intended to enable health systems to plan for activity in a way that enables improved A&E performance. Allocations also allow for a 2.3 per cent growth in non-elective admissions and a 1.1 per cent growth in A&E attendances. It is expected that government will roll forward the goal of ensuring aggregate performance against the four-hour target of 90 per cent for September 2018, with the majority of providers achieving 95 per cent for March 2019 and a return to overall adherence to the 95 per cent standard during Plans should demonstrate how commissioners and providers will complete the implementation of the integrated urgent care strategy. All providers and commissioners should work together to reduce length of stay. Community providers will be invited to participate in a new local incentive scheme where savings from acute excess bed day costs can be reinvested to expand community and intermediate care. 210 million CCG Quality Premium incentive funding will be contingent on performance on moderating demand for emergency care. Referral to treatment times Allocations now allow for improvements in the volume of elective surgery and improvements in waits over 52 weeks. Commissioners and providers are asked to plan on the basis that their RTT waiting list will be no higher in March 2019 than March 2018, and should aim to reduce it. National numbers of patients waiting over 52 weeks should be halved by March Provider plans will need to consider the capacity required to deliver growth in elective and non-elective activity. Integrated system working Integrated care systems (previously known as accountable care systems) will continue to be rolled out voluntarily. The existing ICS areas should prepare a single system operating plan narrative, rather than individual organisational narratives, and NHS England and NHS Improvement will focus their assurance on these system plans, not organisational ones. There will be a further, non-recurrent, allocation within each STP to support its leadership. 2

41 The existing ICS areas should prepare a single system operating plan narrative, rather than individual organisational narratives, and NHS England and NHS Improvement will focus their assurance on these system plans, not organisational ones. All ICSs will work within a system control total, with flexibility to vary individual control totals. All ICSs will be required to operate under system control total incentive structures by 2019/20, but there will be some flexibility on this in 2018/19. Systems adopting this structure will have a more autonomous regulatory relationship with NHS England and NHSI. Winter demand and capacity There will be no additional winter funding in 2018/19. Systems will need to demonstrate that winter plans are embedded in both system and individual organisation operating plans. There is a requirement for each system to produce a separate winter demand and capacity plan. Guidance for these plans will be available by March 2018 Process and timetable Commissioners and providers should update the 2018/19 year of their existing twoyear plans to take account of these changes. Where changes need to be reflected in finance, activity or other schedules, a contract variation should be agreed and signed no later than 23 March

42 4

43 Recommendation(s) Governing Body are asked to Note the NHS England and NHS Improvement Refreshing NHS Plans for 2018/19 Guidance Note the National and CCG Planning Timetable Approve the approach taken by the CCG prior to Governing Body sign off of refreshed plans on 15 th March 2018 Impact analysis Impact on Quality of services provided via the refreshing of 2018/19 plans Quality impact are to be primarily monitored through the Quality and Safety Committee Equality Equality impact of services provided via the refreshing of 2018/19 plans impact are to be monitored through the Engagement and Experience Committee Sustainability Sustainability impact is to be assessed as part of the Accountable Care impact System Financial Financial framework for commissioners is identified in the planning implications guidance Legal nil implications Management Any conflicts of interest are monitored in line with the CCG s conflict of of Conflicts of interest procedures Interest Consultation / Engagement (internal departments, clinical, stakeholder & public/patient) Report previously presented at Risk analysis Assurance Framework Consultation and engagement are a full part of the CCG s commissioning business case process monitored by the Engagement and Experience Committee Various elements of the report have been presented previously in meeting the planning guidance across the governance structure Risks identified in meeting the planning guidance are captured via the Corporate Risk Register Impacts on all Assurance Framework risks across the four Corporate Objectives 5

44 6

45 Refreshing NHS Plans for 2018/19 Published by NHS England and NHS Improvement

46 OFFICIAL Refreshing NHS plans for 2018/19 Version number: 1.0 First published: February 2018 Prepared by: NHS England and NHS Improvement This document is for: Foundation Trusts, NHS Trusts, Direct Commissioners and CCGs and should be read in conjunction with the NHS Operational Planning and Contracting Guidance Publications Gateway Reference: and This information can be made available in alternative formats, such as easy read or large print, and may be available in alternative languages, upon request. Please contact or 2

47 OFFICIAL Contents 1 Introduction Financial Framework Planning Assumptions for emergency care and Referral to Treatment Times Delivery of Next Steps Priorities Integrated System Working Process and Timetable Annex 1: 2018/19 Deliverables

48 OFFICIAL 1 Introduction 1.1 The NHS already has two-year contracts and improvement priorities set for the period 2017/19. These were based on the NHS Operational Planning and Contracting Guidance published in September 2016 and reflected in the March 2017 document Next Steps on the NHS Five Year Forward View. 1.2 The November 2017 budget announced additional NHS revenue funding of 1.6 billion for 2018/19, which will increase funding for emergency & urgent care and elective surgery. In addition, for other core frontline services such as mental health and primary care, the Department of Health & Social Care (DHSC) is making a further 540 million available through the Mandate over the coming financial year. It is now our collective responsibility to ensure we deliver the best possible health service within the funds available. This joint NHS England and NHS Improvement updated guidance sets out how these funds will be distributed and the expectations for commissioners and providers in updating their operational plans for 2018/ In line with the priorities set out by the NHS England Board on 30 November 2017, for 2018/19 we will build on the progress made in 2017/18 and protect investment in mental health, cancer services and primary care in line with the available resources and agreed plans. Recognising the scale of unmet need in mental health, the importance of cancer services and the intense pressures on primary care we believe it would be unacceptable to compromise progress on these services. This means a continued commitment to deliver the cancer waiting time standards, achievement by each and every CCG of the Mental Health Investment Standard, service expansions set out by the Mental Health Taskforce and General Practice Forward View commitments, consistent with the expectations already set out in the planning guidance. 1.4 Given that two-year contracts are in place, 2018/19 will be a refresh of plans already prepared. This will enable organisations to continue to work together through STPs to develop system-wide plans that reconcile and explain how providers and commissioners will collaborate to improve services and manage within their collective budgets. Additional freedoms and flexibilities, described in this guidance, will support the most advanced Integrated Care Systems to lead this process. 1.5 Our energies must remain focused on improving the quality of care for patients and maintaining financial balance, whilst working in partnership to strengthen the sustainability of services for the future. 2 Financial Framework Financial Framework for CCGs 2.1 The resources available to CCGs will be increased by 1.4 billion, principally to fund realistic levels of emergency activity in plans, the additional elective activity 4

49 OFFICIAL necessary to tackle waiting lists, universal adherence to the Mental Health Investment Standard and transformation commitments for cancer services and primary care. This additional investment will be made available in the following ways: the requirement for CCGs to underspend 0.5% of their allocations has been lifted for 2018/19, releasing 370 million of CCGs resources to fund local pressures and transformation priorities. The requirement to use a further 0.5% of CCGs allocations solely for non-recurrent purposes has also been lifted; 600 million will be added to CCG allocations for 2018/19 (which otherwise remain unchanged), distributed in proportion to CCGs target allocations (which have been updated to reflect the latest population estimates and other data) 1 ; and a new 400 million Commissioner Sustainability Fund (CSF) will be created, partly mirroring the financial framework for providers, to enable CCGs to return to in-year financial balance, whilst supporting and incentivising CCGs to deliver against their financial control totals. 2.2 CCGs will be expected to plan against financial control totals communicated at the outset of the planning process 2 alongside revised allocations. CCGs collectively will be expected to deliver financial balance after the deployment of the Commissioner Sustainability Fund, and control totals will be set on this basis. Drawdown of cumulative underspends will be available subject to affordability, and where agreed with the relevant NHS England regional team. 2.3 CCGs control totals will take into account each CCG s financial performance in 2017/18. Any CCG that is overspending in 2017/18 will be expected to improve its in-year financial performance by at least 1% of its overall allocation, and those with longer standing and/or larger cumulative deficits will be given a more accelerated recovery trajectory. Commissioner Sustainability Fund 2.4 Where it is agreed that a CCG is unable to operate within its recurrent allocation for 2018/19 it will be required to commit to a credible plan, agreed and aligned at STP level, to deliver a stretching but realistic deficit control total set by NHS England and it will then qualify to access the Commissioner Sustainability Fund provided it delivers its financial control total. 2.5 All CCGs will be expected to achieve a minimum of financial balance with zero deficits, following deployment of any CSF allocations. Full details on the operation of the CSF will be published shortly. 1 Revised CCG allocations have been published alongside this document on a provisional basis and for planning purposes, subject to confirmation at the NHS England public Board meeting on 8 February CCGs will be informed of their control total by NHS England in writing, shortly after this guidance is published. 5

50 OFFICIAL Provider Sustainability Fund and Financial Framework for NHS Providers million will be added to the 1.8 billion Sustainability and Transformation Fund to create an enhanced 2.45 billion Provider Sustainability Fund, targeted at the same objectives as the existing Sustainability and Transformation Fund. The additional 650 million must deliver at least a pound-for-pound improvement in the aggregate provider financial position and will be reflected in 2018/19 provider control totals 3. As in 2017/18, 30% of the total 2.45 billion fund will be linked to A&E performance. Full details will be published separately via an update to the existing Sustainability and Transformation Fund guidance. To access the performance element, each provider will need to achieve A&E performance in 2018/19 that is the better of either 90% or the equivalent quarter for 2017/18. The provider sector will plan and deliver a balanced income and expenditure position for 2018/19 after deployment of the 2.45 billion Provider Sustainability Fund. 2.7 Providers will be expected to plan on the basis of their 2018/19 control totals. Provider plans must make clear whether the Board has confirmed acceptance of its control total. NHS Improvement will use the completed financial planning template to capture this decision. If the control total has not been accepted, this is likely to trigger action under the Single Oversight Framework. 2.8 Providers who accept their control totals and so have access to the Provider Sustainability Fund for 2018/19 will continue to be exempt from the application of an agreed range of contractual performance sanctions, as set out in the existing NHS Standard Contract. NHS England will shortly consult on changes to the Contract to extend this exemption to all national contractual performance sanctions except those relating to mixed sex accommodation, cancelled operations, Healthcare Associated Infections and the duty of candour, on the basis that continuing NHS Improvement oversight, including the NHS Improvement Single Oversight Framework, will ensure that NHS providers continue to perform to acceptable levels against all national standards. Neither providers nor commissioners should include the expected impact of contractual sanctions in their plans, whether or not the provider has accepted its control total and so has access to the Provider Sustainability Fund. Providers who accept control totals (and associated conditions) will also be eligible to be considered for any discretionary capital allocations. Capital and Estates 2.9 The 2017 Autumn Budget provided an extra 354 million of public capital in 2018/19 and set out the Government s commitment to delivering its share of the NHS property and estates investment recommended in the Naylor review. NHS England and NHS Improvement are working together with DHSC and HMT to prioritise the allocation of additional STP capital. In updating 2018/19 operational plans, STPs and providers should not assume any capital resource 3 Providers will receive a letter from NHS Improvement informing them of changes to their previously notified 2018/19 control totals shortly after this guidance is published 6

51 OFFICIAL above the level in the current 2018/19 operating plans unless NHS England and NHS Improvement have given written confirmation of additional resource The approval of additional STP capital will be contingent on the STP having a compelling estates and capital plan. The STP plan must be fully aligned with the overarching strategy for service transformation and financial sustainability. This plan must set out how the individual organisations in the STP will work together to deploy capital funding to support integrated service models, maximise the sharing of assets and dispose of unused or underutilised estate. In addition, plans will need to demonstrate both value for money and savings to the STP over a reasonable payback period, taking full account of the life cycle costs associated with any new asset. STPs will also be expected to ensure that they maximise opportunities for self-funding of schemes using their own capital and receipts from land disposals and are fully considering the use of private finance where this provides value for money. Further information on the next steps regarding STP capital will be communicated separately Providers are asked to actively consider the requirement for funding critical estate backlog within their capital plan and explain their strategy for investment in backlog work and risk mitigation including how they will reduce operational expenditure relating to estate and facilities. National Tariff 2.12 The two-year National Tariff Payment System which came into effect from 1 April 2017 remains in place for next year. Local systems are encouraged to consider local payment reform, in particular to complement the introduction of advice and guidance services. Local systems are also encouraged to introduce appropriate local tariffs for emergency ambulatory care where they have not already done so, to replace the current A&E and non-elective tariffs for appropriate conditions. The next round of interventions eligible for direct reimbursement through the Innovation and Technology Payments, a programme designed to incentivise take-up of the latest innovations across the NHS, will be published by 31 March. Underlying Assumptions 2.13 Local systems are expected to continue to implement the priority efficiency programmes within the 10 Point Efficiency Plan. This includes taking every opportunity to maximise provider operational productivity, guided by the Model Hospital portal, and to participate fully in associated programmes. It also includes the implementation of Getting It Right First Time recommendations; participation in networked arrangements for procurement, corporate services and diagnostic services; achieving best practice in clinical and other workforce productivity standards (including reducing agency staff usage); and improving the safety and efficiency of providers estate and facilities. Providers and STPs should also consider how to make best use of the digital and technological systems and innovations available to them. In addition to the moderation of emergency demand discussed below, the use of RightCare, elective care 7

52 OFFICIAL redesign, urgent and emergency care reform, medicines optimisation, and more integrated primary and community services are also key areas of focus CCGs should assume that the current high level of discretionary prices for generic drugs in short supply will not persist in 2018/19. In 2018/19, CCGs will receive the remaining period of temporary benefit from changes made to Category M generic drug prices designed to recover excess community pharmacy margin from previous years (i.e. the Cat M clawback will not continue beyond 2017/18). Beyond this, no assessment has yet been made of whether upward or downward adjustments to generic drugs prices will be needed in 2018/19 to reflect under or over-delivery of community pharmacy margin delivered in 2016/17 and 2017/18. So no allowance for this should be included in CCG plans In December 2017, NHS England issued guidance on Items that should not routinely be prescribed in primary care: Guidance for CCGs. This guidance is aimed at reducing the routine prescribing of 18 ineffective and low clinical value medicines, such as some dietary supplements, herbal treatments and homeopathy. It is assumed CCGs will save up to 141 million a year from this programme. NHS England has also launched a public consultation (closing 20 March 2018) on reducing prescribing of over-the-counter medicines for 33 minor, short-term health concerns, as well as vitamins and probiotics. Depending on the outcome of the consultation, it is assumed this could save the NHS up to 136 million a year. CCGs should consider how to locally implement guidance on the 18 ineffective and low clinical value medicines and consider the potential impact of any developments concerning over the counter medications following the consultation It is assumed that all CCGs continue to work with the NHS England Continuing Healthcare strategic improvement and QIPP programmes to increase standardisation of processes and adopt best practice to deliver the targeted reduction in growth, thus mitigating cost and volume pressures, including the impact of any increases to Funded Nursing Care rates Where the activity, cost and efficiency assumptions made by an STP do not enable each of its organisations to meet the control totals set by NHS England and NHS Improvement, the STP will need to agree additional cost containment measures and highlight any implications. This includes potential impacts on the range or level of services to be provided, and where surpluses will be created to offset any unavoidable deficits within the STP. When considering options to deliver control totals, STPs must ensure the alignment of commissioner and provider assumptions. They must also ensure that plans continue to meet the requirements for A&E, RTT and cancer set out in this letter and that patients are able to exercise choice as set out in the NHS Constitution We are working through the implications of the Government s commitment on NHS pay described in the 2017 Autumn Budget and will publish further guidance in due course. Until this is available the impact of any changes to NHS pay beyond the published assumptions should be excluded from 8

53 OFFICIAL plans. It is essential that the 2018/19 pay costs in financial planning returns are an accurate reflection of the cost of the current, published pay assumptions Further details about CQUIN, Quality Premium, national contract and winter planning are set out in section 6. Specialised Commissioning 2.20 The contracting approach for specialised services continues into 2018/19, aligned to implementation of the Carter review. Specialised commissioners and providers will need to review the 2018/19 activity plans and agree any contract variations required in accordance with the contractual process and to the national timetable. Activity plans for 2018/19 will be reviewed as part of routine in-year contract management, incorporating delivery of QIPP planning and appropriate CQUIN benefit realisation. Locally priced services reform to reduce cost per weighted activity unit, multi-year medicines optimisation approach underpinned by CQUIN, and further reforms to the medical device supply chain, will continue. It remains a priority to have robust and high quality data flows to support accurate reimbursement, in particular of tariff-excluded high cost drugs and devices. 3 Planning Assumptions for Emergency Care and Referral to Treatment Times Emergency Care 3.1 The combination of clarity on control totals for providers and commissioners, underpinned by the increased provider sustainability fund and the new commissioner sustainability fund, paid for using additional budget funding, should enable health systems to fund and plan for this year s activity in a way that enables improved A&E performance in 2018/19. In addition, the allocations for 2018/19 allow for 2.3% growth in non-elective admissions and ambulance activity and 1.1% growth in A&E attendances. This is in aggregate for England and reflects recent trends, but activity growth patterns to be reflected in plans will in practice vary by commissioner and provider. 3.2 Our expectation is that the Government will roll forward the goal of ensuring that aggregate performance against the four-hour A&E standard is above 90% for the month of September 2018, that the majority of providers are achieving the 95% standard for the month of March 2019, and that the NHS returns to 95% overall performance within the course of STPs, commissioner and providers should review assumptions for levels of A&E attendances and nonelective admissions to ensure they reflect recent trends, adjusting as appropriate for demand management and other efficiency schemes that have been agreed between CCGs and providers. Given the differential implications for both bed capacity and cost, organisations will be required to plan and report non-elective admissions of less than one day separately from those of one day or more. Plans will also be collected on planned bed numbers to ensure 9

