NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY TUESDAY 14 th FEBRUARY 2017 AT 2.30PM BOARDROOM, THE DEPARTMENT AGENDA

Transcription

1 ` NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY TUESDAY 14 th FEBRUARY 2017 AT 2.30PM BOARDROOM, THE DEPARTMENT AGENDA Part 1: Introductions and Apologies 1.1 Declarations of Interest All 1.2 Minutes and action points from the meeting Attached on 10 th January 2017 All 1.3 Matters Arising All Part 2: Updates 2.1 Feedback from Committees: Report no: GB Finance Procurement & Contracting Committee Dr Nadim Fazlani - 24 th January 2017 HR Committee - 24 th January 2017 Prof Maureen Williams Healthy Liverpool Programme Board Tom Jackson 25 th January 2017 Quality Safety & Outcomes Committee Dave Antrobus 7 th February Chief Officer s Update Verbal Katherine Sheerin 2.3 Public Health Update Verbal Dr Sandra Davies 2.4 Update from Health & Wellbeing Board Verbal - 26 th January 2017 Dr Nadim Fazlani Part 3: Performance 3.1 Finance Update December 2016 Month 9 Report no: GB Tom Jackson 1 Page 1 of 2

2 3.2 CCG Corporate Performance Report February 2017 Report no: GB Stephen Hendry 3.3 Emergency Care Improvement Programme: Report no: GB Whole System Enquiry Visit Liverpool & Ian Davies South Sefton Health Economy. Part 4: Strategy and Commissioning 4.1 NHS Right Care Programme Report no: GB Dr Maurice Smith 4.2 Review of Orthopaedic Services Report no: GB Dr Fiona Lemmens 4.3 Armed Forces Covenant Report no: GB Ian Davies Part 5: Governance 5.1 Secondment Policy Report no: GB Prof Maureen Williams 6. Questions from the Public 7. Date and time of next meetings: Tuesday 14 th March 2017 at 2.30pm Boardroom, The Department For Noting: HR Committee 15 th November 2016 Finance Procurement & Contracting Committee 20 th December 2017 Healthy Liverpool Programme Board 21 st December 2016 Quality Safety & Outcomes Committee 3 rd January Page 2 of 2

3 Report no: GB NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY TUESDAY 14 TH FEBRUARY 2017 Title of Report Lead Governor Senior Management Team Lead Report Author(s) Summary Recommendation Relevant Standards or targets Feedback from Committees Dr Nadim Fazlani, Dr Rosie Kaur, Dave Antrobus, Prof, Maureen Williams Cheryl Mould, Primary Care Programme Director, Tom Jackson, Chief Finance Officer, Jane Lunt, Head of Quality/Chief Nurse, Katherine Sheerin, Chief Officer Cheryl Mould, Primary Care Programme Director, Tom Jackson, Chief Finance Officer, Jane Lunt, Head of Quality/Chief Nurse The purpose of this paper is to present the key issues discussed, risks identified and mitigating actions agreed at the following committees: Finance Procurement & Contracting Committee - 24 th January 2017 HR Committee - 24 th January 2017 Healthy Liverpool Programme Board 25 th January 2017 Quality Safety & Outcomes Committee 7 th February 2017 This will ensure that the Governing Body is fully engaged with the work of committees, and reflects sound governance and decision making arrangements for the CCG. That Liverpool CCG Governing Body: Considers the report and recommendations from the committees Approves the amended Terms of Reference for the Quality Safety and Outcomes Committee 29 Page 1 of 10

4 FINANCE, PROCUREMENT AND CONTRACTING COMMITTEE TUESDAY 24 TH JANUARY 2017 AT 10AM ROOM 2, THE DEPARTMENT, LEWIS S BUILDING RENSHAW STREET L1 2SA Part 1: Introductions and Apologies 1.1 Declarations of Interest All 1.2 Minutes and action points from the meeting Attached on 20 th December 2016 All 1.3 Matters Arising All Supportive and End of Life Care Service Derek Rothwell Ratification of Procurement Decision from November 2016 Part 2: Updates 2.1 Telehealth Technology Service Procurement Report no: FPCC Derek Rothwell Part 3: Performance 3.1 Finance Update December 2016 Month 9 Report no: FPCC Tom Jackson 3.2 Emergency Care Improvement Programme: Report no: FPCC Whole System Enquiry Visit Liverpool & Ian Davies South Sefton Health Economy Part 4: Strategy and Commissioning 4.1 Contract Update November Month /17 Report no: FPCC Derek Rothwell 4.2 North West Adult Specialised Severe and Complex Report no: FPCC Obesity Services (Bariatric) Procurement Update Derek Rothwell 30 Page 2 of 10

