Governing Body Vice Chair and Lay Member, Camden. Governing Body Chair, Camden CCG

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1 NCL Joint Commissioning Committee Thursday 5 th October pm Main Conference Hall Cypriot Community Centre Earlham Grove London N22 5HJ Voting Members Ms Karen Trew (Chair) Dr Mo Abedi Ms Sorrel Brookes Dr Peter Christian Ms Bernadette Conroy Ms Kathy Elliott Mr Simon Goodwin Ms Catherine Herman Ms Helen Pettersen Dr Kevan Ritchie Dr Jo Sauvage Dr Barry Subel Non-Voting Members Cllr Jason Arthur Ms Parin Bahl Cllr Alev Cazimoglu Ms Sharon Grant Dr Jeanelle De Gruchy Cllr Richard Olszewski Cllr Hugh Rayner Governing Body Vice Chair and Lay Member, Enfield CCG Governing Body Chair, Enfield CCG Governing Body Lay Member, Islington CCG Governing Body Chair, Haringey CCG Governing Body Lay Member, Barnet CCG Governing Body Vice Chair and Lay Member, Camden CCG NCL Chief Finance Officer, Barnet, Camden, Enfield, Haringey and Islington CCGs Governing Body Non-Clinical Vice Chair and Lay Member, Haringey CCG NCL Accountable Officer, Barnet, Camden, Enfield, Haringey and Islington CCGs Governing Body Clinical Vice Chair, Camden CCG Governing Body Chair, Islington CCG Governing Body Clinical Vice Chair, Barnet CCG Councillor, Haringey London Borough Council Chair, Healthwatch Enfield Councillor, Enfield London Borough Council Chair, Healthwatch Haringey Director of Public Health, Haringey London Borough Council Councillor, Camden London Borough Council Councillor, Barnet London Borough Council Attendees Mr Paul Sinden Mr Andrew Spicer Apologies Cllr Janet Burgess Dr Debbie Frost Dr Neel Gupta Minutes Ms Louisa Dearman NCL Director of Performance and Acute Commissioning, Barnet, Camden, Enfield, Haringey and Islington CCGs NCL Head of Governance and Risk, Barnet, Camden, Enfield, Haringey and Islington CCGs Councillor, Islington London Borough Council Governing Body Chair, Barnet CCG Governing Body Chair, Camden CCG Quality and Governance Support Officer 1. Introduction AGENDA Lead Action Paper Time Page 1.1 Welcome and Apologies for Absence Chair Note Verbal Declaration of Interests Chair Note Gifts and Hospitality Register Chair Note Verbal

2 1.4 Minutes of the Committee Meeting on Chair Approve rd August Notes from the Seminar held on 7 th Chair Note September Action Log Chair Note Questions from Public Chair Note Verbal Governance 2.1 Update on Independent Chair and Independent Clinicians Helen Pettersen Note Verbal Activity and Performance 3.1 Acute Contract Report Paul Sinden Note Learning Disabilities- Transforming Care Cohort Paul Sinden Note Commissioning 4.1 System Intentions Paul Sinden Note Procedures of Limited Clinical Effectiveness Mark Eaton Approval 4.2 (To follow) Planning for Winter 2017/18 Paul Sinden Note Royal Free Medium-Term Financial Strategy Peter Ridley Note Risk 5.1 NCL Joint Commissioning Committee Risk Register Paul Sinden Discuss Questions from Public 6.1 Question and Answer Session Chair Discuss Verbal Any Other Business 7.1 Forward Planner 2017/18 Chair Discuss Deadline for submission of reports for the next meeting- Monday 27 th November Date of next and future meetings: 2017: Thursday 7 th December Camden- Venue TBC Chair Note Verbal

3 NOTES 3

4 BARNET, CAMDEN, ENFIELD, HARINGEY AND ISLINGTON CLINICAL COMMISSIONING GROUPS: NCL JOINT COMMISSIONING COMMITTEE REGISTER OF INTERESTS Agenda Item: 1.2 Voting Members NAME TITLE NAME OF ORGANISATION AND NATURE OF ITS BUSINESS POSITION HELD / NATURE OF INTEREST DATE DECLARED DATE UPDATED Dr Mo Adebi Chair, Enfield Clinical Commissioning Group East Enfield Medical Practice - GP Practice GP Principal 27/06/ /06/2017 Ms Sorrel Brookes Ms Bernadette Conroy Dr Peter Christian Lay Member, Islington Clinical Commissioning Group Lay Member, Barnet Clinical Commissioning Group Chair, Haringey Clinical Commissioning Group Evergreen Surgery Limited - GP Practice Director and Shareholder 27/06/ /06/2017 Brick Lane Surgery Medicare Medical services LLP - Runs walk in centre at Evergreen and South East Locality access hub DM786 Limited Property management Company GP Principal 27/06/ /06/2017 Wife also a GP Principal Director and Shareholder 27/06/ /06/2017 Director, Wife is a Director, Mother and children are shareholders 27/06/ /06/2017 DM786 Health Ltd Health Consultancy (not actively trading) Director, Wife is a Director, Mother and children are shareholders 27/06/ /06/2017 Prime Point Limited Primary care medical services provider (not actively trading) Enfield Health Partnership Limited, Provider of community gynaecology service Enfield Healthcare Alliance Limited runs Chalfont Road and Boundary Court GP Practices Director/Shareholder 27/06/ /06/2017 Shareholder 27/06/ /06/2017 Shareholder 27/06/ /06/2017 Southbury GP Surgery Wife is a salaried GP 27/06/ /06/2017 South East Locality access hub Wife is a locum GP 27/06/ /06/2017 Carlton House Surgery GP Partner 27/06/ /06/2017 Help On Your Doorstep Trustee 07/07/ /07/2017 East London Music Group Trustee 07/07/ /07/2017 University of Cambridge Idependent Chair of the Building and Estates Committee 27/06/ /06/2017 North London NHS Estates Partnership Non-executive director 27/06/ /06/2017 Community Health Partnership Non-executive director 27/06/ /06/2017 Bancrofts School Governor 27/06/ /06/2017 St Paul s Way Trust School Trustee 27/06/ /06/2017 Network Homes Chair 27/06/ /06/2017 Hadley Wood Association Trustee 27/06/ /06/2017 Royal Free London NHS Foundation Trust Hospital Husband is consultant anaesthetist and Clinical Director 27/06/ /06/2017 Muswell Hill Practice GP Partner 27/06/ /06/2017 Federated4Health, the pan-haringey GP federation Muswell Hill Practice is a member and Practice Manager at Muswell Hill Practice is Chair 27/06/ /06/2017 WISH- urgent care provider at Whittington Hospital Muswell Hill Practice is a member 27/06/ /06/2017 Muswell Hill Practice Practice provides anticoagulant care to Haringey residents under a contract with Haringey CCG. 27/06/ /06/2017 4

5 The Hospital Saturday Fund - a charity which gives money to health related issues. The Lost Chord Charity - organises interactive musical sessions for people with dementia in residential homes. Haringey Health Connected, the federation of west Haringey GP practices Member and wife is a Patron 27/06/ /06/2017 Wife is a patron 27/06/ /06/2017 The Practice Manager at Muswell Hill Practice is the Finance Director 27/06/ /06/2017 Ms Kathy Elliott Lay Member, Camden CCG Governing Body Camden Patient and Public Engagement Group Member 27/06/ /06/2017 Caversham Group Practice- Patient Participation Group Member 27/06/ /06/2017 Kaeconsulting - independent consultancy Owner/Director 27/06/ /06/2017 UK Public Health Register (UKPHR) Assessor and Chair of the Registration Panel 27/06/ /06/2017 Dr Debbie Frost Chair, Barnet Clinical Commissioning Group Faculty of Public Health Member 27/06/ /06/2017 PHAST - public health consultancy Associate 27/06/ /06/2017 Millway Practice GP Partner 27/06/ /06/2017 Barndoc Healthcare Ltd GP Partner is a member of the Pan Barnet Federated GPs Network Board. GP Partner colleague at Millway Practice is the Chair of Barndoc Healthcare Ltd GP Partner colleague at Millway Practice is a member of the Pan Barnet Federated GPs Network Board 27/06/ /06/ /06/ /06/2017 Mid-West GP Federation Member 27/06/ /06/2017 KPMG Son is a graduate trainee with the KPMG Banking Sector 27/06/ /06/2017 Mr Simon Goodwin NCL Chief Finance Officer, Barnet, Camden, Enfield, Haringey and Islington Clinical Commissioning Groups Chief Financial Officer for the 5 CCGs in North Central London (Barnet, Enfield, Haringey, Islington and Camden) Chief Finance Officer for the five CCGs 14/06/ /08/2017 East London NHS Foundation Trust Wife is a senior manager 14/06/ /08/2017 Dr Neel Gupta Chair, Camden Clinical Commissioning Group The Keats Group Practice Salaried GP, no other interests declared. 27/06/ /06/2017 Ms Helen Pettersen NCL Accountable Officer, Barnet, Camden, Enfield, Haringey and Islington Clinical Commissioning Groups No interests declared No interests declared No interests declared 27/06/2017 Dr Kevin Ritchie Bloomsbury Surgery GP Partner 13/06/ /06/2017 Dr Josephine Sauvage Dr Barry Subel Chair, Islington Clinical Commissioning Group Clincial Vice Chair, Barnet CCG Haverstock Healthcare Limited GP Practice is a shareholder 13/06/ /06/2017 Central Health Evolution Limited GP practice is a member 13/06/ /06/2017 Camden Clinical Assessment Service ('CCAS') Assessor Provde 2-4 sessions per month 13/06/ /06/2017 City Road Medical Centre GP Partner 27/06/ /06/2017 Islington GP Federation City Road Medical Centre is a member practice 27/06/ /06/2017 Health Education North Central and East London Non-executive Board Member 27/06/ /06/2017 South Islington GP Alliance ('SIGPAL') City Road Medical Centre purchased shares to support the development of SIGPAL. The shares are held as a joint asset by the practice and not by individual partners 27/06/ /06/2017 Ravenscroft Medical Centre GP Partner 28/07/ /07/2017 South Locality Barnet Practices Network Limited Director 28/07/ /07/2017 Royal Free London NHS Foundation Trust Hospital Wife is a specialist in haemophilia at Royal Free Hospital. 28/07/ /07/2017 Ms Karen Trew Lay Member and Vice Chair, Enfield Clinical Commissioning Group NHSE Performer List Decision Panel (outside of North Central London) Chair of Panels 27/06/ /06/2017 Broxbourne School Hertfordshire Chair of the Governing Body 27/06/ /06/2017 5

6 Wormley C of E Primary School, Hertfordshire Chair of the Governing Body 27/06/ /06/2017 North East London ('NEL') CCGs 111 Procurement Chair and non-scoring panel member (providing assurance to NEL CCGs on process) 27/06/ /06/2017 Lloyds Pharmacy Clinical Homecare Son employed in operational role 27/06/ /06/2017 Non Voting Members NAME NAME OF ORGANISATION AND NATURE OF ITS BUSINESS POSITION HELD / NATURE OF INTEREST DATE DECLARED DATE UPDATED Ms Sharon Grant OBE Chair, Healthwatch Haringey Bernie Grant Arts Centre Partnership Limited Director 12/07/ /07/2017 Bernie Grant Trust Trustee 12/07/ /07/2017 Public Voice Community Interest Company Chair 12/07/ /07/2017 Haringey Citizen's Advice Bureau Member 12/07/ /07/2017 Foods Standards Agency- Food Hygeine Regulation Scheme subcommittee Member 12/07/ /07/2017 Metropolitan Police independent advisory committee Haringey Member 12/07/ /07/2017 Unite Trade Union Member 12/07/ /07/2017 Occasional research, unremunerated, on NHS Wales & other patient voice issues for a Labour MP Researcher 12/07/ /07/2017 Dr Jeanelle De Gruchy Director of Public Health, London Borough of National Association of Directors of Public Health Vice President 27/06/ /06/2017 Haringey Attendees NAME NAME OF ORGANISATION AND NATURE OF ITS BUSINESS POSITION HELD / NATURE OF INTEREST DATE DECLARED DATE UPDATED Mr Will Huxter NCL Director of Strategy No interests declared No interests declared 31/07/ /09/2017 Mr Ian Porter Director of Corporate Services, Camden CCG No interests declared No interests declared 27/06/ /06/2017 Mr Paul Sinden Mr Andrew Spicer NCL Director of Performance and Acute Commissioning, Barnet, Camden, Enfield, Haringey and Islington Clinical Commissioning Groups NCL Head of Governance and Risk, Barnet, Camden, Enfield, Haringey and Islington Clinical Commissioning Groups No interests declared No interests declared 27/06/ /06/2017 WEL CCGs Brother is Director of Commissioning (Transformation) 27/06/ /06/2017 6

7 NORTH CENTRAL LONDON ( NCL ) JOINT COMMISSIONING COMMITEE Minutes of the meeting held in public on Thursday 3 rd August 2017 from 3pm pm Seminar Room 2, Resource for London, 356 Holloway Road, London N7 6PA Present: Voting Members: Ms Sorrel Brookes (Chair) Dr Mo Abedi Dr Peter Christian Ms Bernadette Conroy Ms Kathy Elliott Mr Simon Goodwin Dr Neel Gupta Ms Catherine Herman Ms Helen Pettersen Dr Jo Sauvage Dr Barry Subel Governing Body Lay Member, Islington CCG Governing Body Chair, Enfield CCG Governing Body Chair, Haringey CCG Governing Body Lay Member, Barnet CCG Governing Body Lay Member, Camden CCG NCL Chief Finance Officer Governing Body Chair Elect, Camden CCG Governing Body Vice Chair and Lay Member, Haringey CCG NCL Accountable Officer Governing Body Chair, Islington CCG Clinical Vice Chair, Barnet CCG Non-Voting Members: Cllr Janet Burgess Councillor, Islington Council Ms Sharon Grant Healthwatch Chair, Haringey Cllr Val Duschinsky Councillor, Barnet Council Dr Jeanette De Gruchy Director of Public Health, Haringey Council Cllr Richard Olszewski Councillor, Camden Council In Attendance: Mr Paul Sinden Mr Andrew Spicer Apologies: Cllr Jason Arthur Cllr Alev Cazimoglu Ms Deborah Fowler Dr Debbie Frost Cllr Hugh Rayner Ms Karen Trew Minutes Mr David Triggs NCL Director of Performance and Acute Commissioning NCL Head of Governance and Risk Councillor, Haringey Council Councillor, Enfield London Borough Council Chair, Healthwatch Enfield Governing Body Chair, Barnet CCG Councillor, Barnet Council Governing Body Vice Chair and Lay Member, Enfield CCG Board Secretary, Enfield CCG 7

8 1. Introduction 1.1 Welcome The Chair welcomed everyone to the meeting and invited introductions around the table. It was noted that this was the second meeting of the NCL Joint Commissioning Committee ( JCC ) under the new commissioning arrangements for NCL CCGs. 1.2 Declarations of Interest These were noted as recorded in the papers subject to corrections to the interests of Simon Goodwin which were recorded incorrectly. Simon Goodwin confirmed the following interests: Chief Financial Officer for the 5 CCGs in North Central London (Barnet, Enfield, Haringey, Islington and Camden); Wife is a senior manager at East London NHS Foundation Trust. 1.3 Declarations of Gifts and Hospitality There were no declarations of gifts or hospitality offered or received. 1.4 Minutes of the Meeting on 6 th July The minutes were approved as an accurate record. 1.5 Action Log The following updates were given: Action 1: Committee Terms of Reference: These were on the agenda for this meeting. Action completed; Action 2: Acute Commissioning Report (Whittington Health): Paul Sinden explained that the report included both acute and community contract baselines for Whittington Health. Future papers would disaggregate information between acute commissioning and community services for the Trust; Action 3: Acute Commissioning Report (Royal Free): The Acute Commissioning report in the papers covered the issue of data quality for the August 2017 meeting. Action completed; Action 4: Transforming Care Programme: It was noted that an update on costings would be presented to the Committee in October 2017; Action 5: Transforming Care Programme: A risk relating to quality assurance of packages of care established in the community had been added to the risk register, and shared with CCGs for inclusion into local registers. Action completed; Action 6: Transforming Care Programme: Updates on quality assurance process included in the Committee papers for August Action completed; Action 7: Committee Risk Register: The register had been updated for the operational risks identified at the July 2017 Committee. Further discussion would be undertaken as part of the seminar to be held in September 2017 with a focus on strategic risks. 1.6 Questions from the Public There were no questions from the public. It was noted that the next formal Committee would be held on 5 October 2017 commencing at 3pm. 2 Governance 2.1 Terms of Reference Update 8

9 2.1.1 The Committee received and noted the updated terms of reference. Barnet CCG had approved the term of reference via Chair s action. Each of the other four CCG Governing Bodies had approved the terms of reference. It was noted that the main changes to the terms of reference included: Three independent clinicians to be appointed to the Committee with at least one being a nurse and one being a secondary care clinician; Recruitment of independent clinical members permitted using existing CCG Governing Body members; The nurse representative could be appointed from primary care as well as secondary care background; Two Healthwatch representatives rather than one; Clarity on voting and non-voting members; Part two meetings to be kept to a minimum and minutes to be shared at the next Part One meeting It was noted that recruitment of the independent chair and independent clinical members of the Committee was underway and expressions of interest had been received for all posts The Committee discussed and noted the report. 3 Activity and Performance 3.1 Acute Commissioning Report The Committee considered a report that set out an overview of provider contracts for which management had been delegated to the Joint Commissioning Committee. The report incorporated acute hospital contracts and the Integrated Urgent Care service (NHS 111 and GP out-of-hours) provided by London Central and West (LCW) Unscheduled Care Collaborative The intention was to also use this report in the future within CCG Governing Bodies and supporting Committee structures to prevent duplication of reporting. It was noted that the report would continue to evolve. The Director of Performance and Acute Commissioning highlighted key areas of the report by exception Cancer 62 day standard: The North Central London (NCL) trajectory had recently been refreshed, with the expectation that the standard would be achieved by September There was an assumption within this that UCLH would not recover its position until March The NHS Constitution standard is that 93% receive treatment within 62-days of GP referral. The recovery trajectory for NCL was achieved in April and May 2017, but un-validated performance in June was at 73% against a trajectory of 76% (validation of pathways usually increases performance, so final June position expected to be close to trajectory). For June 2017 the Committee noted that: UCLH achieved its improvement trajectory; The main lag in performance accrued from Royal National Orthopaedic Hospital, commissioners are working with the Trust on its remedial action plan to recover performance; Analysis of waiting list trends indicates a risk of a backlog of work at Whittington Health Recovery of the 62-day target was centred on a five-point plan that focused on: Reducing median waits from GP referral to first outpatient appointments to seven-days (the national standard is fourteen days); Implementing optimal pathways for lung and cancer with the focus on these pathways as they have historically had the most 62-day breaches, and straight-to-test for lower gastro-intestinal patients on the two-week pathway from GP referral to provide earlier diagnostic analysis; Inter-provider transfers being within 38 days of the 62-day pathway to allow recipient Trusts time to complete treatment; 9

10 Waiting list management (daily) to stop avoidable breaches; Root cause analysis of all 62-day breaches plus harm reviews for any waits in excess of 100 days A&E: Performance across the sector was variable, with no NCL providers achieving their improvement trajectories for quarter one in 2017/18 with the exception of Whittington Health. A degree of improvement was apparent although clearly further was required to meet trajectories and retain the 95% standard Emergency Departments with the most fragile performance were North Middlesex University Hospital (NMUH) and Barnet Hospital with both units yet to de-escalate from winter bed capacity. Both were the focus of escalation meetings with NHS England and NHS Improvement. The Committee requested that performance data for the Royal Free and Barnet sites separately rather than be amalgamated for the Trust as a whole. It was noted that CCG teams had walked the emergency care pathways at NMUH to experience the pressure the unit operated under, understand the patient experience, and identify opportunities for pathway improvements. Details were presented around the work to sustain patient flow at NMUH that included: Alternatives to A&E including streaming into urgent care by emergency nurse practitioners and communications to ensure expended access primary care hubs were used effectively; Efficient patient flows within the hospitals including use of ambulatory care; Ensuring community capacity to reduce the number of people in hospital beds who could be discharged into community services or return home (delayed transfers of care and medically optimised patients) It was noted that each A&E Delivery Board in North Central London had to submit plans for winter 2017/18 to NHS England and NHS Improvement by the end of September 2017, with plans demonstrating capacity in hospitals, community services, social care, primary care and mental health to cope with additional emergency patient flows over the winter. It was noted that UCLH had also experienced issues in maintaining the A&E standards and had been outside targets since April Referral to Treatment ( RTT ): Although NCL as a whole was currently achieving the RTT standard, there was a risk that the position may start to deteriorate due to the focus on other areas such as Cancer and A&E. Pressure on delivering this waiting time standard was indicated by the growth in the number of people waiting for treatment. The standard that 92% of people waiting for treatment had been on a waiting list for less than 18 weeks was currently met on an aggregate level in North Central London (92.8%), and this compares favourably to performance across London (88.7%). During discussion of the report members requested further information be provided, including waiting list profiles to enable better trend analysis Patient Experience. Friends and Family Test ( FFT ) received a low positive response rate at North Middlesex University Hospital for outpatient appointments, maternity and A&E attendances relative to other providers in North Central London and across London Diagnostics. Performance against the six-week waiting time standard was on an improving trend for North Central London providers. The standard that 99% of people receive their test within 6 weeks is currently met on an aggregate level in North Central London (92.2%), and this compared favourably to performance across London (98%) London Ambulance Service. The disparity in performance across NCL boroughs for the ambulance eight-minute waiting time standard from call to arrival for emergency calls was under investigation, with improvement plans in place for Barnet, Enfield and Haringey. NCL performance was 69.5% against the 75% standard in May 2017 (68.9% in April), with performance varying from 82.4% in Camden to less than 65% in Barnet, Enfield and Haringey Integrated Urgent Care. The report on investigations carried out into allegations made in The Sun would be received by the Committee in October The allegations resulted in declaration of a serious incident, and the provider was fully co-operating with the investigations. The NCL 10

11 Clinical Responsible Officer undertook an immediate assessment to ensure the service was safe to continue, and from this commissioners and NHS England agreed that there was no evidence identified to suggest that the service was unsafe or that any patient harm had occurred Contracts and finance. The Committee received financial information restricted to contracts that had been delegated to the Joint Commissioning Committee (JCC). Contract performance in 2017/18 was framed within the two-year contracts for 2017/18 and 2018/19 as signed in December Provider data quality. The Committee noted that data quality in provider reports for May 2017 had improved compared to the April 2017 reports. The claims and challenges process indicated that most concern over data quality accrued from Royal Free London Over performance against contract remains a key risk for all CCGs in 2017/18. At month 3 NCL CCGs have reported overall year-to-date acute over performance of 447k and a forecast outturn over performance of 3.1m The forecast for the year-end takes into account individual CCG adjustments for the impact of STP interventions later in the year and the impact of marginal rates, with the impact of the latter being a 5.7m reduction in forecast outturn. The deterioration in forecast outturn compared to the year-to-date position accrues in part from risk-assessed local delivery of STP and local Quality Innovation Productivity and Prevention ( QIPP ) interventions. Progress on QIPP plans were reported at each CCG Governing Body The underlying year-end position on acute contracts on a full payment-by-results tariff (after removing the impact of marginal rates applied in-year) would be over performance of 8.9m at month three The report provided an overview of contracts by providers identifying risks and mitigating actions to address those risks The following key risks were noted: The underlying contract run-rates for 2017/18 being in excess of 2016/17 with the exception of Whittington Health at month three; The use of marginal rates to counter over performance in 2017/18 ( 5.7m assumed for the year-end at month three); Significant reported over performance at Royal Free Hospital, particularly in diagnostic imaging, electives and outpatients; Disproportionate increases in price compared to activity trends across NCL providers for electives, outpatient first attendances and outpatient follow-ups; The impact of A&E up-coding at North Middlesex University Hospital and Whittington Health; The dependence on delivery of Sustainability and Transformation Plan (STP) interventions to bring contract performance back to planned levels. At month three local risk assessments indicated 7m slippage on impact; The cost pressure to CCGs accruing from the introduction of the new tariff, with costs being 11m over the funding adjustment received by the five CCGs Mitigations were noted as follows: Existing marginal rate arrangements to be continued into 2018/19, as included within signed contracts and 2018/19 System Intentions. At present, the forecast outturn assumes a saving of 5.7m due to marginal rate application; Additional capacity from CCG and North East London Commissioning Support Unit (NELCSU) teams identified to support delivery of STP interventions; Deep-dives initiated at Royal Free to understand the over performance in diagnostic imaging, which was believed to have been caused by a counting and coding error. This was being addressed through contractual routes and challenges had been issued to understand the growth in electives and outpatients; 11

12 Investigations and contract challenges (in line with national contract guidelines) and the process agreed for 2017/18; Investigation into the impact of both tariff changes and IR (Identification Rules) changes between CCGs and Specialist Commissioning to continue throughout the year, with recommendations made to CCGs to challenge regulatory bodies where appropriate Actions: To develop the performance report to enable JCC to see trends going forward; To separate out information for the Royal Free and Barnet Hospital sites for A&E performance; To receive an update on plans for winter 2017/ The Committee discussed and noted the report. 3.2 Learning Disabilities Transforming Care Cohort The Committee considered an update report on the Transforming Care Programme which aimed to reduce the number of hospital beds commissioned for patients with a learning disability and/or autism and transfer their care into the community by March The programme had been established in response to the Winterbourne View scandal The report addressed a request for further information by the Committee on the quality assurance process for transferring care from inpatient settings into community packages in July Legal challenges to the transfer of packages of care into the community had been received from families of people in placements at Harperbury Specialist Residential Services in Hertfordshire. Changing our Lives, an independent rights based learning disability rights group, had been commissioned to undertake detailed life planning for each resident, and Hertfordshire Council were providing an overview of social work services and co-ordination of legal services (not legal representation) on behalf of all patients Service developments to support the Transforming Care Programme with these services including: Multi-Agency Hub, incorporating a care team to coordinate discharge and pilot multiagency case conferences for long stay in-patients. Starts September 2017; Positive Behaviour Support (PBS) School of Excellence, to develop best practice PBS across NCL, including providers, support workers, and families. Service specification in development; Accommodation Project, to source property for patients requiring bespoke solutions. Starts October The Committee would receive a report on the financial impact of the Programme in October 2017 following a more detailed assessment of the cost of community packages of care for both health and social care It was noted that financial and qualitative risks for the Programme had been included in the JCC risk register During discussions there was reference to the need to provide more information on the Transforming Care Programme and link this to local CCG web sites. It was also agreed that legal costs be carefully monitored and an update be provided at the October meeting Actions: The need for more information to be provided and to link to local CCG web sites To provide an update on any legal costs incurred at the October 2017 meeting The Committee discussed and noted the report. 12