54 OFFICIAL sufficient capacity is available throughout the year to meet anticipated demand for emergency and elective care. 3.3 Commissioner and provider plans will be expected to demonstrate how they will complete the implementation of the integrated urgent care strategy that was commenced this year, and how sufficient capacity will be available to meet planned activity growth through a combination of additional beds and/or: reductions in delayed transfers of care (DTOCs), both through reducing NHS-driven DTOCs and through continuing to work with local authorities to reduce social care DTOCs, with the aim of reducing the proportion of beds occupied by DTOC patients to 3.5%; reductions in average length of stay, including a focus on those patients with the longest length of stay as identified in the stranded patients metrics. 3.4 It is clear that there is significant variation in length of stay between providers, particularly in the number of patients with a length of stay over seven days (stranded patients) and a length of stay over 21 days (super stranded patients). We expect all providers and commissioners to work together to focus on reducing their length of stay, and particularly the very long lengths of stay, to release capacity for patients who are legitimately waiting for a hospital bed. 3.5 To further support progress in these areas and free-up capacity, providers of community services will be invited to participate in a new local incentive scheme in conjunction with their CCG whereby they will be able to reinvest savings from acute excess bed day costs to expand community and intermediate care services. This will benefit stranded and super-stranded patients in particular. 3.6 A total of 210 million of CCG Quality Premium incentive funding will be contingent on performance on moderating demand for emergency care. This payment will be conditional on the CCG meeting or improving on the levels jointly planned with providers. The principal metric for this purpose will be the level of growth in non-elective activity compared to the agreed plan. Referral to Treatment Times 3.7 The 2018/19 allocations now allow for improvements in the volume of elective surgery being funded next year, and improvements in the number of patients waiting over 52 weeks. A more significant annual increase in the number of elective procedures compared with recent years means commissioners and providers should plan on the basis that their RTT waiting list, measured as the number of patients on an incomplete pathway, will be no higher in March 2019 than in March 2018 and, where possible, they should aim for it to be reduced. Numbers nationally of patients waiting more than 52 weeks for treatment should be halved by March 2019, and locally eliminated wherever possible. The planning assumption for England as a whole is for 4.9% growth in total outpatient attendances (4.0% per working day) and up to 3.6% growth in elective admissions (2.7% per working day). It is also assumed that GP referrals will increase by 0.8% (i.e. no change per working day). The planned growth levels required will vary locally and therefore activity plans should be reviewed 10

55 OFFICIAL to ensure delivery of these objectives, adjusting as appropriate for demand management and other efficiency schemes which have been jointly agreed between commissioners and providers. Systems will be expected to plan and report separately on day case and inpatient elective activity, based on their trend performance, the profile of expected referrals and the composition of their existing waiting list. Systems will be expected to demonstrate to regional teams that their RTT plans are robust and realistic, and that they make best and flexible use of available capacity across their STP footprint in order to optimise delivery against the objectives above. 3.8 Provider plans will need to consider the capacity required to deliver the growth in non-elective and elective activity and the impact on workforce, finance and productivity. Alongside these capacity considerations it remains essential that providers manage within their agency ceilings. 4 Delivery of Next Steps Priorities 4.1 The NHS is already working to two-year priorities as set out in last year s planning guidance and the March 2017 Next Steps on the Five Year Forward View. This document confirms the deliverables for 2018/19. These are set out in Annex 1, together with the progress made against 2017/18 deliverables. 5 Integrated System Working 5.1 In 2018/19, we expect all STPs to take an increasingly prominent role in planning and managing system-wide efforts to improve services. STPs should: ensure a system-wide approach to operating plans that aligns key assumptions between providers and commissioners which are credible in the round; work with local clinical leaders to implement service improvements that require a system-wide effort; for example, implementing primary care networks or increasing system-wide resilience ahead of next winter; identify system-wide efficiency opportunities such as reducing avoidable demand and unwarranted variation, or sharing clinical support and back office functions; undertake a strategic, system-wide review of estates, developing a plan that supports investment in integrated care models, maximises the sharing of assets, and the disposal of unused or underutilised estate; and take further steps to enhance the capability of the system including stronger governance and aligned decision-making, and greater engagement with communities and other partners, including where appropriate, local authorities. STPs should also take steps to resource their own infrastructure. Although these should be mainly drawn from their constituent organisations, NHS England will be making a further nonrecurrent allocation within each STP to support its leadership in 2018/19 on the same basis as last year. 11

56 OFFICIAL Integrated Care Systems 5.2 We will reinforce the move towards system working in 2018/19 through STPs and the voluntary roll-out of Integrated Care Systems. Integrated Care Systems are those in which commissioners and NHS providers, working closely with GP networks, local authorities and other partners, agree to take shared responsibility (in ways that are consistent with their individual legal obligations) for how they operate their collective resources for the benefit of local populations. 5.3 We are now using the term Integrated Care System as a collective term for both devolved health and care systems and for those areas previously designated as shadow accountable care systems. An Integrated Care System is where health and care organisations voluntarily come together to provide integrated services for a defined population. 5.4 We see Integrated Care Systems as key to sustainable improvements in health and care by: creating more robust cross-organisational arrangements to tackle the systemic challenges facing the NHS; supporting population health management approaches that facilitate the integration of services focused on populations that are at risk of developing acute illness and hospitalisation; delivering more care through re-designed community-based and homebased services, including in partnership with social care, the voluntary and community sector; and allowing systems to take collective responsibility for financial and operational performance and health outcomes. 5.5 There are currently eight areas designated as shadow accountable care systems, plus the two devolved health and care systems based on STP footprints (Greater Manchester and Surrey Heartlands). These systems should prepare a single system operating plan narrative that encompasses CCGs and NHS providers, rather than individual organisation plan narratives. The system operating plan should align key assumptions on income, expenditure, activity and workforce between commissioners and providers. System leaders should take an active role in this process, ensuring that organisational plans underpin and together express the system s priorities. All Integrated Care Systems are expected to produce together a credible plan that delivers the system control total, resolving any disputes themselves, and no shadow Integrated Care System will be considered ready to go fully operational if it is unable to produce such a plan. 5.6 To reinforce this approach to system planning, NHS England and NHS Improvement will focus on the assurance of system plans for Integrated Care Systems rather than organisation-level plans. We expect that Integrated Care Systems will assure and track progress against organisation-level plans within their system, ensuring that they underpin delivery of agreed system objectives. 12

57 OFFICIAL NHS England and NHS Improvement will support system leaders in this task. We have developed a new approach to oversight and support for Integrated Care Systems, based on the principles of setting system-wide goals, streamlining the oversight and support provided by NHS England and NHS Improvement (supported by an integrated framework that brings together the separate frameworks for trusts and CCGs), and working with and through the local system leadership to provide any support or interventions in individual providers or localities. 5.7 Integrated Care Systems will be supported by new financial arrangements: all Integrated Care Systems will work within a system control total, the aggregate required income and expenditure position for trusts and CCGs within the system, as communicated by NHS England and NHS Improvement 4. They will be given the flexibility, on a net neutral basis, and in agreement with NHS England and NHS Improvement, to vary individual control totals during the planning process and agree in-year offsets of financial over-performance in one organisation against financial underperformance in another; in 2018/19, systems are encouraged to adopt a fully system-based approach to the PSF and CSF under which no payment will be made unless the system as a whole has delivered against its system control total. If the system achieves its control total, but individual trusts or CCGs do not, the system will still retain its full share of the PSF ( 2.45 billion in aggregate) and any applicable CSF awards, but NHS England and NHS Improvement will agree with the leadership how those trusts and CCGs shares will be apportioned between local organisations; systems adopting this full incentive structure will operate under a more autonomous regulatory relationship with NHS England and NHS Improvement. NHS England and NHS Improvement will also support fully authorised Integrated Care Systems by exercising their intervention powers alongside the system leadership. For example, where there is a case for regulatory intervention in a trust or CCG to address financial underperformance or issues of quality, the leadership of the Integrated Care System will play a key role in agreeing what remedial action needs to be taken; and all approved Integrated Care Systems will be required to operate under these fully-developed system control total incentive structures by 2019/20. However, in 2018/19 systems that are not ready to proceed with full system incentives and shared intervention arrangements will alternatively be allowed to adopt an interim approach under which only the additional funding that has been put into the PSF ( 650 million in aggregate) will be linked to system financial performance. On this option, no payment will be made from this enhanced funding unless the system as a whole meets its control total. If individual trusts or CCGs miss their organisational control totals, but the system still achieves overall, their share will be apportioned in consultation with the system leadership. However, on this interim option 4 Integrated Care Systems will be informed of their system control total by NHS England and NHS Improvement in writing, shortly after this this guidance is published 13

58 OFFICIAL if the individual trusts or CCGs meet their organisational control totals, but the system does not overall, they will retain access to the relevant share of the existing 1.8 billion PSF and any applicable CSF awards. New Integrated Care Systems 5.8 There is strong appetite amongst other systems to join the Integrated Care System development programme and we anticipate that additional systems will wish to join during 2018/19 as they demonstrate their ability to take collective responsibility for financial and operational performance and health outcomes. STPs that can demonstrate their readiness to join the programme should speak to their regional teams to confirm expressions of interest from all organisations in the STP. We will aim to review any applications to join the programme by March We envisage that over time Integrated Care Systems will replace STPs. 5.9 The next cohort of Integrated Care Systems will be selected from STPs with: strong leadership, with mature relationships including with local government. The leadership team should have effective ways of involving clinicians and staff, the third sector, service users and the public. It should also have the right capability and infrastructure to execute on priorities; a track record of delivery, with evidence of tangible progress towards delivering the priorities in Next Steps on the Five Year Forward View. These systems should be meeting NHS Constitution standards or provide confidence that by working as an integrated system they are more likely to be recovered; strong financial management, with a collective commitment from CCGs and providers to system planning and shared financial risk management, supported by a system control total and system operating plan; a coherent and defined population that reflects patient flows and, where possible, is contiguous with local government boundaries; and compelling plans to integrate primary care, mental health, social care and hospital services using population health approaches to redesign care around people at risk of becoming acutely unwell. These models will necessarily require the widespread involvement of primary care, through incipient networks. Public Engagement 5.10 As systems make shifts towards more integrated care, we expect them to involve and engage with patients and the public, their democratic representatives and other community partners. Engagement plans should reflect the five principles for public engagement identified by Healthwatch and highlighted in the Next Steps on the Five Year Forward View. 14

59 OFFICIAL 6 Process and Timetable 6.1 The task for commissioners and providers is to update the 2018/19 year of existing two-year plans to take account of the points set out above and to ensure that operating plans: are stretching and realistic, and show a bottom line position consistent with the control totals set by NHS England and NHS Improvement; are the product of partnership working across STPs, with clear triangulation between commissioner and provider plans and related contracts to ensure alignment in activity, workforce and income and expenditure assumptions and with assurance from STP leaders that this is the case whilst ensuring the updated plans and contracts are aligned between commissioners and providers. As a result of the activity moderation incentives in the new Commissioner Sustainability Fund and the revised Quality Premium scheme, it is now more critical than ever that activity and finance plans are aligned between commissioners and providers; and include appropriate phasing profiles to reflect seasonal changes in demand, especially related to winter, and ensuring efficiency savings are not back-loaded into the later part of the financial year. Contract Variations 6.2 Where the 2018/19 plans have changed and these changes need to be reflected in the finance, activity or other schedules for the second year of twoyear contracts, a contract variation should be agreed to this effect, and signed no later than 23 March The NHS Standard Contract sets out clear rules relating to the updating of a contract for a second year, and our expectation is therefore that there should be no disputes between commissioners and providers about these variations. 6.4 Where commissioners and providers fail to reach timely agreement the dispute resolution process in the contract should be followed. Starting with escalated negotiation, the process then moves into mediation. Mediation may be undertaken within STPs if both parties are in agreement, or where this is not possible, it may be arranged with a third party. Where, exceptionally, agreement is not reached through mediation, organisations will be expected to follow the Expert Determination process set in the dispute resolution guidance, which will be published shortly. NHS England and NHS Improvement will view use of mediation, and in particular determination, as a failure of local system relationships and leadership. This guidance also provides detailed advice about the rules within the Contract on varying a contract for its second year. 6.5 On 3 January 2018, NHS England published a National Variation to the Standard Contract. This was principally to give effect to changes to the ambulance response standards, but took the opportunity to incorporate other national policy requirements which had been announced since the planning round. In particular, these related to: prohibiting the sale of sugary 15

60 OFFICIAL drinks on NHS provider premises; prohibiting the provision or promotion of certain legal services from NHS provider premises; and mandating participation by NHS providers in the Nationally Contracted Products Programme. Commissioners and providers are legally bound to incorporate these changes into local contracts. Plan Submissions 6.6 All commissioners (CCGs and direct commissioning including specialised) and all providers are required to submit a full suite of operating plan returns to the deadlines in the national timetable (see below); and also adhere to the contract variation deadlines and processes. We will update technical planning guidance to support the submission of templates to ensure plans are completed on a consistent basis and to a high standard. The data collected will be used to inform decision making and will also form the plan against which 2018/19 delivery is judged. All organisations must ensure submissions are accurate, detailed and consistent with their Board approved plans. 6.7 For providers the first and final plan submission will include finance, activity, workforce and triangulation returns alongside an update to the existing two-year plan narrative. For providers that are part of an Integrated Care System the provider plan narrative will be updated with a system plan narrative that describes the key changes to the existing plan, which will be assured jointly by NHS England and NHS Improvement. 6.8 Provider workforce plans will need to consider the significant workforce supply and retention challenges in the NHS. For 2018/19, providers are expected to update their workforce plans to reflect latest projections of supply and retention, taking into account the supply of staff from Europe and beyond, changes to NHS nursing and allied health professional bursaries, improvements expected in agency and locum use. Plans should also be updated to take account of the strengthening of bank arrangements and opportunities identified for improved productivity and workforce transformation through new roles and/or new ways of working. It is important that workforce plans are detailed and well-modelled and align with both financial and service activity plans to ensure the proposed workforce levels are affordable, efficient and sufficient to deliver safe care to patients. The workforce plans submitted will be used nationally for pay modelling during the year. 6.9 Commissioners will need to submit draft and final commissioner operating plan updates, using the financial, performance activity and milestone plan templates. These and the supporting guidance will be issued separately. Draft and final finance, performance and activity plans must be consistent, and triangulated with provider expectations For STPs, para 2.17 sets out the requirement to ensure alignment in activity, income and expenditure assumptions across STPs. Building on the 2017/18 in year contract alignment approach, we will be asking STP leaders to return a contract and plan alignment template to demonstrate that updated plans and contracts are aligned financially between commissioners and providers. 16

61 OFFICIAL CQUIN and Quality Premium 6.11 NHS England will shortly be publishing an update to the 2017/19 CQUIN guidance. This update is required to provide indicator thresholds for some indicators for year 2 of the scheme. As part of the update, NHS England will clarify the requirements around the influenza vaccination indicator. In addition, NHS England has made some changes to the anti-microbial resistance indicator to take account of supply issues. The sepsis indicator will also be updated to require providers to replace locally devised protocols with a National Early Warning Score (NEWS) by March In September 2017, the National Quality Board strongly endorsed NEWS as a standardised system between clinicians in the acute setting to help early detection of deterioration/ identification of sepsis. Organisations will also be required to make a one-off data return in relation to the healthy food and drink indicator at the end of Q In addition, in light of the specific challenges around delivering provider side balance, NHS England has agreed with NHS Improvement to offer a temporary relaxation of an element of the scheme for acute providers. Our shared position is that this concession is being made in 2018/19 only. On the basis that there are multiple initiatives supporting the discharge agenda, we have agreed to suspend the proactive and safe discharge indicator for acute providers, with the remaining five indicators in the scheme increasing their weighting from 0.25% to 0.3% as a temporary measure for 2018/ This change will have implications for the linked indicators in Community and Care Home settings. We are issuing an updated indicator for Care Home providers. For Community providers, we expect CCGs to either take this opportunity to include a local CQUIN indicator in their contracts, or increase the weights of the remaining five indicators in the scheme to 0.3% The 0.5% risk reserve CQUIN will be withdrawn in 2018/19. The 0.5% will be added to the engagement CQUIN, which will increase as a result to 1% Our collective expectation is that the degree of conditionality in CQUIN will return to its 2017/18 levels from 2019/20. These temporary suspensions are not an indication of our future intentions for the CQUIN scheme, in respect of the quantum, the number of indicators, or their respective weightings In line with our policy intent that CQUIN is realistically earnable, NHS England and NHS Improvement will be trialling a new triangulated provider/ commissioner finance return, to confirm whether CQUIN awards have been earned during the year As previously indicated, the 2018/19 Quality Premium scheme will be restructured to include an incentive on non-elective demand management. Given the significant emphasis we wish CCGs to give to this issue, the nonelective measure will make up the majority of the Quality Premium scheme, with a potential award of 210 million nationally. We will retain a number of the existing quality measures, which will be linked to the remainder of the potential 17

62 OFFICIAL Quality Premium funding, and we will continue to moderate payment through the operation of the existing Finance and Quality gateways. We will shortly publish updated guidance which will set out the full details of the revised scheme. Winter Demand & Capacity Plans 6.18 There will be no additional winter funding in 2018/19. To ensure that winter preparation has been undertaken well in advance and using existing funds, systems will need to demonstrate that winter plans are embedded both in their system plans and in individual organisations operating plans, including realistic phasing of non-elective and elective activity across the year To support this there is a requirement for each system to produce a separate winter demand and capacity plan, triangulating the finance and activity implications along with the actions and proposed outcomes. Guidance on submitting these winter plans will be available by March Timetable Item Date ICS system control total changes and assurance statement submitted By 1 March 2018 Local decision to enter into mediation for 2018/19 contract variations 2 March 2018 Draft 2018/19 Organisational Operating Plans submitted 8 March 2018 Draft 2018/19 STP Contract and Plan Alignment template submitted 8 March 2018 National deadline for signing 2018/19 contract variations and contracts 23 March /19 Expert Determination paperwork completed and shared by all parties 27 April 2018 Final Board or Governing Body approved Organisation Operating Plans submitted 30 April /19 Winter Demand & Capacity Plans submitted 30 April 2018 Final 2018/19 STP Contract and Plan Alignment template submitted Final date for experts to notify outcome of determinations for 2018/19 update 30 April June

63 Annex 1: 2018/19 Deliverables Reminder of 2018/19 deliverables drawn from Next Steps on the NHS Five Year Forward View published in March 2017 The NHS already has two-year priorities, set out in last year s Planning Guidance and the March 2017 publication of the Next Steps on the NHS Five Year Forward View. This Annex confirms these deliverables for 2018/19. For national targets we will, where appropriate, provide disaggregated STP and CCG-level improvement targets and templates to ensure plans are completed on a consistent basis. 1. Mental Health Overall Goals for We published Implementing the Mental Health Forward View in July 2016 to set out clear deliverables for putting the recommendations of the independent Mental Health Taskforce Report into action by 2020/21. The publication of Stepping Forward to 2020/21 5 in July 2017 provides a roadmap to increase the mental health workforce needed to deliver this. Making parity a reality will take time, but this a major step on the journey towards providing equal status for mental and physical health. These ambitions are underpinned by significant additional funding for mental health care, which should not be used to supplant existing spend or balance reductions elsewhere. Progress in 2017/18 On track to ensure an extra 35,000 children and young people are able to access services this year. 70 new or extended community eating disorder services funded and commissioned. 81 new beds for Children and Adolescent Mental Health Services (Tier 4) and at least another 50 beds will open by Deliverables for 2018/19 Additional funding has now been built into CCG 2018/19 allocations to support the expansion of services outlined in this planning guidance and the specific trajectories set for 2018/19 to deliver the Five Year Forward View for Mental Health. Progress to be made against all deliverables in the Next Steps on the NHS Five Year Forward View and the Implementing the Mental 5 Stepping Forward to 2020/21: Mental Health Workforce Plan for England (Health Education England).