5 4.3 Enhanced GP role in Care Homes Report no: FPCC Derek Rothwell/ Jacqui Campbell 4.4 Proposal to extend GP OOHs Contract Report no: FPCC Ian Davies 4.5 Deployment of Digitally Enabled Community Report no: FPCC Services Dave Horsfield Part 5: Governance No items 6. Date and time of next meeting: Tuesday 28 th February 2017 Room 2 at 10am to 12.30pm The Department, Lewis s Building, L1 2SA. 31 Page 3 of 10

6 LIVERPOOL CCG CORPORATE GOVERNANCE TEMPLATE COMMITTEE MINUTES Committee: Finance, Procurement and Contracting Committee Meeting Date: 24 January 2017 Chair: Dr Nadim Fazlani Key issues: Risks Identified: Mitigating Actions: 1. Telehealth Technology Service Procurement 2. North West adult Specialised and Complex Obesity Services (Bariatric) Procurement Bidder queries received relating to procurement process Termination of the NHS E procurement of Bariatric services - due to bidders not being able to deliver services at national tariff prices 3. GP Out of Hours Service Current GP Out of Hours (OOH) service expires in September Changing OOH environment and links with 111 service mean that an integrated model of service cannot accurately be defined at the current time. 4. Delivery of Forecast Outturn position as per NHS England Business Planning Rules Increased Contract expenditure (activity increases at Royal Liverpool) and delivery of Financial Recovery Plan (phase I & II) place risk on delivery of outturn position Cancel the result of the initial Invitation to Tender (ITT) and undertake a re-run of the ITT stage of the procurement NHS E seek to extend current Bariatric services provider contract by 12 months whilst (a)identifying provider / providers who can deliver services at national tariff, and (b) establish any tariff uplift requirements and investigate alternative options Extend the current OOH service by 2 years to expire in September 2020 to enable alignment with 111 contract and thereby enable an integrated service model to be defined and procured in 2019 in readiness for service start in October Monitoring of Financial Recovery plan mitigations and any additional solutions, position reviewed regularly through Financial Recovery Group and Finance Committee. Recommendations to NHS Liverpool CCG Governing Body: 1. To note the above issues, risks and mitigating actions. 32 Page 4 of 10

7 NHS LIVERPOOL CLINICAL COMMISSIONING GROUP HR COMMITTEE TUESDAY 24 TH JANUARY 2017 AT 2PM MEETING ROOM 2, 3 rd FLOOR, LEWIS BUILDING A G E N D A Section 1: Standing Items 1.1 Welcome and Introductions All 1.2 Declaration of Interests All 1.3 Minutes and actions from the previous meeting Prof Maureen held on 15 th November 2016 Williams Section 2: Items for Decision 2.1 Secondment Policy HR Lisa Doran 2.2 NHS Liverpool CCG s Workforce Race Equality HR Standard (WRES) Andy Woods 2.3 LCCG workforce Equality & Diversity Plan 2017 to HR Andy Woods Section 3: Items for Discussion 3.1 Policies approval process update Verbal Prof Maureen Williams Section 4: Items for Information None 5. Date and time of next meeting TBC 33 Page 5 of 10