13 4 Commissioning 4.1 System Intentions 2018/ The Committee considered a paper setting out an initial draft of system intentions for 2018/19. The report highlighted a shift from commissioning to system intentions in recognition of Sustainability and Transformation Plan (STP) and new NCL CCG commissioning arrangements The intentions were underpinned by a set of principles for the system to work together, building on those used to agree contracts for 2017/18 and 2018/ The System Intentions focused on: Delivery of Sustainability and Transformation Plan (STP) priorities; Local priorities for CCGs agreed with local stakeholders; The context of financial challenges in the health and care system and the development of a financial strategy for NCL; A focus on alignment of CCG intentions to present an aggregate and coherent picture to providers, but with room for individual CCG intentions outside of the STP; Greater alignment with specialist commissioning; The need to continue work on system incentives and contract form to better align system incentives to support delivery of the STP; Contract requirement for 2018/19 and in particular the need to set contract baselines for 2018/19; Joint commissioning with local authorities and extending this beyond social care to cover housing, employment and prevention; National planning priorities including the refresh of the Five Year Forward View. Any formal guidance for 2018/19 had yet to be published by NHS England / NHS Improvement The Committee were asked to consider planning assumptions for 2018/19 as these would be used to derive contact baselines for the next year. The baseline for 2018/19 would be based on the run-rate from contracts in 2017/ It was noted that System Intentions signalled the trialling of contract forms in 2018/19 as an alternative to payment-by-results (cost and volume contracts) for hospital providers to better align system incentives. Work was underway with providers to achieve this, with potential to switch to new contract models in 2019/20 if agreed by commissioners and providers The Committee supported the work on contract form as a signal for new ways of working between commissioners and providers as the best way to support delivery of new service models in the STP and to resolve the overall financial deficit in NCL The Committee requested that a plain English version of System Intentions be developed for use with broader stakeholders Actions: To develop locally focused plain English version of System Intentions. To take the System Intentions to each CCG Governing Body in September The Committee discussed and noted the report. 4.2 Alignment Opportunities for CCG and Specialist Commissioning It was noted that many providers in North Central London had contracts with both CCGs and Specialist Commissioning. The Committee reviewed a paper that proposed ways for the two commissioning teams to build on existing links and effectively manage provider contracts through: 13

14 Joint contract management frameworks and meetings with providers; Taking on lead commissioning arrangements where either CCGs or Specialist Commissioning held the vast majority of contract value with a provider; Co-commissioning of care pathways that straddle services commissioned by CCGs and Specialist Commissioning to improve patient pathways and experience; Paul Sinden indicated that the acute commissioning report would include an update on the impact of changes to allocation rules between CCGs and Specialist Commissioning contract performance The Committee discussed and noted the report. 5. Risk 5.1 NCL Joint Commissioning Committee Risk Register The Committee received an update to the risk register which aimed to capture the main risks for the JCC. The risk register had been updated for the additional operational items discussed by the Committee at its meeting in July The register would be further update to reflect strategic risks as well as operational risks The new risks added to the register included: Effective communication of the remit of the Joint Commissioning Committee to stakeholders; Ensuring member attendance at the Committee; Ensuring relationships with providers were sufficiently robust to enable delivery of contracts for 2017/18 and 2018/19; Mobilisation of STP and CCG QIPP plan interventions to ensure contracts are delivered within budgets; Management of acute contracts to avoid over performance and deliver 2017/18 contracts within baselines; Ensuring the needs of individuals are met as packages of care are transferred into the community for the Transforming Care cohort within Learning Disabilities It was recommended that risks with a pre-mitigation score of 16 or more be placed on CCG risk registers. From the August register this included: Delivery of waiting time standards for cancer 62-days and A&E 4-hour wait; Managing acute contracts within budgets; Mobilisation of STP and QIPP plans Action: To incorporate strategic risks into the risk register for the Committee The Committee discussed and noted the report. 6. Public Questions 6.1 There were no questions asked. 7. Any Other Business 7.1 Committee Forward Plan 2017/18 14

15 7.1.1 The JCC noted that the forward planner had been changed to reflect the revised dates for Committee meetings and seminars adjusted to avoid clashes with CCG Governing Body meetings It was noted that items for the October meeting would include: Standing items for acute commissioning and risks; An update on Transforming Care Programme financial forecasts; System intentions for 2018/19 sent to providers on 30 September 2017; Procedures of limited clinical effectiveness (PoLCE) NCL CCGs adopting Enfield CCG approach for adherence to evidence-based medicine subject to consultation; Receipt of investigations into LCW Integrated Urgent Care service It was noted that subjects for Seminar scheduled for 7 September 2017 included: Review of acute commissioning paper; Work on contract form and system incentives; Preparation of system intentions for 2018/19; Risk register development of strategic risks The Committee discussed and noted the 2017/18 Forward Planner. 7.2 Any Other Business The Accountable Officer asked the Committee to consider a request received from the Local Medical Committee ( LMC ) to be a member of the JCC The Committee considered that the JCC was meeting held in public and there was no reason that the LMC should not attend meetings. However, the main remit for the JCC was acute commissioning/ secondary care and there was no reason for the LMC to be added to the committee s membership. LMC was a member of the Primary Care Co-commissioning Committee and this was considered appropriate The Committee discussed the request. The Committee agreed that membership of the JCC not be expanded to include Local Medical Committee representation. 8. Date of Next and Future Meetings 8.1 The next Committee meetings are: 5 th October 2017 from 3pm to 5pm; 7 th December 2017 from 3pm to 5pm; 1 st February 2018 from 3pm to 5pm. 8.2 Meeting Close 8.2 The meeting closed at 4.20pm. These minutes are agreed to be a correct record of the Part 1 meeting of North Central London Joint Commissioning Committee held on Thursday 3 rd August 2017 Signed.. Date 15

16 NORTH CENTRAL LONDON JOINT COMMISSIONING COMMITEE Notes from the CCG Seminar held on Thursday 7 September 2017 Holbrook Committee Room, Enfield CCG, 116 Cockfosters Rd, EN4 0DR. Present: Ms Karen Trew (Chair) Governing Body Vice Chair and Lay Member, Enfield CCG Dr Mo Abedi Governing Body Chair, Enfield CCG Ms Sorrel Brookes Governing Body Lay Member, Islington CCG Dr Peter Christian Governing Body Chair, Haringey CCG Ms Bernadette Conroy Governing Body Lay Member, Barnet CCG Mr Mark Eaton Director of Recovery, Enfield CCG (for Item 2.1) Mr Simon Goodwin NCL Chief Finance Officer Dr Neel Gupta Governing Body Chair Elect, Camden CCG Ms Catherine Herman Governing Body Vice Chair and Lay Member, Haringey CCG Ms Helen Pettersen NCL Accountable Officer Dr Jo Sauvage Governing Body Chair, Islington CCG Mr Paul Sinden NCL Director of Performance and Acute Commissioning Mr Andrew Spicer NCL Head of Governance and Risk Apologies: Dr Debbie Frost Ms Kathy Elliott Governing Body Chair, Barnet CCG Governing Body Lay Member, Camden CCG 1. Introduction 1.1 Welcome The Chair welcomed all those present to the first meeting of the North Central London ( NCL ) Joint Commissioning Committee The Chair confirmed that all voting members were present and that the meeting was quorate. Apologies for absence were noted as above. 1.2 Declarations of Interest There were no new declarations of interest made. 1.3 Declarations of Gifts and Hospitality There were no declarations of gifts or hospitality offered or received. 1.4 Opening Remarks The Chair advised that the next formal Committee to be held in public was on 5 October 2017 at 16

17 Cypriot Community Centre, Earlham Grove, London N22 5HJ. 2. Procedures of Limited Clinical Effectiveness 2.1 Enfield CCG Adherence to Evidence Based Medicine Mark Eaton introduced the work Enfield CCG had undertaken on adherence to evidence based medicine Enfield CCG had undertaken a consultation exercise, based on adherence to evidence based medicine, to extend the current policy for procedures of limited clinical effectiveness to incorporate a further 13 procedures. The consultation process had been agreed through the local Health and Wellbeing Board and Health Overview Scrutiny Committee The outcome of the consultation was that 11 procedures would be added to the Enfield CCG policy for procedures of limited clinical effectiveness, but following the consultation process access to hearing aids and knee replacements would not be altered On 5 October the Committee would receive a paper that considered expanding the Enfield work to the other four CCGs in NCL. This would be done on the basis of the outcome of the Enfield CCG consultation. In October the Committee would therefore consider: The principles behind the work on adherence to evidence based medicine; The supporting clinical evidence; Agree the level of consultation each CCG would need to undertake to adopt the Enfield CCG work; The outcome from Enfield CCG Governing Body, the STP Health and Care Cabinet, and the Joint Health Overview Scrutiny Committee; That for the above each CCG would be at a different start-point but should aim for a common end-point The paper presented would go to Enfield CCG Governing Body and the STP Health and Care Cabinet on 20 September 2017 and Joint Health Overview Scrutiny Committee on 22 September, prior to consideration by the Committee on 5 October System Intentions for 2018/ System Intentions for 2018/ Paul Sinden introduced an updated draft of system intentions for 2018/19 following review at the Joint Commissioning Committee in August 2017, by CCGs, and at the Sustainability and Transformation Plan (STP) Executive Leadership Summit held on 5 September. This version of system intentions will also be going to the five CCG Governing Bodies in September Paul Sinden provided an update on the further development of System Intentions following review by the August 2017 Committee: a) The addition of procurement principles agreed with providers to support delivery of the STP; b) The development of an easy read version to share with stakeholders. The initial draft would be ready for the Committee meeting on 5 October 2017; c) The development of the process for the 2018/19 planning round; d) The identification of local CCG priorities. 17

18 3.2 Planning Round for 2018/ Paul Sinden provided an overview of preparations for the 2018/19 planning round. It can be taken in conjunction with the development of system intentions for 2018/ The approach to 2018/19 had been agreed between commissioners and providers including: a) The principles by which commissioners and providers would work together in planning for 2018/19 which were similar to those used for 2017/18; b) Principles included a system-wide approach for 2018/19; c) A process for agreeing contract baselines for 2018/19 by December 2017 (Contracts for signed in December 2016 allowed for the negotiation of contract baselines for 2018/19); d) All other contract terms would be carried forward from 2017/18 into 2018/19 including the use of marginal rates, process for claims and challenges, penalties, CQUIN and key performance indicators; e) Baselines for 2018/19 would be derived from the run-rate (or plan) for 2017/18 adjusted for growth, tariff (+0.1%), and the impact of STP and local interventions. Growth and interventions were likely to offset each other as in 2017/18; f) 2017/18 forecast outturn would be materially determined by the growing impact of STP interventions in the latter part of the year. This would be the pivotal negotiation point in agreeing opening baselines for 2018/19; g) Agreement of contract baselines by December 2017 would be assisted by the use of trigger points and a process to adjust the contract baseline in March 2018 should the baseline for 2018/19 be materially incorrect (this process was included in the contract for 2017/18 with the trigger being 0.5% of contract value but was not enacted as the recalculation of STP interventions was less than 0.5% of the contrast baseline); h) Formal planning guidance for 2018/19 from NHS England / NHS Improvement had yet to be received. 3.3 Contract form and system incentives The Seminar received an overview of work underway to develop system incentives and contract form to better support the STP, with a proposal to shadow-run alternatives to payment-byresults ( PbR ) for hospital contracts in 2018/19 in co-production with providers for potential use in 2019/20. An acute contract modelling group, with membership from commissioners and providers, has been established to consider alternative contract forms This built on the contract round for where acute hospital contracts moved to the use of marginal rates rather than the full payment-by-results tariff for variances from plan. This was partial progress in moving hospital contracts away from PbR The backdrop to the work on alternative contract forms being considered included: Changes to contract form and commissioning were an enable for delivery of the STP, as current incentives and contract form do not support delivery of the STP; The emergence of new models of care as set out in the Five Year Forward View, and through integrated care pioneers and Vanguards. Work is already underway in NCL to implement new models of care and alternative contract forms; Contract models to support new models of care, and alternatives to payment-by-results include Capitation, Block, Outcomes based approaches, and Aligned incentives contract (minimum income guarantee approach) An acute contract modelling group had been established, with commissioners and providers, and was focussing on the development of an aligned incentives contract. This was similar to the minimum income guarantee (MIG) approach considered for 2017/18, as a stepping stone from current arrangements (including payment-by-results for acute providers) to a more populationbased approach. To support this providers have agreed access to open book information on 18

19 cost profiles. 4. Risk 4.1 Committee Risk Register Strategic risks were identified strategic risks to add to the risk register for the Committee. These risks would be reported to the Committee meeting to be held on 5 October The strategic risks identified included: Winter pressures and A&E; Implementing the STP schemes and shifting activity away from acute providers; Cost of reorganising the system; Workforce; The NHS England assurance process impacting on staff capacity to deliver; Finance; Political environment; Capacity and timescale for delivery. 5. Independent Chair 5.1 Appointment of independent Chair Interviews for the Independent Chair had been undertaken but an appointment had not been made. It was agreed that a Lay Member representative from the Committee undertake the role of Chair for six months, after which the appointment of an Independent Chair would be further considered It was agreed that Karen Trew, the lay representative from Enfield CCG, would Chair the Committee during this time Interviews for the three Independent Clinicians would take place in September Any Other Business 6.1 There was no other business. 19

20 Agenda Item: 1.6 Action No NORTH CENTRAL LONDON JOINT COMMISSIONING COMMITTEE ACTION LOG AUGUST 2017 Meeting Date Action Lead Deadline Update 1. 3 rd August 2017 Acute Commissioning Report To develop the performance report to enable JCC to see trends going forward. Paul Sinden October 2017 Meeting Update on : Meeting with CCGs held in September 2017 to further develop the acute commissioning report rd August 2017 Acute Commissioning Report To separate out information for the Royal Free and Barnet Hospital sites for A&E performance. Paul Sinden October 2017 Meeting Update on : Completed. Report splits out A&E performance by site rd August 2017 Acute Commissioning Report To receive an update on plans for winter 2017/18. Paul Sinden October 2017 Meeting Update on : Completed. Overview of winter plans on agenda for 5 October rd August 2017 Transforming Care Partnership The need for more information to be provided and to link to local CCG web sites. Paul Sinden October 2017 Meeting Update on : Committee papers are uploaded to CCG websites rd August rd August 2017 Transforming Care Partnership To provide an update on any legal costs incurred at the October meeting. System Intentions To develop locally focused plain English version of System Intentions. Paul Sinden Paul Sinden October 2017 Meeting October 2017 Meeting Update on : Completed. Included in report to Committee on 5 October. Future reports will provide updates on any legal costs incurred. Update on : Initial draft included in report to Committee on 5 October rd August 2017 System Intentions To take the System Intentions to each CCG Governing Body in September Paul Sinden October 2017 Meeting Update on : Completed. Paper to Committee reflects feedback from the five CCG Governing Bodies th July 2017 Acute Commissioning Report Ascertain whether community services have been included in the Haringey and Islington acute contracts and report to the Committee. 20 Paul Sinden October 2017 Meeting Update on : Completed. The Whittington Health baseline in the report includes both the hospital and community elements of the contract. The detail of the report only picks up performance in relation to the hospital element of the

21 Agenda Item: 1.6 contract. The report to the October 2017 disaggregates community and acute expenditure th July 2017 Transforming Care Programme Provide the Committee with further details on the financial impact of the Transforming Care Programme. Paul Sinden October 2017 Meeting Update on : Completed. The updated financial assessment for the programme is on the agenda for the Committee in October th July 2017 Risk Register Update the Committee s risk register to reflect discussion at the August 2017 meeting and discuss wider engagement with the Local Authorities. Paul Sinden October 2017 Meeting Update on : The risk register has been updated for both strategic risks (identified at the CCG seminar in September 2017) and operational risks previously identified by the Committee. 21

22 NCL Joint Commissioning Committee Meeting on Thursday 5 th October 2017 Report title Update on Independent Chair and Independent Clinicians Agenda item 2.1 Date 28 September 2017 Lead director Report author Paul Sinden Director of Performance and Acute Commissioning Andrew Spicer NCL Head of Governance and Risk Tel/ Tel/ p.sinden@nhs.net Tel andrew.spicer1@nhs.net Tel Sponsor(s) (where applicable) Tel/ Report summary This report provides an update on recruitment to the roles of Independent Chair and Independent Clinicians on the NCL Joint Commissioning Committee ( Committee ). Independent Chair Interviews for the Independent Chair took place in August 2017 but an appointment was not made. At the CCG Seminar held on 7 September 2017 it was agreed that a Lay Member representative from the Committee undertake the role of Chair for six months, after which the appointment of an Independent Chair would be further considered. At the seminar it was agreed that Karen Trew, the lay representative from Enfield CCG, would Chair the Committee during this time. Section 8 of the terms of reference allow for the appointment of a Vice Chair through the following provisions: The Chair of the Committee shall be independent and shall ordinarily not be an officer, employee or office holder of any of the NCL CCGs except to the extent necessary to hold a contract for the role of independent Chair. Where the Chair is unable to participate in a meeting or vote due to absence or a conflict of interest the Vice Chair may chair the meeting. The Vice Chair of the Committee shall be a lay member from an NCL CCG. Independent Clinicians The terms of reference allow for the appointment of three independent clinicians to the Joint Commissioning Committee. These posts are there to represent North Central London as a whole rather than an individual CCG. 22

23 From the three independent clinical posts, the terms of reference require at least one to be a secondary care clinician and at least one to be a nurse. In July revisions to the terms of reference were approved and this included some amendments to the recruitment of the independent clinicians: They could be recruited from existing CCG Governing Body Members; The nurse appointed could be from primary care as well as secondary care; The Secondary Care Clinician does not have to be a Consultant and to remove the requirement to have at least 10 years experience. Interviews for the independent clinicians were held in September 2017 and resulted in the appointment of two nurse representatives and one secondary care doctor representative to the Joint Commissioning Committee. Purpose (tick one only) Recommendation Information Approval To note The NCL Joint Commissioning Committee is asked to: Note the report. Decision Conflicts of Interest Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy. Strategic Direction The report supports the following strategic objectives: Commission the delivery of NHS constitutional rights and pledges; Improve health outcomes, address inequalities and achieve parity of Esteem; Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for- money services. Identified risks and risk management actions Resource implications Engagement Equality analysis Report history Next steps Appendices impact This report helps to maximise the opportunities and benefits of the five NCL CCGs working together to commission services for the benefits of patients. The report sets out that the independent clinical advisors at the Committee be met from within existing resources across the five North Central London Clinical Commissioning Groups. The report is presented to the NCL Joint Commissioning Committee which includes elected GP representatives, lay members, Healthwatch, Public Health and representatives from each NCL London borough. This report was written in accordance with the provisions of the Equality Act The report follows on from the approval of revised terms of reference for the Committee in July The three appointed independent clinicians to join the Joint Commissioning Committee. None 23

24 NCL Joint Commissioning Committee Meeting on 5 th October 2017 Report title Acute Contract Report Agenda Item 3.1 Date 28 th September 2017 Lead director Report author Paul Sinden Director of Performance and Acute Commissioning Sarah Rothenberg NCL POD Deputy Director (Enfield MDT) NEL Commissioning Support Unit Tel/ Tel/ p.sinden@nhs.net Tel sarahrothenberg@nhs.net Tel Ruth Donaldson NCL POD Deputy Director (Islington MDT) NEL Commissioning Support Unit ruth.donaldson1@nhs.net Tel Sponsor(s) (where applicable) Tel/ Report summary 1. Introduction This report sets out an overview of provider contracts for which management was delegated to the Joint Commissioning Committee by the five Clinical Commissioning Groups (CCGs) in North Central London (NCL) in November The report therefore incorporates: Acute hospital contracts; Integrated Urgent Care service (NHS 111 and GP out-of-hours) provided by London Central and West (LCW) Unscheduled Care Collaborative. 2. Content In line with the functions listed above the NCL Joint Commissioning Committee will consider all aspects of provider performance to ensure there is a comprehensive oversight of contract management. This will include: Quality and performance The quality and performance section of the report provides a summary of nationally and locally reported data, describes the overall quality of the acute services in North Central London and the actions being taken to deliver sustainable improvement. The report shows published performance for August 2017 for A&E, July 2017 for the other standards and more recent un-validated information where available. The section includes the ratings from the Care Quality Commission (licencing regulator), information on patient safety and patient experience measures, delivery of NHS Constitutional Standards and service quality concerns that may result from poor service performance P a g e

25 Contracts and Finance For CCG finances, the report focuses on the performance of contracts falling within the remit of the Joint Commissioning Committee rather than overall CCG positions. The position shown uses month four information (July 2017), which is reported as month four + 1 in line with reporting arrangements to show a projected month five position. The report provides details of: Performance by Trust; Performance by point of delivery (POD) including A&E attendances, non-elective admission and outpatient attendances; Run-rate of expenditure to support trend analysis; Performance by CCG; Narrative to support the figures, including risks and mitigations. The appendix to this report shows further, more detailed information at an individual CCG level, and can be made available on request. 3. Quality and performance The Committee is asked to NOTE the assessment of provider performance below: Cancer 62 day standard Performance of the NCL aggregated 62 Day Cancer Waiting Time (CWT) declined to 75.7% in July 2017, below the 85% threshold and the trajectory target of 81.1%. A reduction of 27.5 fewer breaches would have delivered NCL compliance this month. NCL Providers are working to a five-point action plan which is a key driver to support sustainable recovery of the 62 Day Standard, and includes RCA (root cause analysis) for all breaches. NCL 62 Day Trajectory of September 2017 is as risk due to delays in release of Tranche 2 Recovery funding monies from the National Team to support sustainable delivery across the Sector. The Committee is asked to note that given current performance the standard is unlikely to be recovered until November 2017 rather than the original plan of September Data Source: Open Exeter There has been an improvement in performance cross three out of five NCL Providers albeit only Whittington achieved the standard in NCL this month with a performance of 86.7% P a g e

26 NCL Patient Transfer List (PTL) has increased in recent weeks with a backlog estimate of 90 as of 10 September Fortnightly STP specific Performance Leadership Group and individual trust meetings support governance and action plans to recover the standard. Reduction of the backlog is pivotal to recovery of the waiting time standard. North Central London ranked fourth out of the five London Sustainability and Transformation Plan footprints in July 2017 for performance against the 62-day waiting time standard from GP Referral to treatment. Given the shortfall in performance against the standard the NCL recovery plan is subject to escalation meetings with NHS England and NHS Improvement, with escalation meetings focusing on performance improvement at UCLH and Royal Free London. Recovery of the 62-day target is centred on a five-point plan that focuses on: Reducing median waits from GP referral to first outpatient appointments to seven-days (the national standard is fourteen days); Implementing optimal pathways for lung and cancer, with the focus on these pathways as they have historically had the most 62-day breaches; Straight-to-test for lower gastro-intestinal patients on the two-week pathway from GP referral to provide earlier diagnostic analysis; Waiting list management (daily) to stop avoidable breaches; Root cause analysis of all 62-day breaches plus harm reviews for any waits in excess of 100 days. Breach analysis for any inter-provider transfers that take place after day 38 on the 62-day pathway leaving the receiving Trust 24 days to initiate treatment. 62 day GP Referral Standard Performance by London STP STP Footprint Apr-17 May-17 Jun-17 Jul-17 North Central London (NCL) 77.30% 79.90% 76.00% 75.70% North West London (NWL) 81.90% 77.70% 81.82% 84.80% South West London (SWL) 87.90% 87.30% 85.80% 83.70% South East London (SEL) 79.30% 69.0% 75.05% 71.90% North East London (NEL) 84.50% 82.20% 74.80% 86.10% Threshold 85.00% 85.00% 85.00% 85.00% Data Source: Open Exeter NCL Sector Wide Performance against All Cancer standards is as shown below: 26 3 P a g e