64 OFFICIAL end of March Expanded specialist perinatal care with over 5,000 additional women accessing these services between April and December Contracts awarded for four new Mother and Baby Units. Continued to meet the waiting time standard for early intervention in psychosis. Physical health checks and interventions for patients with severe mental illness in secondary care, with 60% of people in inpatient settings and 42% in community mental health teams receiving this to date. Health Education England (HEE) expects to provide over 600 training places for Improving Access to Psychological Therapies (IAPT) practitioners. At least 800 practitioners in primary care settings by March mental health new care models up and running and an additional 7 go live by April CCGs have continued to meet the dementia diagnosis standard, which was at 68.3% by December Seven Global Digital Exemplar Mental Health Trusts, funded to identify trusts which they will partner with as fast followers. Health Forward View in 2018/19 with all CCGs and STPs required to: Each CCG must meet the Mental Health Investment Standard (MHIS) by which their 2018/19 investment in mental health rises at a faster rate than their overall programme funding. CCGs auditors will be required to validate their 2018/19 year-end position on meeting the MHIS. Ensure that an additional 49,000 children and young people receive treatment from NHS-commissioned community services (32% above the 2014/15 baseline) nationally, towards the 2020/21 objective of an additional 70,000 additional children and young people. Ensure evidence of local progress to transform children and young people s mental health services is published in refreshed joint agency Local Transformation Plans aligned to STPs. Make further progress towards delivering the 2020/21 waiting time standards for children and young people s eating disorder services of 95% of patient receiving first definitive treatment within four weeks for routine cases and within one week for urgent cases. Deliver against regional implementation plans to ensure that by 2020/21, inpatient stays for children and young people will only take place where clinically appropriate, will have the minimum possible length of stay, and will be as close to home as possible to avoid inappropriate out of area placements, within a context of additional beds. Continue to increase access to specialist perinatal mental health services, ensuring that an additional 9,000 women access specialist perinatal mental health services and boost bed numbers in the 19 units that will be open by the end of 2018/19 so that overall capacity is increased by 49%. 20

65 OFFICIAL Continue to improve access to psychology therapies (IAPT) services with, maintaining the increase of 60,000 people accessing treatment achieved in 2017/18 and increase by a further 140,000 delivering a national access rate of 19% for people with common mental health conditions. Do so by supporting HEE s commissioning of 1,000 replacement practitioners and a further 1,000 trainees to expand services. This will release 1,500 mental health therapists to work in primary care. Approximately two-thirds of the increase to psychological therapies should be in new integrated services focused on people with co-morbid long term physical health conditions and/or medically unexplained symptoms, delivered in primary care. Continue to ensure that access, waiting time and recovery standards are met. Continue to work towards the 2020/21 ambition of all acute hospitals having mental health crisis and liaison services that can meet the specific needs of people of all ages including children and young people and older adults; and deliver Core 24 mental health liaison standards for adults in 50% of acute hospitals subject to hospitals being able to successfully recruit. Ensure that 53% of patients requiring early intervention for psychosis receive NICE concordant care within two weeks. Support delivery of STP-level plans to reduce all inappropriate adult acute out of area placements by 2020/21, including increasing investment for Crisis Resolution Home Treatment Teams (CRHTTs) to meet the ambition of all areas providing CRHTTs resourced to operate in line with recognised best practice by 2020/21. Review all patients who are placed out of area to ensure that have appropriate packages of care. 21

66 OFFICIAL Deliver annual physical health checks and interventions, in line with guidance, to at least 280,000 people with a severe mental health illness. Provide a 25% increase nationally on 2017/18 baseline in access to Individual Placement and Support services. Maintain the dementia diagnosis rate of two thirds (66.7%) of prevalence and improve post diagnostic care. Deliver their contribution to the mental health workforce expansion as set out in the HEE workforce plan, supported by STP-level plans. At national level, this should also specifically include an increase of 1,500 mental health therapists in primary care in 2018/19 and an expansion in the capacity and capability of the children and young people s workforce building towards 1,700 new staff and 3,400 existing staff trained to deliver evidence based interventions by 2020/21. Deliver against multi-agency suicide prevention plans, working towards a national 10% reduction in suicide rate by 2020/21. Deliver liaison and diversion services to 83% of the population. Ensure all commissioned activity is recorded and reported through the Mental Health Services Dataset. 2. Cancer Overall Goals for Advance delivery of the National Cancer Strategy to promote better prevention and earlier diagnosis and deliver innovative and timely treatments to improve survival, quality of life and patient experience by 2020/21. 22

67 OFFICIAL Progress in 2017/18 Cancer survival at its highest ever with latest figures showing that one-year cancer survival is up by over 2,000 people a year. 95.1% of people seen by a specialist within two weeks of an urgent GP referral for suspected cancer, with 5.1% more patients being seen in the 12 months to November 2017 than in the previous 12 months. Ten multidisciplinary rapid diagnostic and assessment centres in place across the country by March 2018, supporting patients with complex symptoms through to diagnosis. We are on track to deliver the largest radiotherapy upgrade programme in 15 years modern radiotherapy have now funded 26 new machines in 21 trusts in 2017/18. Half of the country s Cancer Alliances have begun to roll out personalised follow-up after cancer treatment. Added 22 more drugs to the Cancer Drugs Fund, which have benefitted nearly 7,500 more patients, taking the total since the reformed CDF launched in July 2016 to 15,700 patients having benefited from 52 drugs treating 81 different cancers. Deliverables for 2018/19 Ensure all eight waiting time standards for cancer are met, including the 62 day referral-to-treatment cancer standard. The 10 high impact actions for meeting the 62 day standard should be implemented in all trusts, with oversight and coordination by Cancer Alliances. The release of cancer transformation funding in 2018/19 will continue to be linked to delivery of the 62 day cancer standard. Support the implementation of the new radiotherapy service specification, ensuring that the latest technologies, including the new and upgraded machines being funded through the 130 million Radiotherapy Modernisation Fund, are available for all patients across the country. Ensure implementation of the nationally agreed rapid assessment and diagnostic pathways for lung, prostate and colorectal cancers, ensuring that patients get timely access to the latest diagnosis and treatment. Accelerating the adoption of these innovations helps meet the 62 days standard ahead of the introduction of the 28 day Faster Diagnosis Standard in April Progress towards the 2020/21 ambition for 62% of cancer patients to be diagnosed at stage 1 or 2, and reduce the proportion of cancers diagnosed following an emergency admission. Support the rollout of FIT in the bowel cancer screening programme during 2018/19 in line with the agreed national timescales following PHE s procurement of new FIT kit, ensuring that at least 10% of all bowel cancers diagnosed through the screening programme are detected at an early stage, increasing to 12% in 2019/20. Participate in pilot programmes offering low dose CT scanning based on an assessment of lung cancer risk in 23

68 OFFICIAL CCGs with lowest lung cancer survival rates. Progress towards the 2020/21 ambition for all breast cancer patients to move to a stratified follow-up pathway after treatment. Around two-thirds of patients should be on a supported self-management pathway, freeing up clinical capacity to see new patients and those with the most complex needs. All Cancer Alliances should have in place clinically agreed protocols for stratifying breast cancer patients and a system for remote monitoring by the end of 2018/19. Ensure implementation of the new cancer waiting times system in April 2018 and begin data collection in preparation for the introduction of the new 28 day Faster Diagnosis standard by Primary Care Overall Goals for Stabilise general practice today and support the transformation of primary care and for tomorrow, by delivering General Practice Forward View and Next Steps on the NHS Five Year Forward View. Progress in 2017/18 52% of the country now benefitting from extended access including appointments on evenings and weekends, beating the target of 40% for 2017/18. Primary care workforce: o Over 770 additional GP trainees started specialist training since 2015 baseline (3,157 in total in 2017/18); o Begun GP international recruitment, with the first 100 GPs being recruited; Deliverables for 2018/19 Progress against all Next Steps on the NHS Five Year Forward View and General Practice Forward View commitments. This includes all CCGs: Providing extended access to GP services, including at evenings and weekends, for 100% of their population by 1 October This must include ensuring access is available during peak times of demand, including bank holidays and across the Easter, Christmas and New Year periods. Delivering their contribution to the workforce commitment 24

69 OFFICIAL o Launched the GP Retention Scheme; o Recruitment of an additional 505 clinical pharmacists, in addition to the 494 already in post. Investment in general practice continues to increase on track to deliver the pledged additional 2.4 billion by CCGs investing in line with expectations set out in the 2017/18 NHS s Planning Guidance, for additional primary care transformation investment ( 3/head) over two years. Invested in upgrading primary care facilities, with 844 schemes completed and a further 868 schemes in development. to have an extra 5,000 doctors and 5,000 other staff working in primary care. CCGs will work with their local NHS England teams to agree their individual contribution and wider workforce planning targets for 2018/19. At national aggregate level we are expecting the following for 2018/19: o CCGs to recruit and retain their share of additional doctors via all available national and local initiatives; o 600 additional doctors recruited from overseas to work in general practice; o 500 additional clinical pharmacists recruited to work in general practice (CCGs whose bids have been successful will be expected to contribute to this increase); o An increase in physician associates, contributing to the target of an additional 1000 to be trained by March 2020 (supported by HEE); o Deliver increase to 1,500 mental health therapists working in primary care. Investing the balance of the 3/head investment for general practice transformation support. Actively encourage every practice to be part of a local primary care network, so that there is complete geographically contiguous population coverage of primary care networks as far as possible by the end of 2018/19, serving populations of at least 30,000 to 50,000. Investing in upgrading primary care facilities, ensuring completion of the pipeline of Estates and Technology Transformation schemes, and that the schemes are delivered within the timescales set out for each project. Ensuring that 75% of 2018/19 sustainability and resilience funding allocated is spent by December 2018, with 100% of the allocation spent by March

70 OFFICIAL Ensuring every practice implements at least two of the high impact time to care actions. In all practices, delivering primary care provider development initiatives for which CCGs will receive delegated budgets, including online consultations. Where primary care commissioning has been delegated, providing assurance that statutory primary medical services functions are being discharged effectively. Lead CCGs expected to commission, with support from NHS England Regional Independent Care Sector Programme Management Offices, medicines optimisation for care home residents with the deployment of 180 pharmacists and 60 pharmacy technician posts funded by the Pharmacy Integration Fund for two years. 4. Urgent and Emergency Care Overall Goals for Redesign and strengthen the urgent and emergency care system to ensure that patients receive the right care in the right place, first time. Progress in 2017/18 More patients able to speak to a clinician about their urgent and emergency care needs when calling NHS % of answered calls now receive clinical input, up from 22% last year. Piloted and evaluated NHS 111 Online in a number of areas, with 27% of the population now able to access urgent and emergency care advice through this online portal. Deliverables for 2018/19 Ensure that aggregate performance against the four-hour A&E standard is at or above 90% in September 2018, that the majority of providers are achieving the 95% standard for the month of March Also Trusts are expected to improve on their performance each quarter compared to their performance in the same quarter the prior year in order to qualify for STF payments. 26

71 OFFICIAL 110 Urgent Treatment Centres (UTCs) designated according to the revised standard specification. Ambulance Response Programme implemented in all English mainland ambulance trusts. 105 Trusts received capital funding of 96.7 million to implement front-door clinical streaming. Over 90% of Trusts now have this in place. 1,491 beds have been freed up as a result of reducing delayed transfers of care (DTOC). 30 million awarded to 74 areas to increase number of acute hospitals meeting the Core 24 standard for 24/7 mental health liaison teams. 97% of A&Es, 98% of the initial cohort of UTCs and 96% of e-prescribing pharmacies now have access to primary care records through either summary care records or local record sharing portals. Implementation of the NHS 111 Online service to 100% of the population by December Access to enhanced NHS 111 services to 100% of the population, with more than half of callers to NHS 111 receiving clinical input during their call. Every part of the country should be covered by an integrated urgent care Clinical Assessment Service (IUC CAS), bringing together 111 and GP out of hours service provision. This will include direct booking from NHS 111 to other urgent care services. By March 2019, CCGs should ensure technology is enabled and then ensure that direct booking from IUC CAS into local GP systems is delivered wherever technology allows. Designate remaining UTCs in 2018/19 to meet the new standards and operate as part of an integrated approach to urgent and primary care. Work with local Ambulance Trusts to ensure that the new ambulance response time standards that were introduced in 2017/18 are met by September Handovers between ambulances and hospital A&Es should not exceed 30 minutes. Deliver a safe reduction in ambulance conveyance to emergency departments. Continue to make progress on reducing delayed transfers of care (DTOC), reducing DTOC delayed days to around 4,000 during 2018/19, with the reduction to be split equally between health and social care. Continue to improve patient flow inside hospitals through implementing the Improving Patient Flow guidance 6. Focus specifically on reducing inappropriate length of stay for admissions, including specific attention on stranded and

72 OFFICIAL super stranded patients who have been in hospital for over 7 days and over 21 days respectively. Continue to work towards the 2020/21 deliverable of all acute hospitals having mental health crisis and liaison services that can meet the specific needs of people of all ages including children and young people and older adults; and deliver Core 24 mental health liaison standards for adults in 50% of acute hospitals, subject to hospitals being able to successfully recruit. Ensure that fewer than 15% of NHS continuing healthcare full assessments take place in an acute setting. Continue to progress implementation of the Emergency Care Data Set in all A&Es (Type 1 and Type 2 by June 2018; and Type 3 by the end of 2018/19). Increase the number of patients who have consented to share their additional information through the extended summary care record to 15% and improve the functionality of e-scr by December Implement a proprietary appointment booking system at particular GP practices, 50% of integrated urgent care services and 50% of UTCs by May 2018, supported by improved technology and clear appointment booking standards issued by December Continue to rollout the seven-day services four priority clinical standards to five specialist services (major trauma, heart attack, paediatric intensive care, vascular and stroke) and the seven-day services four priority clinical standards in hospitals to 50% of the population. 28

73 OFFICIAL 5. Transforming Care for People with Learning Disabilities Overall Goals for Our goal is to transform the treatment, care and support available to people of all ages with a learning disability, autism or both so that they can lead longer, happier, healthier lives in homes not hospitals. Progress in 2017/18 22% increase in the number of annual health checks delivered by GPs to improve access to community alternatives to hospital and tackle premature mortality. New and expanded community teams to support people with a learning disability at risk of admission to hospital, backed by 10 million transformation funding. 6% reduction in inappropriate hospitalisation of people with a learning disability, autism or both, between March and November 2017, totalling a 14% reduction since March In addition, over 100 people previously in hospital for 5 years or more were discharged between March and November Tackling premature mortality by beginning to systematically review and learn from deaths of patients with learning disabilities by March Deliverables for 2018/19 All Transforming Care Partnerships (TCPs), CCGs and STPs are expected to: Continue to reduce inappropriate hospitalisation of people with a learning disability, autism or both, so that the number in hospital reduces at a national aggregate level by 35% to 50% from March 2015 by March As part of achieving that reduction we expect CCGs and TCPs to place a particular emphasis on making a substantial reduction in the number of long-stay (5 year+ inpatients). Continue to improve access to healthcare for people with a learning disability, so that the number of people receiving an annual health check from their GP is 64% higher than in 2016/17. CCGs should achieve this by both increasing the number of people with a learning disability recorded on the GP Learning Disability Register, and by improving the proportion of people on that register receiving a health check. Make further investment in community teams to avoid hospitalisation, including through use of the 10 million transformation fund. Ensure more children with a learning disability, autism or both get a community Care, Education and Treatment Review (CETR) to consider other options before they are admitted to hospital, such that 75% of under 18s admitted to hospital have either had a pre-admission CETR or a CETR immediately post admission. 29

74 OFFICIAL Continue the work on tackling premature mortality by supporting the review of deaths of patients with learning disabilities, as outlined in the National Quality Board 2017 guidance. 6. Maternity Overall Goals for Continue to make maternity services in England safer and more personal through the implementation of the Better Births. Progress in 2017/18 Continuing the year on year safety improvements to maternity services including, since 2010, a 16% reduction in stillbirths, 10% reduction in neonatal mortality and 20% reduction in maternal deaths. Seven maternity early adopters established covering 125,000 births a year to implement specific elements of Better Births and service improvements. Pilots of continuity of carer established to over 3,000 women. 44 Local Maternity Systems established bringing together commissioners, providers and service users to lead and deliver transformation of maternity services in every part of the country. We will exceed the planned goal of 2,000 more women receiving specialist perinatal care in 2017/18, with over 5,000 additional women accessing these services between April and December Four new mother and baby units also funded. Deliverables for 2018/19 Deliver improvements in safety towards the 2020 ambition to reduce stillbirths, neonatal deaths, maternal death and brain injuries by 20% and by 50% in 2025, including full implementation of the Saving Babies Lives Care Bundle by March Increase the number of women receiving continuity of the person caring for them during pregnancy so that by March 2019, 20% of women booking receive continuity. Continue to increase access to specialist perinatal mental health services, ensuring that an additional 9,000 women access specialist perinatal mental health services and boost bed numbers in the 19 units that will be open by the end of 2018/19 so that overall capacity is increased by 49%. By June 2018, agree trajectories to improve the safety, choice and personalisation of maternity. 30

75 OFFICIAL N.B. This is not a comprehensive list of Next Steps deliverables for 2018/19, simply an aide memoire covering these service improvement areas. CCGs and STPs should also continue to work to reduce inequalities in access to services and in people s experiences of care. 31

76 Enc C Item 8 Quality & Performance Report

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78 Meeting name Governing Body Meeting date 15 th February 2018 Title of paper Quality & Performance Report Executive / Clinical Lead(s) Author(s) Mr Andrew Russell, Chief Nurse Mr Anthony Fitzgerald, Director of Strategy & Delivery Performance and Intelligence Team Quality Team Purpose of Paper - Executive Summary This report sets out the key quality and performance issues to be noted by the NHS Doncaster Clinical Commissioning Group (NHS Doncaster CCG) Governing Body on an exception basis. The performance rating, indicated by Red, Amber, Green or Blue status, denotes the current month performance and does not reflect the historic trends. The key areas of change, both positive and negative, to note since the last report are: NHS Doncaster Clinical Commissioning Group (CCG) The two Delivery Plan focus areas this month are Mental Health and Dementia The percentage of patients waiting on a Referral to Treatment pathway less than 18 weeks at the end of December decreased to 90.45% against the 92% target. The percentage of people receiving a diagnostic test within 6 weeks decreased to 97.47% in December failing the 99% target. A&E performance was 87.2% in January which is below the 95% target and also failed to meet the recovery trajectory (90.0%). Cancer Only 2 measures failed to meet the Q3 target: 2 week wait for first outpatient appointment for patients referred urgently with breast symptoms improved by 4.4% and just failed to meet the 93% target at 92.45%. Two week wait performance met the target in Q3 for the first time since Q3 2016/17. The 62-day wait from urgent GP referral to first definitive treatment for cancer improved by 7.38% in Q3 but failed to meet the 85% target at 82.66%. However in the month of December the target was met at 86.0% for the first time since July Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTHFT) There was one 52 week breach during December Rotherham, Doncaster & South Humber NHS Foundation Trust (RDASH) Child and Adolescent Mental Health Services (CAMHS) due to a new reporting system CAMHS data is not available at time of writing IAPT access rate Q3 performance was 3.9%, the measure will be achieved based on performance in Q4 with the target set at 4.2%. Other Commissioned Services