8 LIVERPOOL CCG CORPORATE GOVERNANCE TEMPLATE COMMITTEE MINUTES Committee: HR Committee Meeting Date: 24 th January 2017 Chair: Maureen Williams Key issues: Risks Identified: Mitigating Actions: 1. Secondment Policy The organisation s approach to secondments may not be clear or fair Clear policy drawn up and discussed by the HR Committee and approved for submission to the Governing Body 2. LCCG Workforce Race Equality Standard (WRES) Failure to publish on- line means LCCG will be non-compliant with the standard. HR Committee approved report and agreed to it being uploaded onto the LCCG website, therefore organization is compliant 3. LCCG Workforce Equality & Diversity Plan Equality delivery systems are part of NHSE framework on equality & diversity inclusion and are part of the assurance process. Without a policy, LCCG would be non-compliant with the standard The plan was discussed and approved, demonstrating compliance with appropriate standards Recommendations to NHS Liverpool CCG Governing Body: 1. To note the minutes. 2. To approve the Secondment Policy 34 Page 6 of 10

9 Healthy Liverpool Programme Board Wednesday 25 January pm to 5pm Board Room, The Department, Lewis s Building AGENDA 1.0 Welcome and Introductions T Jackson 2.0 Minutes of the last meeting T Jackson 3.0 Matters Arising All 4.0 Performance 4.1 Programme Highlight reports (attached) 5.0 Strategy & Commissioning Clinical Directors For discussion 5.1 Community Care Teams Tony Woods For discussion 6.0 Governance 6.1 Risk Register and Update C Hill For discussion 7.0 Any Other Business All 8.0 Communication/messages from this meeting All 9.0 Date and time of next meeting Wednesday 22 February 2017, 3pm to 5pm, Board Room 35 Page 7 of 10

10 LIVERPOOL CCG CORPORATE GOVERNANCE TEMPLATE COMMITTEE MINUTES Committee: Healthy Liverpool Programme Board Meeting Date: 25 January 2017 Chair: Tom Jackson Key issues: Risks Identified: Mitigating Actions: 1. Impact of Community Care Teams to ensure that Community Care Team implementation is on track and delivering the required outcomes. 2. Orthopaedics Reconfiguration to ensure a sound case for change is shared and accepted by key stakeholders. to ensure a robust process is followed, aligned to a detailed system plan. 3. Physical Activity and Sport Programme to ensure the sustainability of physical activity and sport programme for the city. clear plan for continued roll out of Community Care Teams, with implementation to be completed by April evidence of impact : avoidable admissions reduced by 10% compared to the same period last year (month 7 data) case for change being shared with key stakeholders by the end of January whole system plan developed and being performance managed. clear evidence of a positive impact: - Fit for Me survey showed 50% recognition of the campaign, 18% of those had taken action - Liverpool has moved to 4 th place of 8 core cities for participation in sport. the Physical Activity and Sport Executive Group are working to find sources of funding for 2017/2018 onwards. Recommendations to NHS Liverpool CCG Governing Body: 1. To note the key issues and risks. 36 Page 8 of 10

11 Part 1: Introduction & Apologies QUALITY SAFETY AND OUTCOMES COMMITTEE TUESDAY 7 TH FEBRUARY PM TO 5PM BOARDROOM THE DEPARTMENT A G E N D A 1.1 Welcome & Introductions ALL 1.2 Declaration of Interests ALL 1.3 Minutes and Actions from 3 rd January 2017 Chair 1.4 Matters Arising Part 2: Updates Part 3: Strategy & Commissioning 3.1 A Progress Report re Paediatric Speech and Language QSOC Therapy at Liverpool Community Health NHS Trust Kerry Lloyd Part 4: Performance 4.1 Spire Health Care Quality Profile QSOC Kellie Connor 4.2 HCAI Quarter 3 Update QSOC Alison Thompson Part 5: Governance 5.1 Serious Incident Overview 2016/17 Quarter 3 QSOC Denise Roberts Date & Time of next meeting Tuesday 7 th March pm to 5pm Boardroom, The Department 37 Page 9 of 10