27 2-WEEK WAIT - ALL SUSPECTED CANCER 2-WEEK WAIT - BREAST SYMPTOMS (CANCER NOT INITALLY SUSPECTED) 31-DAY - FIRST TREATMENT ALL CANCER 31-DAY - 2nd/SUBSEQUENT TREATMENT (DRUG) 31-DAY - 2nd/SUBSEQUENT TREATMENT (RADIOTHERAPY) 31-DAY - 2nd/SUBSEQUENT TREATMENT (SURGERY) 62-DAY URGENT GP REFERRAL ALL CANCER 62-DAY - SCREENING ALL CANCERS 62-DAY - CONSULTANT UPGRADE ALL CANCERS Target 2016/17 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Trend from April 16 North Middlesex 94.8% 93.2% 93.9% 95.9% 97.4% 95.2% 93.4% 94.5% 95.6% 95.2% 94.0% 95.8% 94.3% 96.2% 97.3% 95.7% 93.9% Royal Free 93.9% 93.0% 93.0% 93.5% 95.1% 93.9% 94.1% 95.3% 94.2% 93.9% 92.7% 93.6% 94.4% 91.0% 94.3% 94.9% 94.1% RNOH 93% 98.1% 93.9% 94.5% 99.2% 100.0% 100.0% 99.4% 98.5% 98.9% 98.6% 97.6% 96.8% 98.8% 97.4% 99.3% UCLH 91.6% 84.7% 85.8% 88.2% 87.4% 90.5% 89.9% 95.5% 96.7% 94.9% 93.5% 95.6% 95.3% 93.5% 94.1% 95.0% 95.6% Whittington 96.5% 97.6% 96.4% 96.4% 97.7% 97.9% 96.6% 98.7% 97.2% 93.4% 94.7% 97.1% 94.6% 92.4% 93.2% 95.3% 95.7% North Middlesex 93.7% 92.5% 93.7% 94.6% 96.2% 94.0% 94.2% 94.3% 97.2% 88.5% 89.0% 96.7% 93.1% 97.9% 100.0% 97.8% 93.9% Royal Free 95.1% 94.6% 94.1% 94.6% 93.0% 94.0% 94.7% 94.7% 96.9% 96.5% 98.8% 97.4% 92.8% 93.1% 92.8% 91.7% 93.2% RNOH 93% UCLH 81.1% 18.5% 45.3% 79.5% 76.2% 94.5% 95.0% 97.9% 96.5% 98.1% 96.9% 91.7% 96.7% 94.0% 93.0% 91.2% 93.9% Whittington 98.0% 98.1% 95.4% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 93.4% 98.7% 92.9% 96.0% 94.1% 100.0% 100.0% North Middlesex 99.4% 97.5% 100.0% 98.9% 100.0% 100.0% 98.8% 98.7% 100.0% 100.0% 98.9% 100.0% 100.0% 98.3% 98.6% 100.0% 100.0% Royal Free 97.7% 96.5% 98.4% 97.3% 96.7% 95.0% 96.5% 97.8% 100.0% 99.4% 99.0% 99.4% 97.3% 97.7% 98.4% 96.4% 96.6% RNOH 96% 88.6% 87.5% 66.7% 71.4% 80.0% 91.7% 95.2% 80.0% 100.0% 72.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% UCLH 95.5% 96.1% 89.8% 83.3% 94.9% 93.2% 98.8% 94.2% 96.7% 97.2% 95.8% 97.3% 96.3% 96.3% 93.6% 87.6% 93.3% Whittington 99.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% North Middlesex 99.6% 100.0% 100.0% 100.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Royal Free 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% RNOH 98% UCLH 99.9% 100.0% 99.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.7% 100.0% 99.7% 100.0% 100.0% 100.0% 100.0% Whittington 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% North Middlesex 99.4% 100.0% 100.0% 100.0% 98.8% 100.0% 98.4% 100.0% 95.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.3% 100.0% Royal Free 99.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% RNOH 94% UCLH 99.4% 100.0% 99.0% 98.9% 98.9% 97.8% 100.0% 99.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.1% Whittington 100.0% 100.0% North Middlesex 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Royal Free 99.0% 100.0% 97.0% 100.0% 96.3% 100.0% 100.0% 100.0% 97.9% 100.0% 100.0% 100.0% 97.9% 97.4% 97.9% 100.0% 95.1% RNOH 94% 89.8% 100.0% 100.0% 100.0% 100.0% 77.8% 82.1% 88.9% 95.5% 80.0% 94.4% 100.0% 100.0% 100.0% 95.0% UCLH 94.5% 95.2% 91.3% 92.1% 95.2% 100.0% 94.3% 97.4% 97.7% 92.9% 93.8% 94.2% 94.0% 84.6% 92.0% 94.0% Whittington 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% North Middlesex 77.2% 73.8% 76.5% 71.0% 68.5% 67.1% 66.0% 61.1% 94.9% 88.1% 89.3% 78.6% 88.9% 86.7% 87.3% 89.5% 79.3% Royal Free 80.0% 79.9% 81.0% 85.8% 76.3% 75.5% 78.0% 73.7% 82.1% 82.7% 81.8% 79.8% 82.9% 87.9% 83.2% 81.4% 77.1% RNOH 85% 67.8% 33.3% 85.7% 44.4% 38.5% 53.3% 84.6% 56.5% 100.0% 90.0% 88.9% 100.0% 81.8% 71.4% 71.4% 84.2% UCLH 69.7% 70.9% 67.2% 80.0% 68.6% 71.2% 73.2% 68.5% 75.0% 76.3% 61.6% 70.1% 63.8% 60.0% 71.1% 62.9% 65.5% Whittington 87.3% 88.1% 84.2% 94.9% 83.3% 93.5% 74.5% 84.4% 84.2% 92.3% 82.7% 100.0% 92.9% 85.4% 88.9% 84.4% 86.7% North Middlesex 92.4% 50.0% 100.0% 100.0% 100.0% 100.0% 100.0% 86.7% 66.7% 100.0% 100.0% 100.0% 100.0% 100.0% 73.7% 66.7% Royal Free 91.6% 92.5% 100.0% 92.2% 96.6% 96.6% 90.9% 80.0% 91.9% 86.8% 92.2% 70.0% 92.5% 91.8% 96.6% 85.7% 94.0% RNOH 90% UCLH 79.4% 60.0% 84.6% 90.0% 84.2% 66.7% 69.2% 94.4% 91.7% 73.3% 69.2% 92.9% 80.0% 66.7% 44.4% 71.4% Whittington 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% North Middlesex 92.1% 93.2% 94.9% 93.0% 90.9% 100.0% 92.6% 93.1% 87.8% 91.0% 92.2% 80.0% 96.0% 96.1% 87.50% 90.74% 89.66% Royal Free 89.7% 86.4% 87.0% 87.5% 82.1% 89.5% 87.2% 91.1% 89.1% 86.5% 93.2% 97.8% 94.4% 92.8% 82.8% 82.5% 81.5% RNOH _ 92.9% 100.0% 100.0% 100.0% 100.0% 0.0% 100.0% 100.0% 50.0% 90.0% UCLH 83.7% 76.5% 85.7% 76.2% 75.0% 68.2% 85.0% 90.9% 89.3% 86.7% 80.6% 89.6% 87.5% 86.8% 70.6% 82.5% Whittington 70.0% 100.0% 0.0% 0.0% 100.0% 0.0% 100.0% 100.0% 50.0% 100.0% 87.5% 100.0% Data Source: Open Exeter Accident & Emergency (A&E) Performance across the sector is variable, with no NCL provider achieving their Sustainability and Transformation Fund (STF) trajectory with the exception of Whittington for Quarter 1. With the categorisation of Emergency Services (ED) services at Barnet Hospital as category 3 and North Middlesex as Category 4 (an internal NHSE/NHSI performance management measure), NHS England and NHS Improvement are seeking further assurance on delivery of performance standards and quality improvement at those Trusts and within the A&E Delivery Board systems. Barnet CCG commissioned Greater Manchester Academic Health Science Network to review the Unscheduled Care System at Barnet Hospital. The Royal Free London management team are considering the issues identified and the recommendations. The review suggests that there a significant number of actions within Royal Free London control that would support improved performance. The impact on patient experience continues to be monitored, with particular focus on mental health pathways at A&E Delivery Boards and NCL Urgent and Emergency Care Board. September 2017 A&E Provisional Performance for NCL Providers is included in the table below P a g e

28 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 A&E National Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% Trajectory 87.1% 88.9% 91.3% 93.7% 94.5% 94.3% 93.5% 92.5% 92.5% 92.9% 93.9% 94.9% 89.5% 90.8% 92.1% 93.1% 93.6% 92.9% NCL Aggregate Current Performance 86.3% 87.4% 89.2% 91.4% 92.7% 90.9% 89.0% 87.7% 86.8% 85.4% 88.8% 89.2% 89.5% 91.1% 90.5% 89.4% 89.3% 89.2% Moorfields North Middlesex Royal Free UCLH Whittington Trajectory 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Current performance 96.3% 97.3% 98.9% 99.0% 97.7% 98.8% 97.0% 99.3% 99.4% 98.7% 98.7% 96.9% 95.7% 98.0% 98.7% 98.7% 98.1% 99.4% Total A&E Attandances Breaches Trajectory 72.0% 72.0% 78.0% 86.0% 90.0% 89.0% 88.0% 87.0% 85.0% 86.0% 90.0% 95.0% 85.0% 87.0% 89.0% 91.0% 93.0% 92.0% Current performance 72.6% 72.9% 77.1% 89.1% 92.5% 87.7% 87.7% 83.5% 79.4% 76.0% 82.3% 85.6% 82.4% 83.7% 82.1% 81.9% 80.3% 83.2% Total A&E Attandances Breaches Trajectory 90.0% 92.0% 93.0% 95.0% 95.0% 95.0% 92.0% 90.0% 91.0% 91.0% 92.0% 92.0% 86.6% 87.2% 88.7% 89.6% 89.8% 90.1% Current performance 90.3% 92.5% 90.2% 91.3% 90.0% 87.9% 85.5% 85.0% 83.6% 83.0% 87.1% 85.4% 87.6% 90.3% 87.0% 86.1% 88.7% 86.3% Total A&E Attandances Breaches Trajectory 88.0% 90.9% 92.8% 95.0% 95.0% 95.0% 95.0% 92.9% 93.8% 95.0% 95.0% 95.0% 91.0% 92.8% 95.0% 95.0% 95.2% 92.6% Current performance 87.9% 88.3% 92.0% 89.9% 90.6% 86.9% 86.6% 85.5% 86.0% 86.4% 89.2% 89.6% 90.9% 90.2% 92.1% 88.2% 88.9% 90.2% Total A&E Attandances Breaches Trajectory 88.0% 92.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 90.0% 92.0% 93.0% 95.0% 95.0% 95.0% Current performance 84.1% 85.9% 87.7% 87.9% 92.7% 93.4% 88.1% 85.1% 85.8% 82.9% 86.6% 88.4% 91.1% 93.5% 92.4% 92.2% 90.5% 87.0% Total A&E Attandances Breaches Data Source: Daily Sitrep un-validated data from local trusts Performance across Royal Free London hospital sites is included in the table below. Royal Free Combined Barnet Site Royal Free Site Trajectory Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep % 92.0% 93.0% 95.0% 95.0% 95.0% 92.0% 90.0% 91.0% 91.0% 92.0% 92.0% 86.6% 87.2% 88.7% 89.6% 89.8% 90.1% Current performance 86.46% 90.95% 86.92% 87.32% 83.94% 85.92% 80.67% 78.82% 75.51% 76.85% 82.73% 80.96% 82.34% 90.75% 83.45% 83.71% 89.52% 85.40% Total A&E Attandances Breaches Current performance 90.96% 91.00% 90.11% 92.10% 92.60% 85.09% 84.15% 86.61% 85.24% 84.22% 87.38% 85.03% 89.15% 86.32% 85.62% 84.50% 88.13% 82.69% Total A&E Attandances Breaches Data Source: Daily Sitrep un-validated data from local trusts NHS England are developing plans for additional challenge and support from 1 October 2017 for the winter pressures. NCL CCGs and A&E Delivery Boards have submitted information about CCG and Trust winter planning to NHSE. In October 2017 the Committee is receiving a separate paper on planning for winter 2017/18. Referral to Treatment (RTT) Although as a sector NCL is achieving the 18-week RTT constitutional standard there is some NHS Trust and CCG underperformance in July 2017 for both UCLH and Enfield CCG. Early Indicator Tools are showing increasing patient transfer lists (PTL) particularly in Dermatology, neurology and neurosurgery. NHSE are encouraging CCGs to look more closely at patients on long waiting RTT pathways seeking information about patients on pathways that had breached the 52 week standard in July NCL CCG s continue to work with NHS trusts to confirm treatment dates or plans for patient on pathways waiting for 45 weeks and over, and carry out Clinical Harm Reviews for all those who breach 52 weeks. Providers are only required to report Harm Reviews on patients who have had a 52 week breach This report shows the shape of the waiting list (number of patients waiting, by weeks waited) which can be used to track movement month on month P a g e

29 There is clearly an impact on patient experience if the overall volume of patients waiting starts to increase, and work on assurance with providers is summarised above, but it also represents a potential financial risk for the CCGs if performance needs to be recovered in the future. There is month on month growth in people waiting over 18 weeks which will continue to be closely monitored. Although the main area of growth is in non-admitted, there has also been an increase in admitted waits P a g e

30 This is harder to address particularly with the winter pressures and presents a greater financial risk to the CCGs. The situation will continue to be monitored and flagged as a risk where appropriate. There is a regular review of volume and shape of the Referral to Treatment waiting list at North Central London, CCG and Trust level. Care Quality Commission Inspections All NCL acute trusts have been subject to a Care Quality Commission (CQC) (regulatory inspectors) inspection in the last 18 months; one specialist Trust with three years. North Middlesex University Hospital has been subject to review by the General Medical Council and more recently NHS Improvement. Progress with quality improvement actions is monitored by monthly Clinical Quality Review meetings (CQRG). Royal Free London was subject to two unannounced inspections of ITU and the dialysis unit on the Barnet site; no immediate concerns were raised. The reports were not published at the time of writing. All Trusts have implemented improvement action plans in response to CQC recommendations; plans incorporate other quality improvement plans within the organisations to facilitate local ownership and governance. Progress with CQC or Trust improvement actions is monitored at least quarterly by the respective CQRG. Patient Experience: The Committee is asked to note the following for patient experience at local acute trusts: Benchmarked with all 23 London acute providers, with Royal Free London, UCLH and Royal National Orthopaedic Hospital (RNOH) are found in the bottom half of the table for the Inpatient Friends and Family Test (FFT) scores. Moorfields Eye Hospital (MEH) ranks first, Whittington sixth and North Middlesex seventh out of 23 London trusts. For Maternity FFT, North Middlesex scores worst across London for patient satisfaction. However, North Middlesex was not found to be an outlier as measured by Getting it Right First Time (GIRFT) outcomes data. This showed maternity outcomes rates most often as expected and on some measures of adverse outcomes was reported as less than expected. The Outpatient FFT scores in NCL are adversely affected by poor North Middlesex poor performance. FFT scores in the North Middlesex outpatient department (OPD) remain ranking worst in London in June P a g e

31 Poor satisfaction scores have been a longstanding issue for North Middlesex. Although North Middlesex continues to be ranked last when benchmarked with London providers, North Middlesex has put in place a comprehensive action plan to improve the patient experience in outpatient clinics. Diagnostics NCL CCGs as an aggregate have met the diagnostic standard since March 2017 with performance in July 2017 at 99.24% (against a target of 99% seen within 6 weeks) Threshold Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Barnet CCG Camden CCG Enfield CCG Haringey CCG Islington CCG NCL STP Percentage of patients waiting within 6 weeks at month end Percentage of patients waiting within 6 weeks at month end Percentage of patients waiting within 6 weeks at month end Percentage of patients waiting within 6 weeks at month end Percentage of patients waiting within 6 weeks at month end Percentage of patients waiting within 6 weeks at month end 99% 98.27% 98.73% 99.08% 99.49% 99.02% 99.54% 99.56% 99.63% 98.68% 97.33% 98.70% 99.58% 99.41% 99.29% 99.20% 99.03% 99% 96.16% 96.39% 97.51% 98.66% 97.65% 98.71% 99.25% 99.16% 99.43% 99.48% 99.83% 99.63% 99.29% 98.90% 98.75% 99.00% 99% 98.61% 99.12% 99.17% 98.81% 99.06% 99.44% 99.33% 99.04% 98.38% 96.86% 98.72% 99.45% 99.41% 99.50% 99.46% 99.59% 99% 98.11% 98.56% 99.13% 98.97% 98.87% 99.28% 98.89% 98.87% 98.65% 98.68% 99.55% 99.43% 98.96% 99.25% 99.12% 99.41% 99% 96.43% 97.04% 97.80% 98.45% 97.83% 98.69% 99.29% 99.17% 99.41% 99.33% 99.78% 99.66% 99.39% 98.99% 99.10% 99.02% 99% 96.70% 98.15% 98.64% 98.93% 98.59% 99.21% 99.28% 99.19% 98.81% 98.08% 99.21% 99.54% 99.32% 99.23% 99.16% 99.24% There have been difficulties delivery the standard at Great Ormond Street and local BMI hospitals in July P a g e 31

32 Provider Performance ROYAL FREE LONDON NHS FOUNDATION TRUST UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST THE WHITTINGTON HOSPITAL NHS TRUST ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST GREAT ORMOND STREET HOSPITAL FOR CHILDREN NHS FOUNDATION TRUST SPIRE RODING HOSPITAL NORTH EAST LONDON TREATMENT CENTRE CARE UK BMI - THE LONDON INDEPENDENT HOSPITAL MOORFIELDS EYE HOSPITAL NHS FOUNDATION TRUST CENTRAL AND NORTH WEST LONDON NHS FOUNDATION TRUST BMI THE CAVELL HOSPITAL BMI - HENDON HOSPITAL BMI - THE KINGS OAK HOSPITAL Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 YTD % Change from Jul % 99.80% 99.61% 99.85% 99.84% 99.93% 99.05% 97.26% 98.62% 99.61% 99.45% 99.49% 99.49% 99.32% 99.44% -0.48% 93.68% 96.34% 92.91% 95.24% 96.46% 97.79% 99.02% 99.02% 99.65% 99.37% 99.25% 99.62% 98.91% 99.57% 99.33% 3.35% 99.50% 99.10% 98.90% 99.33% 98.22% 96.95% 97.13% 97.08% 99.51% 99.32% 99.06% 99.39% 99.05% 99.42% 99.23% 0.32% 99.89% 99.32% 99.51% 99.72% 99.51% 99.84% 99.13% 99.13% 99.58% 99.16% 99.03% 99.12% 99.06% 99.05% 99.06% -0.28% 96.68% 96.27% 95.13% 96.26% 95.36% 95.66% 90.64% 92.93% 97.19% 99.20% 98.57% % % 99.38% 99.52% 3.23% 89.97% 93.78% 91.81% 93.79% 95.64% 95.12% 96.80% 94.83% 95.69% 96.02% 93.57% 96.61% 96.45% 97.73% 96.15% 4.21% % % % % % % % % % % % % % % % 0.00% 81.25% 84.52% 84.29% 94.00% 92.40% 88.74% 93.41% 91.19% 76.39% 85.52% 83.97% 95.77% 98.31% % 94.32% 18.32% 97.92% 96.97% 95.41% 94.07% 99.26% 95.88% 96.30% 90.20% % % % % % 95.80% 98.59% -1.20% % % % % % % % % % % % % % % % 0.00% % % % % % % 96.77% 98.73% 98.88% 98.33% % % % % % 0.00% % 75.00% 90.91% 81.82% 90.91% % % % % % 89.47% % 96.88% 97.58% 29.17% % 66.67% % % % % % % % % % % % % % % % % % % 0.00% Trend London Ambulance Service: New Ambulance Quality Indicators being introduced in November 2017 will focus on: Identifying the most seriously ill patients as early as possible; Increased time to assess incidents; New clinical code sets and response categories; New target indicators and measures. The Red 1 and Red 2 system will be replaced by a new Ambulance Response Programme prioritisation system which sets four new categories: Category 1 (8%) Immediately life threatening; 7 Minute mean response time; 15 minute 90th centile response time; Category 2 (48%) Potentially Serious Condition; 18 Minute mean response time; 40 minute 90th centile response time. Category 3 (34%) Urgent problem; 120 minutes 90th centile response time. Category 4 (10%) Urgent problem(transport or Hear and Treat); 180 minutes 90th centile response time. Barnet CCG would have issued a contract penalty notice (CPN) for underperformance of response times but with the implementation of the new programme NHS England have advised that penalties should not be incurred. Vehicle Tethering has been implemented by London Ambulance Service across NCL CCG s with the intention to reduce the incidence of ambulances leaving their sector and improve emergency response times, particularly in Barnet, Enfield and Haringey where performance has lagged behind the standard. The impact is being monitored and early results indicate a reduction in ambulances travelling out of sector from July onwards. This should translate into improved emergency response times P a g e

33 Integrated Urgent Care Service London Central and West (LCW) Unscheduled Care Collaborative provide the integrated urgent care service that covers both the NHS 111 service and GP out-of-hours. LCW are meeting all of the agreed national and local KPIs apart from call waiting time. A revised performance trajectory has been agreed with the provider, with recovery expected by November A Serious Incident (SI) occurred at London Central West Unscheduled Care Collaborative (LCW.) in April An undercover journalist from The Sun newspaper made a number of allegations about the integrated urgent care service. The NCL Clinical Responsible Officer undertook immediate assessment to ensure the service was safe to continue, and commissioners and NHS England agreed there was no evidence identified to suggest that the service was unsafe or that any patient harm had occurred. A commissioner initiated external review has been procured in addition to the provider serious incident root cause analysis investigation. The external review is being led by Professor David Colin Thome. Due to the complexity of this investigation and time limitations by the external team, this investigation has taken longer than planned. However, the last interviews are being scheduled so that the final report can be written by the external investigators. This will be shared as soon as it is completed. 4. Contracts Contract performance in 2017/18 is set within the framework of the two-year contracts for 2017/18 and 2018/19 signed in December 2016: Contracts were agreed with Marginal Rates of 50% (Royal Free London, North Middlesex and Whittington) and 75% (University College London Hospitals) for 2017/18, which will apply both above and below the agreed threshold. Marginal rate exclusions (i.e. items/services to not be included in marginal rate calculation e.g. blocks) have been agreed with all providers apart from Royal Free London. The list of items in dispute with this provider has been reduced to productivity metrics and direct access diagnostics, with a final agreement expected to be agreed as part of the Quarter 1 reconciliation to be completed in October 2017; This Marginal Rate agreement helps to mitigate the risk of over performance to commissioners, and offers protection to providers in terms of underperformance, if activity falls below plan for the impact of Sustainability and Transformation Plan (STP) interventions; As part of the overall contract settlement there was also an agreement to reduce the transactional burden of the claims and challenges process for both commissioners and providers in order to free up capacity for more transformational projects and support delivery of the Sustainability and Transformation Plan (STP). Providers (Royal Free 10 P a g e 33

34 London, North Middlesex and Whittington) and commissioners have worked together to agree a single cross NCL position on this, with a single item the monitoring of Procedures of Limited Clinical Effectiveness (POLCE) still to be determined. Ambitious STP activity reductions have been included in all acute provider contracts, which equate to 36m across all NCL providers. The HRG4+ level detail (Healthcare Resource Group) (the currency in which activity is measured and paid for) has now been included in all plans. Growth of 3% has been agreed in all contracts, with the offsetting STP reductions at a similar level. The key risk is that STP reductions are largely phased to quarters three and four of 2017/18; When reporting contract performance, forecast outturn projections will need to take into account the potential for a deteriorating position against plan at the end of the financial year if STP interventions do not deliver the anticipated reductions in activity. 5. Finance and activity The Committee is asked to note the following when considering the CCG finance and activity position for contract baselines: Data provided by Providers was of sufficient quality to enable reporting of financial performance. NCL CCGs have reported overall year-to-date acute over performance of 3m and a forecast outturn over performance of 11.2m (see table below); For their four main acute Providers, NCL CCGs have reported year-to-date over performance of 11.4m and forecast outturn over performance of 15.8m (see table below). The forecast for the year-end takes into account individual CCG adjustments for the impact of STP interventions later in the year and the impact of marginal rates, with the impact of the latter being a 12.3m reduction in forecast outturn. The improvement in the run-rate of the main providers forecast outturn ( 15.8m) compared to the year-to-date position ( 11.4m) accrues in part from the phasing of risk-assessed local delivery of STP (QIPP) interventions. 11 P a g e 34

35 Other Acute contains: Non Contract Activity Service level agreement (SLA) exclusions Out of sector contracts including Bart s Health and Imperial College Healthcare. The bulk of the positive variance in other acute relates to delivery of CCG local QIPP that sits outside of the main 4 providers. Financial Mitigations The Committee is further asked to note CCGs have included the following mitigations in their year-end forecasts for acute contracts, and they are summarised in the table below. CCG Barnet Camden Enfield Haringey Islington Critical Care Reduced by Reduced by Reduced by Reduced by Reduced by FOT Variance 25% 25% 25% 25% 25% Marginal Rate application Applied CSU estimate Applied CSU estimate Applied CSU estimate Applied CSU estimate Applied CSU estimate STP Applied using Applied using Applied using Applied using Applied using In-Contract Interventions CCG work CCG work CCG work CCG work CCG work stream monitoring submissions stream monitoring submissions stream monitoring submissions stream monitoring submissions stream monitoring submissions The adjustments for critical care and STP interventions have been applied to the forecast outturn position only, attributing to the difference between the year to date variance and the forecast outturn variance. Marginal rates have been applied to both year to date and forecast outturn positions. The rationale for these adjustments in more detail is described for each CCG below P a g e

36 Sustainability and Transformation Plan (STP) interventions The planned impact of STP activity reductions in 2017/18 reduces acute contract baselines by 36m across all NCL providers. STP Interventions are heavily weighted to delivery later in 2017/18 with 27m of the 36m impact phased into quarters three and four as indicated in the graph below. The phasing of STP interventions, and risks to delivery, need to be factored into the risks of over performance on acute contracts by the year-end. The table below summarises year-end delivery assumptions by each CCG against the 33.4m planned impact of STP intervention on the main 4 acute contract baselines in 2017/18: At month five forecast outturn includes an assumption of 8m slippage against delivery of the Sustainability and Transformation Plan interventions at the main 4 providers. Slippage is most pronounced at Barnet CCG with an assumed 32% delivery of STP interventions against the NCL average of 75%. There is also 2.8m of in-contract STP QIPP at other providers that brings the total incontract QIPP target to 36.3m. Application of marginal rates The table below summarises the application of marginal rates by CCGs at month five: The forecast outturn of 11.2m over performance across the five CCGs for our four main hospital acute providers is net of the application of marginal rates allowed for in the P a g e

37 contracts. At month five marginal rates are forecast to yield 12.3m benefit to CCGs in 2017/18. The underlying year-end over performance on the acute contracts on a full payment-byresults tariff would be 23.5m. Claims & Challenges As part of the 2017/19 NHS Standard Contract, Parties (NCL CCG s, North Middlesex, Royal Free London and Whittington) committed to significantly reducing the numbers of claims and challenges and associated management infrastructure servicing these. Whilst recognising that we would be managing risk in a different way, the approach agreed was we will put it right together rather than we will follow a rigid adversarial process. Following dialogue between commissioners and providers Parties involved supported a revised claims and challenges process was agreed and endorsed on 21 st July 2017 by Contract Development Group (CDG) and Finance Activity Modelling Group (FAM). This revised process was agreed in full with the exception of Procedures of Limited Clinical Effectiveness (PoLCE). Parties continue to explore options for the PoLCE claims and challenges process. A summary of claims raised to date for NCL CCG for all trusts is presented in Table A. Of the 33.9m raised to date, 4.7m have been accepted (14%). Table A: Claims by CCG Table B below indicates the level of claims submitted at each of the four main acute trusts with the level of claims currently accepted. The level of accepted claims are subject to increase as part of the Quarter one reconciliation process, which is currently underway. Table B: Accepted by Trusts Analysis by Trust indicates that the contract with Royal Free has the highest value and volume of outstanding claims and challenges, and this contract presents the biggest risk in reaching agreement of the quarter one position. Many of the items requiring resolution accrue from prior years. The quarter one reconciliation process will be used to settle the position on the claims and challenges raised above P a g e