79 The new reporting standards have now been published by the Yorkshire Ambulance Service. All 4 categories (ranging from Life Threatening to Less Urgent) 3 were not met during January Refreshing NHS Plans for 2018/19 Planning Guidance A paper has been received from NHS England and NHS Improvement which gives updated guidance and sets out how funds will be distributed, and the expectations for commissioners and providers in updating their operational plans for 2018/19. The performance and activity expectations include: Where a shadow accountable care system is in place a single system operating plan narrative is required and the plan should align key assumptions on income, expenditure, activity and workforce between commissioners and providers. Allocations allow for a 2.3 per cent growth in non-elective admissions and a 1.1 per cent growth in A&E attendances nationally, however locally estimated growth is to be reflected in plans. Commissioners and providers are asked to plan on the basis that their RTT waiting list will be no higher in March 2019 than March 2018, and should aim to reduce it. The number of 52 week breaches should be halved nationally, and aimed to be eliminated locally. A&E - ensuring aggregate performance against the four-hour target of 90 per cent for September 2018, with the majority of providers achieving 95 per cent for March 2019 and a return to overall adherence to the 95 per cent standard during Reduce length of stay in hospital with a focus on patients in hospital over 7 days and over 21 days Continue to reduce delayed transfers of care with the aim of reducing the proportion of beds occupied by DTOC patients to 3.5% Children and Young People eating disorders - 95% of patient receiving first definitive treatment within four weeks for routine cases and within one week for urgent cases. Children with a learning disability, autism or both get a community Care, Education and Treatment Review (CETR) to consider other options before they are admitted to hospital, such that 75% of under 18s admitted to hospital have either had a pre-admission CETR or a CETR immediately post admission. Some specific changes to the CQUIN and Quality Premium frameworks have also been announced. Recommendation(s) The Governing Body is asked to: Note the key quality performance areas for attention. Impact analysis Quality impact Equality impact Positive quality impact from a consistent focus on quality outcomes. Specific quality impact as identified in the report. Neutral

80 Sustainability impact Financial implications Legal implications Management of Conflicts of Interest Consultation / Engagement (internal departments, clinical, stakeholder & public/patient) Report previously presented at Risk analysis Assurance Framework Nil As identified in the report. Nil The report is for information no conflicts of interest identified. It should be noted that some Governing Body members may be employed in secondary employment by organisations referenced in this report: please see Register of Interests for details. N/A N/A Risks are captured in the Executive Summary. 2.1, 2.2, 2.3, 2.4, 3.1

81 Delivery Plan Highlight & Exception Report Planned Care Measures - Matrix Actions Summary Quality One of the two Quality measures; '92% of RTT maintained across all specialities' is failing. Nine specialities remain non-compliant in December at DBTHFT. Weekly PTL meetings take place with Care Groups where Delivery Plans are discussed to bring performance levels back in line with commissioned activity and meeting RTT. Management of the key areas takes place through fortnightly advanced performance meetings with Ophthalmology, General Surgery, ENT and Orthopaedics. A Trust level RTT recovery plan to meet 92% is under development jointly with the CCG. Completed 12 On Track 11 Slightly Off 0 Off Track 1 % of Actions On Track & Completed 95.8% Activity The measure '2017/18 Reduction in planned care referrals by 6%' is achieving target with a 7.9% fall in GP Referrals (less 2WW adjusted for working days) year to date. Actions Off Track and Slightly Off Track Finance 'Reduction in planned care spend (DBH) 2017/18' remains off track with the QIPP savings not being attained due to a number of factors including QIPP schemes being behind and additional RTT activity being performed to see long waiters and over performance on the contract in the last 6 months of 2016/17 which would have increased contract plan if the contract was set as at month 12. Additional QIPP schemes are however seeing savings which weren't originally in the plan. Expected QIPP saving Year to Date (YTD) is 2,052,000, actual QIPP saving at M9 is 1,205,000. Development of Shared Decision Making Strategy, including the review and enhanced use of patient decision aids - Planned Care Programme Board support the decision to incorporate signposting of shared decision making resource for patients and the public within the draft Communications strategy for Planned Care. Strategy is to encapsulate all elements of Planned care including Prevention agenda, Living Well and end of life care. This includes NICE patient decision tools and information on NHS choices and Patient Info website. Cancer Measures - Matrix Quality Activity Measures for finance are in development. Actions Off Track (Cont) Only one measure failed to achieve target from the National Cancer Measures for November Day Standard failed (83.9%), but higher than the previous months performance. Prostate pathway remains a focus and key issues are mainly related to the start of the pathway and the need for diagnostic tests. DBTHFT have been successful in securing funding for Quarter 3 and Quarter 4 for diagnostic capacity (MRI) and for administrative MDT support. The number of patients receiving first treatment remains below the trajectory, however Diagnostic performance is currently on track at DBTHFT, achieving target in November 2017 at 99.3%. Actions Summary Completed 0 On Track 5 Slightly Off 4 Off Track 2 Actions Off Track and Slightly Off Track % of Actions On Track & Completed 45.5% Ensure WW NICE Guidance implemented across Primary Care - No further action required currently, revised proformas in place within primary care. Feedback sought from DBTH regarding adherence to use of newly agreed proformas, if lack of adherence DCCG to follow up with Primary care. Support Increase in provision of straight to test (direct access diagnostic) pathways in line with 2WW NICE Guidance 2015 and within High Value Pathways (HVP) work (Cancer Alliance footprint) and review innovative diagnostic solutions to increase capacity to meet demand - Work ongoing with Living with and Beyond Cancer Team aligned to SYNDB Cancer Alliance. Work progressing within Breast, with revised stratified pathway available within February, Prostate pathway work ongoing aligned to pathways developed and revised within Wakefield and Colorectal pathway to be developed within our ACS. 'Commission and implement the Yorkshire and Humber High Value Pathway Specifications - Discussion regarding stratified pathways of care and commissioning method locally ongoing within SYBND Cancer Alliance. Development of pathways ongoing as per update within straight to test. Develop a regional Chemotherapy model (Impact measure 16) - Meeting planned between DBTH and Weston Park Hospital 6 March 18. This will incorporate findings and next steps following WPH hospital visits across ACS. Feedback to Cancer Alliance scheduled for March 18. Ensure all breast cancer patients have access to stratified follow up pathways of care. Also work with DBHFT and Primary Care to develop ambitions and framework for access to services for patients with re-occurrence - Update as above regarding breast stratified pathways of care. Awaiting final ACS version for review and implementation. Ensure all prostate and colorectal cancer patients have access to stratified follow up pathways of care. Also work with DBTHFT and Primary Care to develop ambitions and framework for access to services for patients with re-occurrence. As per above update regarding stratified pathways of care for Colorectal and Prostate. 4

82 Medicines Management Measures - Matrix Actions Summary Quality Activity All quality measures are on track which are patients adopting self care for minor ailments and patients with long term conditions accessing pharmacy and lifestyle advisory services. Data indicates on average High Risk antibiotic prescribing is reducing. Completed 0 On Track 12 Slightly Off 0 Off Track 0 % of Actions On Track & Completed 100.0% Actions Off Track and Slightly Off Track Finance The measure to reduce growth in medicines expenditure is on track overall. Data is updated every quarter, GP Practices are reducing the growth in expenditure, the CCG growth in expenditure has increased. Expected QIPP saving YTD is 3,257,000 Actual QIPP saving at M9 is 2,502,000. All actions are on track including developing the OptimiseRx profile and identifying primary care rebates schemes suitable for implementation across Doncaster. Children's Measures - Matrix Actions Summary Activity Finance Activity for paediatric assessments is silightly off track as the current activity is within a 5% margin of the target. Asthma emergency admissions and URTI emergency admissions are off target year to date. There were no Tier 4 admissions in November A total of 163,000 has been saved out of the projected 219,000 year to date position as at M9. Completed 0 On Track 5 Slightly Off 1 Off Track 1 % of Actions On Track & Completed 71.4% Measures for Quality are in development. Actions Off Track and Slightly Off Track Commission a Paediatric Respiratory Nurse - The revised costings from RDaSH for the wider Children's nursing service have been sent to DCCG for judgement. There is a dis crepency on non-pay costs that we need to find a solution for. Ultimate decision to be made by end of Jan. This continues to hold up the commissi oning of a paediatric respiratory nurse. Commission a responsive community provision for the mild to moderately unwell children - The above action continues to hold up the commissioning of a paediatric respiratory nurse. Learning Disabilities Measures - Matrix Actions Summary Activity There is 1 measure off track this month; the Transforming Care Partnership (covering Sheffield, North Lincolnshire, Rotherham and Doncaster CCGs) trajectory of moving people to community is off track at the end of Quarter /18 at 39 people against a trajectory of 21. The case managers from across the TCP are meeting with DCCG's Chief Operating Officer weekly to ensure a reduction in numbers is achieved. Completed 0 On Track 3 Slightly Off 1 Off Track 1 % of Actions On Track & Completed 60.0% Finance A total of 0 has been saved out of the projected 11,000 end of year position (M9). Actions Off Track and Slightly Off Track Reduce Out of Area (OOA) placements, step down from locked rehabilitation - Current numbers have reduced to 12 currently admitted to an Inpatient bed in Doncaster. This is still currently above the anticipated trajectory of 10. Care and Treatment Reviews and Care Education Treatment Reviews are all up to date and acti ve work is being undertaken across the patch with Specialised Commissioning. A Provider Event has been scheduled for 24/01/18 to begin to stimulate the market further. Implement intermediate care model - step down and step up crisis management - The Extra Care Suite will be picked up as part of the Service Development and Improvement Plan with RDASH in 2018/19 to continue to explore options going forward. revised timeframes for this work will be identified from this. 5

83 Community & End of Life Measures - Matrix Actions Summary Quality Activity Both Friends and Family Test measures are on track, however the number of deaths in hospital within 72 hours of admission rose above the target to 35 in December. All measures are on track with the exception of Home Emergency Alarm Response Team (HEART) referrals for falls which rose to 274 in December against a target of fewer than 242. Completed 1 On Track 4 Slightly Off 1 Off Track 1 % of Actions On Track & Completed 71.4% Activity A total of 912,000 has been saved out of the projected 1,293,000 year to date position as at M9. Actions Off Track and Slightly Off Track Further increase the number of individuals within services to have undertaken Gold Standard Framework (GSF) training across the Borough with a new focus on Care Homes and Domiciliary care providers - Training plan has been developed and offer for Care homes devised. Need to liaise with Care Homes Programme Manager to progress. Following the outcome from the NHS England Yorkshire & Humber review of neuro-rehabilitation services we will ensure that local patient pathways are aligned during phase 1 and that local commissioned services are reviewed to improve and standardise the quality for patients with acquired brain injury during phase 2 - Chief Operating Officers have been asked whether there is agreement to pursue this opportunity, and to identify a lead within each CCG to work with NHS England. Mental Health Measures - Matrix Activity Finance One measure was off track this month, the access rate to Improving Access to Psychological Therapy (IAPT). RDASH's IAPT access rates remain below the cumulative target as at December at 12.80% against a 15% target. Work is currently being completed to extend the IAPT service to include, and focus on, patients with diabetes. It is anticipated that through this work and general awareness raising will have a positive effect on access rates. This will however be monitored during the year. This is a stretch target for RDASH with the national target to achieve 4.2% access during Quarter 4. NHS Doncaster performance during Q2 was 4.4%. The measure to meet the mental health Investment Standard is on track. Expected QIPP saving Year to Date (YTD) is 278,000 actual QIPP saving at M9 is 209,000. It is expected to meet the targeted savings by March Actions Summary Completed 0 On Track 9 Slightly Off 1 Off Track 1 Actions Off Track and Slightly Off Track % of Actions On Track & Completed 81.8% Development of collaborative pathways to deliver physical health for people with severe and enduring mental health problems - Work to be undertaken in Q4 2017/18 to begin to develop Serious Mental Illness checks for patients with severe and enduring mental health (MH) problems. The scope will look to encompass Learning Disability health checks as well as MH diagnosis. Transferring stable patients back to primary care including training at practice level by RDASH consultant and locally developed algorithm to support. Annual health check - will be further local tools developed to support - Local Medical Council dialogue underway. Clarifying RDaSH support offer and patient care need for patients identified as appropriate for discharge. Care Homes Measures - Matrix Quality Activity No further update from previous month: The implementation of the care home strategy across Doncaster is the in the early stages of planning and development. Therefore the impact measures currently remain off track. The implementation of the care home strategy across Doncaster is the in the early stages of planning and development. Activity measures are seeing a reduction for Emergency Admissions, A&E and YAS with another slight increase in Emergency Care Practitioner visits for September Expected QIPP saving Year to Date (YTD) is 2,500,000 actual QIPP saving at M9 is 1,875,000. Actions Summary Completed 0 On Track 13 Slightly Off 0 Off Track 0 Actions Off Track and Slightly Off Track % of Actions On Track & Completed 100.0% No further update from previous month: All actions are on track including determining and establishing the Primary Care support model and developing and implementing integrated health and social care training and robust recruitment induction process across care home and home care sector. 6

84 Dementia Measures - Matrix Actions Summary Quality The dementia quality measures are overall 'On Track'. There were no new delayed discharges in Winderemere for the month of December, however the Year to Date figure if Delayed Discharges is above that of last years position. Additional capacity is continuing to be put into home care and social workers are being recruited which should alleviate the pressure. Doncaster's Dementia Diagosis Rate has continued to decrease from August 2018 but remains above the National average. Completed 0 On Track 6 Slightly Off 0 Off Track 0 % of Actions On Track & Completed 100.0% Actions Off Track and Slightly Off Track Activity There are no activity measures that are 'Off-Track'. The measure Total Number of Deaths in Hospital will continue to be measured as it fluctuates throughout the year and at this point the Doncaster Dementia Strategic Partnership will continue to monitor the trend. Please note national data as of May 2017 currently does not identify where a patient is resident in a care home. This reporting is expected to resume but currently there are no timescales. All actions are on track including developing and enhancing the post diagnostic offer through reconfiguration of existing contracts and resources Primary Care Measures - Matrix Quality Investment Workforce Workload Both actions (Primary Care Dashboard and National GP Resilience Programme) which contribute to the Quality measure are on track. Further details on these actions can be found on the full delivery plan dashboard. The investment measure is currently slightly off track due to the Extended Primary Care and Estates action been reported as amber. No further progress has been achieved in regards to the Extended Primary Care action which was reported as been slightly off track last month. Further progress has also been achieved in regards to the Estates action and a brief is expected to be presented at the March Primary Care Committee. The workforce measure is slightly off track as the workforce action has been rated as amber. This is due to the work with the Accountable Care System and Health Education England experiencing further delays. No further progress has been achieved in regards to this actions. The workload measure is currently on track as all three related actions (Patient Online, Up skilling of Clerical Staff and Releasing Time For Care) are all rated as green. Further details on these actions can be found on the full delivery plan dashboard. Actions Summary Completed 0 On Track 11 Slightly Off 3 Off Track 0 Actions Off Track and Slightly Off Track % of Actions On Track & Completed 78.6% Is the out of hospital care pillar to the Primary Care Strategy. Current suite of enhanced services are being delivered by general practice effectively - The delays with the implementation of inter practice referral process for Tier 2 enhanced services still remains. The Extended Primary Care Pillar is being refreshed as part of the wider Primary Care Strategy refresh. Development of Primary Care estates strategy including consideration for national estates funding routes - The CCG is supporting 4 capital business as usual bids to NHS England. The Primary Care focuesed estates strategy has gained momentum and a brief has been drafted by CityCare. This brief will be presented to the Priamry Care Commissioning Committee for discussion in March Output and progress of the ACS workforce work stream - The CCG is working with local stakeholders to develop a primary care workforce strategy. More detailed updates will be provided as this work progresses. NHS England are fully funding the Apex Workforce Tool. The CCG has expressed an interest in rolling this out across Doncaster. 7