12 LIVERPOOL CCG CORPORATE GOVERNANCE TEMPLATE COMMITTEE MINUTES Committee: Quality, Safety & Outcomes C tee Meeting Date: 7 th February 2017 Chair: Dave Antrobus (Apols, Jane Lunt in the Chair) Key issues: Risks Identified: Mitigating Actions: 1. Liverpool Community Health Paediatric Speech & Language Therapy Service Improvement Work. Improvement works potentially fails to achieve intended reduction of waiting times and improvement in service delivery. Monthly overview of Action Plan and improvement trajectory by CCG. Oversight within Liverpool Community Health by Board. Oversight via Clinical Quality Oversight Group ( CQOG ). 2. Impact of Healthcare Acquired Infections ( HCAIs ) on patients outlined via 2 case studies. Case Studies highlighted the complexity of some patient pathways. Wider system (Health & Social Care) interdependencies highlighted. Wider work to improve flow out of hospital continues with focus on complex patients. CCG able to utilise commissioning influence across Primary, Secondary and Tertiary Care to ensure effective interventions such as prescribing are in place. Clear strategies to support system reduction in HCAIs e.g. Anti-Microbial Strategy Recommendations to NHS Liverpool CCG Governing Body: 1. Note the issues and the actions to mitigate risks. 38 Page 10 of 10

13 Report no: GB NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY TUESDAY 14 th FEBRUARY 2017 Title of Report Finance Update December 2016 Month 9 Lead Governor Senior Management Team Lead Report Author Summary Tom Jackson Chief Finance Officer Tom Jackson Chief Finance Officer Mark Bakewell Deputy Chief Finance Officer This paper summarises the CCG s financial performance for the month of December 2016 (Month 9) for the CCG Governing Body and contains details regarding a) Financial Performance in respect of delivery of NHS England Business Planning Rules particularly regarding in-year surplus position and treatment of non-recurrent headroom b) Assessment of risk to the delivery of forecast surplus position given current / required mitigating actions as identified within Financial Recovery Plan as shared with NHS England. Based on information available in early February regarding financial performance, the combined impact of increased healthcare expenditure and lower than planned CCG mitigations Page 1 of 27 39

14 through its recovery plan would suggest a lower likelihood of delivery of the 1% +1% target surplus position. Recommendation The Governing Body is requested to note: the current financial position and risks associated with delivery of the forecast outturn position, the proposed recovery solutions of 8.1m required to deliver the target surplus based on current forecast outturn assumptions (unchanged from Month 8) that based on information available in early february, the CCG is unlikely to deliver the 1% + 1% ( 16.4m) surplus for the financial year and is being reported to NHS England as part of Month 10 Reporting arrangements Relevant standards/targets Financial Duties NHS England Business Rules Page 2 of 27 40

15 Financial Performance Update Month 9 (December) 2016/17 1. PURPOSE The purpose of this report is to provide the Governing Body with an update on the CCG s financial performance for the financial year. 2. RECOMMENDATIONS The Governing Body is requested to note: the current financial position and risks associated with delivery of the forecast outturn position, the proposed recovery solutions of 8.1m required to deliver the target surplus based on current forecast outturn assumptions (unchanged from Month 8) that based on information available in early february, the CCG is unlikely to deliver the 1% + 1% ( 16.4m) surplus for the financial year and is being reported to NHS England as part of Month 10 Reporting arrangements (see page 21) 3. SUMMARY Discussions with NHS England during October resulted in a change of approach to the CCG s reporting of Business Rules in respect of its surplus position with a revised target of a 1% surplus ( 8.017m (rather than 14.4m (1.7%)) and, the re-establishment of the nonrecurrent headroom (1%) 8.362m. This results in a revised targeted cumulative surplus position of 16.4m, being consistent with delivery NHS England Business Planning Rules for the financial year but different to original CCG Plan Submissions ( 14.4m) and again to NHS England Expectations (Circa 22m) as per Section 3 Month 9 financial reporting has resulted in further operational pressures (predominantly increases in Acute Commissioning expenditure) increasing the recovery gap / required solutions to 8.1m (of which 7.4m have been assumed as per phase 2 of the CCG Recovery planning process. 41 Page 3 of 27