38 Quarter One reconciliation process Commissioners are in the process of agreeing quarter one reconciliation with all providers with a deadline for agreement or escalation of any outstanding issues by 29th September. The below gives a brief update on the status for each contract, with the Royal Free London contract presenting the largest challenge for agreement: Whittington: Agreement has been reached between the Trust and CCGs with the exception of a claim for A&E Coding changes which has been escalated for agreement. UCLH: There is no material difference on the outstanding issues with exception of claims validation. Both the Trust and NEL CSU are validating the effects of a Sepsis coding change to ensure this is cost neutral for 2017/18. Royal Free London: It is not expected that resolution will be reached on the quarter one reconciliation by 29 th September, however two meetings a week have been scheduled for the next four weeks in order to resolve any outstanding matters. Outstanding queries fall into four categories, with the quarter one reconciliation amount shown as listed below: Contract issues: Patient Transport Services ( 1.3m), Metrics ( 1m), including Non-Consultant Led Outpatient activity ( 1.7m) Counting and Coding: Direct Access ( 913k), trauma and orthopaedics, A&E at Barnet Hospital ( tbc), Medical Oncology ( 250k), urgent care centre rebate ( 731k), palliative care ( 400k), direct access ultrasound charging ( 464k), radiology ( 112k), audiology ( 115k), identification rules for Child and Adolescent Mental Health services ( 163k), renal activity ( tbc) Change in plan and double billing: Stroke Rehab ( 141k for the year), Rehab, and ophthalmology ( 2.1m for the year) Other: Procedures of limited clinical effectiveness (PoLCE), Emergency Threshold, Readmissions at the Trust, Readmissions to other providers, Marginal Rate application. North Middlesex: The outstanding issues for resolution are Claims and an A&E coding change. It is anticipated that agreement will be reached by 29 th September. Financial Run Rates Run-rates provide a high-level view of expenditure on acute contracts. In line with the phasing of STP interventions above, the run-rate of expenditure on acute contracts should reduce in the second half of 2017/18, and will be an important determinant of contract baseline for 2018/ P a g e

39 Run-rate analysis for month five shows an increase compared to month four by 16% for Royal Free London and 5% for UCLH. There have been decreases of 5% for North Middlesex, and 4% for Whittington. In comparison to this time last year, Royal Free London is 14% higher YTD, UCLH 11% higher YTD, Whittington 2% higher YTD and North Middlesex remaining static. Royal Free London relates to increase primarily in Outpatients, Elective and A&E which are being challenged as part of the Quarter 1 reconciliation process; The Whittington increase primarily relates to A&E cost increases in part due to increased tariffs for 2017/18 and also due to coding changes which are being challenged. Maternity has also seen an increase from last year due to tariff uplifts; The UCLH increase primarily relates to higher non-elective activity, and emergency admissions are on an upward trend compared to last year. There is also an increase in the number of cancelled operations year on year at UCLH which indicates that the increase in emergency activity is taking over capacity for elective activity. Comparisons between years can be misleading due to IR (Identification Rules) year on year changes that have switched commission responsibility, and associated cost, between Specialist Commissioning and CCGs. The run-rate movement month on month will continue to be reviewed alongside performance against plan, as a useful indicator of underlying contract performance in 2017/18 that will be the start point for contract baselines in 2018/19. Main risks and mitigations The Committee is asked to note the main risks on acute contracts, and the mitigating actions being taken to address those risks: Risks The underlying contract run-rates for 2017/18 being in excess of 2016/17. Run-rate in 2017/18 will influence opening contract baselines for 2018/19; The use of marginal rates to counter over performance in 2017/18 ( 12.3m assumed for the year-end at month five); Significant reported over performance at Royal Free London, particularly in outpatients, electives and A&E; Disproportionate increases in price compared to activity trends across NCL providers for electives, outpatient first attendances and outpatient follow-ups; The impact of A&E up-coding at North Middlesex and Whittington, although this is being addressed as part of quarter one reconciliations The dependence on delivery of Sustainability and Transformation Plan (STP) interventions to bring contract performance back to planned levels in forecast outturn positions; The cost pressure to CCGs accruing from the introduction of the new tariff, with costs being 11m over the funding adjustment received from NHS England by the five CCGs. Actions Existing marginal rate arrangements to be continued into 2018/19, as included within signed contracts and 2018/19 System Intentions. At present, the forecast outturn assumes a saving of 12.3m due to marginal rate application; Additional capacity from CCG and North East London Commissioning Support Unit (NEL CSU) teams identified to support delivery of Sustainability and Transformation Plan interventions; Deep-dives initiated at Royal Free London to understand the over performance in diagnostic imaging, which is believed to have been caused by a counting and coding error. This is being addressed through contractual routes. Challenges will also be issued to understand the growth in electives and outpatients; Investigations and contract challenges (in line with national contract guidelines); P a g e

40 Investigation into the impact of both HRG4+ and IR (Identification Rules) changes to continue throughout the year, with recommendations made to CCGs to challenge regulatory bodies where appropriate; Further investigation to be carried out into the growth of non-electives at UCLH, with contract challenge route to be followed if appropriate. A summary of financial performance by Trust by POD (Point of delivery) and Trust by CCG follows. The appendix contains more detailed information and can be made available on request. Individual Trust performance The section summarises performance against plan for each Trust by CCG. The detailed report, available on request, provides a more granular analysis of Trust performance against plan. Whittington At month five overall performance across North Central London is close to plan. Barnet, Enfield and Haringey CCGs are over performing whilst Camden CCG is underperforming and Islington CCG is reporting to plan values. Overall over performance is 761k year to date (YTD) across the five CCGs, reducing to 403k forecast outturn over performance. The improvement from year-to-date to forecast outturn accrues from adjustments made to the forecast outturn position for Sustainability and Transformation Plan (STP) and QIPP interventions which will come into effect in the later part of the year. The table below shows the split between Acute and Community reporting for the Whittington with Community activity forming part of a block contract. Across the five CCG s over performance in seen in: A&E ( 1.1m) in part driven by a coding change which is being picked up as part of the quarter one reconciliation process; Electives ( 390k) driven by trauma and orthopaedics. The main adjustments to the provider reported position include: A&E: a risk rated adjustment for the coding changes, actuals will be reported post quarter one reconciliation; Critical Care Work in Progress (costs of people currently in critical care beds but yet to be charged to CCGs) included in year-end cost estimates to ensure forecasts reflect future high-cost cases; Critical Care adjustment to forecast outturn (25% reduction or increase to bring to plan values) this removes recurrent impact of high-cost cases incurred to date; P a g e

41 Breast Surgery coding change (where the provider has given notice of a coding change with immediate effect, but where the cost implication will not be effective for 18 months in line with contract provisions); Assumptions for delivery of STP interventions applied by CCGs; Application of the 50% marginal rate where applied by CCGs. Further action on the contract for future reports will include: Contract Variation to change CCG s contract values to take into account the application of changes to identification rules between CCGs and Specialist Commissioning. Royal Free London The position reported at month five for Royal Free London shows a 9.2m (2.6%) forecast over performance against the contract plan for NCL CCGs at the year-end. Over performance at the year-end is driven by outpatients ( 8.0m), electives ( 2.7m), Accident & Emergency ( 2.2m), Diagnostic Imaging ( 1.1m) and Regular Attenders ( 0.75m) There is partially offsetting under performance in other primarily accruing from application of marginal rates (- 4.7m) and Critical Care (- 1.1m) This represents an adverse movement in forecast outturn of 3.9m from month four to month five. This movement accrues from a reduction in the impact of STP interventions offset by increased protection from marginal rates ( 3m). The remaining movement is driven by increased activity in Critical care ( 459k), Drugs and Devices ( 195k) and Maternity ( 104k). The Trust has made adjustments to the plan for the year, with the plan shifting significantly at point of delivery level; 2.9m has come out of the plan for radiology outpatients and moved into diagnostic imaging. Royal Free London have been asked to explain this movement, as it does not reflect the Trust s original plan and has not been agreed with CCGs. This has shifted over performance from diagnostic imaging into outpatients. As activity for both diagnostic imaging and outpatients sits within the scope of marginal rate there is no further impact on forecast outturn. North East London Commissioning Support Unit (NEL CSU) has challenged areas of over-performance with Royal Free London at the Contract Technical Group and a meeting took place on 5 September 2017, where Royal Free London provided initial rationale for some areas, however there was no resolution and further discussion and analysis is required. This is being picked up through the quarter one reconciliation process, and summarised below. Outpatients 8.0m The forecast outturn pressure ( 8m) accrues from: Cardiology 2.2m; Nephrology 1.8m; Trauma & Orthopaedics 1.6m; Ophthalmology 0.8m P a g e

42 Dermatology 0.8m In addition the Trust has been challenged on the removal of 2.9m from the plan for radiology outpatients and moved into diagnostic imaging. Within Cardiology there has been a switch to consultant led firsts ( 191), which are multidisciplinary with two staff members, from non-consultant firsts ( 66). The Trust has advised that they undercharged activity in 2016/17; the coding has now been updated and is now being coded in line with guidance. NEL CSU are reviewing trend data to analyse the value of this counting and coding change and will provide a response, as well as investigating the criteria for a patient that requires multidisciplinary teams at appointments. No agreement has been made to accept the Trust view and this issue remains under active investigation at Technical Group. The over performance in Nephrology is due to a misattribution of specialised commissioned activity. Royal Free London has advised that renal services at Royal Free London require local specialty codes. The specialised commissioning grouper is not able to pick these up and so this activity has been allocated to CCGs in error. This will form part of the challenges process. Over performance in Trauma & Orthopaedics is reported in both first and follow-up attendances. The Trust has been asked if this accrues from the new service model for Camden CCG. The Ophthalmology over performance is evident at Enfield CCG 778k where there is a negative plan ( 505k) due to the value of the service transfer, however there is 273k reported against this. Royal Free London has been requested to comment on the number of zero and negative plans at Speciality level. NEL CSU have asked Royal Free London to provide a rationale for the over performance in Dermatology and Gynaecology. Electives 2.7m Elective over performance is forecast to be 2.7m by the year-end, with the Enfield CCG position being 3.4m over plan, and by specialty accrues from: Ophthalmology 2.3m; Trauma & Orthopaedics 1.6m; ENT 518k. Over performance in ophthalmology, and for Enfield CCG, flows from the service transfer by the CCG. There is a negative plan for Ophthalmology in Enfield 1.9m due to the value of the service transfer, however there is 620k reported against this. Royal Free London has been requested to comment on the number of zero and negative plans at Speciality level. The trust has been asked to investigate the over performance in trauma & orthopaedics, and again this may accrue from the new service model in Camden. Accident & Emergency 2.2m A&E is forecast to over perform by 2.2m by the year end. At HRG level, this can be attributed to: Emergency Medicine, Category 1 Investigation with Category 1-2 treatment 1.2m Emergency Medicine, Category 2 Investigation with Category 1 Treatment 944k Analysis has shown a shift from the least complex HRG (Emergency Medicine, No Investigation with No Significant Treatment) to the HRGs above, with the resulting P a g e

43 increase in costs being 600k for the full year. NEL CSU believe this may be the result of counting and coding changes, as Royal Free London have sought to improve their data quality. This was raised with the Trust at the Technical Group on 19 September Diagnostic Imaging 1.1m There has been a favourable movement ( 399k) within Diagnostic Imaging. The performance position has been reduced by the removal of 2.9m from the plan for Radiology Outpatients and moved into Diagnostic Imaging. Royal Free London have been asked to explain this movement, as it does not reflect the Trust s original plan. There is an apparent counting and coding change from October 2016 within direct access diagnostics. Royal Free London argue that this is a data mapping issue which has since been corrected, however NEL CSU are disputing this. This relates to activity only at the Hampstead site and is materially impacting Barnet and Camden CCGs. Regular Attenders 0.75m Within Regular Attenders there appears to be a step change in medical oncology activity in December Royal Free London have responded that they undercharged activity in 2016/17; this has now been updated and is being coded correctly. NEL CSU will review data from 2014/15 before providing a response. Contract adjustments The following adjustments have been made to the Trust s reported position to arrive at the CCG position in the report: Marginal Rate in line with the contract agreement for activity above and below the baseline to be paid at 50% (- 9.8m) STP Achievement has been estimated ( 3.0m); To bring patient transport back to plan as per block contract for this element ( 6.0m); To bring the urgent care centre rebate back to plan, as per the agreement of the prior year arbitration decision (50% of the difference in tariffs - 664k); To reduce the forecast outturn under performance across NCL in Critical Care by 25% for all CCGs except Enfield ( 328k); Enfield CCG have reduced the forecast outturn for Critical Care to reflect non recurrent activity ( 843k); To bring productivity back to plan. Royal Free London had included the credit in months one and two, but has not done so for months three and four ( 5.9m); To bring CQUIN to plan 7.6m; Remove Camden musculo-skeletal and value based commissioning activity ( 4.0m); Remove Enfield Rehab and Ophthalmology ( 4.8m); Estimated Claims and Challenges ( 1.2m). University College London Hospitals (UCLH) The year-to-date position reported at month five for UCLH shows a 2.6m (3%) over performance against the contract plan for NCL CCGs P a g e

44 The forecast outturn for month five deteriorated by 1.2m compared to month four. At an NCL level the movement was driven by reduction in the forecasted impact of STP and local QIPP interventions ( 1.2m); additional activity billable to CCGs which UCLH notified the CSU had been billed to NHS England in error (c. 0.6m); these two issues offset an overall NCL improvement in the underlying activity of ( 0.6m). At an NCL level the year-to-date position is driven by significant over performance in nonelective emergency admissions ( 2.2m) which are15% over plan in activity and 11% above plan in cost. Non-elective admissions in July did reduce, which has resulted in an improved position against plan, however it remains the material driver of over performance in the contract. Critical care bed days ( 1.5m) over performance is the other driver of over performance against plan for NCL. These areas of over performance are partially offset by lower levels of elective, maternity, A&E and diagnostic imaging activity. Outpatients is performing slightly above the plan in terms of costs, but activity is slightly below plan at an NCL level. The forecast position shows an improvement from the year-to-date position, with over performance at outturn predicted to reduce to 1.2m (1%). The improvement in the forecast position is due to the phasing of delivery of STP interventions in the second half of 2017/18, with a total of 3.1m removed from the forecast in month five to reflect this delivery. A marginal rate estimated impact adjustment has also been applied both the year-to-date and forecast outturn positions. Critical Care: 1.5m over YTD (16%), 0.5m over FOT (2%) The year-to-date position is in part driven by high volumes of bed days for lower complexity patients, alongside some high cost patients who have been discharged for Islington and Haringey CCGs. These high cost patients have been partially mitigated by the work in progress accruals made at 2016/17 year end. At an NCL level the monthly volume and value of critical care bed days billed by UCLH is in line with the 2016/17 averages. This suggests year-to-date over performance is primarily related to phasing of the plan and high cost patients. NCL CCGs have also applied a 25% risk rating on forecast outturn over and under performance which is intended to reflect the volatility of critical care forecasting in the early months of the year. This level of risk rating will reduce in later months reporting and should result in a more stable critical care outturn prediction. Non-Elective: 2.2m over YTD (14%), 3.3m over FOT (8%) The position improved in month five due to low volumes of activity reported by UCLH in comparison to previous months. This may not be indicative of a longer term trend and further work outlined below is still required to understand the position more fully, although the reduction in the level of over performance between year-to-date and forecast outturn suggests some of the year-to-date position is due to the phasing of the plan. Year-to-date positions at UCLH and North Middlesex are partially offset by underperformance at Royal Free London and Whittington for non-elective admissions. The CSU is leading a piece of more detailed analysis around the emergency admissions position and potential drivers which will include, but not be limited to, length of stay; A&E conversion rate; casemix and coding; cancelled operations; shifts of activity between providers. This went to the September technical group and the results will be shared with CCGs. Maternity: ( 0.2m) under YTD (-2%), 0.3m over FOT (1%) A forecast outturn pressure is predicted for NCL at UCLH, despite year-to-date performance being in line with the plan. The driver is standard antenatal pathways, which 21 P a g e 44

45 represents a shift away from the more complex ante-natal casemix reported by the Trust in 2016/17. Across NCL providers CCGs are forecasting an overall 2.9m underspend at the year-end; the predicted over performance at UCLH may be a result of a shift in provider share due to patient choice. Drugs and Devices: 0.2m over YTD (6%), 0.8m over FOT (10%) There is material over performance coming through in the contract for tariff excluded drugs for Barnet, Haringey and Islington. Further detailed analysis of the underlying drug expenditure is required to inform further action. Excluded drugs were an area of significant transfer from NHS England to CCGs in 2017/18 for UCLH, therefore there is a risk of allocation transfers not matching actual costs in this area. Trend data with 2017/18 commissioner rules applied to 2016/17 suggests the activity for excluded drugs has not materially changed over the past 12 months. North Middlesex University Hospital At Month five, the North Middlesex contract is over spending by 3.1m, with the forecast year-end position being over performance of 4.7m. A&E NCL wide activity in the Emergency Department (ED) in the first four months is above the average monthly activity level in 2016/17. Financial over performance is driven by both an increase in activity compared to plan (20%), and a change of coding (80%). The resulting year-to-date position is an over performance of 1.1m (22%). This higher case mix is caused by an over spend in two HRGs: VB03Z (category 3 investigation with category 1-3 treatment) and VB08Z (category 2 investigation with category 2 treatment). The over spend at month four for HRG VB03Z is 452k and the over spend for HRG VB08Z is 354k. The forecast outturn cost pressure of these two HRG s for all NCL CCGs is 2.4m. The CSU is in discussions with the Trust regarding this over-performance and a potential counting and coding challenge. These two HRGs are a significant cost pressure and will be included in the quarter one reconciliation process. It is likely that this issue will be escalated because of its financial materiality. The increase has not been seen at other Trusts. The increase for VB03Z is due to the additional counting and coding of CT scans. The increase in VB08Z activity is due to the additional counting and coding of x-rays. Ambulatory Care The Ambulatory Care Unit is over performing year-to-date by 626k (56%). There are a number of drivers of this change; changes in pathway, pressures on A&E to achieve the four hour waiting time standard and increase in STP pathways to see more activity within the Ambulatory Care setting. There has been a corresponding decrease in short stay non-elective admissions of 647k in line with pathway changes that offset the increase P a g e

46 Non-elective admissions Non-electives are over performing year-to-date by 1,379k 9%), which is a 3% deterioration of the performance compared to last month. The risk is that patients that were once being admitted in a non-elective short stay setting are now being admitted as longer-stay non-elective patients. The specialities that are over performing are: geriatric medicine, gastroenterology, and trauma and orthopaedics. Outpatients Outpatient appointments are over performing year-to-date by 623k (15%), which is a 5% deterioration of the performance compared to last month. Follow up outpatient appointments are over performing year-to-date by 604k (21%), which is a 6% deterioration of the performance compared to last month. Outpatient Procedures are over performing by 506k (26%), which is a 12% deterioration of the performance compared to last month. There is no one reason for the over performance and it is occurring across a number of specialities. An adjustment should be made for the Enfield CCG Community Ophthalmology service, a 500k reduction to the plan, but this does not account for all the over performance. Contributory factors include increased GP referrals and increased capacity, including front loading planned activity early in the year by the Trust but, the most significant factor is the below plan delivery of STP schemes. Other Providers by Exception Barts In the latest data submission the Trust had only coded approximately 50% of the month four initial (flex) activity, due to knock on effects from the cyber-attack. This has caused particular accuracy issues when reporting Bart s financials, so has been escalated with the provider. As a result at the last Commissioner Contract Review Group the Trust was reminded of its obligations under the NHS Contract with an Information Contract Penalty Notice one possible sanction Commissioners might consider. The Trust has therefore constructed a recovery trajectory with the objective designed to achieve 95% flex completeness in respect of the August data and 100% completeness in respect of the July final (freeze) data. CCG Commentary Barnet CCG The total budget expenditure on Acute contracts is 273.7m which is net of 9m QIPP ( 7m is in acute contracts). At Month five the forecast outturn is 279.9m, which is an overperformance against plan of 6.2m. The position show a movement of 4.4m over month four with a year to date (YTD) over-performance of 1.8m. This position includes QIPP at full delivery. Current expected slippage is 4.3m in total and 3.8m in acute areas. Royal Free London The largest contract by far is Royal Free London ( 181m). The underlying position at Month five (excluding QIPP) is over-spend of 3.5m. This is driven by QIPP slippage of 0.3m against the revised QIPP plan ( 3.7m on original plan), over-performance of 3.9m partially offset by marginal rate benefit of 0.7m. Over-performance is in outpatients, A&E and diagnostics. Other in sector UCLH forecast outturn is an under-performance of 0.5m. This is mainly due to Maternity, Outpatients, Non-Electives, Electives, Drugs and Devices and is net of 0.3m marginal rate in UCLH favour; The forecast outturn for other acute trusts in sector is an over-performance of 0.8m. This mainly driven by Whittington of 0.2m and Moorfields Eye Hospital of 0.2m P a g e

47 Other acute spend London Ambulance Service and SLA exclusions over-performance of 0.1m and 0.1m respectively; Forecast outturn for Out of Sector Acute Trusts is an over-performance of 1m, spread across a number of organisations with the only material underperformance expected at Barts of 0.3m (albeit this may be due to the data issues not fully resolved); Winter Pressures over-performance of 0.6m. A review is being carried out to mitigate the risk and ensure expenditure is kept within plan. Camden CCG Overall the CCG forecasts to achieve its control total at the end of the year. The overall position for the CCG has worsened by 0.3m. This is due to over performance in the acute contracts particularly at Royal Free London. The CCG is forecasting to overspend on Acute contracts by 4.2m. Risks Potentials risks for the CCG:- The risk on the QIPP under delivering risk is 1.16m; 2m deficit for delegated primary care commissioning; Over performance in acute contracts. Mitigations 2m non recurrent reserves; Support from other CCGs for the Primary care deficit; New schemes have been identified to bridge the current QIPP gap; Enfield CCG At month five there is a forecast over-spend against plan of 4.4m. However this is based on a number of adjustments and contains further risks. The current assessment of QIPP estimates slippage of 7.5m in total split between 2.5m within Acute Contracts and 5m outside of Acute contracts. This slippage has been absorbed in the overall financial position through a number of non-recurrent mitigations which remain high risk. The CCG continues to hold 6.0m of identified QIPP not built into contracts or budgets. North Middlesex The contract with North Middlesex is over performing year to date by 2.8m and forecast to over-spend by 4.4m at year end. The key areas of over-performance are forecast to be non-elective ( 3.9m), outpatients ( 3.6m) and A&E ( 1.4m). This is partially offset by a forecast under-spend in maternity ( 0.8m). Included in the position are adjustments for STP achievement and the impact of the marginal rate at 50%. No other challenges are included in the position. Royal Free London The contract with Royal Free London is over-spent by 2.6m year to date and forecast to over-spend by 3.6m at year end. The key over-performing areas are forecast to be electives ( 3.7m), outpatients ( 3.4m) and maternity ( 0.7m). Included in the position are adjustments for STP achievement and the impact of the marginal rate at 50%. No other challenges are included in the position. University College London Hospitals (UCLH) The contract with UCLH is under-spent by 0.3m year to date and forecast to underspend by 0.6m at year end. The key under-performing areas are forecast to be elective (0.4m) and outpatients ( 0.3m). This is partially offset by a forecast overspend in non-elective ( 0.1m) P a g e

48 Included in the position are adjustments for STP achievement and the impact of the marginal rate at 25%. No other challenges are included in the position. Haringey CCG At Month five the forecast outturn on acute contracts is 225.7m, which is an over-spend against plan of 2.7m. However this is based on a number of adjustments and contains further risks. In particular this includes the impact of recovery actions of around 5.9m. The position also forecasts QIPP slippage of around 0.8m, largely relating to STP planned care. The over-spends within the acute contracts accrue from North Middlesex ( 0.2m), Whittington ( 0.2m) UCLH ( 0.8m), and Royal Free London ( 0.2m). The out of sector providers are also reporting overspends of 1.5m for Barts ( 0.3m), Homerton ( 0.4m), Guys ( 0.4m), Imperial ( 0.3m), and Royal Brompton ( 0.3m). The out of sector contracts do not benefit from marginal rate protection. Whittington The contract is performing to plan at month five and forecast to over-spend by 0.2m at year end. Year to date over-performance is being reported in A&E, elective and outpatients. This is offset by under-spends in critical care, diagnostic imaging and maternity. Included in the position are adjustments for STP achievement and the impact of the marginal rate at 50%. North Middlesex The contract is over-performing by 0.2m at month five and forecast to over-spend by 0.2m at year end. Year to date over-performance is being reported in outpatients ( 2.3m) and is largely offset by under-spends in non-elective ( 0.6m), maternity ( 0.7m), diagnostic imaging ( 0.6m), and critical care 0.3m. Included in the position are adjustments for STP achievement, VB11Z coding and counting challenges, critical care performance and the impact of the marginal rate at 50%. Islington CCG At Month five, the overall acute position is reporting a pressure of 1.6m for forecast outturn, of which 1m is a contributing factor due to acute QIPP slippage (mainly STP Planned Care). This represents the main financial risk to the CCG. The main in-sector pressure accrues from UCLH ( 1.5m), but is largely offset by the under spend at Royal Free London ( 1.5m). The main problem for Islington at present are pressures from out of sector contracts which do not benefit from marginal rate protection, for example, Barts ( 0.8m), Homerton ( 0.5m), and Guys ( 0.3m). University College London Hospitals (UCLH) Year to Date (YTD) reported a 1.5m over performance (non-elective, critical care, drugs and devices). Forecast outturn reported a 1.4m over performance (nonelectives, elective, drugs and devices and offset by A&E). This position includes adjustments for STP achievement at 75% and the impact of marginal rate at 75%. The year-to-date position has seen a pressure in critical care due to a long stay patient discharged however these costs have been adjusted for the in the forecast outturn to mitigate a potential upward trend. Whittington Year-to-date reported a 0.7m over performance (A&E, electives). Forecast outturn reported a break even position as this includes an adjustment for STP achievement at 75% of planned levels and the impact of marginal rate at 50%. Pressure continues to P a g e