85 Urgent Care Measures - Matrix Quality Activity Finance A&E 4 hour performance remains challenging, with winter pressures reducing performance. This is monitored through the local weekly operational group and performance monitored daily. The Ambulance Response Programme continues to be implemented and the performance against set standards is now being published at YAS level. Response times in November have improved from last month but are still not meeting the standards. Delayed Transfers of Care (DToC) have risen slightly in October. DTOC workshops have taken place and agreed actions built into the Action Plan. Workstreams to be established in January to take forward these actions. Front Door Assessment and Signposting Service (FDASS) Streaming is currently not achieving 20% streamed away from ED however streaming decreased in November to 13.8%. An action plan is in place from the Trust to increase streaming in line with the audit results. Reduction in ambulance conveyance recording has changed to Phase 3 of NHS England s Ambulance Response Programme (ARP) pilot and cannot be compared with previous months and work continues on Intermediate Care pathways to reduce conveyance rates. The invest to save on FDASS to avoid double funding has not yet been agreed, however please see the update above regarding streaming actions to increase streaming to 20%. As the reduction in ambulance conveyance is improving but not currently on target, the associated costs are also not currently on target. Expected QIPP saving YTD 1,086,502, Actual QIPP saving at M9 is 384,018. Actions Summary Completed 4 On Track 8 Slightly Off 3 Off Track 1 Actions Off Track and Slightly Off Track % of Actions On Track & Completed 75.0% Ensure recommendations are implemented to secure improved consistency of streaming and streaming rates to Urgent Care Centre (UCC), other departments within DRI and out of the acute hospital - Front Door Assessment and Signposting Service (FDASS) Action plan continues to be worked through with regular updates reported via SRG. The first 3 weeks of January 18 have focussed on a Doncaster and Bassetlaw Teaching Hospital (DBTH) internal #System Perfect, with daily escalation meetings taken place, but analysis of this and winter casemix will be undertaken and evaluated. Streaming rates have improved during early January. Work across SRG to ensure that 4 hour A&E standard is delivered - 4 Hour performance has been extremely challenging throughout December moving into January with December performance at 88.5%. YTD performance 91.54%.Performance has been closely monitored with NHS England and daily escalation meetings have been taking place at the acute hospital as part of the #System Perfect approach. Performance will continue to be monitored daily with support from the wider operations groups. Implementation of paramedic pathfinder - Work continues with YAS at a local level to ensure that crews are aware of the pathways available to them and how to access them. Concentrated work is going in to this to ensure that local crews are confident with regards to how and when to use the pathways, with a Continuing Professional Development event taking place in early January. Agree and implement changes to Delayed Transfers of Care (DTOC) capturing and reporting - The daily escalation approach, as part of DBH internal #System Perfect in January has focussed maximising patient flow and minimising delays across the system. DTOC Workshop to take place 16 January 2018, focussed on the 8 High Impact Changes; actions to take forward to be identified during the workshop with a focus on implementation during the next whole system System Perfect in late February/ Early March. Finance Intermediate Care Measures - Matrix Actions Summary Quality Activity Patient feedback from the Rapid Response Service continues to be very positive 77% of patients accepted on to the pathway were supported at home and 86% of the 107 people contacted for feedback said they felt the service made them feel safer at home. Overall numbers of step-up referrals continue to increase. Overall conveyances to A&E for 65s and over, following a 999 call are the same as this position last year. However, the number conveyed due to a fall is on a downward trend and is significantly lower than at this point last year. The number of over 65s identified as recieving no significant treatment is lower in November than the previous year and is on a dwonward trend. A&E attendances for 65s and over are still higher in November than this time last year, however, unplanned admissions are lower, those for falls being significantly lower. Unplanned admissions for General Medicine continued to be lower than the previous year. Bed based Intermediate care activity is still on a downward trend. Community referrals continue to be higher than the previous year, mainly due to increased ECP referrals and Rapid Response. The Proportion of patients discharged to a care home from an intermediate care bed stands at 14% in November and is higher than at this time last year. In addition there has been an upward trend since September. Completed 1 On Track 6 Slightly Off 1 Off Track 0 Actions Off Track and Slightly Off Track % of Actions On Track & Completed 87.5% Complete financial and activity modelling - Work on scope and financial envelope is complete and has been included in draft specification (se below) but still requires formal sign off. Intermediate Care is scheduled for discussion at place plan finance group meeting on 29th January 2018 where they will agree next steps. Finance At month 8, QIPP savings are showing in several areas - YAS conveyances ( 13,170, conveyances for falls ( 18,224)and nonelectives ( 124,853). The YTD expected saving was 928,000 and the actual total M9 QIPP saving achieved was 696,000 This includes a forecast for conveyances as the dataset is a month in arrears. 8

86 Impact Measure Progress NHS Doncaster CCG Mental Health Delivery Plan Actions Progress One measures was off track this month, the access rate to Improving Access to Psychological Therapy (IAPT). Implementation of Single Point of Access for all age Mental Health Services Develop the IAPT pathway to include joint care management of people with long term conditions. RDASH's IAPT access rates remain below the cumulative target as at December at 12.80% against a 15% target. Activity On Track Work is currently being completed to extend the IAPT service to include, and focus on, patients with diabetes. It is anticipated that through this work and general Development of collaborative pathways to deliver physical health for people with severe and enduring mental health problems Core 24/7 MH liaison development awareness raising will have a positive effect on access rates. This will however be monitored during the year. This is a stretch target for RDASH with the national target to Transferring stable patients back to primary care including training at practice achieve 4.2% access during Quarter 4. NHS Doncaster Development of community based model to improve perinatal mental health level by RDASH consultant and locally developed algorithm to support. Annual performance during Q2 was 4.4%. health check - will be further local tools developed to support Measure to meet the mental health Investment Standard is on track. Modernise the adult mental health acute care and home treatment pathway Communication to both staff/primary care and to general public on service changes. Finance On Track Expected QIPP saving Year to Date (YTD) is 278,000 actual QIPP saving at M9 is 209,000. It is expected to meet the targeted savings by March Progress development of early intervention in psychosis services Bringing out of area patients back from locked rehabilitation and children also done (tripartite funding). Deliver IAPT Plus and start the development of IAPT to include employment advisors improving access to employment opportunities Measures Activity Reduce the the number of A&E attendances (psychiatric conditions, all patients) against baseline 25.00% IAPT - DCCG patients who have entered at RDASH (i.e.) received treatment as a proportion of people with anxiety or depression (cumulative target 17.5% for 16/17 and 20% for 17/18) % 15.00% 10.00% 5.00% 0.00% Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Number of A&E attendances with psychiatroc conditions (all patients) Target IAPT - People who have entered (i.e.) received treatment as a proportion of people with anxiety or depression (cumulative target 19%) Target IAPT - DCCG patients who have entered (i.e.) received treatment as a proportion of people with anxiety or depression at any provider 110% Patient experiencing a first episode of psychosis treated with a NICE approved care package within 2 weeks (53% target) 4.55% 4.50% 4.45% 4.40% 4.35% 4.30% Access rate of DCCG entering into treatment at any provider (target 4.2% during Q4) 100% 90% 80% 70% 60% 50% 4.25% 40% Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec % Q1 2017/18 Q2 2017/18 Q3 2017/18 Q4 2017/18 Percentage of patients experiencing a first episode of psychosis treated with a NICE approved care package within 2 weeks (53% target) Target Finance Increase baseline spend on MH services to deliver MH Investment Standard % reduction in avoidable A&E attendances by frequent fliers Aug-17 Sep-17 Oct-17 Nov-17 Dec /18 forecasted outturn ( '000s) 2016/17 outturn ( '000s) Quality, Innovation, Productivity and Prevention (QIPP): Expected QIPP saving Year to Date (YTD) is 278,000 actual QIPP saving at M9 is 209,000. It is expected to meet the targeted savings by March

87 Period by: ACTIONS Indicator Performance Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 On Track On Track On Track On Track On Track On Track On Track On Track On Track On Track Mar-18 Implementation of Single Point of Access (SPA) for all age Mental Health (MH) Services Update (Narrative) RDaSH continues to improve SPA for MH services. RDaSH continues to improve SPA for MH services. RDaSH continues to improve SPA for MH services. RDaSH continues to improve SPA for MH services. A review of the service is scheduled for Q3 to form contracting decisions in 2018/19. RDaSH continues to improve SPA for MH services. A review of the service is scheduled for Q3 to form contracting decisions in 2018/19. RDaSH continues to improve SPA for MH services. A review of the service is scheduled for Q3 to form contracting decisions in 2018/19. RDaSH continues to improve SPA for MH services. A review of the service is scheduled for Q3 to form contracting decisions in 2018/19. The Single point of access for all age MH services continues to develop and a review will be undertaken in December to inform contracting intentions for 2018/19. Continue to fund non recurrently and are undertaking a full review of the single point of access which will continue into 2018/19. Continue to fund non recurrently and are undertaking a full review of the single point of access which will continue into 2018/19. An evaluation of the crisis hub has been requested iand due to take place in May Indicator Performance On Track On Track On Track On Track On Track On Track On Track Slightly Off Track Slightly Off Track Slightly Off Track Dec-18 Development of collaborative pathways to deliver physical health for people with severe and enduring mental health problems Update (Narrative) Improving Access to Psychological Therapies (IAPT) specification to be amended to include Medically Unexplained Symptoms and Long Term Conditions from 2018/19. IAPT Task and Finish group has been established to begin underpinning pilot of potential work streams in year. Sustainability and Transformation Plans (STP) work stream has also been established across the patch with the first meeting being held on 6th June. STP work stream has commenced. Task and finish group has met and work commenced to identify relevant long terms conditions. In line with Five Year Forward View for Mental Health guidance this is being developed into a specification. In line with Five Year Forward View for Mental Health guidance this is being developed into a specification. The Accountable Care System (ACS) workstream will initially focus on diabetes. In line with Five Year Forward View for Mental Health guidance this is being developed into a specification. The Accountable Care System (ACS) workstream will initially focus on diabetes. In line with Five Year Forward View for Mental Health guidance this is being developed into a specification. The Accountable Care System (ACS) workstream will initially focus on diabetes. Work to be undertaken in Q4 2017/18 to begin to develop Serious Mental Illness checks for patients with severe and enduring mental health (MH) problems. The scope will look to encompass Learning Disability health checks as well as MH diagnosis. Work to be undertaken in Q4 2017/18 to begin to develop Serious Mental Illness checks for patients with severe and enduring mental health (MH) problems. The scope will look to encompass Learning Disability health checks as well as MH diagnosis. Work to be undertaken in Q4 2017/18 to begin to develop Serious Mental Illness checks for patients with severe and enduring mental health (MH) problems. The scope will look to encompass Learning Disability health checks as well as MH diagnosis. Indicator Performance On Track Slightly Off Track Slightly Off Track Slightly Off Track On Track On Track On Track On Track On Track On Track Mar-19 Development of community based model to improve perinatal mental health Update (Narrative) Crisis Café proposal to be delivered to SMT on First round of Perinatal Bids was unsuccessful. Second round of bidding will become available in July/ August First round of Perinatal Bids was unsuccessful. Second round of bidding will become available in July/ August Still awaiting bidding option to become available. ACS meetings being held to develop bid for wave 2 Bidding options are likely to become available imminently. A joint bid with Rotherham and Sheffield CCGs is being developed so ready to submit as soon as it is launched. Bidding options are likely to become available imminently. A joint bid with Rotherham and Sheffield CCGs is being developed so ready to submit as soon as it is launched. The ACS perinatal group continues to meet monthly to ensure a joint bid is ready for Wave 2. The bidding window was due to be open in Summer 2017 but is currently delayed by NHS England. The ACS perinatal group continues to meet monthly to ensure a joint bid is ready for Wave 2. The bidding window was due to be open in Summer 2017 but is currently delayed by NHS England. The ACS perinatal group continues to meet monthly to ensure a joint bid is ready for Wave 2. The bidding window was due to be open in Summer 2017 but is currently delayed by NHS England. Mar-18 Indicator Performance On Track On Track On Track On Track On Track On Track On Track On Track On Track On Track Modernise the adult mental health acute care and home treatment pathway Update (Narrative) Work underway in secondary care pathway to align both services. The Secondary Care Acute pathway group is working on revisions to the service and meets monthly. The Secondary Care Acute pathway group is working on revisions to the service and meets monthly. The Secondary Care Acute pathway group is working on revisions to the service and meets monthly. The Secondary Care Acute pathway group is working on revisions to the service and meets monthly. The Secondary Care Acute pathway group is working on revisions to the service; this includes psychiatric decision unit and street triage service. The Secondary Care Acute pathway group is working on revisions to the service; this includes psychiatric decision unit and street triage service. A Workshop has been arranged to begin to scope this work in November. A mapping exercise workshop has been undertaken in November with providers looking at the acute care pathway, home treatment and recovery services. A detailed plan will inform the Executive team of the gaps to service and influence the 5 Year Forward View intentions for acute care. Mapping to be extended to include Community Led Support and community provision. Proposals are then to be worked up for implementation in 2018/19 Jointly working up components of the Crisis Resolution Home Treatment model (CCG & RDaSH) to inform case for change. Engagement underway with Doncaster Council Adult Commissioning, Public Health and South Yorkshire Police. Mar-18 Mar-18 Progress development of early intervention in psychosis (EIP) services Indicator Performance Update (Narrative) Indicator Performance On Track On Track On Track On Track On Track On Track On Track On Track On Track On Track Working towards an EIP specification in line with the 5 Year Forward View. Working towards an EIP specification in line with the 5 Year Forward View. Meeting arranged for the 23rd of June to continue to develop specification. 23rd of June meeting rearranged; now awaiting date. Currently blending business case for enhancement with service specification and meeting being arranged to review revised document. Business case is now being finalised and finance is being mapped towards the proposal. Business case is now being finalised and finance is being mapped towards the proposal. Business case has been finalised and approved by RDaSH. The service is now out to recruitment which will allow the service to meet the stretch target set. Service is finalised and will begin early implementation in Mobilisation has begun and outcomes have been developed Implementation underway, monitoring agreed. On Track On Track On Track On Track On Track On Track On Track On Track On Track On Track Deliver IAPT Plus and start the development of IAPT to include employment advisors improving access to employment opportunities Update (Narrative) IAPT specification to be amended to include employment support from 2018/19. IAPT Task and Finish group has been established to begin underpinning pilot of potential work streams in year. STP work stream has also been established across the patch with the first meeting being held on 6th June STP work stream has commenced. Task and finish group has met and work commenced to identify relevant long terms conditions. STP (moving ACS) work stream has commenced. A task and finish group has met and work has commenced to identify relevant long terms conditions. ACS work stream has commenced in this area and is being expanded to include people with serious mental health needs. ACS work stream has commenced in this area and is being expanded to include people with serious mental health needs. ACS work stream has commenced in this area and is being expanded to include people with serious mental health needs. The service has commenced accepting IAPT referrals from diabetic patients. The IAPT service is now working with diabetic referrals into the service. Work is being undertaken to ensure the access target begins to recover closer to the trajectory. The recovery rate is being monitored for any unintentional impact from this work and further outcome measures are being developed between the CCG and RDASH. The IAPT service is now working with diabetic referrals into the service. Work is being undertaken to ensure the access target begins to recover closer to the trajectory. The recovery rate is being monitored for any unintentional impact from this work and further outcome measures are being developed between the CCG and RDASH. The IAPT service is now working with diabetic referrals into the service. Work is being undertaken to ensure the access target begins to recover closer to the trajectory. The recovery rate is being monitored for any unintentional impact from this work and further outcome measures are being developed between the CCG and RDASH. Mar-18 Mar-18 Develop the IAPT pathway to include joint care management of people with long term conditions (LTC). Indicator Performance Update (Narrative) Indicator Performance On Track On Track On Track On Track On Track On Track On Track On Track On Track On Track IAPT specification to be amended to include Medically Unexplained Symptoms and Long Term Conditions from 2018/19. IAPT Task and Finish group has been established to begin underpinning pilot of potential work streams in year. STP work stream has also been established across the patch with the first meeting being held on 6th June STP work stream has commenced. Task and finish group has met and work commenced to identify relevant long terms conditions. In addition an interoperability group is scoping the feasibility of adding alerts to Emergency Department for respiratory conditions and some mental health clustering. This piece of work is IAPT task and finish meeting again on the 24th July to continue to scope LTC's. Diabetes has been identified as first LTC and work will commence as of the 1st of October. Diabetes has been identified as first LTC and work will commence as of the 1st of October. Diabetic referrals have now commenced within IAPT. Diabetic referrals have now commenced Diabetic referrals have now commenced within IAPT and will be reviewed prior to a within IAPT and will be reviewed prior to a larger roll out of services in March larger roll out of services in March Condition set and model to apply for 2018/19 under discussion. Slightly Off Track Slightly Off Track Slightly Off Track On Track On Track On Track On Track On Track On Track On Track Core 24/7 MH liaison development Update (Narrative) Bid for wave 1 was unsuccessful. Doncaster CCG will submit a bid for phase 2 in Autumn Bid for wave 1 was unsuccessful. Doncaster CCG will submit a bid for phase 2 in Autumn Meetings are being arranged with DBTHFT/RDaSH and led through the Sustainability and Transformation Partnerships (STP) to identify and undo any potential blockages. Working as part of the ACS model meeting with other areas to develop and progress mental health liaison service in Doncaster. Working as part of the ACS model meeting with other areas to develop and progress mental health liaison service in Doncaster this is now being linked to the acute and emergency mental health pathway. Working as part of the ACS model meeting with other areas to develop and progress mental health liaison service in Doncaster this is now being linked to the acute and emergency mental health pathway. Working as part of the ACS model meeting with other areas to develop and progress mental health liaison service in Doncaster this is now being linked to the acute and emergency mental health pathway. Working as part of the ACS model meeting with other areas to develop and progress mental health liaison service in Doncaster this is now being linked to the acute and emergency mental health pathway. Testing approaches as part of the winter money proposals. Awaiting feedback from DBHFT and RDASH. Testing approaches as part of the winter money proposals. Awaiting feedback from DBHFT and RDASH. Mar-18 Transferring stable patients back to primary care including training at practice level by RDASH consultant and locally developed algorithm to support. Annual health check - will be further local tools developed to support Indicator Performance Update (Narrative) Slightly Off Track Slightly Off Track Slightly Off Track On Track On Track On Track On Track Slightly Off Track Slightly Off Track Slightly Off Track Work ongoing with RDaSH consultants to establish an appropriate pathway of care. Work ongoing with RDaSH consultants to establish an appropriate pathway of care. Meeting arranged for late June to pursue a pilot of patients to be transferred back to Primary Care, Processes have now been finalised to start this work. Potential pilot sites are now being identified. Discussion with pilot sites has commenced. Further work is being undertaken with Medicines Management regarding medication classification. Discussion with pilot sites has commenced. Further work is being undertaken with Medicines Management regarding medication classification. Discussion with pilot sites has commenced. Further work is being undertaken with Medicines Management regarding medication classification. The Local Medical Council have requested further dialogue regarding the pathway before this can be rolled out further. Discharge plans have been written by RDASH ready for the service to begin to discharge back to the community. The Local Medical Council have requested further dialogue regarding the pathway before this can be rolled out further. Discharge plans have been written by RDASH ready for the service to begin to discharge back to the community. Local Medical Council dialogue underway. Clarifying RDaSH support offer and patient care need for patients identified as appropriate for discharge. Mar-18 Indicator Performance On Track On Track On Track On Track On Track On Track On Track On Track On Track On Track 10

88 Communication to both staff/primary care and to general public on service changes. Update (Narrative) Due to be completed Autumn Due to be completed Autumn Due to be completed Autumn Due to be completed Autumn Due to be completed Autumn Due to be completed Autumn Due to be completed Autumn Service changes are ongoing and continue to be disseminated where appropriate. The most recent change to service is the IAPT care navigation that is being communicated by GP practices. Service changes are ongoing and continue to be disseminated where appropriate. The most recent change to service is the IAPT care navigation that is being communicated by GP practices. Service changes are ongoing and continue to be disseminated where appropriate. Joint CCG and Local Authority procurement for community led support and peer support nearing completion. Mar-18 Indicator Performance On Track On Track On Track On Track On Track On Track On Track On Track On Track On Track Bringing out of area patients back from locked rehabilitation and children also done (tripartite funding). Update (Narrative) Due to commence in Summer Due to commence in Summer Work is ongoing through robust case management to bring people back from Locked rehab. Including identifying patient need and values and matching with local providers. Work is continuing. Work is continuing. Work is continuing. Work is continuing. Work is ongoing, looking at the Transforming Care Partnership (TCP) principles to future proof CCG principles. Work is ongoing, looking at the Transforming Care Partnership (TCP) principles to future proof CCG principles alonside the ACS workstream. Out of Area improvement trajectory to be finalised for March Transparency of Psychiatric Intensive Care Unit (PICU) occupancy and referral / discharge pathway expected January / February. Key risks and messages CCG mental health leads have meet with Chief Superintendent of Doncaster District Police force to progress discussions on alternative to section 136 suite. 11