16 For NHS England Reporting purposes, the revision to the 1% surplus figure as at Month 7 also excludes the 1% headroom from both the year to date / forecast outturn financial position as per NHS England instructions. It is anticipated that this will be released into the CCG position by instruction of NHS England at some point during the remainder of the financial year and will support delivery of the cumulative surplus of 16.4m (equivalent to 2%) Due to the level of financial risk identified within the financial year, a financial recovery plan has now been shared with NHS England and is being closely monitored by the Financial Recovery Oversight Group (FROG), supporting both the delivery of the 2016/17 forecast outturn position and reviewing planning assumptions for future years given the challenging nature of the CCGs financial position. 4. BUSINESS RULES BACKGROUND Following discussions with NHS England in October, the CCG amended its reporting with regards to business planning rule elements of cumulative surplus (minimum 1%) and non-recurrent headroom (1%). The delivery of a 16.4m cumulative surplus (equivalent to 1% + 1%) by the end of 2016/17 financial year remains subject to risk with savings detailed in the financial recovery section below being required to be actioned in order to deliver the revised position. The table below shows the relative movement between months comparing the relative elements of business planning rules at each point in the reporting cycle of the financial year Cumulative Surplus In Year Surplus / (Deficit) Non recurrent Headroom Plan* 14.4m 1.7% m* (1%) Month m 1.7% m (1%) Month m 1.7% m (1%) Month m 1.7% 0 0 Month 7** m - 2%*** 1.9m 0.3% 8.362m (1%) Month 8** m - 2%*** 1.9m 0.3% 8.362m (1%) Month 9** m - 2%*** 1.9m 0.3% 8.362m (1%) * The operational plan for 2016/17 - Liverpool CCG Financial Plan 2016/17 paper taken to the Governing Body meeting on 12 April 2016, referred to a return to NHS England business rules and the reduction of the 2016/17 planned surplus to 1% to reflect transformation investment intentions and increasing cost pressures. The CCG was advised by NHS England in early April 2016 that an increased level of drawdown on centrally held funds to the CCG as a result of the reduction could not be accommodated. Consequently, the final plan submission for 2016/17 42 Page 4 of 27

17 showed a 1.7% planned surplus. The plan narrative indicated that this was predicated by the retention of the 1% non-recurrent funds internally to the CCG. ** CCG received confirmation from the Area Team that the Non Recurrent set aside headroom will not leave the CCGs accounts and will support the year end position. The targeted cumulative surplus m therefore consists of 1% business rules surplus plus retained 1 % nonrecurrent headroom (see *** below re corresponding values) ***Determination of 1% surplus and 1% headroom are on different calculations as per below methodology 1% Surplus = 1% of Total Allocation (including Non-Recurrent and Running Costs) less Primary Care 1% Non-Recurrent = 1% of Recurrent Allocation (including Primary Care) 5. FINANCIAL PERFORMANCE The below sections summarise the key information regarding month 9 (December) reporting position for NHS Liverpool Clinical Commissioning Group Month 8 Reporting - Financial Performance Key Information The CCG is monitored against a number of business rules as per NHS England planning guidance, with particular regards to delivery of planned surplus (minimum of 1%), establishing a contingency (of at least 0.5%) and the availability of at least 1% headroom (nonrecurrent) within the annual planning process. The table below describes the CCG s self-assessed performance against financial performance and statutory measures (regarding resource and cash limits) given the information contained within this report. Financial Performance (Business Rules) Q1 Q2 Q3 Q4 YTD Surplus 1% Non-Recurrent Provider Contract Performance Running Cost Allowance 43 Page 5 of 27

18 Statutory Duties Q1 Q2 Q3 Q4 YTD Revenue Resource Limit Cash Limit Better Payment Practice Code a) Revenue Resource Limit and Planned Expenditure The resources available to the CCG within the 2016/17 financial year are described within the table below; these include the CCG s programme (recurrent and non-recurrent) and running cost allocations and also the amount delegated by NHS England for CCG commissioning of Primary Care (GP practices) 000 Total Notified Allocation 769,888 Total Non-Recurrent Allocation 22,655 Primary Care Co Commissioning 66,357 Revenue Resource Limit (Programme) 858,900 Running Costs Allocation 10,617 Total Allocation 869,517 A breakdown of the CCG s non-recurrent resources within the 2016/17 financial year can be found below 44 Page 6 of 27