49 be reflected in A&E and electives with slight growth levels adjusted for the latter in the later part of the year. 6. Report Development This is the fourth acute commissioning report provided to the North Central London Joint Commissioning Committee, and has been updated with changes following feedback received from previous reports. The intention is that this report is also used by CCGs to inform their respective Governing Bodies and supporting Committees of acute contract performance. The Committee is therefore asked to make recommendations for further development of the report to ensure that the Joint Commissioning Committee and CCGs receive a comprehensive and rounded assessment of provider performance. Purpose (tick one only) Information Approval To note Decision Recommendation The Joint Commissioning Committee is asked to: NOTE and COMMENT ON the report; COMMENT ON the report format. Conflicts of Interest Strategic Direction Identified risks and risk management actions Resource implications Engagement Equality impact analysis Report history Next steps Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy. The acute commissioning report supports delivery of the following strategic objectives: Commissioning the delivery of NHS constitutional rights and pledges; Improving the quality and safety of commissioned services; Improving health outcomes, address inequalities and achieve parity of esteem; Maintaining financial stability and ensure sustainability through robust planning and commissioning of value-for- money services. The main risks to note are include in the opening risk register for the Joint Commissioning Committee and include: Performance risks to delivery of NHS Constitution Standards for A&E and Cancer 62-days; The provision of robust activity and finance information to support understanding performance against plan for acute hospital providers; Embedding contract provisions for marginal rates and a streamlined claims and challenges process into provider contracts in 2017/18. For CCG finances, the report focuses on the performance of contracts falling within the remit of the Joint Commissioning Committee rather than overall CCG positions. The report is presented to the NCL Joint Commissioning Committee which includes elected GP representatives, lay members, Healthwatch, Public Health and representatives from each NCL London borough. This report was written in accordance with the provisions of the Equality Act The report has been developed with reference to contract reports provided to individual CCGs in 2016/17. The Acute Commissioning Report will now be used at individual CCG Committee meetings to provide an overview of contract performance. 26 P a g e 49

50 The report will be developed in response to feedback from the Joint Commissioning Committee and CCG Committees. Appendices None. The detailed acute commissioning report can be made available on request. 27 P a g e 50

51 NCL Joint Commissioning Committee Meeting on Thursday 5 th October 2017 Appendix: Report title Transforming Care Programme Update Agenda item 3.2 Date Lead director Report author Sponsor(s) (where applicable) Paul Sinden Director of Performance and Acute commissioning NCL Kath McClinton Assistant Director Special Projects Islington CCG and Senior Responsible Officer (SRO) Transforming Care Programme Tel/ Tel/ Tel/ p.sinden@nhs.net kathmcclinton@nhs.net Report summary Transforming Care is a national programme, established in the wake of the Winterbourne View scandal, aimed at supporting people with learning disabilities to live rewarding and fulfilling lives in the community and prevent the need for long term hospital care. As part of this we are required to reduce the number of hospital beds commissioned for patients with a learning disability and/or autism by the end of March 2019, when the Programme ends. The Joint Commissioning Committee received an update on the Transforming Care Programme in July The report provided an overview of the Programme including a summary of the initial financial modelling undertaken to estimate the likely financial impact of the Programme on North Central London s health and care system. The July report noted that further modelling was planned to provide a greater level of level of detail on the likely costs of the Programme. This report updates the Committee on this work and outlines a number of scenarios modelled through the data collected. Primarily, the data shows that locally, the financial impact on the local health and care system (where hospital care is already locally funded by CCGs) is likely to be low, based on the assumption that existing funding will be recycled across the health and social care system to ensure continued support for people within the Programme. However, NCL is expected to face significant financial pressure through funding community or hospital placements for individuals discharged from NHS England-funded secure hospital settings. Whilst discussions regarding 51

52 a possible funding transfer from NHS England continue, to date, there is no assurance that CCGs will be supported to alleviate or reduce this pressure. Purpose (tick one only) Information Approval To note Decision Recommendation Conflicts of Interest Strategic Direction Identified risks and risk management actions Resource implications The committee is asked to Note this report; Note the lack of transparency regarding funding transfer from NHS England; Agree the principle for CCG funded patients that funding flows from the CCGs to the Local Authorities on discharge to the community. Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy. Delivery of the Transforming Care Programme supports: Commissioning the delivery of NHS constitutional rights and pledges; Improving the quality and safety of commissioned services; Improve health outcomes, address inequalities, and achieve parity of esteem; Integrate and enable local services to deliver the right care in the right setting at the right time; Achieving the aims of the Care Closer to Home workstream in the North Central London Sustainability and Transformation Plan. The main risks identified in the Transforming Care Programme update are: The pace of change required to meet the challenging bed reduction target by March 2019; Lack of clarity on income following patients from Specialist Commissioning for NHS England funded patients, with further guidance from NHS England awaited. Resource implications are identified as follows: For NHSE funded patients there is a financial risk in the order of 3.3m - assuming no funding transfer from NHS England. For CCG funded patients there is money in the system to cover the cost of discharging this cohort into the community. Where future community costs are attributable to the Local Authority, it is assumed that CCGs will transfer applicable funds to Local Authorities on discharge. There is a pressure of c. 0.2m to the system. Community infrastructure is expected to be impacted as patients are discharged to the community. In particular, this impact will be affected by the discharge of patients with a forensic history, who may require additional support to manage associated risks. Engagement Equality impact analysis The Transforming Care Board oversees implementation of the programme, with membership of the Board including CCG and Local Authority representatives from across the five boroughs, NHS England; Mental Health Trusts, Healthwatch, and Family Carers. This report was written in accordance with the provisions of the Equality Act

53 Report history This is a follow up report to the North Central London Joint Commissioning Committee. In July the Committee received an update on the Transforming Care Programme with a recommendation to report back to the Committee with an update on the financial position. Local implementation is overseen by the Transforming Care Board, supported by an Implementation Group and a series of task and finish groups Next steps Agree appropriate escalation of concerns to NHSE regarding anticipated funding pressures resulting from patients discharged from secure inpatient settings. Continue with patient discharges as planned to meet NCL s trajectory Appendices 1. North Central London Transforming Care Banding Framework 53

54 1. INTRODUCTION 1.1. Transforming Care is a national programme aimed at supporting people with learning disabilities to live rewarding and fulfilling lives in the community and prevent the need for long term hospital care The three-year programme, established by NHS England in the wake of the abuse scandal at Winterbourne View Hospital, is due to end in March By the end of the Programme Transforming Care Partnerships (TCPs) will be expected to have met their targets for hospital bed reduction as set out by NHS England. NCL partnership has 81 patients defined as being in the Transforming Care cohort and the target set by NHS England is to reduce that number to 48 by 31 March This can only be achieved through a whole-systems approach across health and care which prevents future hospital admissions as well as discharging current patients This report outlines the financial modelling developed since July 2017 to understand the likely financial impact of the Programme on North Central London s health and care economy. 2. NORTH CENTRAL LONDON TRAJECTORY 2.1. NCL Transforming Care Partnership has one of the highest cohort of patients across London (81), funded through either the individual CCGs or through NHS England Specialist Commissioning. It should be noted an additional three patients were identified during the course of this exercise so the modelling is based on 84 patients not 81. North Central London continues to be performance managed by NHS England on the cohort of The overall target is to reduce the use of inpatient beds from 81 to 48 by the end of March This reduction of 33 is sub-divided by commissioner. The target for the CCG funded beds is to reduce from 41 to 21; for Specialist Commissioned beds the target is to reduce from 40 to In relation to performance we are meeting the targets and North Central London is slightly ahead of the trajectory. However, it should be noted that the patients remaining in hospital tend to have more complex needs and are harder to discharge. These individuals are likely to require bespoke and often expensive community packages. 3. WORK UNDERTAKEN 3.1. The July Joint Committee report noted that the initial financial modelling undertaken across North Central London projected a net cost pressure the health and care system, based on the assumption of achieving the trajectory outlined above. It was further noted that the modelling was fairly crude, it was based on average costs and that further work was planned to refine the modelling to provide far greater detail on the likely costs of the Programme. 54

55 3.2. Since July a significant amount of work has taken place within a very short period of time to develop this modelling. A banding framework (Appendix1) was developed by commissioners to capture the wide range of individual patient needs covering five different levels of care. These bandings range from low level support costing under 200 per week to the highest level of individual bespoke packages of care. This band is further sub-divided according the staff ratio likely to be needed, going up to 5,000+ per week. costs for care in these bandings have been used Commissioners across North Central London then worked with their operational teams to apply this framework to their local patient cohort, identifying the most likely care setting required on discharge for each individual patient. Colleagues in Specialist Commissioning completed the same exercise for their cohort of patients. Finance support has been provided by Islington Council one day a week The outcome of this work is that we now have robust financial data on all the patients in scope. For CCG funded patients we have actual costs of hospital placements, actual costs for those already discharged and for those remaining in hospital we have used the bandings. Similarly, for NHS England funded patients, actual costs have been used where they are available and the banding costs used for those who remain in hospital It should be noted that this work is based on the best available information about discharge dates. Although all patients have planned discharge dates, actual discharge dates will vary over the next eighteen months which will impact on modelling the trajectory target. 4. FINANCIAL IMPACT 4.1. Table 1 below is a snapshot of the cost currently in the wider system for the 84 patients, and the likely full-year effect impact of all patients moving into the community, split by commissioner. Table 1: Summary of total patient cohort costs CCG Full Year Effect ( '000) Patients Current cost to system ( '000) Full Year Effect of discharge ( '000) Net Impact ( '000) CCG 35 6,759 7, NHSE 49 8,574 6,244 (2,329) 84 15,333 13,549 (1,784) 4.2. In this unlikely scenario, if all NHSE patients were to discharge the total pressure to the local health and care economy is 6.24m. The CCG pressure is 7.31m, but there is funding in the current system of 6.76m. While some of these costs are stranded, the expectation is that much of this would flow with the patient. Stranded costs are predominantly block purchased acute mental health beds, which remain in the mental health system At a patient level, ignoring stranded costs, if all the 84 patients were discharged there is an overall saving to the system of 1.784m. 55

56 4.4. Not all patients, however, will be discharged by March Some patients have discharge dates beyond the life of the Programme, some need to remain in forensic secure services and the 10 patients at Harperbury Hospital are unlikely to be discharged within the lifetime of the programme, if at all, due to legal restrictions outlined in the August report to the Joint Commissioning Committee The following tables outline the likely financial impact assuming the trajectory is met. It is difficult to precisely predict these costs as we don t know precisely which patients will be discharged on which dates over the next eighteen months. Although all patients have planned discharge dates, actual discharge dates will vary Trajectory costs have been modelled by taking those patients already discharged and assuming the remaining discharges are the higher cost patients. On discharging to trajectory at patient level the following tables evidence that there is enough funding in the system for CCG funded patients when ignoring stranded costs. There is a saving arising on discharging to trajectory, which could be used to offset some of the stranded costs Table 2a: Discharges to date plus higher cost patients Commissioner Discharges CCG / NHSE 2017/18 Baseline ( '000) Full Year Effect of Transfer to Area ( '000) Net Impact ( '000) CCG 20 4,045 3,859 (186) NHSE 23 3,748 3,325 (423) 43 7,793 7,184 (609) Table 2a above assumes that in addition to those who have already been discharged, the remaining patients who will be discharged will be those with the most costly community packages. Whilst in reality this is unlikely to be the case, this scenario allows us to understand the worst case financial position, if NCL were to meet only the Programme target number of discharges. It does not include the possibility of any additional patients being discharged over and above the target. The summary shows that: there is enough funding within the local system ( 4.04m) to cover the future community costs for patients who are currently CCG-funded ( 3.85m) The discharge of 23 NHSE patients would cost 3.32m per annum. This would present as a pressure for NCL, due to there currently being no agreement for funding to transfer to CCGs. It should be noted that there is an assumption that funding will transfer from CCGs to Local Authorities to meet the social care element of community packages. When modelling patients with the soonest discharge dates rather than the higher cost patients the pressure arising from CCG patients reduces by 40k and for NHSE patients 548k. The Net impact to the programme is an increased saving of 325k, which does not align with the reduced pressure because it takes into account the current system cost. 56

57 4.7. To meet the trajectory, 20 CCG funded patients need to be discharged. North Central London will aim to continue to discharge patients once this target is met, which results in 23 in total and is the number used in the remainder of the tables. This excludes the Harperbury patients Table 3 CCG Patients likely for discharge Current Commissioner CCG Discharges Discharges Current System Cost ( '000) Full Year Effect of Transfer to Area ( '000) Net Impact ( '000) Block Contract Haringey (42) Block Contract Islington (320) Block Contract (362) Spot Camden (248) Spot Enfield Spot Haringey 9 2,103 2, Spot Islington (92) Spot 19 3,851 3,728 (123) 23 4,542 4,056 (485) This table models the financial impact if all 23 remaining CCG patients with a discharge date before the end of the Programme were successfully discharged. It is not possible to repeat this exercise for NHSE-funded patients as there has been no indication that additional patients will be discharged beyond the target trajectory. The breakdown identifies the impact in relation to each CCG/Local Authority area, but also how this impact is affected by current commissioning arrangements (i.e. block and spot). Whilst overall there is enough funding in the system to support future discharge costs for all 23 patients, at an individual CCG level, Haringey, Islington and Enfield are likely to face additional pressures. Enfield community costs are expected to exceed current costs by 0.1m per annum. In Islington and Haringey, the picture is further impacted by the stranded costs that are attached to the block commissioning arrangements for 4 patients. Whilst the future community costs are expected to be considerably less than current block costs, the future costs create a new pressure across Haringey and Islington of 0.328m per annum (although the Islington pressure will be partly offset by the 0.09m saving against current spot arrangements). Additionally, for Haringey, there is a further 0.1m pressure against the future costs compared to current spend for those currently funded via spot arrangements. It has been assumed that funding will transfer from CCGs to Local Authorities to meet the social care element of community packages Table 4a: Financial Impact of Assumed transfers and funding flows 57

58 Current Commissioner Discharges Current System Cost ( '000) Current System Cost available to flow ( '000) Full Year Effect of Transfer to Area ( '000) Net Impact to Local Area ( '000) CCG 23 4,542 3,851 4, NHSE 23 3,748-3,325 3, ,289 3,851 7,382 3,531 The above table shows the impact to the local area if all 23 remaining CCG patients with a discharge date before the end of the Programme were successfully discharged, along with the 23 NHSE discharges (in line with trajectory). An assumption has been made that the current CCG non-stranded system cost will flow. This would result in a small NCL pressure of 0.2m per year. For NHSE-funded patients, due to the lack of an agreement to transfer funding from NHSE to CCGs as these patients are discharged, the assumption is that there will be an overall pressure to NCL of 3.3m to support these individuals in the future. Total pressure across NCL for all patients discharged would be 3.5m. It has been assumed that where required, funding will transfer from CCGs to Local Authorities to meet the social care element of community packages The following tables 4b and 4c show the impact to local CCG area with assumed funding flows, summarising the arising CCG 0.205m and NHSE 3.325m impacts Table 4b Impact to NCL of CCG patient transfers with assumed funding flows Current Commissioner Discharges Current System Cost ( '000) Current System Cost available to flow ( '000) Full Year Effect of Transfer to Area ( '000) Net Impact to Local Area ( '000) Camden (248) Enfield Haringey 10 2,276 2,103 2, Islington ,542 3,851 4, Table 4b is an expansion of table 4a above, and shows the impact by CCG area of all 23 anticipated discharges, which equates to a 205k pressure to the STP area split as above. Whilst the overall pressure is 205k, this includes savings of 248k in Camden. Excluding this saving, the pressure for affected CCGs could be as high as 243k (Haringey). Barnet do not have any other CCG-funded patients to discharge apart from those who are at Harperbury, and are therefore not included in the above table. An assumption has been made that available funding of 3.85m will follow patients where possible. It has been assumed that where required, funding will transfer from CCGs to Local Authorities to meet the social care element of community packages. 58

59 Table 4c Impact to NCL of NHSE patient transfers with assumed funding flows Current Commissioner Discharges Current System Cost ( '000) Current System Cost available to flow ( '000) Full Year Effect of Transfer to Area ( '000) Net Impact to Local Area ( '000) Barnet Camden Enfield Haringey 7 1,403-1,165 1,165 Islington 5 1, ,748-3,325 3,325 Table 4c shows the impact to each CCG based on 23 NHSE discharges. The assumption is that no funding will flow from NHSE, resulting in an annual pressure across NCL, in particular Haringey ( 1.1m), Islington ( 0.8 m) and Barnet ( 0.7m). It has been assumed that where required, funding will transfer from CCGs to Local Authorities to meet the social care element of community packages. 5. CONCLUSION 5.1. The financial modelling set out in this report sets out a range of scenarios based on discharges occurring in line with trajectory, as well as additional discharges where this would be in the best interest of the patient In each scenario, the data shows that that there is little opportunity for savings across the NCL health and social care system; whilst funding across the footprint is largely sufficient to cover the community costs for CCG-funded patients as they are discharged, there is a significant risk in relation to the discharge of 23 NHSE-funded patients, which would result in an annual pressure of over 3m to NCL There is the possibility that this pressure could be at least partially alleviated, were funding from NHSE to flow with the patient to CCGs upon discharge. However, the continued lack of clarity from NHSE with regards to any funding transfer arrangement means that at this stage, an assumption must be made that no funding will transfer, resulting in NCL bearing the full pressure. However, NHS England are being pursued to transfer funds in line with repatriation from inpatient placements The modelling has demonstrated there is sufficient funding in the current NCL system to support the discharge of CCG funded patients to community settings assuming funding transfers align to the costs incurred by Local Authorities. In order to alleviate a future funding pressures for Local Authorities, an in-principle agreement is required from the five North Central London CCGs to transfer funds as outlined. 6. RECOMMENDATIONS 6.1. It is recommended that the Committee: 59

60 i) Note this report ii) Note the lack of transparency regarding funding transfer from NHS England, and the financial risk that this presents to NCL iii) Agree the principle of funding flow from CCGs to Local Authorities on discharge to the community 60

61 Appendix 1 NORTH CENTRAL LONDON TRANSFORMING CARE BANDING FRAMEWORK Banding 1. Home - low support Supported Accomm - Low Support Supported Accomm or Res Care - Medium Support Supported Accomm or Res Care - High Support a. Bespoke package - 1: b. Bespoke package - mostly 2+: c. Bespoke package - all 2+: Banding/Expected Community Destination Projected Community Costs (weekly) 1. Home/community/with family - low support Supported Accommodation with Low Support Supported Accommodation or Residential Care with Medium Support 4. Supported Accommodation or Residential Care with High Support 5. Bespoke package in any setting a. 1:1 with intermittent 2:1 and/or waking night b. Majority of support is at least 2:1, waking night c. All support is at least 2:1, at least 1 waking night Notes Likely to be for patients who normally lived independently or with family with low support before discharge & expect to return to the same or similar setting For those who will need a designated supported accommodation service, with background support but low levels of 1:1 For those who will need a designated supported accommodation or possibly residential care service, with background support and significant 1:1 For those who will need a designated supported accommodation or possibly residential care service, with high levels of 1:1 and possibly some 2:1 and/or waking night support 61

62 NCL Joint Commissioning Committee Meeting on Thursday 5 th October 2017 Report title System Intentions for 2018/19 Agenda item 4.1 Date 28 th September 2017 Lead director Report author Sponsor(s) (where applicable) Paul Sinden Director of Performance and Acute Commissioning Paul Sinden Director of Performance and Acute Commissioning Tel/ Tel/ Tel/ p.sinden@nhs.net p.sinden@nhs.net Report summary North Central London CCGs System Intentions for 2018/19 Introduction This paper summarises the system intentions for North Central London (NCL) CCGs for 2018/19. System intentions set out our priorities for the next financial year that will be reflected in contracts with local providers. System intentions The draft is based on the following principles agreed at the North Central London (NCL) CCG Joint Commissioning Committee (JCC) on 6 July 2017: Intentions should signal a clear change in the relationship between commissioners and providers compared to previous years through a move to system intentions from commissioning intentions. This is done in recognition of development of the Sustainability and Transformation Plan and the new commissioning arrangements for the five North Central London CCGs; Intentions should be concise and present an aggregated position for the five CCGs, and reference how plans for 2018/19 will be formed on the basis of agreed areas of work between commissioners and providers including the Sustainability and Transformation Plan workstreams; Whilst the focus is on aggregate intentions across the five CCGs there will be some scope for local CCG intentions to deliver CCG financial plans; Intentions should reflect the priorities identified through engagement with patients and public; We need to ensure that agreements for 2017/18 and 2018/19 in provider contracts signed in December 2016 are carried forward into 2018/19. This would include contract form; Contracts signed in December 2016 indicated that contract values for 2018/19 will need to be determined and agreed during 2017/18, with an insert into the signed contracts indicating that 2018/19 contract values will be based on the agreed 2017/18 contract flexed for outturn adjustments for 2017/18, plus 2018/19 growth and less the impact of STP interventions in 2018/19; 62

63 Hospital contracts remain on a payment-by-results format in 2017/18 and 2018/19, albeit modified for marginal rates, and intentions would therefore need to cover changes to tariff, and rules on counting and coding. The draft system intentions are also consistent with the NCL CCG Commissioning Strategy developed in 2016, as an enabler for delivery of the NCL Sustainability and Transformation Plan. The Committee is asked to note and comment on the procurement principles that will underpin system intentions and delivery of the Sustainability and Transformation Plan. Feedback from CCG Governing Bodies A draft of system intentions were presented to the five CCG Governing Bodies during September 2017, and to providers through Sustainability and Transformation Plan meetings. The provider response on the shift from commissioning intentions to system intentions has been positive. Feedback is summarised below and reflected in the revised system intentions in appendix one: Work on new contact form and incentives to support delivery of local priorities including the Sustainability and Transformation Plan should promote a greater outcomes focus; Engagement with stakeholders, both locally through CCGs and through the Sustainability and Transformation Plan, should be on-going to ensure that intentions are reflective of priorities identified by stakeholders; Engagement with stakeholders should be supported by an easy read version of system intentions. An initial draft is set out in appendix two for comment; Prevention focus should be in both primary and secondary care; Reducing variation in primary and secondary care should support the aim of reducing health inequalities and inequality in access to services; Contracts should specify requirements for both electronic transfer of data from providers to GPs when patients are discharged from hospital care and availability of appointments that can be booked through the electronic referral system. Provisions for this are built into contract documentation and will be developed through STP workstreams for planned care and digital; The addition of procurement principles, requested by local providers for inclusion, that underpins system intentions and delivery of the Sustainability and Transformation Plan. Procurements when undertaken should promote social value; Intentions should specify local priorities outside of the STP that will have a material impact on provider contracts in 2018/19. These local intentions should be aligned across CCGs to provide a coherent and consistent set of service changes to providers that allow provider to take out costs in line with activity reductions; Given the financial pressures faced by both commissioners and providers there will be a need to identify further savings schemes during 2018/19. In accordance with commissioning principles these schemes should focus on system-wide solutions that reduce overall costs and not merely transfer pressures between organisations. Planning timetable for 2018/19 A detailed planning timetable for 2018/19 has been developed, with the timetable assuming agreement of contract baselines with providers for 2018/19 and operating plans for 2018/19 being finalised by the end of December Both contract baselines and operating plans will include the impact of Sustainability and Transformation Plan interventions for 2018/19. 63

64 The planning timetable has been shared with providers for consideration, and has been established in advance of any formal planning guidance from NHS England (NHSE) or NHS Improvement (NHSI). Purpose (tick one only) Information Approval To note Decision Recommendation The Joint Commissioning Committee is asked to: NOTE and COMMENT ON the draft system intentions for 2018/19; NOTE and COMMENT On the draft procurement principles included within system intentions. Conflicts of Interest Strategic Direction Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy. System intentions for 2018/19 will support delivery of: The North Central London Sustainability and Transformation Plan; Local CCG priorities including joint commissioning priorities with Local Authorities. System intentions will be determined by: Local priorities to deliver the health and improvement priorities agreed through the Health and Wellbeing Board and informed by the Joint Strategic Needs Assessment; The North Central London Sustainability and Transformation Plan; The carry forward of priorities from 2017/18 included in current two-year contracts with providers for 2017/18 and 2018/19; National planning guidance including the refresh of The Five Year Forward View. Identified risks and risk management actions Resource implications Engagement Equality impact analysis The main risks to generating commissioning intentions for 2018/19 within CCG resource envelopes are: Delivery of the targeted activity reductions and cost savings from STP interventions and local QIPP in 2017/18; Developing further QIPP and STP interventions proposals for 2018/19; Triangulation of CCG and Trust views on 2017/18 forecast outturn and the impact of 2018/19 Sustainability and Transformation Plan workstream interventions; Ensuring agreements in two-year contracts for 2017/18 and 2018/19 signed in December 2016 are carried forward from 2017/18 into 2018/19. Plans for 2018/19 will need to be developed within CCG resource envelopes and encompass run-rates from 2017/18 adjusted for demographic growth, the impact of Sustainability and Transformation Plan and local QIPP interventions, and the impact of national planning guidance. Intentions should reflect the priorities identified through engagement with patients and public. Local CCG engagement timelines will be built into the process for generating system intentions, as well as being informed by on-going engagement structures. This report was written in accordance with the provisions of the Equality Act

65 Report history Next steps Appendices Development of system intentions for 2018/19 has been considered by: North Central London (NCL) Contract Delivery Group on 26 May 2017; The Senior Management Team of the five North Central London CCGs on 6 and 20 June 2017; The NCL CCG Joint Commissioning Committee on 6 July 2017 where the outline for system intentions was agreed. Next steps in the development of system intentions for 2018/19 will be to: Identify Sustainability and Transformation Plan (STP) workstream priorities, and the associated finance and activity impact; Identify local CCG priorities over and above STP priorities, and align them where possible to maximise system benefit; Enact local CCG engagement plans with stakeholders to ensure plans are reflective of local priorities; Develop a set of outcome indicators used in the update to the Five Year Forward View and the NCL Sustainability and Transformation Plan (STP) to underpin intentions for 2018/19; Develop plans for 2018/19, including the negotiation of contract baselines with providers, by December Appendices are: Appendix One initial draft of system intentions for 2018/19 to be sent to providers in September Appendix Two initial draft of easy read version of system intentions for 2018/19. 65