89 Quality On Track Impact Measure Progress The dementia quality measures are overall 'On Track'. There were no new delayed discharges in Winderemere for the month of December, however the Year to Date figure if Delayed Discharges is above that of last years position. Additional capacity is continuing to be put into home care and social workers are being recruited which should alleviate the pressure. Doncaster's Dementia Diagosis Rate has continued to decrease from August 2018 but remains above the National Dementia Delivery Plan Dashboard Continue to raise dementia awareness, reduce dementia stigma and proactively promote dementia prevention Create, apply and monitor evidence based dementia standards for risk prevention, screening, referral, assessment and treatment and post diagnostic support Monitor, analyse, report and manage all activity across the dementia pathway Actions Progress Activity On Track Work with partners and educational colleagues to deliver HEE mandate - (fit for purpose workforce) There are no activity measures that are 'Off-Track'. The measure Total Number of Deaths in Hospital will continue to be measured as it fluctuates throughout the year. Create equality and ageless assessment and treatment services Please note national data as of May 2017 currently does not identify where a patient is resident in a care home. This reporting is expected to resume but currently there are no timescales. Develop and enhance post diagnostic offer through reconfiguration of existing contracts and resources National Dementia Aims Doncaster Dementia Diagnosis Rate Doncaster Rightcare Group Dementia Diagnosis Rates 2017/18 76% 100% 75% 95% 90% 74% 85% 73% 80% 75% 72% 70% 71% 65% 70% April May June July August September October November December January February March 60% April May June July August September October November December January February March National Average Darlington CCG Hartlepool CCG Barnsley CCG Durham Dales, Easington & Sedgefield CCG Wigan Borough CCG Rotherham CCG Wakefield CCG Mansfield & Ashfield CCG North East Lincolnshire CCG Tameside & Glossop CCG Doncaster CCG 2017/ /17 Acute Dementia Activity Non-Elective Admissions into DRI 5% reduction of Non-Elective Admissions into DRI Target Re-admissions into DRI 340 3, , , , , April May June July August September October November December January February March 0 April May June July August September October November December January February March 2017/ /17 Non-Elective Admissions (Cumulative) Non-Elective Admissions (Target) 2017/ /17 Average Length of Stay in Hospital Admissions from Care Homes Total Deaths in Hospital for People with Dementia April May June July August September October November December January February March 0 April May June July August September October November December January February March 2017/ / / / / / Number of Deaths within 3 days of admission into DRI for People with Dementia 2016/ /18 Community Dementia Activity Number of Delayed Discharges from Windermere Number of Admissions and Occupancy Levels of Windermere % % % % % % 0 April May June July August September October November December January February March 0 April May June July August September October November December January February March 0% 2017/ /17 Number of Admissions into Windermere Occupancy Levels Average Length of Stay within Windermere 85% of referrals to the Older Peoples Mental Health Service are assessed within 2 weeks % % % % 90% 88% % 50 84% 0 April May June July August September October November December January February March 82% April May June July August September October November December January February March 2016/ / /18 Please see Intermediate Care dashboard for QIPP measures. Finance 12

90 ACTIONS Indicator Performance Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 On-Track On-Track On-Track On-Track On-Track Continue to raise dementia awareness, reduce dementia stigma and proactively promote dementia prevention Update (Narrative) Doncaster has over Dementia friends and over 100 DF champions. The diagnosis rate is 75%. Prevention leaflet has been updated and circulated. Doncaster has over Dementia friends and over 100 DF champions. The diagnosis rate is 75%. Prevention leaflet has been updated and circulated. Doncaster has over Dementia friends and over 100 DF champions. The diagnosis rate is 75%. The prevention agenda is on track as part of the DDSP action plan Doncaster has over Dementia friends and over 100 DF champions. The diagnosis rate is 74.8%. The prevention agenda is on track as part of the DDSP action plan Doncaster has over Dementia friends and over 100 DF champions. The diagnosis rate is 74.8%. The prevention agenda is on track as part of the DDSP action plan Create, apply and monitor evidence based dementia standards for risk prevention, screening, referral, assessment and treatment and post diagnostic support Indicator Performance Update (Narrative) Indicator Performance On-Track On-Track On-Track On-Track On-Track 95% of referrals for dementia diagnosis are diagnosed within 10 weeks. Commissioners are working with providers to achieve 6 weeks from referral to diagnosis by The Doncaster Admiral service is commissioned to be a point of contact on discharge from assessment and treatment services. 95% of referrals for dementia diagnosis are diagnosed within 10 weeks. Commissioners are working with providers to achieve 6 weeks from referral to diagnosis by The Doncaster Admiral service is commissioned to be a point of contact on discharge from assessment and treatment services. 95% of referrals for dementia diagnosis are diagnosed within 10 weeks. Commissioners are working with providers to achieve 6 weeks from referral to diagnosis by The Doncaster Admiral service is commissioned to be a point of contact on discharge from assessment and treatment services. 95% of referrals for dementia diagnosis are diagnosed within 10 weeks. Commissioners are working with providers to achieve 6 weeks from referral to diagnosis by The Doncaster Admiral service is commissioned to be a point of contact on discharge from assessment and treatment services. 95% of referrals for dementia diagnosis are diagnosed within 10 weeks. Commissioners are working with providers to achieve 6 weeks from referral to diagnosis by The Doncaster Admiral service is commissioned to be a point of contact on discharge from assessment and treatment services. On-Track On-Track On-Track On-Track On-Track Monitor, analyse, report and manage all activity across the dementia pathway Update (Narrative) Performance reports on track and reported on time. The CCGs dementia delivery plan and the HWB Dementia OBAT for he now been aligned and signed off Performance reports on track and reported on time. The CCGs dementia delivery plan and the HWB Dementia OBAT for he now been aligned and signed off Performance reports on track and reported on time against the CCGs dementia delivery plan and the HWB Dementia OBAT for Performance reports on track and reported on time against the CCGs dementia delivery plan and the HWB Dementia OBAT for Performance reports on track and reported on time against the CCGs dementia delivery plan and the HWB Dementia OBAT for Work with partners and educational colleagues to deliver HEE mandate - (fit for purpose workforce) Indicator Performance Update (Narrative) Indicator Performance On-Track On-Track On-Track On-Track On-Track Statutory partners are well on track for ensuring all staff have Tier 1 and or tier 2 training for those staff who mare "patient facing". Care Home and Domiciliary care market requires further attention/planning Statutory partners are well on track for ensuring all staff have Tier 1 and or tier 2 training for those staff who mare "patient facing". Care Home and Domiciliary care market requires further attention/planning Statutory partners are well on track for ensuring all staff have Tier 1 and or tier 2 training for those staff who mare "patient facing". Care Home and Domiciliary care market requires further attention/planning Statutory partners are well on track for ensuring all staff have Tier 1 and or tier 2 training for those staff who mare "patient facing". Care Home and Domiciliary care market requires further attention/planning Statutory partners are well on track for ensuring all staff have Tier 1 and or tier 2 training for those staff who mare "patient facing". Care Home and Domiciliary care market requires further attention/planning On-Track On-Track On-Track On-Track On-Track Create equality and ageless assessment and treatment services Update (Narrative) Work is progressing with commissioners and providers to create an ageless service for assessment and treatment, specifically focusing on the Young Onset Dementia service and the Older Peoples Mental Health Liaison service elements. A clear plan of how this will be implemented is expected to be agreed and in place by December Work is progressing with commissioners and providers to create an ageless service for assessment and treatment, specifically focusing on the Young Onset Dementia service and the Older Peoples Mental Health Liaison service elements. A clear plan of how this will be implemented is expected to be agreed and in place by December Work is progressing with commissioners and providers to create an ageless service for assessment and treatment, specifically focusing on the Young Onset Dementia service and the Older Peoples Mental Health Liaison service elements. A clear plan of how this will be implemented is expected to be agreed and in place by December Work is progressing with commissioners and providers to create an ageless service for assessment and treatment, specifically focusing on the Young Onset Dementia service and the Older Peoples Mental Health Liaison service elements. Service improvements have been identified to move part of the OPMH Liaison service from being ward based to the front door. The intention being improving triage at the point of presentation, preventing admission where three is no clinical indication whilst harmonising care pathways into the community. This will initially be piloted for 3 months. The evaluation will inform future service provision. Work is progressing with commissioners and providers to create an ageless service for assessment and treatment, specifically focusing on the Young Onset Dementia service and the Older Peoples Mental Health Liaison service elements. Service improvements have been identified to move part of the OPMH Liaison service from being ward based to the front door. The intention being improving triage at the point of presentation, preventing admission where three is no clinical indication whilst harmonising care pathways into the community. This will initially be piloted for 3 months. The evaluation will inform future service provision. Indicator Performance Slightly Off Track Slightly Off Track Slightly Off Track On-Track On-Track Develop and enhance post diagnostic offer through reconfiguration of existing contracts and resources Update (Narrative) Work is progressing with current providers to commission a whole post diagnostic service via a ACP route. It is proposed the new model will be in place for April A project plan has been developed with timescales to ensure this. A draft service specification for the Post Diagnostic Service has been developed for consideration. From June 2017 a dementia family support service (befriending and volunteering) is in place operating on a locality basis across the 4 sectors. This will feature as part of the whole post diagnostic service via the ACP from 1 April Timescales have slipped slightly due to the challenges in relation to NHS/LA procurement regulations and the reconfiguration of existing contracts. The current service model for post diagnostic service (i.e. TDAS) has been extended following a paper to JCCC for a further two years until March A business case will be presented to BCF panel in November for formal approval. Following approval all partners will convene to discuss next steps and development of the model over the next 2 years. DCCG will continue to work with RDaSH on the reconfiguration of YODS and the CST/Complex Care elements which will form part of the post diagnostic service. The current service model for post diagnostic service (i.e. TDAS) has been extended following a paper to JCCC for a further two years until March The business case which was presented to BCF was approved. An away day for all partners who are part of the post diagnostic service will take place on 1 December 2017 for them to work through the future development of the service and propose arrangements in working as an Alliance. CCG will continue to work with RDaSH on the reconfiguration of YODS and the CST elements which will form part of the post diagnostic service. The current service model for post diagnostic service (i.e. TDAS) has been extended following a paper to JCCC for a further two years until March The business case which was presented to BCF was approved. An away day for all partners who are part of the post diagnostic service took place on 1 December 2017 for them to work through the future development of the service and propose arrangements in working as an Alliance. CCG will continue to work with RDaSH on the reconfiguration of YODS and the CST elements which will form part of the post diagnostic service. Monthly meetings with all partners have been scheduled from January The current service model for post diagnostic service (i.e. TDAS) has been extended following a paper to JCCC for a further two years until March The business case which was presented to BCF was approved. An away day for all partners who are part of the post diagnostic service took place on 1 December 2017 for them to work through the future development of the service and propose arrangements in working as an Alliance. CCG will continue to work with RDaSH on the reconfiguration of YODS and the CST elements which will form part of the post diagnostic service. Monthly meetings with all partners have been scheduled from January

91 Section 2: NHS Constitution Indicators (NHS Doncaster CCG) Referral to Treatment Times (RTT) Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks Commissioner Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Doncaster CCG 90.43% 90.75% 90.93% 90.90% 91.27% 91.25% 91.35% 90.71% 90.63% 89.95% 91.25% 91.73% 90.45% Rightcare Peer Group 89.66% 90.17% 90.40% 90.34% 90.24% 90.85% 90.87% 90.66% 90.55% 90.61% 91.05% 90.84% Doncaster and Bassetlaw Teaching Hospitals Foundation Trust (DBTHFT) 90.1% 90.3% 90.5% 90.5% 90.4% 90.6% 90.9% 90.3% 90.1% 89.5% 90.7% 90.8% 89.6% England 89.79% 90.02% 90.05% 90.65% 89.95% 90.47% 90.33% 89.95% 89.50% 89.23% 89.42% 89.8% Standard 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 93% Patients on incomplete non-emergency pathways who have been waiting no more than 18 weeks 92% 91% 90% 89% 88% Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Doncaster CCG Rightcare Peer Group Doncaster and Bassetlaw Teaching Hospitals Foundation Trust (DBTHFT) England Target 14

92 Performance for DCCG patients remains below target at 90.45% in December 2017 with 8 specialties failing to meet the 92% standard: ENT (85.00%) General Surgery (85.03%) Trauma and Orthopaedics (89.62%) Ophthalmology (89.98%) Cardiology (89.94%) Rheumatology (87.22%) Urology (91.45%) General Medicine (89.97%) DBTHFT also failed to meet the target at 89.6% and 9 specialties falling below 92%, Dermatology being the additional specialty to the list above for DCCG. A joint task and finish group has been established between DCCG and DBTHFT to present findings on a number of scenarios regarding RTT performance to understand at a specialty level how many patients would need to be treated to meet RTT, whether that is feasible, by when, and how much any additional activity would cost. The Trust have purchased the Gooroo Planner product to improve capacity planning which is currently being tested with the Trust s data and the Task and Finish Group will report back to both organisations senior management. The Planned Care Programme Board is managing the process of demand management which shows an overall reduction in GP and increase in consultant to consultant referrals. A Deep Dive to understand the increase in consultant to consultant referrals is underway which has found some coding changes but also some real increases. The reasons for the real increases have been audited and a response is awaited from the Trust on the next steps to reduce unnecessary referrals and outpatient appointments. Work is being undertaken with HealthWatch to reduce short notice hospital cancellations and DNA rates. A report was received and discussed at the January Planned Care Programme Board. Weekly Patient Tracking List meetings continue to take place within the Trust with Care Groups where delivery plans are discussed to bring performance levels back in line with commissioned activity and meeting the RTT target. Management of the key areas takes place through fortnightly advanced performance meetings with Ophthalmology, General Surgery, ENT and Orthopaedics. 15

93 Patients waiting less than 6 weeks for a diagnostic test Commissioner Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Doncaster CCG 99.25% 98.16% 98.66% 96.89% 97.65% 98.79% 97.44% 98.32% 95.57% 97.56% 98.87% 99.06% 97.47% Rightcare Peer Group 97.68% 97.77% 98.87% 98.69% 98.53% 98.60% 98.48% 98.88% 98.18% 98.42% 98.20% 98.12% DBTHFT 99.31% 98.08% 98.93% 97.43% 97.54% 98.50% 97.71% 98.67% 96.17% 98.12% 99.30% 99.30% 98.49% England 98.33% 98.27% 98.96% 98.94% 98.20% 98.10% 98.12% 98.17% 97.80% 98.71% 98.26% 98.60% Standard 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 100% 99% 98% 97% 96% 95% Patients waiting less than 6 weeks for a diagnostic test Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Doncaster CCG Rightcare Peer Group DBTHFT England Standard Performance for DCCG fell to below target in December 2017 at 97.47%. Performance at the Trust also fell to 98.49% after achieving the target for the previous 2 months. The key issue at DBTHFT was a deterioration in Audiology performance due to staff absences over the Christmas period. The key to improving performance has been identified as maintaining contracted activity and ensuring the cancelled clinics and new to follow up ratios are within the ratios set by the CCG. 16

94 Dual-energy X-ray absorptiometry (DEXA) Scans at STHFT have also contributed to the deterioration in CCG performance. There have been 2 issues with the scans; the first was the break-down of a machine. This caused a significant issue within this speciality as patients have to be scanned on the same machine when having a repeat scan. This issue was resolved but created a backlog. However the most important issue in contributing to the current backlog is staffing. Sheffield Teaching Hospital have now recruited but there is a circa 10 week training programme. A&E attendance to admission, transfer or discharge A&E attendances under 4 hours from arrival to admission, transfer or discharge Provider Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 DBTHFT 84.96% 88.70% 92.70% 90.37% 91.40% 92.46% 93.20% 93.57% 93.72% 92.81% 91.15% 88.57% 87.20% England 77.60% 87.60% 90.00% 90.48% 89.71% 90.71% 90.35% 90.28% 89.70% 90.10% 88.85% Standard 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% Recovery Trajectory N/A N/A N/A 90.0% 90.0% 90.0% 93.1% 93.1% 93.1% 90.2% 90.2% 90.2% 90.0% 17

95 100% 95% 90% 85% 80% 75% 70% A&E attendances under 4 hours from arrival to admission, transfer or discharge Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Doncaster & Bassetlaw Teaching NHS FT England Standard Recovery Trajectory Performance during January 2018 fell to 87.2% which did not achieve the 95% standard or the NHS Improvement recovery trajectory for the month of 90.0%. Streaming from A&E to other services fell slightly to 15.3%. Performance continued to be affected through January 2018 by bed capacity within the Trust and increases in attendance numbers through the Emergency Department (ED) along with increased acuity seen in resusication and major figures. The number of Category 1 transports from the Yorkshire Ambulance Service was also over predicted levels (see page 31) which has affected the capacity of ED during the month. Winter monies have been used by the Trust to open additional escalation beds to ease this pressure. Non-urgent Elective operations were not planned over the Christmas period and into early January however after a review during the month the recommencement of these has been implemented. It is anticipated that by the end of February the Trust will be providing 100% of their planned workload. Twice daily senior reviews of all patients to facilitate discharge within the Trust to increase flow through ED continued into January. 18

96 A further System Perfect initiative was implemented in January (including health and social care partners) focusing on the whole system from admission avoidance to discharge at all points on the pathway. This worked well across all partners however a review of the process has been completed and discussed through weekly pathway meetings. Cancer Measures 2 week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP Commissioner Q4 16/17 Apr-17 May-17 Jun-17 Q1 17/18 Jul-17 Aug-17 Sep-17 Q2 17/18 Oct-17 Nov-17 Dec-17 Q3 17/18 Doncaster CCG 92.00% 86.76% 91.50% 92.92% 90.63% 91.84% 87.54% 90.64% 89.98% 93.46% 94.49% 92.57% 93.52% Rightcare Peer Group 95.78% 94.17% 95.74% 94.80% 94.94% 94.98% 94.87% 95.44% 95.11% 96.44% 95.43% DBTHFT 89.0% 86.7% 91.2% 90.6% 90.6% 91.5% 88.1% 90.6% 89.9% 93.4% 93.97% England 94.73% 92.80% 94.01% 94.09% 93.69% 94.05% 93.60% 94.00% 93.69% 94.70% 95.10% Target 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 19