19 Other Non-Recurrent Allocations 's Return of Prior Year Surplus 14,427 GP Access 44 Vanguard Funding 914 Additional MH 309 Public Health 16 IM&T 5,000 TB Funding 16 CAMHS 129 Vanguard Funding 251 Local Evaluation Funding for Walton Neuro network 37 Charge Exempt Oversee Visitors 85 Community Development Fund - Perinatal Mental Health 554 Quality Premium Awards Total 22,655 b) 2016/17 Year to Date Position as at Month 9 (December) The CCG is currently reporting a year to date over performance of 4.601m against budgeted expenditure as at December This is partly due to the changes described in the revision to the 1% surplus figure as at Month 7 (and changes to the 1.7% surplus figure) with the resulting impact of the 1% headroom being excluded from the year to date / forecast outturn financial position as per NHS England instructions. The resulting movement from a forecast outturn surplus position of 14.4m to 8.017m is an in-year deficit position of 6.4m, of which the pro-rata year to date deficit would be 4.81m if all expenditure were in line with plan (excluding headroom which will be released into the CCG position at a point to be determined by NHS England within the financial year) However, a combination of factors including budget profiling (e.g. 1% headroom held in M12) and operational performance pressures against planned levels, increase the year to date over performance to 4.601m as per the table below and with a full cost centre breakdown included in Appendix One for further analysis. 45 Page 7 of 27

20 2016/ / / /17 Budget M9 YTD M9 YTD M9 YTD Budget Actual Variance m m m m RESOURCE ALLOCATION (869,517) (652,113) (652,113) 0 ACUTE TOTAL 417, , ,280 3,935 COMMUNITY HEALTH SERVICES TOTAL 94,540 71,790 72, CONTINUING CARE TOTAL 31,372 23,649 26,553 2,904 MENTAL HEALTH TOTAL 81,454 61,064 62,241 1,177 OTHER PROGRAMME (INC RESERVES) 40,309 29,056 24,357 (4,699) TOTAL PRIMARY CARE TOTAL 179, , ,716 2,268 PROGRAMME COSTS TOTAL 844, , ,279 5,927 RUNNING COSTS TOTAL 10,617 7,966 6,640 (1,326) EXPENDITURE TOTAL 855, , ,919 4,601 TOTAL (14,427)* (10,795) (6,194) 4,601 *NHS Ledger / Reporting Restriction prevent adjustment of planned surplus position with ledger to the revised figure (excluding headroom) Year to Date Position - Key Variances and Exceptional Items Detailed Year to Date performance positions are included within Appendix One of this Report i. Acute Contracts The net Acute Commissioning expenditure position is currently 3.9m over planned levels as at December 2016, this is mainly due to an acute contract performance position of 3.7m, pressures of 0.6m in Non-Contracted Activity are offsetting by slippage on Winter Resilience and high cost drugs of 0.4m Further Contract Performance information is included within the contracts update to FPCC on a bi-monthly basis. The month 9 finance information reflects activity information received to date (based on Month 8 activity (November). The Royal Liverpool University Hospitals NHS Trust contract is the main movement between the respective months reporting positions. 46 Page 8 of 27