66 Appendix One: North Central London CCGs System Intentions for 2018/19 1. Introduction This document sets out system intentions and actions we intend to take for 2018/19 that support the direction of travel in the North Central London Sustainability and Transformation Plan (STP) for the next five years. 2. System Intentions Intentions for 2018/19 build on the collaborative approach in developing the Sustainability and Transformation Plan (STP), and to the contract round for 2017/18 and 2018/19 facilitated through the STP. Continuation of this is collaborative approach is underpinned by a move from commissioning intentions in 2017/18 to system intentions in 2018/19. The shift to system intentions will be underpinned by a set of principles by which we would like to work together: Partner organisation will work together for the benefit of local people; We will involve local people on our design, planning and decision-making; Partner organisations will find innovative ways to cede current powers and controls to explore new ways of working together; We will be open, transparent and enabling in sharing data, information and intelligence in all areas including finance, workforce and estates; Partner organisations will find ways to risk-share during transformational change; We will find ways to share joint incentives and rewards; Partner organisations will make improvements by striving to be the best together; We will be rigorous in ensuring value for money and financial sustainability. Our system intentions for 2018/19 therefore describe the areas where joint working across CCGs and providers that will ensure the best outcomes for patients by planning and commissioning at scale or across the whole health and care system, with acknowledgement that there will be local plans for each CCG for specific areas of delivery. The Sustainability and Transformation Plan (STP) provides a detailed picture of the local health and care landscape; the population demographics; and acute, community, mental health, social care and primary care provision in the five boroughs. The STP also sets out the case for change and our ambition for an overarching model of care in North Central London (NCL). System intentions will not duplicate this information in detail and should be read in conjunction with the STP. The rapidly changing health and social care landscape also requires us to begin to redefine our role as commissioners and our business as usual. Our system intentions therefore focus on things we need to do to ensure we continue to deliver value, reduce inequalities, as well as ensure the local system retains the capability to focus on delivering high quality care for our population. 3. Strategic challenges The local health system faces five main strategic challenges: Prevention. Prevention and population health needs to be central to our plans to reduce the health and wellbeing gaps, care and quality gaps, and finance and efficiency gaps in North Central London (NCL). Improving health outcomes and delivering long-term benefits for the population as a whole will require delivery at scale, upfront investment, and close working with local authorities to address the wider determinants of health. Prevention focus should be in both primary and secondary care. Financial challenge. Developing the STP has led to a common understanding that we operate as a system in deficit. We need to understand the cost of delivering services and change the way we work to align incentives, reduce duplication, and take cost out of the system. 66

67 Delivery of the Sustainability and Transformation Plan. The Sustainability and Transformation Plan (STP) provides a plan for our system to work together to better meet the needs of the population, improving quality, and setting out how local services will evolve and become sustainable over the next five years. The STP workstreams, for both service models and enablers, set out ambitions for changes at scale that require us to work together in different ways. The priorities for these workstreams are central to our system intentions for 2018/19. Continuing to deliver value and reduce variation in care. We know across the range of providers in North Central London (NCL) there are inequalities in outcomes, service quality, and unwarranted variations in cost. We want to work to ensure that care is always of the highest possible standard and that we reduce waste in the system. We are committed to addressing shortcomings in the quality of service delivery through delivery of the STP, service change, and also through use of the new commissioning arrangements for NCL CCGs introduced in 2017/18. Reducing variation in primary and secondary care will support our aim to reduce health inequalities and inequality in access to services. Redefining our business as usual. The five year forward view sets out new models of care many of which support delivery of our Sustainability and Transformation Plan (STP). New ways of working will require us to think differently about how we commission health and care services and how organisations work together to ensure we continue to deliver improvements in outcomes for our population. 4. Achievements in 2017/18 Intentions for 2018/19 build on the collaborative approach in developing the Sustainability and Transformation Plan (STP), and to the contract round for 2017/18 and 2018/19 facilitated through the STP. This approach has yielded A greater alignment of commissioner and provider plans through the Sustainability and Transformation Plan (STP) including an agreed set of service improvement priorities; A common understanding of the underlying financial pressures across the NCL health and care system; Contracts for 2017/18 and 2018/19 incorporating service improvement priorities in the STP, and delivered to the national planning timetable; New commissioning arrangements for NCL CCGs providing impetus for greater alignment of commissioning priorities and creating greater delivery capacity across commissioners and providers. 5. North Central London System Intentions Intentions for 2018/19 seek to address the areas of priority for joint commissioning across the five North Central London (NCL) CCGs, to further align intentions of the CCGs for the best system impact, the rationale for acting jointly across NCL, and to identify the levers and mechanisms that will ensure that the Sustainability and Transformation Plan (STP) is delivered across the health and care system. 5.1 Sustainability and Transformation Plan Priorities Pivotal to intentions for 2018/19 will be delivery of jointly agreed STP priorities signed off by Health and Care Cabinet incorporating both priorities from service workstreams (prevention, care closer to home, urgent and emergency care, planned care, and mental health) and support from enabling functions to deliver service priorities (finance, interoperability, estates, workforce, system incentives). 5.2 Priorities from local engagement with stakeholders Engagement with local people across North Central London CCGs has identified priorities for delivering health and care services: The need to invest in prevention and primary care; Better co-ordination of care for the individual supported by making general practice the centre of coordinated care through health and care teams working around the practice; Co-production of care and helping people manage their own care; Improving the quality of, and reducing the variation of, primary care and secondary care services. National and local strategies have a strong alignment to how people tell us they would like to see services provided. 67

68 This focus on promoting health and wellbeing, maintaining independence, and streamlining care leads us to consider: How we improve outcomes over the long-term for some of our vulnerable population groups; Models of care and payment mechanisms that promote and enable delivery of care more effectively and efficiently. 5.3 Financial challenges Developing the STP has led to a common understanding that we operate as a system in deficit. Latest forecast for 2017/18 indicate a system deficit of 97m against CCG and Trust financial control totals. The normalised deficit for the year, after removing the benefit of non-recurrent support is 137m (source North Central London Finance and Activity Modelling (FAM) Group 21 July 2017). The system deficit is after delivery of significant provider cost improvement programmes (CIP) and CCG QIPP programmes of between 4% and 4.5% in 2017/18. In addition to STP workstream interventions, system intentions for 2018/19 will therefore focus on reducing the system financial deficit through: A greater understanding of provider cost profiles to better align cost improvement programmes (CIP) and CCG QIPP plans to ensure that service improvements can be delivered at the same time as removing costs from the system and delivering financial sustainability; Development of a financial strategy for North Central London (NCL) in recognition of the need to promote system sustainability as well as individual organisation sustainability. The NCL-wide financial strategy is required as: Individual CCGs are in different financial positions; If the wide disparity in CCG financial positions is not addressed implementation of Sustainability and Transformation Plan initiatives could be put at risk; To provide resilience to all CCGs in the light of limited funding uplifts for the next two years and service pressures; CCGs need to work with providers to best achieve the conditions for receipt of sustainability funds by providers. Given the financial pressures faced by both commissioners and providers there will be a need to identify further savings schemes during 2018/19. In accordance with commissioning principles these schemes should focus on system-wide solutions that reduce overall costs and not merely transfer pressures between organisations. 5.4 Local CCG intentions not covered by Sustainability and Transformation Plan Our system intentions for 2018/19 focus on joint working across CCGs and providers to deliver the best outcomes for patients by planning and commissioning at scale or across the whole health and care system. However, there will also be local plans for each CCG for specific areas of delivery that are the result of local engagement and/or required for CCGs to meet their financial duties. CCGs will also seek to align locally identified priorities to retain commissioning at scale. 5.5 Greater alignment with specialist commissioning Current arrangements for commissioning specialised services can create fragmented pathways that are suboptimal clinically. Better alignment of CCG and specialist commissioning locally will allow pathways to be aligned and perverse incentives to be removed. In 2018/19 CCGs will therefore work with the NHS England Specialist Commissioning Team to: Hold joint contract management meetings with providers; Establish lead commissioner arrangements with CCGs and Specialist Commissioning taking on management of overall contracts where they are the predominant commissioner and currently manage the vast majority of the contract baseline; Co-commission pathways that are fragmented across CCG and Specialist commissioned services. 68

69 Across the footprint of North Central London we now have a chance to look at a range of specialised services that might benefit patients from being co-commissioned or being commissioned more locally. These pathways include: Critical care pathways including a focus on neuro-rehabilitation; Bariatric care (with weight management); Psychiatric Intensive Care Unity care with a particular focus on women s care; Child and Adolescent Mental Health (CAMHs) Tier Four services; Forensic mental health and locked rehab; Eating disorders; HIV and sexual health services. 5.6 System incentives and contract form CCGs would like to continue to work with providers in 2018/19 to further develop system incentives and options for contract form that better support the new models of care in the Sustainability and Transformation Plan (STP) being established across North Central London (NCL). This work is being undertaken through the established acute contract modelling group, with membership from both providers and commissioners to ensure that options for the use of alternative contract forms are co-produced. CCGs believe that work on the realignment of system incentives and contact form are priorities for 2018/19 as: Commissioning and contract form do not yet reflect the progress being made locally in developing and delivering new models of care in NCL; The need to achieve balanced budgets across the health and care system will be supported by a redesign of system incentives, payment mechanisms, and contracting structures; In preparation for contracts for 2019/20 and onwards CCGs would therefore like to shadow-run alternative contract forms in 2018/19 to ensure that any changes support delivery of the STP and balance risk equitably across the system. 5.7 Contract requirements for 2018/19 Two-year contracts for 2017/18 and 2018/19 were signed in December Whilst there are no major national contract adjustments anticipated at this stage there are key contract terms that will require local negotiation and agreement to underpin the second year of the 2017/19 contract (2018/19). Contracts signed in December 2016 provided for negotiation and agreement of contract baselines for 2018/19 during 2017/18. This is built into the planning timetable for developing plans for 2018/19. Contract baselines for 2018/19 will be reflective of the run-rate (outturn) for 2017/18 adjusted for growth and the impact of Sustainability and Transformation Plan and QIPP interventions. It should also be noted that plans for 2018/19 will need to respond to any emerging national policy and associated planning guidance. Any updates to national technical guidance, including for tariff, will be dealt with separately to system intentions. 5.8 Working with local authorities on joint commissioning With both health and social care organisations facing financial and operating challenges, we need to develop closer working with local authorities. We need to develop ways of working that mean we can tackle broader determinants of health as part of our move to population based health models and new models of care. Closer working with local authorities also brings the opportunity to join up services and improve care for vulnerable people. In 2018/19 we will: Take forward work to transform care across the five boroughs, including a focus on services for people with learning disabilities; Adopt a clear approach to integration with Councils beyond social care for broader determinants of health housing, employment, prevention alliances with the third sector; Develop joint commissioning plans with local authorities with a focus on transforming care for people with learning disabilities and delivery of the Better Care Fund. 5.9 Procurement principles 69

70 Through development of the Sustainability and Transformation Plan (STP) Trusts have asked CCGs to consider their approach to procurement in delivering service improvements. In response CCGs have developed the following procurement principles to support both delivery of the STP and decision-making on the best route to delivering service improvements: The priority is to commission high quality local services for the residents of North Central London; CCGs will therefore first work with existing providers to best ensure these high quality local services are provided (only where local providers cannot provide services to the requisite quality and value or meet service gaps the CCGs will consider procurement to remedy this); In line with the move towards system intentions rather than commissioning intentions, any procurement exercise will take into account the impact on system cost for the NCL STP as a whole for example, taking into account stranded costs and avoiding cost-shifting between one part of the system and another; Services will be developed and procured in line with the Sustainability and Transformation Plan; The CCG will engage with all providers to communicate the priorities and commissioning intentions of the CCG in order to ensure transparency; The CCG will involve the public, patients and carers in proposals to change services which affect them and more generally in the different aspects of commissioning services such as, planning and design; A range of expertise from a variety of providers will be used to develop detailed service specifications for new service models ensuring all providers are treated equally and the specification does not discriminate against providers; All decisions to procure services will be evidenced based taking into account clinical effectiveness, patient safety, outcomes, quality improvement and value for money; Procurement decisions will consider not only the whole life cost of the intended improvements but also how the procurement outcome will deliver social value to the local area; The CCG will act with a view to securing the needs of the people who use the services, improve the quality of the services and improving efficiency in the provision of the services including through the services being provided in an integrated way (including with other health care services, health-related services or social care services); All procurements will comply with the requirements of the CCGs standing financial orders and standing financial instructions. All procurements will comply with the requirements of European Union procurement processes, where they apply and all procurements will comply with the principles-based approach set out in the NHS (Procurement, Patient Choice and Competition)(No.2) Regulations 2013; Specialist procurement advice will be taken to ensure the best procurement decision and route is adopted. The CCGs welcome feedback from Trusts and other stakeholders on these procurement principles. 6. National Context System intentions for North Central London in 2018/19 are consistent with: The joint NHS England / NHS Improvement NHS Operational Planning and Contracting Guidance for ; Refresh of the Five Year Forward View published in NHS England / NHS Improvement NHS Operational Planning and Contracting Guidance for The guidance sets out how the NHS operational and planning processes would support delivery of Sustainability and Transformation Plans and financial sustainability in the NHS. The guidance set out the financial and business rules for both 2017/18 and 2018/19. The guidance indicated that: There needed to be a radical change in the behavioural dynamics of planning and contracting towards a more collaborative process; This would be underpinned by simplified approaches to contracting and flexibility in implementing strategies; 70

71 Partnership working would be incentivised by a number of funding streams available at a Sustainability and Transformation Plan (STP) level; Local health economies with robust STPs could adopt system control totals for finance, providing transparent opportunities for the sharing of risk. Work by commissioners and providers on the contract round for 2017/18 and 2018/19 made progress on the above, and system intentions for 2018/19 are designed to continue that process. Refresh of the Five Year Forward View The NHS Five Year Forward View set out how the NHS needed to change to meet the needs of the population and set out three improvement opportunities - a health gap, a quality gap, and a financial sustainability gap. These gaps were targeted to be closed by a better integration of primary and specialist hospital care, physical and mental health services, and of health and social care. Delivery of these improvement opportunities was to be supported by change within the NHS, wellfunctioning social care, extra capital investment, transformation funding, and a focus on prevention and public health. Priorities identified for 2017/18 are also framed within the constraints of the requirement to deliver financial balance across the NHS and therefore the main 2017/18 national service improvement priorities for the NHS are: Improving A&E performance including upgrading the wider urgent and emergency care system; Strengthening access to high quality GP services and primary care; Improvement in cancer services (including against waiting time standards) and mental health. Delivery of the national service improvement priorities and financial balance will be further supported by: Supporting service redesign through Sustainability and Transformation Plans; A focus on funding and efficiency through the NHS ten-point efficiency plan; Delivery on the enablers for service improvement including workforce, safer care, technology and innovation. The link to the refresh of the Five Year Forward View is provided below: FORWARD-VIEW.pdf Plans for 2018/19 will also need to respond to any emerging national policy and associated planning guidance. 7. Outcomes A section on outcomes will be included in the intentions for 2018/19 incorporating the outcomes used in the update to the Five Year Forward View and the NCL Sustainability and Transformation Plan (STP). This was not done for 2017/18. 71

72 Appendix Two: North Central London CCGs System Intentions for 2018/19 1. Introduction System intentions set out priorities for the development of local healthcare services for the following year. Historically they have been communicated to local providers by CCGs in advance to make sure that priorities are included in local contracts and service changes made. For 2018/19 our system intentions (and priorities) for North Central London are influenced by: Development of the North Central London Sustainability and Transformation Plan (STP); Local CCG priorities developed with stakeholders; National planning guidance including delivery of NHS Constitution waiting time standards for A&E, cancer, and surgery (referral-to-treatment), and in addition other service priorities set out in the NHS Five Year Forward View including access to primary care and mental health services. 2. System Intentions Intentions for 2018/19 signal a more collaborative approach between commissioners and providers than in prior years. This builds on the joint development of the Sustainability and Transformation Plan (STP) for North Central London with the STP allowing commissioners and providers to: Agree service improvement priorities and plans to implement those priorities; Have a common understanding of financial pressures across the NCL health and care system; Agree contracts for 2017/18 and 2018/19 that reflect service improvement priorities in the STP and seek to address financial pressures across the system. System intentions for 2018/19 therefore focus on how joint working across CCGs and providers can improve outcomes for patients by planning and commissioning across the whole health and care system in North Central London, whilst allowing scope for local plans for each CCG for specific areas of delivery. Our system intentions therefore focus on things we need to do to ensure we continue to deliver value, reduce inequalities, as well as ensure the local system retains the capability to focus on delivering high quality care for our population. 3. Strategic challenges The Sustainability and Transformation Plan (STP) provides a detailed picture of the local health and care landscape in North Central London including: Population trends that will impact on delivery of health and care services including the impact of general growth, diversity, and an ageing population; Current service provision, across hospital, community, mental health, social care and primary care services, and the variation in the quality and efficiency of care provided across the range of providers; The need to change how services are delivered, the case for change, to meet the five strategic challenges in the health and care system summarised below. Prevention. We need to place greater priority on prevention and population health needs to reduce health inequalities, care and quality gaps, and address financial pressures. This should be a focus for all healthcare providers and be delivered through close working with local authorities to address the wider determinants of health. Financial challenge. Developing the STP has led to a common understanding that in North Central London we operate as a system in deficit. We need to understand the cost of delivering services and change the way we work to align incentives, reduce duplication, and take cost out of the system. Delivery of the Sustainability and Transformation Plan. The Sustainability and Transformation Plan (STP) provides a plan for our system to work together to better meet the needs of the population, improve service quality, and deliver financial balance over the next five years. Workstreams have been established to develop and implement plans for both services (prevention, care closer to home, urgent and emergency care, planned care, and mental health) and support from enabling functions to deliver service priorities (finance, interoperability, estates, workforce, system incentives). 72

73 Continuing to deliver value and reduce variation in care. Much of our effort in the STP will go towards reducing inequalities in outcomes, improving service quality, and reducing unwarranted variations in cost across providers in North Central London. We want to work to ensure that care is always of the highest possible standard and that we reduce waste in the system. New models of care. The national five year forward view sets out new models of care many of which support delivery of our Sustainability and Transformation Plan (STP). These models encourage collaborative working across providers and are being developed locally through the STP workstreams for urgent and emergency care, care closer to home, mental health and planned care. As we look to new models of service provision we also need to consider new models for commissioning and new incentive models to best support service improvements. 4. North Central London System Intentions Intentions for 2018/19 seek to address the areas of priority for joint commissioning across the five North Central London (NCL) CCGs and through this to further align intentions of the CCGs for the best system impact. The intentions also identify the levers and mechanisms that will best ensure that the Sustainability and Transformation Plan (STP) is delivered across the health and care system. a. Sustainability and Transformation Plan Priorities Delivery of jointly agreed Sustainability and Transformation Plan (STP) are central to system intentions for 2018/19. STP priorities focus on both service workstreams (prevention, care closer to home, urgent and emergency care, planned care, and mental health) and support from enabling functions to deliver those service priorities (finance, interoperability, estates, workforce, system incentives). b. Priorities from local engagement with stakeholders Engagement with local people across North Central London CCGs has identified priorities for delivering health and care services: The need to invest in prevention and primary care; Better co-ordination of care for the individual supported by making general practice the centre of coordinated care through health and care teams working around the practice; Co-production of care and helping people manage their own care; Improving the quality of, and reducing the variation of, primary care and secondary care services. National and local strategies have a strong alignment to how people tell us they would like to see services provided. This focus on promoting health and wellbeing, maintaining independence, and streamlining care leads us to consider: How we improve outcomes over the long-term for some of our vulnerable population groups; Models of care and payment mechanisms that promote and enable delivery of care more effectively and efficiently. c. Financial challenges Developing the STP has led to a common understanding between commissioners and providers that we operate as a system in deficit. The latest forecast for 2017/18, as at July 2017, indicates a system deficit of 97m against combined CCG and Trust financial plans. The deficit position assumes delivery of significant savings schemes of 4%-4.5% across the system. System intentions for 2018/19 will therefore focus on reducing the system financial deficit through: Developing an NCL-wide financial strategy that promotes a sustainable health and care system and reduces the deficit across the system and not just for individual organisations; Doing this by better aligning provider cost improvement programmes (CIP) and CCG savings plans to ensure that service improvements can be delivered at the same time as removing costs from the system and delivering financial sustainability. Given the financial pressures faced by both commissioners and providers there will be a need to identify further savings schemes during 2018/19. In accordance with commissioning principles these schemes 73

74 should focus on system-wide solutions that reduce overall costs and not merely transfer pressures between organisations. d. Local CCG intentions not covered by Sustainability and Transformation Plan Our system intentions for 2018/19 focus on joint working across CCGs and providers to deliver the best outcomes for patients by planning and commissioning across the whole health and care system. However, there will also be local plans for each CCG for specific areas of delivery and population needs that are the result of local engagement. CCGs will also seek to align locally identified priorities where possible to retain commissioning at scale and provide a co-ordinated approach to providers. e. Greater alignment with specialist commissioning Specialist Commissioning, carried out by NHS England, commission complex high cost and low volume services that are most effectively commissioned over a larger population footprint than North Central London. Examples of specialist services include haemophilia, forensic mental health services and eating disorders. Many providers in North Central London have contracts with both CCGs and specialist commissioners. In 2018/19 CCGs will seek to work with specialist commissioning to better align our service priorities and work with providers. We will do this by holding joint contract management meetings with providers, and jointly commission pathways that run across the responsibility of both CCG and specialist commissioners. Joint commissioning will focus on those pathways that include specialised services that might benefit patient experience from being jointly commissioned or being commissioned more locally. These pathways include: Critical care pathways including a focus on neuro-rehabilitation; Bariatric care (with weight management); Psychiatric Intensive Care Unity care with a particular focus on women s care; Child and Adolescent Mental Health (CAMHs) Tier Four services; Forensic mental health and locked rehab; Eating disorders; HIV and sexual health services. f. System incentives and contract form Development and delivery of new models of service provision also need new models for commissioning and new incentive models. System incentives need to be realigned to support investment in prevention and primary care. The introduction of new contract forms and incentives will be best delivered by CCGs developing them with providers. CCGs would therefore like to continue to work with providers in 2018/19 to further develop system incentives and options for contract form that better support the new models of care in the Sustainability and Transformation Plan (STP). CCGs believe that work on realigning system incentives and contact form are priorities for 2018/19 as: Commissioning and contract form do not yet reflect the progress being made locally in developing and delivering new models of care in NCL; The need to achieve balanced budgets across the health and care system will be supported by a redesign of system incentives, payment mechanisms, and contracting structures; In preparation for contracts for 2019/20 and onwards CCGs would therefore like to shadow-run alternative contract forms in 2018/19 to ensure that any changes support delivery of the STP and balance risk equitably across the system. g. Contract requirements for 2018/19 74

75 Two-year contracts for 2017/18 and 2018/19 were signed in December The contracts require the negotiation and agreement of contract baselines for 2018/19 during 2017/18. Contract baselines for 2018/19 will be reflective of the run-rate (outturn) for 2017/18 adjusted for growth and the impact of Sustainability and Transformation Plan and local CCG interventions. h. Working with local authorities on joint commissioning In 2018/19 we will seek to extend joint working with local authorities from the traditional alignment of health and social care services to better tackle broader determinants of health by working more closely with housing, employment, and prevention alliances with the third sector. This will help both health and social care organisations tackle financial and operating challenges. Closer working with local authorities also brings the opportunity to join up services and improve care for vulnerable people. In 2018/19 we will develop joint commissioning plans with local authorities with a focus on transforming care for people with learning disabilities and delivery of the Better Care Fund. STP workstreams for care closer to home, urgent and emergency care, estates and interoperability provide further opportunities for health and care services to work together i. Procurement principles Through development of the Sustainability and Transformation Plan (STP) providers have asked CCGs to consider their approach to procurement in delivering service improvements or to address service gaps. In response CCGs have developed a set of procurement principles that first focus on working with local providers to commission high quality services for the residents of North Central London. Where quality and/or service gaps cannot be closed with existing providers CCGs will consider procurement to remedy this. Any procurements undertaken will: Consider the impact on overall system costs as a whole, Be aligned with the Sustainability and Transformation Plan; Be transparently communicated to providers; Consider social value and the clinical evidence available; Involve the public, patients and carers in proposals to change services which affect them and more generally in the different aspects of commissioning services such as, planning and design; Be carried out in line with procurement rules. 5. National Context System intentions for North Central London in 2018/19 are consistent with: The joint NHS England / NHS Improvement NHS Operational Planning and Contracting Guidance for ; Refresh of the Five Year Forward View published in NHS England / NHS Improvement NHS Operational Planning and Contracting Guidance for The guidance sets out how NHS operational and planning processes support delivery of Sustainability and Transformation Plans and financial sustainability in the NHS. The guidance set out the financial and business rules for both 2017/18 and 2018/19 and emphasises the need for a collaborative approach between commissioners and providers. Work by commissioners and providers on the contract round for 2017/18 and 2018/19 made progress on the above, and system intentions for 2018/19 are designed to continue that process. Refresh of the Five Year Forward View The NHS Five Year Forward View set out how the NHS needed to change to meet the needs of the population and set out three improvement opportunities to close a health gap, a quality gap, and a financial sustainability gap. These gaps were targeted to be closed by a better integration of primary and specialist hospital care, physical and mental health services, and of health and social care. 75

76 Delivery of these improvement opportunities was to be supported by change within the NHS, wellfunctioning social care, extra capital investment, transformation funding, and a focus on prevention and public health. Priorities identified for 2017/18 are also framed within the constraints of the requirement to deliver financial balance across the NHS and therefore the main 2017/18 national service improvement priorities for the NHS are: Improving A&E performance including upgrading the wider urgent and emergency care system; Strengthening access to high quality GP services and primary care; Improvement in cancer services (including against waiting time standards) and mental health. Delivery of the national service improvement priorities and financial balance will be further supported by: Supporting service redesign through Sustainability and Transformation Plans; A focus on funding and efficiency through the NHS ten-point efficiency plan; Delivery on the enablers for service improvement including workforce, safer care, technology and innovation. The link to the refresh of the Five Year Forward View is provided below: FORWARD-VIEW.pdf Plans for 2018/19 will also need to respond to any emerging national policy and associated planning guidance. 76