97 100% 2 week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP 95% 90% 85% q q q q3 Doncaster CCG Rightcare Peer Group DBTHFT England Target Two week wait performance has met the standard for the first time in Q3 2017/18 since Q3 2016/17. 2 week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected) Commissioner Q4 16/17 Apr-17 May-17 Jun-17 Q1 17/18 Jul-17 Aug-17 Sep-17 Q2 17/18 Oct-17 Nov-17 Dec-17 Q3 17/18 Doncaster CCG 92.00% 84.44% 88.37% 96.23% 90.28% 86.54% 90.00% 86.96% 88.05% 96.30% 93.15% 89.83% 92.45% Rightcare Peer Group 95.78% 94.83% 96.02% 94.79% 95.28% 95.38% 95.06% 94.99% 95.23% 96.65% 96.20% DBTHFT 93.3% 90.1% 92.8% 94.0% 94.1% 88.0% 93.4% 90.1% 90.6% 92.7% 95.31% England 92.93% 89.70% 90.47% 91.59% 90.67% 93.51% 93.10% 93.20% 90.67% 95.40% 95.60% Target 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 20

98 100% 2 week wait for first outpatient appointment for patients referred urgently with breast symptoms 95% 90% 85% 80% q q q q3 Doncaster CCG Rightcare Peer Group DBTHFT England Target Performance during Quarter 2 remained slightly below the 93% target despite an improvement of 4.4% to 92.45%. 21

99 31-day wait from diagnosis to first definitive treatment for all cancers Commissioner Q4 16/17 Apr-17 May-17 Jun-17 Q1 17/18 Jul-17 Aug-17 Sep-17 Q2 17/18 Oct-17 Nov-17 Dec-17 Q3 17/18 Doncaster CCG 97.60% 99.28% 97.93% 98.22% 98.52% 96.39% 95.77% 90.60% 95.70% 96.40% 100% 96.97% 97.89% Rightcare Peer Group 97.76% 97.68% 98.25% 97.91% 97.98% 98.15% 97.12% 96.80% 97.39% 97.70% 98.26% DBTHFT 99.30% 98.60% 98.61% 98.90% 98.94% 99.39% 98.60% 98.50% 98.90% 100% 100% England 97.47% 97.40% 97.37% 97.51% 97.44% 97.56% 97.70% 97.30% 97.44% 97.72% 97.50% Target 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 100% 99% 98% 97% 96% 95% 94% 93% 31-day wait from diagnosis to first definitive treatment for all cancers q q q q3 Doncaster CCG Rightcare Peer Group DBTHFT England Target 22

100 31 day wait for subsequent treatment where that treatment is surgery Commissioner Q4 16/17 Apr-17 May-17 Jun-17 Q1 17/18 Jul-17 Aug-17 Sep-17 Q2 17/18 Oct-17 Nov-17 Dec-17 Q3 17/18 Doncaster CCG 98.20% 100% 100% 100% 100% 100% 100% 93.75% 98.11% 100% 100% 100% 100% Rightcare Peer Group 97.11% 95.74% 97.25% 98.02% 96.75% 93.75% 95.26% 97.26% 95.37% 96.97% 98.32% DBTHFT 97.73% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% England 95.39% 98.50% 96.09% 96.55% 96.05% 96.00% 95.90% 95.30% 96.05% 95.30% 95.50% Target 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 100% 31 day wait for subsequent treatment where that treatment is surgery 98% 96% 94% 92% 90% q q q q3 Doncaster CCG Rightcare Peer Group DBTHFT England Target 23

101 31 day wait for subsequent treatment where that treatment is drug regimen Commissioner Q4 16/17 Apr-17 May-17 Jun-17 Q1 17/18 Jul-17 Aug-17 Sep-17 Q2 17/18 Oct-17 Nov-17 Dec-17 Q3 17/18 Doncaster CCG 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Rightcare Peer Group 99.55% 100% 99.43% 100% 99.80% 99.39% 99.45% 99.73% 99.55% 99.74% 99.70% DBTHFT 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% England 99.18% 99.30% 99.30% 99.34% 96.05% 99.55% 99.40% 99.20% 99.35% 99.20% 99.50% Target 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 100% 31 day wait for subsequent treatment where that treatment is drug regimen 99% 98% 97% 96% 95% 94% q q q q3 Doncaster CCG Rightcare Peer Group DBTHFT England Target 24

102 31 day wait for subsequent treatment where that treatment is radiotherapy Commissioner Q4 16/17 Apr-17 May-17 Jun-17 Q1 17/18 Jul-17 Aug-17 Sep-17 Q2 17/18 Oct-17 Nov-17 Dec-17 Q3 17/18 Doncaster CCG 93.90% 96.77% 96.00% 97.92% 96.90% 87.50% 100% 100% 96.06% 96.55% 100% 100% 98.59% Rightcare Peer Group 97.93% 99.01% 98.67% 99.34% 99.80% 95.56% 98.02% 97.90% 97.17% 97.48% 98.69% England 97.14% 96.90% 96.55% 96.65% 96.78% 96.87% 97.40% 96.60% 96.64% 96.99% 97.50% Target 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 100% 99% 98% 97% 96% 95% 94% 93% 92% 91% 90% 31 day wait for subsequent treatment where that treatment is radiotherapy q q q q3 Doncaster CCG Rightcare Peer Group England Target 25

103 62-day wait from urgent GP referral to first definitive treatment for cancer Commissioner Q4 16/17 Apr-17 May-17 Jun-17 Q1 17/18 Jul-17 Aug-17 Sep-17 Q2 17/18 Oct-17 Nov-17 Dec-17 Q3 17/18 Doncaster CCG 77.30% 81.82% 79.66% 81.33% 81.73% 76.27% 73.85% 73.58% 75.28% 78.95% 83.87% 86.00% 82.66% Rightcare Peer Group 83.66% 85.01% 84.03% 84.98% 84.50% 82.82% 82.01% 81.91% 82.38% 81.11% 84.20% DBTHFT 86.84% 82.60% 86.05% 85.00% 85.07% 84.93% 86.06% 82.10% 84.80% 86.2% 88.89% Sheffield Teaching Hospitals Foundation Trust (STHFT) 79.06% 84.78% 77.19% 75.88% 78.81% 75.84% 75.15% 82.02% 77.88% 80.40% 78.85% England 81.08% 82.60% 80.80% 80.37% 81.63% 81.22% 82.30% 81.80% 81.36% 82.00% 82.20% Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 90% 62-day wait from urgent GP referral to first definitive treatment for cancer 85% 80% 75% 70% q q q q3 Doncaster CCG DBTHFT England Rightcare Peer Group Sheffield Teaching Hospitals Foundation Trust (STHFT) Target 26

104 Performance for Doncaster CCG improved during Quarter 3 by 7.38% however remains below the 85% target. December 2017 performance however improved to meet the target at 86.0% which is the first time this target has been met for the CCG since July This is largely due to a reduction in the number of patients treated beyond 62 days for Urology cancers, which has steadily reduced since August 2017 when additional funding was received from the Cancer Alliance Transformation funding to improve the Prostate pathway at DBTHFT. Across the Cancer Alliance the Cancer Services Managers continue to review all shared pathways at Day 38. The Trust needs to achieve and maintain a 7 day access either to diagnostics or 1st consultation and achieve discussion at a central Multi Disciplinary Team by Day 24 to allow for a smoother transition to Day 38. In November, 31.03% of patients were seen with 7 days of their referral having been made. Improvement against this measure will continue to be monitored. Dates of inter provider transfer continue to be reviewed across the Cancer Alliance to improve the accuracy of the data and the timeliness of the transfer. Focussed pathway work is underway to implement the national timed pathways for Lung and Prostate across the Cancer Alliance, and a focussed piece of work to improve the Head and Neck pathway is also underway. 27

105 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers Commissioner Q4 16/17 Apr-17 May-17 Jun-17 Q1 17/18 Jul-17 Aug-17 Sep-17 Q2 17/18 Oct-17 Nov-17 Dec-17 Q3 17/18 Doncaster CCG 84.60% 100% 100% 92.31% 96.30% 100% 81.82% 94.44% 92.11% 86.67% 91.67% 100% 91.43% Rightcare Peer Group 94.42% 95.51% 90.36% 95.00% 93.75% 91.59% 87.84% 92.11% 90.70% 93.81% 91.11% DBTHFT 87.95% 100% 100% 93.0% 96.30% 100% 86.67% 95.50% 94.10% 88.24% 91.89% Sheffield Teaching Hospitals Foundation Trust (STHFT) 93.18% 100% 100% 96.67% 98.90% 97.87% 95.45% 91.30% 95.65% % England 91.22% 93.20% 91.96% 91.93% 95.33% 90.53% 91.90% 92.10% 92.33% 89.27% 91.10% Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 100% 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers 90% 80% q q q q3 Doncaster CCG Rightcare Peer Group DBTHFT STHFT England Target 28

106 62-day wait from referral from consultant upgrade to first definitive treatment for all cancers Commissioner Q4 16/17 Apr-17 May-17 Jun-17 Q1 17/18 Jul-17 Aug-17 Sep-17 Q2 17/18 Oct-17 Nov-17 Dec-17 Q3 17/18 Doncaster CCG 83.00% 70.00% 66.67% 76.92% 72.00% 80.00% 92.86% 68.42% 79.25% 85.71% 93.75% 83.33% 90.00% Rightcare Peer Group 85.68% 90.00% 83.67% 88.96% 84.86% 88.34% 88.83% 84.29% 87.32% 87.50% 92.42% DBTHFT 89.4% 83.0% 76.9% 85.2% 80.2% 83.3% 92.7% 72.7% 83.6% 94.1% 88.9% Sheffield Teaching Hospitals Foundation Trust (STHFT) 76.02% 73.08% 77.14% 77.08% 73.97% 66.67% 77.05% 92.96% 69.01% 76.90% 78.85% England 88.50% 88.5% 88.3% 87.0% 86.8% 87.5% 87.7% 87.4% 85.8% 87.1% 93.8% 100% 95% 90% 85% 80% 75% 70% 65% 60% 62-day wait from referral from consultant upgrade to first definitive treatment for all cancers q q q q3 Doncaster CCG Rightcare Peer Group DBTHFT STHFT England 29

107 Yorkshire Ambulance Service (YAS) December January 17 February 17 March 17 April 17 May 17 June 17 July 17 August Category 1 < 8min (contract target 75%) 58.4% 59.5% 60.3% 64.6% 60.2% 60.4% 61.8% 68.1% 57.8% Category 2T < 19 min 67.4% 66.7% 70.7% 74.9% 72.4% 68.4% 70.2% 69.8% 63.6% Category 2R < 19 min Category 3T < 40 min Category 3R < 40 min Category 4 < 90 min Category 4H (triage) < 90 min 81.4% 83.3% 82.1% 82.2% 76.5% 81.1% 72.0% 74.4% 72.2% 64.5% 63.8% 65.5% 77.8% 68.7% 77.4% 64.0% 64.8% 55.3% 64.9% 74.9% 77.1% 85.0% 82.5% 83.2% 72.8% 80.3% 73.3% 64.8% 72.8% 64.9% 67.0% 67.2% 65.5% 59.0% 62.2% 56.2% 94.6% 98.2% 100% 100% 100% 98.7% 99.7% 99.4% 98.9% Category 1 (Life threatening injuries and illness) target of average time less than 7min Category 2 (Emergency) target of average time less than 18 min Category 3 (Urgent) target 90% of times below 2 hours Category 4 (Less urgent) target 90% of times below 3 hours September 17 October 17 November 17 December 17 January 18 00:07:13 00:07:11 00:07:30 00:08:18 00:08:01 00:22:06 00:20:28 00:21:26 00:27:47 00:26:55 01:52:18 01:33:56 01:42:52 02:33:03 02:29:17 03:15:16 02:57:47 02:43:45 Not Available 03:43:23 The previous Red 1 and Red 2 national standards have been replaced by a new call prioritisation system which sets standards for all 999 calls to ambulance services, including those requiring an ambulance intervention passed to ambulance services via 111. These two sets of standards are not comparable. It is the intention that all services nationally will have applied the new standards by 30 th November These new standards are now recorded at a provider level so Doncaster data is no longer available. 30

108 In addition, the revised Clinical Quality Indicators (CQI) will include reporting of data across the patient pathway as Ambulance Trusts begin to utilise national outcome databases. Reporting of CQIs will move to a quarterly schedule to better monitor trends and will be ready for full publication in April 2018 due to the preparatory work required for the new stroke indicator. This requires ambulance services to measure the time it takes from the 999 call to the time it takes positive stroke patients to arrive at a specialist stroke centre so that they can be rapidly assessed for thrombolysis. YAS have seen a continuation of higher than predicted call levels, particularly for Category 1 calls, with high acuity particularly for respiratory patients. Turnaround issues remain at some Trusts in the patch which have caused delays for YAS with vehicles being held up for attending other calls; this has been less of an issue in Doncaster with the Trust retaining 6 th best, on average, for the measure in Yorkshire and Humber. YAS are implementing a low acuity transport response utilising the early responder vehicles to transport walking patients to A&E where appropriate to free up conveyancing vehicles. YAS are also working on implementation of the National Early Warning Tool Score (NEWS) in primary care to help prioritise patients. 31

109 Section 3: Provider Exception Report The following section of the report details performance by exception (those measures either rated Red or have deteriorated outside of normal range) for each main local provider, namely DBTHFT and RDASH and other commissioned services (FCMS and YAS). Performance is across a range of agreed quality and more traditional performance measures. As such the report includes performance as a whole for DBTHFT and Doncaster sites for RDASH, and does not simply relate to services provided to NHS Doncaster CCG. The following includes a summary of provider measures and exceptions, which are those causing concern either cumulatively for the year, quarter or in month. Number of Indicators and percentage within each provider Green Red DBTHFT 16 (55%) 13 (45%) RDASH 32 (86%) 5 (14%) Other Commissioned Services 4 (25%) 12 (75%) DBTHFT RDASH Other Commissioned Services Red Green Total Green Red 32

110 3.1 Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust: Exception Report This section only includes those measures in the DBTHFT contract currently not meeting target, which are not covered by the constitution measures in Section 2. Handovers (ambulance to A&E) no person waiting over 60 minutes Handovers waiting over 60 min Provider Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sept-17 Oct-17 Nov-17 Dec-17 DBTHFT Target Handovers over 60 min Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Handovers (ambulance to DBTHFT A&E) numbers waiting over 60 min Ambulance handovers over 60 minutes increased during December 2017 to 66 however remains comparatively good within Yorkshire and the Humber at 13 th for the length of time handovers take over an hour. Performance issues are addressed during weekly joint meetings with the CCG and it has been agreed that the Trust will review and circulate the handover process with the Yorkshire Ambulance Service (YAS) lead for distribution to new staff. Through Winter Planning processes dedicated ambulance liaison managers have been identified to work with the Trust to support the departments at times of surge. YAS faced high levels of demand and increased handover times due to pressures at acute trusts. Escalation meetings have been held to identify remedial actions as required. 33

111 Cancelled operations Cancelled operations (target less than 0.8%) Provider Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sept-17 Oct-17 Nov-17 Dec-17 DBTHFT 1.8% 1.8% 1.3% 1.0% 1.1% 1.1% 1.0% 1.5% 1.1% 1.0% 1.0% 1.0% 1.5% Target 0.8% 0.8% 0.8% 0.8% 0.8% 0.8% 0.8% 0.8% 0.8% 0.8% 0.8% 0.8% 0.8% Reduction in cancelled operations 2.0% 1.5% 1.0% 0.5% 0.0% Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Reduction in Cancelled Operations Target In December, 1.51% of Trust operations were cancelled. The number of operations performed in December was significantly lower than previous months compared with an average of 5213 year to date, therefore the number of patients cancelled was consistent with the previous month, with 66 patients cancelled out of Fifty one patients were cancelled for theatre reasons and 15 for non theatre reasons. Out of the 66 patients cancelled in total, 53 operations were cancelled for non-clinical reasons: 28 at Doncaster, 22 at Bassetlaw and 3 at Mexborough. 34

112 Cancelled Operations - 28 day standard Provider Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sept-17 Oct-17 Nov-17 Dec-17 DBTHFT Target Cancelled operations - 28 day standard Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Cancelled operations - 28 day standard There were 2 instances in December where patients had their operation cancelled and not re-booked within 28 days. Further details on these instances are awaited from the Trust. 35

113 52 Week Waits Incomplete Pathway 52 Week Waits Incomplete Pathway Provider Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sept-17 Oct-17 Nov-17 Dec-17 DBTHFT Target Week Waits Incomplete Pathway Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec Week Waits Incomplete Pathway There was 1 patient waiting over 52 weeks during December 2017 at DBTHFT within General Surgery. 36

114 Stroke: Proportion of patients directly admitted to a stroke unit under 4 hours (target 90%) the Percentage of applicable patients who are discharged who were given a named person to contact after discharge (target 95%) Proportion of patients directly admitted to a stroke unit under 4 hours (stretch target 90%) Percentage of patients (according to the RCP guideline minimum threshold) given thrombolysis (stretch target 20%) Percentage of applicable patients who are discharged who were given a named person to contact after discharge (stretch target 95%) Oct- 16 Nov- 16 Dec- 16 Jan- 17 Stroke Feb- 17 Mar- 17 Apr % 66.0% 62.9% 49.0% 51.2% 64.3% 56.5% 68.3% 74.5% 73.9% 66.0% 62.2% 66.7% N/A N/A N/A N/A N/A N/A 4.3% 8.3% 10.6% 13.0% 12.0% 2.2% 11.8% 97.2% 82.2% 79.4% 65.9% 74.4% 80.7% 85.0% 80.8% 84.1% 82.2% 90.9% 83.3% 91.1% May- 17 Jun- 17 Jul- 17 Aug- 17 Sept- 17 Oct % Stroke measures 50.0% 0.0% Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Proportion of patients directly admitted to a stroke unit under 4 hours Percentage of applicable patients who are discharged who were given a named person to contact after discharge Percentage of patients (according to the RCP guideline minimum threshold) given thrombolysis Performance against all three measures improved during October 2017 but did not meet the specified targets The percentage of people directly admitted to a stroke ward within 4 hours was 66.7% against a 90% target. 37

115 The percentage of people discharged who were given a named persion to contact after discharge rose to 91.1% against a 95% target. The percentage of people given thrombolysis rose to 11.8% against the target of 20%. A mapping exercise of the stroke pathway has been completed. It focused on key clinical decision points and clinical responsibilities and expectations e.g. medical handover and clinical guidelines. A meeting took place in January to draft a policy to ensure variability in treatment is reduced and embed best practice. YAS have agreed for paramedics to transport thrombolysis patients straight through for computerised tomography (CT) scans. A new overall transfer policy is also being implemented December 2017 to aid flow through the department.. 38