77 NCL Joint Commissioning Committee Meeting on Thursday 5 October 2017 Report title Planning for Winter 2017/18 Agenda item 4.4 Date 29 th September 2017 Lead director Report author Sponsor(s) (where applicable) Paul Sinden Director of Performance and Acute Commissioning Paul Sinden Director of Performance and Acute Commissioning Tel/ Tel/ Tel/ p.sinden@nhs.net Tel p.sinden@nhs.net Tel Report summary 1. Preparing for winter 2017/18 This paper provides the Committee with an update on preparations for winter 2017/18 in the context of current performance against the four-hour A&E waiting time standard and plans submitted by each A&E Delivery Board in North Central London in preparation for the increase level of A&E attendances and non-elective admissions experienced over the winter months. 2. Context: Priorities for 2017/18 Guidance from NHS England and NHS Improvement indicates the following priorities for the remainder of 2017/18: Recovery of the A&E (95%) four-hour waiting time standard by March 2018, with performance over the winter targeted to be the higher of 90% or performance in winter 2016/17 as part of recovery of the standard by March 2018; Recovery of the cancer 62-day waiting time standard (85% of treatments within 62 days of GP referral). Performance and the recovery plan are covered in the acute commissioning report by September 2017; Meeting financial targets. The priorities are consistent with the priorities for 2017/18 set out in the refresh of the Five Year Forward View. 3. Performance against the A&E standard The table below is extracted from the acute commissioning report to the Committee. The report shows that no health and care systems in North Central London are delivering the waiting time standard, with the only exception being Moorfields Eye Hospital. 77

78 Performance, with the exception of Whittington Health in quarter one 2017/18, is also falling behind improvement trajectories and all A&E Delivery Boards are therefore subject to escalation meetings with NHS England and NHS Improvement. Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 A&E National Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% Trajectory 87.1% 88.9% 91.3% 93.7% 94.5% 94.3% 93.5% 92.5% 92.5% 92.9% 93.9% 94.9% 89.5% 90.8% 92.1% 93.1% 93.6% 92.9% NCL Aggregate Current Performance 86.3% 87.4% 89.2% 91.4% 92.7% 90.9% 89.0% 87.7% 86.8% 85.4% 88.8% 89.2% 89.5% 91.1% 90.5% 89.4% 89.3% 89.2% Moorfields North Middlesex Royal Free UCLH Whittington Trajectory 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 97.6% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Current performance 96.3% 97.3% 98.9% 99.0% 97.7% 98.8% 97.0% 99.3% 99.4% 98.7% 98.7% 96.9% 95.7% 98.0% 98.7% 98.7% 98.1% 99.4% Total A&E Attandances Breaches Trajectory 72.0% 72.0% 78.0% 86.0% 90.0% 89.0% 88.0% 87.0% 85.0% 86.0% 90.0% 95.0% 85.0% 87.0% 89.0% 91.0% 93.0% 92.0% Current performance 72.6% 72.9% 77.1% 89.1% 92.5% 87.7% 87.7% 83.5% 79.4% 76.0% 82.3% 85.6% 82.4% 83.7% 82.1% 81.9% 80.3% 83.2% Total A&E Attandances Breaches Trajectory 90.0% 92.0% 93.0% 95.0% 95.0% 95.0% 92.0% 90.0% 91.0% 91.0% 92.0% 92.0% 86.6% 87.2% 88.7% 89.6% 89.8% 90.1% Current performance 90.3% 92.5% 90.2% 91.3% 90.0% 87.9% 85.5% 85.0% 83.6% 83.0% 87.1% 85.4% 87.6% 90.3% 87.0% 86.1% 88.7% 86.3% Total A&E Attandances Breaches Trajectory 88.0% 90.9% 92.8% 95.0% 95.0% 95.0% 95.0% 92.9% 93.8% 95.0% 95.0% 95.0% 91.0% 92.8% 95.0% 95.0% 95.2% 92.6% Current performance 87.9% 88.3% 92.0% 89.9% 90.6% 86.9% 86.6% 85.5% 86.0% 86.4% 89.2% 89.6% 90.9% 90.2% 92.1% 88.2% 88.9% 90.2% Total A&E Attandances Breaches Trajectory 88.0% 92.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 90.0% 92.0% 93.0% 95.0% 95.0% 95.0% Current performance 84.1% 85.9% 87.7% 87.9% 92.7% 93.4% 88.1% 85.1% 85.8% 82.9% 86.6% 88.4% 91.1% 93.5% 92.4% 92.2% 90.5% 87.0% Total A&E Attandances Breaches Hospital Trusts, with their aligned health and care community services, have been riskrated by NHS England and NHS Improvement for resilience in delivering the A&E waiting time standard. The categorisation for North Central London is summarised below: Category Trusts 1. Organisations delivering the A&E Moorfields Eye Hospital waiting time standards 2. Minor to moderate concern about delivery. No escalation UCLH Whittington Health 3. Moderate concern in escalation Royal Free London 4. Highest level of escalation North Middlesex University Hospital Interventions, and focus on performance and recovery plans, from NHS England and NHS Improvement increase with each category. Escalation involves the A&E Delivery Board as performance is seen as a health and care system issue. 4. Urgent and emergency care structures in North Central London The following structures are in place to manage and improve urgent and emergency care pathways in North Central London: North Central London Urgent and Emergency Care Board; A&E Delivery Boards The NCL Urgent and Emergency Board has a strategic focus taking an overview of: Delivery of service transformation interventions in the Sustainability and Transformation Plan workstream for urgent and emergency care; System escalation - opportunities for broader system support across A&E Delivery Boards when particular hospital emergency departments are under extreme pressure; High-level performance overview including delivery against High Impact Changes priorities in winter planning guidance. The High Impact Changes are summarised in appendix two. A&E Delivery Boards have membership from across the health and care system and focus on: 78

79 Operational performance against the waiting time standard; Generation of winter plans and recovery plans that cover the health and care system; Problem solving of operational issues to improve patient flow including admission avoidance, in-hospital flow, and discharges back into the community. The table below summarise membership of the A&E Delivery Boards in North Central London: Barnet Camden Haringey and Enfield Camden CCG; Haringey CCG; Camden Council; Enfield CCG; UCLH; Haringey Council; CNWL; Enfield Council; Barnet CCG; Barnet Council; Royal Free London; Barnet, Enfield and Haringey Mental Health Trust; CLCH; London Ambulance Service; NHS 111 / GP out of-hours; Lay representative; NHS England; NHS Improvement. Camden and Islington Foundation Trust; London Ambulance Service; NHS 111 / GP out of-hours; Lay representative; NHS England; NHS Improvement North Middlesex University Hospital; Whittington Health; Barnet, Enfield and Haringey Mental Health Trust; London Ambulance Service; NHS 111 / GP out of-hours; Lay representative; NHS England; NHS Improvement Islington Islington CCG; Islington Council; Whittington Health; UCLH; Camden and Islington Foundation Trust; London Ambulance Service; NHS 111 / GP out of-hours; Lay representative; NHS England; NHS Improvement 5. National winter planning guidance NHS England and NHS Improvement have been working together on the planning, preparations and management of winter. Dedicated teams are being established at a national and regional (for us London) level to co-ordinate delivery of winter plans and systems resilience. For London, it is proposed that a single winter team jointly supports both the Regional Directors of NHS England and NHS Improvement. In North Central London The Surge Hub provided by Northeast London Commissioning Support Unit (NELCSU) co-ordinates escalation actions on behalf of the A&E Delivery Boards, including daily and escalation reports required by NHS England and NHS Improvement. In addition senior CCG and NELCSU staff participate in an on-call rota to coordinate responses as pressure in an urgent and emergency care system is escalated. Providers have on-call rotas to do the same. Winter operating model It is expected that the winter operating model will be in place from 1 October 2017 to the end of April This involves the day-to-day management of the urgent and emergency care systems, and will include daily internal calls for North Central London co-ordinated by the NELCSU Surge Hub with participation from local A&E Delivery Boards. These internal calls are then followed by a call with NHS England and NHS Improvement to provide an overview of performance and pressure in the system that is informed by daily situation reports (see below) and the internal call. Data information and intelligence 79

80 The daily situation report (SITREPs) provides a snapshot of performance and pressure in the system. The report provides an update for each emergency department but considers performance of the whole health and care system. SITREPs provides the snaphot of performance and pressure that determines if a system will go into escalation over performance with NHS England and NHS Improvement. At times of peak pressure additional escalation calls are held with the regulators. The information is updated each day with comparisons made for all metrics to the same time in the previous week and the average over the last six weeks to provide a barometer of performance and pressures. The latest SITREPs report is appended (from 28 September) and shows: Performance against the A&E waiting time standard; The volume of attendances in the emergency department ( a weekly pattern can be determined with Monday often the busiest day of the week); The volume of 4-hour and 12-hour breaches with the latter treated as a serious incident; The number of ambulance arrivals (surges in arrivals can put pressure on both the emergency department and bed occupancy); Delays in handovers from ambulances to emergency departments, with the daily measure of delays a good indicator of performance against the A&E waiting time standard; The number of emergency admissions in total and for over 75s, with the latter an indication of downstream pressure on beds due to longer lengths of stay; The number of decisions to admit (DTAs) from the previous day not yet placed on a ward. This indicates capacity and flow problems and a need to expedite discharges to return the system to balance; Bed occupancy and the number of beds in the system, additional bed capacity is opened over the winter to accommodate the increase in emergency admissions; The expected bed state at the end of the day; The number of discharges made in the day, and of those the number made in the morning to maximise ward capacity for admissions; The number of people medically fit for discharge but remaining in a hospital bed including delayed transfers of care (DTOC) and medically optimised (MO). The percentage of beds occupied by people medically fit for discharge is measured with the target being a maximum of 5% of beds being occupied in this way; Any infection control issues infection can cause a loss of capacity if beds are closed to admission to isolate an infection issue such as flu or diarrohea and vomiting; Any staffing issues that will impact on capacity; The level of critical care beds available; The number of elective procedures scheduled and cancelled. In the winter nonurgent electives may be cancelled to cope with spikes in non-elective admission. Procedures cancelled on the day should be carried out within 28 days. Cancer capacity is protected; The ration of admission to attendances as a measure of acuity in the system. Bank Holiday and weekend assurance Over the winter existing plans will be supplemented with bank holiday and weekend assurance plans to ensure that the system maintains flow with both hospital and community capacity in place. This is particularly the case in the run up to Christmas and New Year Bank Holiday. The early weeks of the new year are the time that the urgent and emergency care system comes under the most pressure, so assurance plans in the run up to Christmas will focus on: 80

81 Reducing hospital bed occupancy to 90% or below to create capacity for admissions; Ensuring that beds taken up by people medically fit for discharge take up less than 5% of bed stock; Ensure staff rotas are up to establishment in both hospitals and the community; Ensure that capacity in the community is maintained for both admission avoidance and establishing community packages of care. Escalation Escalations will follow a process that is outlined in the Department of Health winter 2017/18 operational arrangements document. Escalation is a response to rising pressure in an urgent and emergency care system and sustained under performance in a system. Under these circumstances internal co-ordination through the Surge Hub and with NHS England and NHS Improvement increases form the scheduled daily calls. SITREPs provides the snaphot of performance and pressure that determines if a system will go into escalation over performance with NHS England and NHS Improvement. At times of peak pressure additional escalation calls are held with the regulators. Reasons for escalation will include: The incidence of 12-hour breaches in emergency departments; Long mental health delays in emergency departments before onward referral into mental health services; Ambulance handover delays; Emergency department redirect requests to alleviate pressure in an emergency department (exceptional cases only); Beds lost to infection control; Beds occupied by people medically fit for discharge; Stranded patients; Availability of bespoke plans to maintain safe services over weekends and Bank Holiday periods; Predicted surges in non-elective admissions through early warning systems in particular from London Ambulance Service; Workforce capacity shortfalls; Availability and responsiveness of community services for both health and social care. 6. North Central London Winter Plans The appendix provides a summary of winter plans submitted by each A&E delivery Board and in particular a checklist of local delivery against the High Impact Changes used as the measures of sustainable delivery of the A&E standard. Each A&E Delivery Board was asked to complete a template to indicate their readiness for going live on the national must do initiatives. The appendix summarises performance and therefore the emerging risks to delivery across NCL. In addition to overall delivery of the A&E waiting time standard the readiness checklist considers progress with: Admission avoidance initiatives: GP streaming in A&E to reduce onward referral including admission; Use of ambulatory care as an alternative to admission; Frailty pathway with comprehensive geriatric assessment; Acute psychiatric liaison to support onward referral into mental health services including admission; 81

82 Enhanced health and care support to care homes; Flu vaccinations for vulnerable residents and staff. Flow within hospital units: Patients being handed over to emergency departments within 15 minutes of arrival by ambulance; SAFER bundle in place; Early discharge planning in place (from date of admission) to ensure planned date of discharge is met; Multi-disciplinary discharge teams in place; Seven day services in place, including pharmacy and diagnostics, to expedite discharges. Effective discharge of patients back in to the community / home to maintain hospital flow: The reduction of delayed transfers of care and medically optimised patients to less than 5% of acute hospital bed base; Less than 15% of continuing healthcare (CHC) assessments being carried out in hospital beds (85% carried out in the community) The use of discharge to assess pathways in place needs assessed in community post discharge rather than from a hospital bed prior to discharge Trusted assessor models in place assessments of needs are made only once and not re-assessed before transfer from hospital into the community SAFER bundle (see flow within hospital units above) The SAFER patient flow bundle blends five elements of best practice S Senior review. All patients will have a senior review before midday by a clinician able to make management and discharge decisions. A All patients will have an expected discharge date and clinical criteria for discharge. This is set assuming ideal recovery and assuming no unnecessary waiting. F Flow of patients will commence at the earliest opportunity from assessment units to inpatient wards. Wards that routinely receive patients from assessment units will ensure the first patient arrives on the ward by 10 am. E Early discharge. 33% of patients will be discharged from base inpatient wards before midday. R Review. A systematic multi-disciplinary team review of patients with extended lengths of stay (>7 days stranded patients ) with a clear home first mindset Alongside overall A&E performance the litmus tests for effectiveness of CCG and Social Care support with regulators will be: The use of primary care hubs and redirection initiatives away from A&E; The reduction of delayed transfers of care and medically optimised patients to less than 5% of acute hospital bed base; Less than 15% of continuing healthcare (CHC) assessments being carried out in hospital beds (85% carried out in the community); Final feedback on winter plans, and the readiness checklist, has yet to be received. Plans will require updating for that feedback and in particular where the readiness checklist shows service gaps against the recommended high impact changes. Purpose (tick one only) Information Approval To note Decision 82

83 Recommend ation The NCL Joint Commissioning Committee is asked to: Note the report; Provide feedback on the plans for winter 2017/18; Conflicts of Interest Strategic Direction Identified risks and risk managemen t actions Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy. The development of winter plans supports: Delivery of NHS constitutional rights and pledges; Improving the quality and safety of commissioned services; Improving health outcomes, address inequalities and achieve parity of esteem; Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for- money services. The main risks accruing from managing winter pressures are: Ensuring sufficient capacity in hospital and community settings to manage the increase in non-elective patient flows, including medical admissions, over the winter period; Protecting elective capacity from additional non-elective activity to maintain referralto-treatment waiting times; Resource implications Engagement Equality impact analysis Report history CCG baselines incorporate finds for winter resilience, although the costs of additional capacity over the winter often outweigh the resilience funds available. Better Care Fund monies are also used to support winter pressures targeting both admission avoidance and prompt discharge back into the community for those people medically fit for discharge. Winter plans have been developed collaboratively through A&E Delivery Boards. This report was written in accordance with the provisions of the Equality Act The initial risk register for the Joint Commissioning Committee has been developed with reference to existing risk registers from individual CCGs. Next steps To implement the plans for winter 2017/18. Appendices Appendices are: Example of daily situation report (SITREPs) A&E Delivery Board winter readiness assessment. 83

84 Select Week Ending Hospital 01/10/2017 Royal Free Hospital Daily Conference Call Report Emergency Department Demand & Capacity Mon Tue Wed Thur Fri Sat Sun Indicator 25/09/ /09/ /09/ /09/ /09/ /09/ /10/2017 Total Last Week 18/09/2017 Mon Tue Wed Thu Fri Sat Sun ED Performance 73.81% 80.91% % 75.41% 81.60% 85.56% 85.11% 85.95% 84.57% 84.89% 85.00% 88.26% 84.77% 89.04% 87.31% 77.04% 80.20% No Of Attendances Breaches Hour Breaches LAS Ambulance Activity EoE Ambulance Activity Ambulance Black Breaches Admissions Discharges > 75 Admissions DTAs In ED Unplaced From Previous Day Total Beds Open At 00: Beds Empty At 00: % Bed Occupancy At 00: % 99.79% 97.13% 0.00% 0.00% 0.00% 0.00% 95.63% 92.51% 96.88% 95.28% 98.13% 96.07% 97.29% 96.06% 96.69% 95.65% 94.63% 93.20% 91.94% 92.58% DischargesBefore Planned Discharges End Of Day Bed Position Infection Control Issues No No No Yes - No - No - Yes - No - No - No - Staffing Issues Yes Yes Yes Yes - Yes - Yes - No - Yes - Yes - Yes - DTOC NHS DTOC Social Medically Optimised Medically Optimised - Int Medically Optimised - Ext % Delayed against bed base 10.33% 10.35% 10.04% 8.33% 7.76% 7.71% 6.88% 10.21% 7.89% 9.38% 7.29% 8.88% 8.35% 8.88% 7.87% 8.88% 7.84% ITU Beds Empty Paediatric Beds Empty HASU Beds Empty Electives Scheduled Electives Cancelled Attendance to Admission Ratio 16.96% 14.89% % 18.34% 15.49% 17.30% 20.40% 18.50% 19.78% 18.63% 18.15% 19.66% 13.01% 15.73% 17.90% 15.80% 6 Week Last Week 19/09/ Week Last Week 20/09/ Week Last Week 21/09/ Week Last Week 22/09/ Week Last Week 23/09/ Week Last Week 24/09/ Week Monday Tuesday Wednesday Thursday Friday Unexpected staffing shortages in ED causing long waits - both nurses and doctors. High attendances. High flows in evening / night. High acuity. Long waits in ED. Poor discharges. OPEL High acuity. Long waits in ED. Late discharges. OPEL Level: 1. Today staffing Issues ED: OPEL Level: 1. Today staffing Issues ED: down 2xB5. Staffing Issues rest of site: down 3xB2, 8xB5, 1xB6, 1xB7. Infection Control Issues: none Level: 1. Today staffing Issues ED: none. Staffing Issues rest of site: down 1xB2, 1xB5, 1xB7. Infection Control Issues: none none. Staffing Issues rest of site: down 3xB5, 1xB7. Infection Control Issues: none 84

85 Week Ending Hospital 01/10/2017 Barnet Hospital Daily Conference Call Report Emergency Department Demand & Capacity Mon Tue Wed Thur Fri Sat Sun Indicator 25/09/ /09/ /09/ /09/ /09/ /09/ /10/2017 Total Last Week 18/09/2017 Mon Tue Wed Thu Fri ED Performance 83.24% 79.18% % 75.00% 81.38% 86.51% 83.58% 83.33% 82.12% 83.07% 86.67% 74.70% 87.57% 79.67% 84.71% 67.81% 79.48% No Of Attendances Breaches Hour Breaches LAS Ambulance Activity EoE Ambulance Activity Ambulance Black Breaches Admissions Discharges > 75 Admissions DTAs In ED Unplaced From Previous Day Total Beds Open At 00: Beds Empty At 00: % Bed Occupancy At 00: % % % 0.00% 0.00% 0.00% 0.00% % 99.80% % 99.95% % 99.70% % 99.90% % 99.34% % 99.70% % 99.90% DischargesBefore Planned Discharges End Of Day Bed Position Infection Control Issues No No No No - No - No - No - No - No - No - Staffing Issues Yes Yes Yes Yes - No - No - Yes - Yes - Yes - Yes - DTOC NHS DTOC Social Medically Optimised Medically Optimised - Int Medically Optimised - Ext % Delayed against bed base 19.45% 18.54% 20.06% % 16.11% 14.89% 16.26% 17.02% 17.53% 19.15% 17.83% 17.33% 17.43% 17.33% 17.69% 17.33% 17.69% ITU Beds Empty Paediatric Beds Empty HASU Beds Empty Electives Scheduled Electives Cancelled Attendance to Admission Ratio 13.07% 17.01% % 15.46% 14.80% 15.72% 13.39% 14.89% 15.34% 14.84% 15.55% 15.43% 13.67% 12.46% 10.63% 11.67% 6 Week Last Week 19/09/ Week Last Week 20/09/ Week Last Week 21/09/ Week Last Week 22/09/ Week Last Week 23/09/2017 Sat 6 Week Last Week 24/09/2017 Sun 6 Week Monday Tuesday Wednesday Thursday Friday Extremely challeneged week with admissions exceeding discharges 4/7. Came on to a challenging start yesterday with 7 pts in ED awaiting a bed with low predicted discharges. Came on to an extremely challenging position with 20Pts alone in ED yesterday Discharges on Friday not enough to get us through the weekend given thenumber High number of ambulance arrivals yesterday with 84 in total. 20Pts in ED awaiting a bed this morning. All morning awaiting a bed on the 12hr clock. Our admissions were extremely high of DTA's we came on to each morning. Staffing issues due to sickness and unfilled non-urgent meetings have been cancelled and all operational support on the wards. On-going work with yesterday and with these also exceeding discharges this has left us in another shifts across the site over the weekend. Higher attenders than usual over the our CCG colleagues to expedite the use of external capacity and any movements on the DTOC and MO's. challenging position this morning. We have 9 Pts in ED awaiting a bed this morning weekend. 7Pts in ED awaiting a bed. Confident that the Predicted discharges will improve with all senior clinicians attending the bed meeting and fully aware of the situation we are in this morning. All non-urgent meetings cancelled with a full operational management support around the wards. OPEL 2 The 3 DTA's before 12:00 have now been placed. OPEL 2. however, we do have good predcicted discharges and have good confirmed discharges home for lunch. OPEL 2. 85

86 Week Ending Hospital 01/10/2017 Chase Farm Hospital Daily Conference Call Report Emergency Department Mon Tue Wed Thur Fri Sat Sun Indicator 25/09/ /09/ /09/ /09/ /09/ /09/ /10/2017 Total Last Week 18/09/2017 Mon Tue Wed Thu Fri ED Performance % % % % % % % % % % % % % % % % % No Of Attendances Breaches Total Beds Open At 00: Beds Empty At 00: % Bed Occupancy At 00: % 94.44% 97.22% 0.00% 0.00% 0.00% 0.00% % 97.69% % 96.76% 94.44% 92.13% 94.44% 93.06% 97.22% 94.33% % 95.72% % 97.11% DischargesBefore Planned Discharges Infection Control Issues No No No No - No - No - No - No - No - No - Staffing Issues No No No No - No - No - No - No - No - No - DTOC NHS DTOC Social Medically Optimised Medically Optimised - Int Medically Optimised - Ext % Delayed against bed base 0.00% 19.44% 19.44% % 34.72% 19.44% 26.39% 16.67% 25.93% 13.89% 29.17% 19.44% 27.83% 19.44% 28.77% 19.44% 28.77% Monday Tuesday Wednesday Thursday Friday 6 Week Last Week 19/09/ Week Last Week 20/09/ Week Last Week 21/09/ Week Last Week 22/09/ Week Last Week 23/09/2017 Sat 6 Week Last Week 24/09/2017 Sun 6 Week 86

87 Week Ending Hospital 01/10/2017 UCLH Daily Conference Call Report Emergency Department Demand & Capacity Mon Tue Wed Thur Fri Sat Sun Indicator 25/09/ /09/ /09/ /09/ /09/ /09/ /10/2017 Total Last Week 18/09/2017 Mon Tue Wed Thu Fri ED Performance 81.21% 81.29% % 91.56% 90.59% 83.38% 88.69% 81.72% 84.76% 88.13% 88.61% 85.12% 87.54% 82.13% 86.92% 85.67% 90.15% No Of Attendances Breaches Hour Breaches LAS Ambulance Activity EoE Ambulance Activity Ambulance Black Breaches Admissions Discharges > 75 Admissions DTAs In ED Unplaced From Previous Day Total Beds Open At 00: Beds Empty At 00: % Bed Occupancy At 00: % 94.01% 94.90% 0.00% 0.00% 0.00% 0.00% 94.43% 92.01% 99.11% 94.10% 99.11% 94.69% 96.45% 95.96% 96.01% 95.85% 95.34% 93.17% 96.90% 91.39% DischargesBefore Planned Discharges End Of Day Bed Position Infection Control Issues No Yes Yes No - No - No - No - No - No - No - Staffing Issues No No No No - Yes - No - No - No - No - No - DTOC NHS DTOC Social Medically Optimised Medically Optimised - Int Medically Optimised - Ext % Delayed against bed base 5.99% 5.32% 4.88% 6.90% 5.40% 5.12% 5.12% 4.90% 4.97% 4.66% 4.30% 5.99% 5.19% 5.99% 5.19% 5.99% 5.23% ITU Beds Empty Paediatric Beds Empty HASU Beds Empty Electives Scheduled Electives Cancelled Attendance to Admission Ratio 17.63% 15.59% % 17.38% 14.96% 16.81% 18.02% 18.71% 19.79% 18.47% 0.00% 19.49% 0.00% 18.08% 0.00% 17.36% 6 Week Last Week 19/09/ Week Last Week 20/09/ Week Last Week 21/09/ Week Last Week 22/09/ Week Last Week 23/09/2017 Sat 6 Week Last Week 24/09/2017 Sun 6 Week Monday Tuesday Wednesday Thursday Friday Nurse staffing issues throughout the Tower and ED. Limited discharges and late 2 bays closed due to confirmed noro virus with 1 empty bed in each. Discharges occurring late in the day 2 bays closed due to confirmed noro virus with 1 empty bed in each. 16 oncology beds discharges yesterday resulting in long waits for beds in the evening and overnight. leading to delays in ED. 16 oncology beds remain closed, and 4 medical beds on T7 ward. OPEL Level 1 remain closed, and 4 medical beds on T7 ward. OPEL Level 1 Delays for bed cleans also impacted this. 16 oncology beds remain closed, and 4 medical beds on T7 ward. OPEL Level 1 Power outage across UCH tower and EGA at approx ITU/Neo natal ran on emergency red sockets. LAS contact directly and divert put on until 0400, imessage sent out to all UCH staff Incident escalated to silver. Internal incident about to be activated but fortunately power supply back at 0350 so decision made not to declare internal incident. Recovery actions carried out as per Internal incident policy including: CCTV not working initially - fixed Call bells and crash call alarms reported not working on T16 + T9 Pharmacy no adverse issues related to temperature control / fridges 87

88 Week Ending Hospital 01/10/2017 Whittington Hospital Daily Conference Call Report Emergency Department Demand & Capacity Mon Tue Wed Thur Fri Sat Sun Indicator 25/09/ /09/ /09/ /09/ /09/ /09/ /10/2017 Total Last Week 18/09/2017 Mon Tue Wed Thu Fri ED Performance 83.69% 95.27% % 91.14% 84.42% 92.80% 91.98% 93.04% 91.08% 95.27% 87.40% 95.26% 88.92% 82.77% 90.68% 79.58% 87.81% No Of Attendances Breaches Hour Breaches LAS Ambulance Activity EoE Ambulance Activity Ambulance Black Breaches Admissions Discharges > 75 Admissions DTAs In ED Unplaced From Previous Day Total Beds Open At 00: Beds Empty At 00: % Bed Occupancy At 00: % 96.43% 97.84% 0.00% 0.00% 0.00% 0.00% 98.66% 96.78% 97.34% 97.94% 96.95% 96.65% 96.52% 96.96% 94.61% 96.33% 96.63% 95.75% 97.27% 95.78% DischargesBefore Planned Discharges End Of Day Bed Position Infection Control Issues No No No No - No - No - No - No - No - No - Staffing Issues No No No No - No - No - No - No - No - No - DTOC NHS DTOC Social Medically Optimised Medically Optimised - Int Medically Optimised - Ext Medically Optimised % Delayed against bed base 10.76% 13.39% 14.29% % 10.90% 9.73% 10.17% 9.13% 10.84% 9.57% 9.54% 11.66% 11.75% 11.82% 11.63% 11.82% 11.57% ITU Beds Empty Paediatric Beds Empty HASU Beds Empty Electives Scheduled Electives Cancelled Attendance to Admission Ratio 9.97% 14.55% % 12.52% 14.77% 14.53% 12.09% 14.46% 10.81% 12.29% 12.77% 13.27% 10.11% 10.41% 9.00% 8.28% 6 Week Last Week 19/09/ Week Last Week 20/09/ Week Last Week 21/09/ Week Last Week 22/09/ Week Last Week 23/09/2017 Sat 6 Week Last Week 24/09/2017 Sun 6 Week Monday Tuesday Wednesday Thursday Friday Opel 1 for ED and Bed capacity.breaches are pre-validation. Many of the breaches Opel 1 for ED and Bed capacity.breaches are pre-validation. Many of the breaches are attributable to over the weekend are attributable to Mental Health-Paediatrics and late decisions Mental Health-Paediatrics and late decisions and specialty referrals. Consultant led ward rounds to Opel 1 for ED and Bed capacity.breaches are pre-validation. Many of the breaches are attributable to Mental Health-Paediatrics and late decisions and specialty referrals. We and specialty referrals. No surgical SHO for Saturday and Sunday-Registrars had to commence with senior nurses reviewing the flow. Virtual Ward/Rapid Response/Ambulatory Care/START had a 12 hour mental health breach - bed was identified but patient was waiting on cover-resulting in some specialty breaches whilst they were in theatre. We started the weekend with empty beds-but have very few anticipated discharges predicted for the weekend and Monday. Beds only became an issue later yesterday evening. all have capacity. transport. Consultant led ward rounds to commence with senior nurses reviewing the flow. Virtual Ward/Rapid Response/Ambulatory Care/START all have capacity 88

89 Week Ending Hospital 01/10/2017 North Middlesex Hospital Daily Conference Call Report Emergency Department Demand & Capacity Mon Tue Wed Thur Fri Sat Sun Indicator 25/09/ /09/ /09/ /09/ /09/ /09/ /10/2017 Total Last Week 18/09/2017 Mon Tue Wed Thu Fri ED Performance 90.65% 74.24% % 93.50% 84.98% 94.20% 84.02% 89.23% 85.04% 82.07% 77.98% 84.87% 81.78% 84.76% 82.28% 91.98% 84.49% No Of Attendances Breaches Hour Breaches LAS Ambulance Activity EoE Ambulance Activity Ambulance Black Breaches Admissions Discharges > 75 Admissions DTAs In ED Unplaced From Previous Day Total Beds Open At 00: Beds Empty At 00: % Bed Occupancy At 00: % % 97.77% 0.00% 0.00% 0.00% 0.00% 97.54% 97.74% 98.88% 99.18% 98.44% 99.31% 95.54% 98.18% 95.76% 98.24% 92.63% 94.73% 97.54% 96.09% DischargesBefore Planned Discharges End Of Day Bed Position Infection Control Issues No No No No - No - No - No - No - No - No - Staffing Issues No No No No - No - No - No - No - No - No - DTOC NHS DTOC Social Medically Optimised Medically Optimised - Int Medically Optimised - Ext % Delayed against bed base 12.50% 13.14% 11.36% % 11.64% 12.05% 11.77% 12.50% 11.53% 12.50% 12.05% 12.50% 12.43% 12.50% 12.20% 12.50% 12.21% ITU Beds Empty Paediatric Beds Empty HASU Beds Empty Electives Scheduled Electives Cancelled Attendance to Admission Ratio 13.17% 16.22% % 15.51% 16.00% 17.74% 13.21% 16.74% 17.13% 16.32% 18.68% 18.34% 18.10% 17.22% 14.98% 15.12% 6 Week Last Week 19/09/ Week Last Week 20/09/ Week Last Week 21/09/ Week Last Week 22/09/ Week Last Week 23/09/2017 Sat 6 Week Last Week 24/09/2017 Sun 6 Week Monday Tuesday Wednesday Thursday Friday Please note that the figures for Friday, Saturday & Sunday are still in the process of being validated. OPEL 2 There were delays due to diagnostics in particular CT causing delays in dept Tuesday performance is unvalidated. A high number of DTA's in the department throughout the day. Wait for first clinician increased in the evening and overnight. At 10pm 3h 30min wait, 120 patients in the department. Detailed review of the day and triggers for reduced performance to be undertaken by operational team 89

90 AEDB Readiness Assessment for Delivery of National Priorities 1.0 Background Each AEDB was asked to complete a template to indicate their readiness for going live on the national must do initiatives. Each AEDB responded and this paper provides a summary of these responses, and therefore the emerging risks across NCL. 2.0 Responses The table below summarises the responses received: Activity / initiative Final Target Final Target Deadline Barnet Camden Haringey Enfield Islingon On track for On track for On track for delivery by target delivery by target delivery by target deadline? Y/N deadline? Y/N deadline? Y/N On track for delivery by target deadline? Y/N On track for delivery by target deadline? Y/N 95% A&E 4 hour standard 95% Mar-18 Yes No Yes Yes % of patients arriving to ED by ambulance handed over within 15 minutes of the 100% Mar-18 ambulance s arrival Yes No No No Co-located GP streaming meeting national guidance in place All Oct-17 Yes Yes Yes Yes Provision of ambulatory emergency care at least 14-hours a day, 7 days a week 100% Sep-17 No Yes No - partially completed Yes Clear frailty pathway in place which includes an early comprehensive geriatric assessment 100% Sep-17 Yes Yes Yes Yes % of wards where SAFER bundle is in place 100% Sep-17 Yes Yes Yes Yes Implementation of the Emergency Care Data Set (ECDS) N/A Oct-17 No Yes No - plans in place Yes % of Trusts have psychiatric liaison services in place 25% Mar-18 Yes Yes Yes Yes Reduce delayed transfers of care to 3.5% 3.50% Sep-17 Yes Yes No - plans in place Yes CHC full assessments in acute settings <15% Mar-18 Yes Yes Yes Yes High Impact Change 1: Implement early hospital discharge planning N/A Sep-17 Yes Yes Yes No High Impact Change 2: Implement system to monitor patient flow N/A Sep-17 Yes Yes Yes No High Impact Change 3: Implement multidisciplinary discharge teams N/A Sep-17 Yes Yes Yes Yes High Impact Change 4: Home First/Discharge to Assess scheme in place N/A Sep-17 Partially- plans in Yes Yes Yes place but not yet established Partial High Impact Change 5: Seven-day service in place N/A Sep-17 Yes Yes No - plans in place but not established No High Impact Change 6: Trusted Assessor models in place N/A Sep-17 Yes Yes No - plans in place but not established No High Impact Change 7: Promoting choice and self-care for patients N/A Sep-17 Yes Yes No - plans in place but not established No High Impact Change 8: Enhanced health and care services in care homes N/A Sep-17 No - plans in place Yes Yes but not established Yes Yes % of acute hospitals that meet the core 24 service standard for adults 13%+ Mar-18 Yes Yes Yes Yes 3.0 Risks per AEDB 3.1 Barnet AEDB The key risk where Barnet AEDB is not on track for delivery is: Provision of ambulatory care 14/7 AEC hours are being extended from 9hrs to 11hrs per day, but there are no plans to extend this to 14hrs. Outside of the 11hr operational day, the emergency department has 24 hr access to next day AEC pathways. Implementation of the Emergency Care Data Set (EDCS) - The trust were not able to give Barnet CCG an answer on this, as they have not had the meeting to discuss it yet, therefore without any assurance Barnet AEDB have recorded this as not on track. 3.2 Camden AEDB North London PARTNERS in health and care AEDB Readiness Assessment for Delivery of National Priorities P a g e 1 90

91 The key risks where Camden AEDB is not on track for delivery are: 95% 4hour standard by March 2018 Camden AEDB have an agreed trajectory with NHS England to deliver performance of 94.4% by March 2018, not 95%. However, 3 of the 4 reported months so far this year (May, June, July) have shown UCLH to be below this trajectory, so achievement is at risk although recovery is still possible (if performance averages 92.8% for the remainder of the year). 100% ambulance handover in 15mins by March % of handovers occurring within 15mins is within the current London Ambulance Service contract. Performance for the last six months, however, shows an average of just 34%, which is why the AEDB feel delivery a not on track. Recent reports from LAS do show an upward trend which is promising but this has not given the Board sufficient confidence yet to believe 100% will be achieved by year end. 3.3 Haringey AEDB The key risks where Haringey AEDB is not on track for delivery are: 100% ambulance handover in 15mins by March 2018 handovers times are not on track for 100% delivery, however the AEDB continues to monitor and support. Also of concern are the following: Provision of ambulatory care 14/7 a 14 hour service currently in place Monday - Friday but with only an 8hour service in operation at the weekends. Implementation of ECDS This is dependent on an upgrade to the Trust's PAS, which is scheduled for early August. This will provide the functionality to implement the ECDS, with a target date of September. Reduced DTOCs to 3.5% by Sept 2017 Plan for target achievement is between Jan- March 2018, which is later than the national deadline of September HIC 4: Home First/Discharge to Assess [Enfield CCG only] Enfield Pathway 1 in place, Pathways 2 and 3 are planned for September but the AEDB feels there is a risk around delivery by the national deadline of September HIC 5: 7 day services the majority of Acute, CHS and Social Care Services provide 7 day services but these are not fully established. HIC 6: Trusted Assessor pilots are planned in Haringey (with 2 Care Homes using winter resilience funding) and Enfield (with 4 care homes with support from the CHAT team), but full rollout is not expected by the national deadline of September HIC 7: Promoting choice and self-care for patients a revised system-wide Choice Policy, with all partner sign-up, is out to public consultation which may not be complete by the national deadline of September HIC 8: Enhanced health and care services in care homes [Haringey CCG only] Rapid Response and Locality Teams are MDTs supported by Health & Social Care working in Care Homes. The AEDB feels there are plans in place to establish these North London PARTNERS in health and care AEDB Readiness Assessment for Delivery of National Priorities P a g e 2 91

92 services fully but this may not take place before the national deadline of September Islington AEDB The key risks where Islington AEDB is not on track for delivery are: 100% ambulance handover in 15mins by March 2018 Year to Date Performance at Whittington Health 31.20% (April to June 2017), hence the AEDB do not feel confident in delivery of 100% by March The 15 minute handover data, however, is unvalidated and reliant on timely data entry by ambulance crews so performance in reality may exceed the published data. Providers do not currently have the opportunity to validate this data. HIC 1: Implement early hospital discharge planning Early discharge planning within acute providers for elective and emergency admissions is in place, so this has been achieved before the national deadline of Sept However community early discharge planning has not yet been reviewed and implemented the review for planned elective admissions will take place between October 17 - Jan 18 and resulting system change or pilots will be undertaken by March 2018, which obviously does not meet the national deadline. HIC 2: Implement system to monitor flow Work yet to commence to collate existing mechanisms and to commence demand and capacity planning. Need to identify leads across all Islington organisations to take this forward. This is expected to be delivered in March 2018, which therefore does not meet the national deadline of September HIC 5: 7 day services Good areas of seven day working across health and care but this is not yet fully comprehensive. Work will be undertaken to evaluate need, demand and capacity for comprehensive seven day working and then proposal for seven day working will be worked up for March 2018, which therefore does not meet the national deadline of September HIC 6: Trusted Assessor Local work being undertaken, and NCL led work is supporting this via UEC STP programme. Some opportunities with the CHC elements of trusted assessor for nursing homes may be rolled out in November 2017, which therefore does not meet the national deadline of September HIC 7: Promoting choice and self care for patients Review of choice policy and documentation to commence shortly and the revised document is planned to be finalised and communicated April 2018, which therefore does not meet the national deadline of September Also of concern is the following: HIC 4: Home First/Discharge to Assess Discharge to Assess pilot on track to roll out in October 2017, slightly later than the national deadline of September. North London PARTNERS in health and care AEDB Readiness Assessment for Delivery of National Priorities P a g e 3 92

93 4.0 Aggregate top risks for NCL In summary the common, highest rated risks for NCL are following: % ambulance handover in 15mins by March Provision of ambulatory care 14/7 3. HIC 1: Implement early hospital discharge planning 4. HIC 2: Implement system to monitor flow 5. HIC 5: 7 day services 6. HIC 6: Trusted Assessor 7. HIC 7: Promoting choice and self-care for patients The most significant initiative which is not on track in 3 of the 4 AEDBs is: 100% ambulance handover in 15mins by March There is a London-wide improvement plan for LAS which is being monitored by the Coordinating Commissioner (Brent CCG). 5.0 Correlation between National Priority schemes and STP programme initiatives For all of these schemes the expectation is that implementation is owned and delivered locally, but for some initiatives there is a degree of central coordination and support via STP projects mostly from the UEC Programme, but also from Planned Care, Mental Health and Care Closer to Home Programmes. The below table explains this in more detail: Activity / initiative Final Target Final Target Deadline Relevant STP programme What is included in STP projects for this national requirement Is the national milestone a KPI for this STP project? 95% A&E 4 hour standard % of patients arriving to ED by ambulance handed over within 15 minutes of the ambulance s arrival 95% Mar-18 UEC None of the STP projects under the UEC programme have achievement of 4hr performance within their stated objectives and therefore there is no plan within the UEC STP programme to enable delivery of 90% 4hr by September or 95% 4hr by March. Each of the 4 A&E Delivery Boards, on the other hand, have Local A&E Improvement Plans with their provider which articulate plans to achieve 4hr performance as per STP trajectories, as well as a number of other national mandates. However, there are a number of transformation plans within the UEC programme which when implemented will ease pressure on A&E departments, through reduced A&E attendances and non-elective admissions, so will support improved 4hr performance. 100% Mar-18 UEC None of the STP projects under the UEC programme have achievement of 15min handover within its stated objectives and therefore there is no plan within the UEC STP programme to enable delivery of this. Each of the 4 A&E Delivery Boards, on the other hand, has a Local A&E Improvement Plan which articulates plans to achieve handover performance, as well as a number of other national mandates. None of the projects within the UEC programme look at ambulance handover times. No No North London PARTNERS in health and care AEDB Readiness Assessment for Delivery of National Priorities P a g e 4 93

94 Co-located GP streaming meeting national guidance in place Provision of ambulatory emergency care at least 14- hours a day, 7 days a week Clear frailty pathway in place which includes an early comprehensive geriatric assessment % of wards where SAFER bundle is in place Implementation of the Emergency Care Data Set (ECDS) % of Trusts have psychiatric liaison services in place Reduce delayed transfers of care to 3.5% CHC full assessments in acute settings High Impact Change 1: Implement early hospital discharge planning High Impact Change 2: Implement system to monitor patient flow High Impact Change 3: Implement multidisciplinary discharge teams High Impact Change 4: Home First/Discharge All Oct-17 UEC The IUC project aims to implement this national initiative across NCL as stated, through providing coordination and problem solving to support local AEDBs as the delivery vehicle 100% Sep-17 UEC The Admission Avoidance project aims to increase the number of pathways offered by ambulatory care units, but does not specifically have a remit to increase the hours of operation. The arrangements need to be agreed at a local level. 100% Sep-17 UEC The Admission Avoidance and Simplified Discharge Projects both aim to provide improved frailty pathways at the front and back doors, to include a comprehensive assessment. Delivery is through the local AEDBs. 100% Sep-17 UEC The Simplified Discharge project aims to support rollout of SAFER across NCL wards, through local AEDBs. N/A Oct-17 None This is out of scope for the STP programme n/a 25% Mar-18 Mental Health This is out of scope for the UEC STP programme. The Mental Health STP programme provides NCL-wide oversight to the issue of psychiatric liaison and is trying to help deliver a common standard and shared learning, but agreement of these arrangements is at a local level. 3.50% Sep-17 UEC The Simplified Discharge project aims to support reduced DTOCs, which is being delivered locally by CCGs and Councils. <15% Mar-18 UEC The Simplified Discharge project aims to reduced assessments taking place in acute settings, through local AEDB, social care and CCG teams. N/A Sep-17 UEC; Planned Care The UEC Simplified Discharge project is looking at expediting discharge through trusted assessment and discharging to assess, although delivery is at a local CCG/Borough/provider level. The Planned care programme have confirmed that they are incorporating into models, where appropriate: rehab, switch from inpatient to day case surgery, enhanced recovery and post-surgery physiotherapy in the community. N/A Sep-17 None This would be of benefit to UEC STP projects, but there is no project currently looking at this. The UEC Board has commissioned a winter Demand and Capacity Model via the CSU Performance team, and the SURGE team are supporting rollout of SHREWD. Therefore neither of these are projects are being led by the UEC STP programme, they are being led by operational / performance teams, but their successful delivery is a key enabler for the UEC STP programme. N/A Sep-17 UEC The UEC Simplified Discharge project is looking at creating joint assessments and standardising process and documentation across NCL for discharge planning, with delivery through local teams. N/A Sep-17 UEC The UEC Simplified Discharge project aims to support implementation of the 4 Discharge to Assess pathways, with delivery through local CCG, social care and provider teams. Yes No Yes Yes To be confirmed by MH Programme Director Yes Yes Yes n/a Yes Yes North London PARTNERS in health and care AEDB Readiness Assessment for Delivery of National Priorities P a g e 5 94

95 to Assess scheme in place High Impact Change 5: Seven-day service in place High Impact Change 6: Trusted Assessor models in place High Impact Change 7: Promoting choice and selfcare for patients High Impact Change 8: Enhanced health and care services in care homes N/A Sep-17 UEC The UEC Simplified Discharge project aims to support implementation of 7 day services, with delivery through local CCG and provider teams. N/A Sep-17 UEC The UEC Simplified Discharge project aims to support implementation of trusted assessors, with delivery through local CCG and provider teams. N/A Sep-17 UEC; Care Closer to Home N/A Sep-17 UEC; The UEC Simplified Discharge project aims to support implementation of streamlined processes for complex/disputed discharges where hospitals/social care departments can implement different approaches to choice, with delivery through local CCG, social care and provider teams. Care Closer to Home workstream projects and interventions will also address the items described in this high impact change particularly around review of patient choice documentation and implementation of integrated personalised commissioning. This is being delivered locally through locality networks and primary care teams. The UEC programme has a number of supportive interventions which relate to care homes: 1. IUC project the *5*6*7 advice line is live and enables care home staff access to clinical advice from the Hub 2. Admission avoidance this project is in it s early stages but in scope is avoiding admissions from those conveyed from care homes 3. Simplified discharge - engagement with care homes is critical in relation to successful delivery of Trusted Assessor arrangements 4. End of Life the Care Facilitator role is being developed with input from care homes and hospices to support patients and staff to reduce ambulance call-outs and hence A&E attends. However, the other elements of the EHCH scheme - namely, primary care support to care homes and quality of care provided in those care homes is being led locally by CCGs. Yes Yes No No % of acute hospitals that meet the core 24 service standard for adults 13%+ Mar-18 Care Closer to Home Mental Health Care Closer to Home projects and interventions will also address the items described in this high impact change but this will depend on local need so will be bespoke solutions delivered through locality networks. This is out of scope for the UEC STP programme. The Mental Health STP programme provides NCL-wide oversight to and is trying to help deliver a common standard and shared learning, but the actual delivery is going on at local level. To be confirmed by MH Programme Director 6.0 Conclusion and Next Steps NCL UEC Board is requested to NOTE and DISCUSS the contents of this report and IDENTIFY SUPPORT available to AEDBs to address the key risks highlighted above. Jenni Frost UEC Programme Director, NCL STP August 2017 North London PARTNERS in health and care AEDB Readiness Assessment for Delivery of National Priorities P a g e 6 95

96 NCL Joint Commissioning Committee Meeting on Thursday 5 th October 2017 Report title Royal Free London Medium-Term Financial Strategy Agenda item 4.4 Date 28 th September 2017 Lead director Report author Sponsor(s) (where applicable) Paul Sinden Director of Performance and Acute Commissioning Paul Sinden Director of Performance and Acute Commissioning Tel/ Tel/ Tel/ p.sinden@nhs.net p.sinden@nhs.net Report summary Royal Free London medium-term financial strategy Royal Free London has developed a medium-term financial strategy to recover the Trust s deficit position. The current forecast is for the Trust to have a 51m deficit against the plan for the year. On 5 October the Trust will present the strategy to the Joint Commissioning Committee with the presentation developed from the one shared with North Central London Joint Health Overview Scrutiny Committee held on 22 September The presentation is to follow and will cover: Context - Recap of North Central London Sustainability and Transformation Plan (STP) financial position; The Royal Free London NHS Foundation Trust financial position within the STP; Diagnosis of the Trust s financial position and drivers of the deficit position; Key elements of the financial strategy. CCGs and the Joint Commissioning Committee will need to identify the impact of the Trust s medium term financial strategy on delivery of the North Central London Sustainability Plan and supporting financial plans. Consideration of impact, both risks and opportunities, will cover strategic fit, financial fit including resolution of contracts with the Trust, and quality fit including patient experience. Purpose (tick one only) Recommendation Information Approval To note The Joint Commissioning Committee is asked to: NOTE the report. Decision 96

97 Conflicts of Interest Strategic Direction Identified risks and risk management actions Resource implications Engagement Equality impact analysis Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy. The Royal Free London medium-term strategy aims to support delivery of: Commissioning the delivery of NHS constitutional rights and pledges; Improving the quality and safety of commissioned services; Improving health outcomes, address inequalities and achieve parity of esteem; Maintaining financial stability and ensure sustainability through robust planning and commissioning of value-for- money services. Delivery of the North Central London Sustainability and Transformation Plan. CCGs and the Joint Commissioning Committee will need to identify the impact of the Trust s medium term financial strategy on delivery of the North Central London Sustainability Plan and supporting financial plans. Consideration of impact, both risks and opportunities, will cover strategic fit, financial fit including resolution of contracts with the Trust, and quality fit including patient experience. Contracts for and beyond will need to be developed within CCG resource envelopes, and be consistent with delivery of the NCL Sustainability and Transformation Plan. CCGs will need to consider the impact of the Trust s financial strategy on this. The report is presented to the NCL Joint Commissioning Committee which includes elected GP representatives, lay members, Healthwatch, Public Health and representatives from each NCL London borough. This report was written in accordance with the provisions of the Equality Act Report history Next steps Appendices The Trust has previously shared its medium-term financial strategy with: North Central London (NCL) Joint Health Overview and Scrutiny Committee on 22 September 2017; Members of NCL CCG Senior Management Team on 15 September Next steps in the development of system intentions for 2018/19 will be to: Identify impact on, and actions required of CCGs to support delivery of the Trust s financial strategy; Identify impact on, and actions required from the Sustainability and Transformation Plan (STP) to support delivery of the Trust s financial strategy. The supporting presentation from Royal Free is to follow. 97

98 NCL Joint Commissioning Committee Meeting on Thursday 5 th October 2017 ` Report title NCL Joint Commissioning Committee Risk Register Agenda item 5.1 Date 28 th September 2017 Lead director Report author Paul Sinden Director of Performance and Acute Commissioning Andrew Spicer NCL Head of Governance and Risk Tel/ Tel/ p.sinden@nhs.net Tel andrew.spicer1@nhs.net Tel Sponsor(s) (where applicable) Tel/ Report summary North Central London Joint Commissioning Committee Risk Register This paper provides an overview of the updated risk register for the North Central London CCG Joint Commissioning Committee. The risk register covers area areas of commissioning delegated to the Committee by the five North Central London CCGs in November The main update to the risk register is the addition of a set of strategic risks to the existing set of operational risks. Strategic risks added to the register include: Winter pressures and A&E; Implementing the STP schemes and shifting activity away from acute providers; Workforce; The NHS England assurance process impacting on staff capacity to deliver; Finance; Political environment; Capacity and timescale for delivery. A current risk score tracker has been included to assist the Committee. In addition, the NCL Joint Commissioning Committee risk register is a dynamic document so to ensure that the Committee focusses on the most significant risks in future meetings only risks with a current risk score of 12 or higher will appear on the NCL Joint Commissioning Committee s Risk Register. The Committee is asked to note that the risk register for the NCL Joint Commissioning Committee has been linked to individual CCG registers and risks will be escalated and deescalated as appropriate. Purpose (tick one only) Recommendation Information Approval To note The NCL Joint Commissioning Committee is asked to: Note the report; Decision 98