116 3.2 Rotherham, Doncaster & South Humber NHS Foundation Trust This section only includes measures in the RDASH contract currently not meeting target which are not included in the constitution measures in Section 2. Improving Access to Psychological Therapies (IAPT) Performance included below shows the cumulative percentage compliance of Doncaster CCG patients attending RDASH services and also a measure of Doncaster CCG patients at all providers. IAPT Access - Compliance of those who have entered (i.e. received) treatment as a proportion of people with anxiety or depression (cumulative for financial year) Commissioner and year Q1 Q2 Q3 Q4 RDASH DCCG 2017/ % 8.90% 12.80% Local Stretch Target 2017/18 5.0% 10% 15% 20% Doncaster CCG (all providers) 2017/18 4.2% 8.4% 39

117 25.00% IAPT Access 20.00% 15.00% 10.00% 5.00% 0.00% Q1 Q2 Q3 Q4 RDASH 2017/18 Target 2017/18 DCCG As at Quarter 3 performance is slightly off track at 12.8%, against the local target of 15%; nationally the service is required to meet 4.2% during Quarter 4. If the performance for Quarter 1 to 3 were to continue RDASH would achieve over 17% for the year however performance for Quarter 3 was reported as 3.9% which would not achieve the national target. The Trust are confident that improved performance in January 2018 and existing planes will ensure this target is met. An action plan is in place which focuses on access to triage and follow up, Drug and Alcohol referrals and also the potential use of the single point of access to aid self- referrals into the service. In addition to this, monthly meetings are being held with commissioners to discuss extending the service to focus on long term conditions beginning with diabetes. This work will focus on developing outcome measures and standards around new clinical outcomes along with promoting the service to community healthcare services and hospitals. It is anticipated that this work will have a beneficial impact on access to the service however meeting the local stretch target remains challenging. 40

118 Child and Adolescent Mental Health Services (CAMHS) reporting During January RDASH have changed their clinical system used for CAMHS and are currently running validation checks to ensure that the reporting of this information is robust. Due to these checks December data in unavailable at the time of writing. Child and Adolescent Mental Health Services (CAMHS) - percentage of referrals starting a treatment plan within 8 weeks (Non Urgent) Services (CAMHS) - percentage of referrals starting a treatment plan within 8 weeks (Non Urgent) Provider Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sept-17 Oct-17 Nov -17 RDASH 85.7% 93.9% 92.3% 94.7% 97.3% 80.8% 90.7% 96.8% 74.4% 93.9% 78.1% 65.7% 97.8% Target 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 100.0% CAMHS - treatment plan start 50.0% 0.0% Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 percentage of referrals starting a treatment plan within 8 weeks / Non Urgent Target Following consistent under performance for this measure in 2016/17 and into 2017/18 a performance contract notice was issued by the CCG at the beginning of October The CCG received a detailed action plan including clear timeframes against each action as requested in the performance notice. To ensure continued attainment of this measure and assurance some changes in the internal support structures of RDASH have been implemented with the Intensive Home Treatment Team supporting this process as a whole and also supporting the Tier 4 placements. RDASH have been asked to demonstrate that the improvements seen will continue and will use information up to February to confirm this. This is also reviewed at the CCG and RDASH Strategic Contracting meeting. 41

119 Speech and Language Service Patients on incomplete pathways (yet to start treatment) should have been waiting no more than 18 weeks Speech and Language Provider Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sept-17 Oct-17 Nov-17 Dec-17 RDASH 100% 100% 100% 100% 100% 100% 100% 99.3% 92.9% 90.2% 80.2% 88.6% 71.1% Target 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% SALT incomplete waits 90.00% 40.00% Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec week incomplete waits Target Performance in December fell slightly to 71.1% against the 92% target. The service continue to triage the patients most at risk. There have been no reported incidents into the Service although they recognise the increased risk particularly with the dysphagia patients. If there is updated information added to the referral from reviews staff are reassessing the severity. The service are now up to full capacity and a locum member of staff will remain in place until April 2018 which will improve reported and resuce the total number of patients on the waiting list. 42

120 3.3 Other Commissioned Services FCMS: Definitive Clinical Assessments undertaken under 60 minutes (non-urgent) Out of Hours - Definitive Clinical Assessment % 90.00% 80.00% 70.00% 60.00% Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Definitive Clinical Assessment <60 mins (non urgent) Target Performance fell again during December continuing a downward trend for 2017/18 as a whole. Performance against this standard is deteriorating mainly because the number of patients included in this measure is reducing due to the implementation of NHS Pathways. Patients who go via the NHS Pathways route are included in the 20 minute Definitive Clinical Assessment measure and therefore as this has been rolled out over time, less patients fall under this measure, and therefore the numbers of patients not having definitive clinical assessment in 60 minutes, whilst it has slightly increased in December, it is lower than in April 2017 when the measure last met target. Month Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sept-17 Oct-17 Nov-17 Dec-17 Advised within minutes Not advised within 60 minutes

121 The longest case breached by 10 hours 47minutes and 13 seconds and was due to the call handler selecting the wrong case type which delayed the clinican. It has been identified by the service that further training around choosing the correct case type, closing down cases on the clinical system and selecting the relevent outcome is needed and will be provided to the staff involved to prevent this happening in the futurethe initial priority for this call was set at red however as this was received from a paramedic should have been put straight through to GP for triage. An incorrect procedure was followed causing a delay. A reminder of the appropriate pathway will be discussed with appropriate staff and the case assessed for clinical harm. This issue and other factors affecting performance are due to be discussed at the service s Clinicians meeting in February. Out of Hours (OOH) Surgery face to face assessments triaged as emergency in less than 1 hour and as urgent under 2 hours; Visits face to face assessments triaged as urgent under 2 hours 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Out of Hours - Surgery and Visits Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Surgery < 1 hour Surgery < 2 hours Target Visits < 1 hour Visits < 2 hours OOH Surgery breaches for Red Priority (1 hour): Performance decreased to 50.0% in December. There were 12 breaches as broken down below: Case Category Dec 17 Patient Choice/first appointment Clinician delay Incorrect reporting

122 Longest wait time from initial assessment: 4 hours 21 minutes. The appointment made was not booked within the two hour timeframe as a GP was not available. This case finished with a red priority and the patient was referred to A&E. Further details of this case are awaited from FCMS. OOH Surgery breaches Amber Priority (2 hours): Performance deteriorated slightly to 73.1% in December with the breaches broken down below. Case Category Dec 17 Patient arrived late Patient Choice/first appointment Clinician delay Incorrect reporting Longest wait time from initial assessment: 6 hours 23 minutes and 56 seconds. This case was finished on a Green Priority. This case involved patient delay. The patient missed the first booked appointment and attended a rescheduled appointment later that day causing the breach. Patient choice/ First Appointment: The majority of these cases breached due to booking the first available appointment. The amount of calls presented increased in December and this influx has increased the service demand significantly, reducing the availability of appointments. OOH Visit breaches Red Priority (1 Hour): There were 3 cases in December all of which breached the 1 hour target. Two of these breaches were the result of clinician delays with the other due to incorrect reporting. The longest delay was 1 hour and 6 minutes for a verification of death. OOH Visit breaches Amber Priority (2 Hours): Performance increased during December to 78.72%. There were 10 breaches resulting from clinician delays. The longest clinical delay was 3 hours 13 minutes and 22 seconds. This case was picked up on the mobile device within the timeframe but was not acknowledged until after the timeframe due to change over of staff resulting in a delayed consultation. The patient was seen immediately after the case was acknowledged. This case was finished on green priority. Actions to prevent this from happening in future are being discussed with FCMS. 45

123 Same Day Health Centre: face to face assessments triaged as emergency and seen in under 1 hour and as urgent under 2 hours 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Same day Health Centre Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 SDHC < 1 hour SDHC < 2 hours Red Priority (1 hour) breaches: Performance improved slightly to 55.6% in December 2017 with 12 breaches as broken down below: Case Category Dec 17 Patient arrived late Patient Choice/first appointment Longest wait time from initial consultation: 3 hours 59 minutes and 49 seconds. This case involved patient choice /first appointment. This case was finished on Green Priority. 46

124 Amber Priority (2 hour) breaches: There were 31 breaches in November with performance increasing to 85.1%. The breaches are broken down below: Case Category Dec 17 Patient arrived late Patient Choice/first appointment Clinician delay Longest wait time from initial consultation: 6 hours 48 minutes and 50 seconds. This case finished with a green priority and involved patient choice/ first appointment. The longest confirmed clinician delay was 2 hours 56 minutes and 41 seconds due to a busy period at a weekend. A clinical review of all breached cases ending in red or amber priority continues to be carried out. Those highlighted as unsafe will be referred back to the consulting clinician for reflection and feedback. This will be audited on a monthly basis. No cases with patient harm have as yet been identified to the CCG. During January 2018 a national issue with the clinical system used at FCMS resulted in some patient attendance data not being sent to the relevant patients GPs in a timely manner. This affected discharge summaries for 1 day and has been resolved. FCMS have been asked to feedback to the CCG on existing escalation plans and mitigation around issues like this in the future. A request has also been made to confirm that there was no patient harm as a result of this incident Nursing / Care Homes / Domiciliary Care Providers The information provided within this section is taken up to 31 st January Since the last Governing body meeting there have been 0 new embargos against admissions / new care packages placed. There is currently 1 home with an embargo in place Serious Case Reviews / Lesson Learnt Reviews No new Serious Case Reviews or Lessons Learnt Reviews have been commissioned since the last Governing Body Report. 47

125 3.3.4 Domestic Homicide Reviews There are currently 2 Domestic Homicide Reviews taking place within Doncaster. An independent chair has been commissioned for both reviews. The check and challenge meetings have taken place for both cases and the Chair is currently developing the Overview Report. A further Domestic Homicide Review was considered and agreed on the 18 th January Doncaster CCG are currently in the process of obtaining the Primary Care records for parties involved. Once obtained chronologies will be developed. A further update will be provided within the February 2018 report Mixed Sex Accommodation Commissioner Dec-16 Jan-17 Breaches of Mixed Sex Accommodation Feb- 17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sept-17 Oct-17 Nov-17 Dec-17 Doncaster CCG No mixed sex accommodation breaches were reported for Doncaster CCG in December Complaints and Concerns (DBTHFT) Complaints and concerns Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Complaints and concerns 48

126 Normal variation is seen in the rate of complaints and concerns. Performance on complaint reply times has increased for the second month in a row. Weekly meetings with care groups and Director of Nursing to review complaint reply compliance are being undertaken in conjunction with quality improvement work Serious Incidents (SI) 40 Serious Incidents 20 0 Q2 2016/17 Q3 2016/17 Q4 2016/17 Q1 2017/18 Q2 2017/18 Serious Incidents Please note that the above figures include incidents which may be subsequently de-logged as a SI. A total of 15 SIs from Q2 have now been delogged. All of the SIs have been reviewed by the CCG and no concerns have been raised Continuing Healthcare (CHC) Percentage of referrals compelted within 28 days of receipt (target > 80%) The percentage of Decision Support Tools (DST) completed in an acute hospital setting (target <15%) Quarter /18 Quarter /18 Quarter / % 31.1% 97.5% 0.4% 0.9% 0.0% 49

127 SECTION 4: Improvement and Assessment Framework NHS England has a statutory duty to conduct an annual performance assessment of every CCG. The annual assessment will be a judgement reached by taking into account the CCG s performance in each of the indicator areas over the full year balanced against the financial management and a qualitative assessment of the leadership of the CCG. To ensure that the framework is being applied consistently, regional and national moderation takes place. As in the Improvement and Assessment Framework covers the following four domains: 1. Better Health: this section looks at how the CCG is contributing towards improving the health and wellbeing of its population and bending the demand curve. 2. Better Care: this focuses on care redesign, performance of constitutional standards, and outcomes, including in important clinical areas. 3. Sustainability: this section looks at how the CCG is remaining in financial balance and securing good value for patients and the public from the money it spends. 4. Leadership: this domain assesses the quality of the CCG s leadership, the quality of its plans, how the CCG works with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity, for example in managing conflicts of interest. Underpinning the four domains are 51 indicators which are used to inform the ratings. According to data published by NHS England in February 2018 Doncaster CCG is in the worst performing quartile in England for the following indicators: 50

128 Better Health Indicator Period DCCG Rank (out of 207) Injuries from falls in people aged 65 and over q1 2017/ Inequality in unplanned hospitalisation for chronic ambulatory care sensitive and urgent care sensitive conditions q1 2017/ Antimicrobial resistance: appropriate prescribing of antibiotics in primary care Sep Sustainability Utilisation of the NHS e-referral service Oct % 163 Leadership Staff engagement index Better Care Cancers diagnosed at an early stage % 173 Cancer 62 day referral to treatment q % 177 One-year survival from all cancers % 175 Reliance on specialist inpatient care for people with a learning disability and/or autism q2 2017/ Maternal smoking at delivery q2 2017/ % 165 Dementia post diagnostic support % 181 Emergency admissions for urgent care sensitive conditions q1 2017/ Patient experience of GP services GPPS % 168 The following work is being undertaken to address performance against these indicators: Injuries from falls in people aged 65 and over As part of the system transformation of Intermediate Care a new Rapid Response Service was launched in January Ambulance staff assess patients who have fallen and those who require short term health or social care support to stay at home will be referred to this service rather than conveyed to A&E. To date 78% of patients accepted on to the pathway were supported at home. Inequality in unplanned hospitalisation for chronic ambulatory care sensitive and urgent care sensitive conditions The Doncaster Health and Wellbeing Board have established a Health Inequalities Steering Group which has developed an Action Plan to address health inequalities in Doncaster. The Steering Group includes representation from DMBC, DCCG, Primary Care Doncaster and Doncaster Healthwatch. Antimicrobial resistance: appropriate prescribing of antibiotics in primary care 51

129 DCCG s prescribing rate of antibacterial items per STAR-PU in achieved the Quality Premium target for reducing antibacterial prescribing. The Medicines Management Delivery Plan aims continue this improvement in reducing anti-microbial resistance. All bar two Doncaster CCG Practices are now utilising the OptimiseRX medicines optimization solution. Utilisation of the NHS e-referral service Slot availability has been increased for two week wait and 18 week wait appointments. Communications to primary care is being undertaken to encourage usage. A Task and Finish Group reporting to the Planned Care Programme Board has been established. DBTHT plan to be paper-light by the end of March 2018 after which GPs who submit a paper referral will be asked to resubmit via ERS within 48 hours. Staff Engagement Index This indicator is derived from the results of the 2016 NHS Staff Survey for DBTHT and RDaSH. DBTHT s overall Staff Engagement Score in 2016 is significantly worse than in 2015 and is in the lowest 20% of its benchmark group. To address this issue DBTHT have developed a Staff Survey Action Plan which contains five key elements: Communicating with staff Listening to staff Involving staff Supporting and engaging with managers A program of staff experience Cancers diagnosed at early stage The proportion increased from 37.8% in 2014 to 48.6% in The Cancer Delivery Plan aims to increase in provision of straight to test (direct access diagnostic) pathways in line with 2 week wait NICE Guidance and within High Value Pathways work and review innovative diagnostic solutions to increase capacity to meet demand. A 'Vague Symptoms' pathway is being piloted which may incorporate shorter waiting times for diagnostics for patients referred via this route. Cancer 62 day referral to treatment Urology is an issue at DBTHT due to demand. Cancer Services Managers are working collaboratively across the Cancer Alliance to review all shared pathways at Day 38. DBTHT need to achieve and maintain 7 day access to either diagnostics or 1st consultation and achieve discussion at a central Multi-Disciplinary Team by Day 24 to allow for a smoother transition to Day

130 One year survival from all cancers The survival rate improved from 68.9% in 2014 to 70.3% in The Cancer Delivery Plan aims to increase one year survival rates to 75% by 2020.This will be achieved via the awareness, prevention and early diagnosis actions in the plan. Reliance on specialist inpatient care for people with a learning disability and/or autism There are currently 12 patients occupying inpatient beds which is above the target of 10. Since April patients have been stepped down into community care. A Care and Treatment Review process has been established to ensure that any hospital admissions are appropriate and discharges planned. Joint work is being undertaken with NHS England to step down patients from Specialised Commissioning to CCG responsibility where appropriate. A Provider Event was held in January 2018 to begin to stimulate the market further and prepare for acceptance of more complex and challenging cases. Dementia care planning and post-diagnostic support This is the General Medical Services Quality and Outcomes Framework (QOF) indicator DEM004 which is the percentage of patients diagnosed with dementia whose care plan has been reviewed in a face-to-face meeting in the preceding 12 months. The post diagnostic Admiral Service has been extended until March An away day for all stakeholders was held in December 2017 to work through the development of the service and arrangements for working as an Alliance. DCCG will continue to work with RDaSH on the reconfiguration of the Young Onset Dementia Service and the Cognitive Stimulation Therapy elements of the post diagnostic service. Monthly meetings with all partners have been scheduled from January Emergency admissions for urgent care sensitive conditions The Urgent Care Delivery Plan aims to increase the proportion of patients streamed away from the Emergency Department at DRI to an average of 20% per month and also to reduce ambulance conveyances to DRI by 2.5% in Streaming increased from 12% in quarter 1 to 15.2% in quarter 3 and 16.4% of patients were streamed in December The Rapid Response service now includes respiratory patients from YAS and this is to be extended to patients referred by GPs. The service continues to maintain around 80% of people accepted at home and feedback from patients remains positive. The Doncaster Place Plan aims to reduce emergency admissions for older people with these conditions by developing out of hospital services and fostering community resilience to improve support and provide services closer to home. Patient experience of GP services 53

131 The Primary Care Delivery Plan aims to reduce inequalities in care and quality between Practices. Joint education programs for GPs and Nurses and education sessions for Practice Managers are being developed. DCCG is launching a patient campaign to raise awareness of Patient Online Services and the Primary Care Team is working with the Data Quality Team to support practices offering the services. Doncaster CCG is in the best performing quartile in England for the following indicators: Better Health Indicator Period DCCG Rank (out of 207) Diabetes patients who achieved NICE targets % 1 Personal health budgets q AMR: Broad spectrum prescribing Sep % 15 Better Care Dementia diagnosis rate Nov % 49 A&E admission, transfer, discharge within 4 hours Dec % 38 Delayed transfers of care per 100,000 population Nov Percentage of NHS Continuing Healthcare full assessments taking place in an acute hospital setting q2 2017/18 0.9% 26 54

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