21 In terms of non-elective admissions, the forecast spend has increased by 398k (0.7%) since last month. This increase is evident in a number of specialties, primarily General Surgery and Geriatric Medicine. Case mix complexity is also a contributory factor with HRGs relating to Septicaemia and Thoracic procedures and disorders increasing. Non-elective excess bed-days forecast spend on these has increased by 186k (4.5%) since last month, particularly in General Surgery, Clinical Haematology and Geriatric Medicine. Additional activity within Outpatient first attendances & Procedures particularly in Gastroenterology, Trauma & Orthopaedics and Ophthalmology has also moved the position. The table below provides further information regarding performance by provider (contract and non-contract positions). ACUTE CONTRACT PERFORMANCE Budget Year to Date (M9) Expenditure Year to Date (M9) Variance (M9) Variance (M9) % R LIV/BRG UNI HOSP NHST 150,380, ,258, , % AINTREE UNI HOSP NHS FT 58,246,444 59,283,133 1,036, % LIVP WOMENS NHS FT 28,990,228 29,967, , % ALDER HEY CHILDRENS FT 21,227,211 22,567,843 1,340, % NW AMBUL SVC NHST 15,218,527 15,549, , % ST HEL/KNOWS TEACH NHST 13,896,312 14,754, , % SPIRE HEALTHCARE LTD 9,196,733 9,273,672 76, % LIVP HRT/CHST HOSP NHS FT 4,529,567 4,897, , % WALTON CENTRE NHS FT 1,492,353 1,659, , % WALTON CENTRE NHS FT - Vanguard 1,164,000 1,164, % SOUTHPORT/ORMSKIRK NHST 766, ,806-24, % WIRRAL UNIV TEACH HOSP NHS FT 619, , , % CHESH/WIRRAL PART NHSFT 554, , % One to One 505, ,653-6, % R LIV/BRG UNI HOSP NHST AQP 464, ,667-20, % R LIV/BRG UNI HOSP NHST CEOV 449, ,325 15, % WARRINGTON/HALTON NHSFT 448, ,930-51, % OTHER 317,131 12, , % WRIGHT/WGN/LEIGH NHS FT 293, , , % LHCH CEOV 225, ,272-19, % COUNTESS OF CHESTER FT 184, ,078 5, % C MANC UNI HOS NHS FT 178, , , % FAIRFIELD INDEPENDENT HOSPITAL 164, ,582-13, % RENACRES HOSPITAL 158, ,067 6, % UNI HOSP SMAN NHS FT 153, , % SALFORD ROYAL NHSFT 153, ,450 82, % ALDER HEY CEOV 138,753 42,564-96, % AINTREE UNI HOSP NHS FT - Lipid 126, , % R LIV/BRG UNI HOSP NHST COPD 114, , % SALFORD ROYAL NHSFT Pas 69,147 68, % AINTREE UNI HOSP NHS FT - AQP 0 204, , % WALTON CENTRE NHS FT - Comm Rehab 0 276, , % NHS StHK 0-1,500,000-1,500, % SMT SAVINGS 0-975, , % Total 310,427, ,122,702 3,695,461 Page 9 of 27 47

22 ii. Community Health Contracts The net community health services expenditure position is currently over planned levels by 0.3m as at December Activity based community contracts performance (Spa Medica, AQP Physio and Podiatry contracts) being the main driver with a 0.8m over performance and additional cost pressures in Intermediate / Palliative Care of 0.4m. These are offset against cost savings of 0.9m against Long Term Conditions / Digital Programme, partly as agreed through the financial recovery process. COMMUNITY SERVICES Budget Year to Date (M9) Expenditure Year to Date (M9) Variance (M9) LPOOL COMM HC NFT - SLA 50,823,070 51,576, ,000 AINTREE UNI HOSP NHS FT - Diabetes 2,744,426 2,744,426 0 LPOOL COMM HC NFT - Anticoag 1,001,027 1,107, ,540 SPECSAVERS HEARCARE LTD 708, ,177 37,427 LPOOL COMM HC NFT - Podiatry 578, ,154 28,526 SPAMEDICA 262, , ,870 BPAS 176, , ,388 OTHER 73,875 48,956-24,919 LPOOL COMM HC NFT - 15/16 creditors 0-145, ,937 LPOOL COMM HC NFT - Interpreter 0 11,916 11,916 LCC (LCH Contract Income CEDAS) 0-753, ,000 STROKE ASSOCIATION 0 172, ,750 INJURY CARE CLINICS LTD 0 91,235 91,235 WIRRAL COMM NFT 0 38,245 38,245 PRIORY MEDICAL CENTRE 0 98,523 98,523 BOOTS HEARINGCARE LTD 0 38,351 38,351 Total 56,368,523 57,176, ,915 iii. Continuing Care Continuing Care costs are over budget by 2.9m, mainly due to increases in CHC Adult Fully Funded care packages ( 1.4m year to date) and in FNC ( 1.4m year to date) due to in year increases in charges as previously notified. There is also a year to date overspend in Adult joint funded packages of 0.2m which is marginally offset by a 0.1m under spend in CHC Children packages. Page 10 of 27 48

23 iv. Mental Health Contracts Mental Health costs are over budget by 1.2m as a result of a combination of additional CAMHS expenditure of 0.8m (due to costs incurred for Transformational Funding that had not been budgeted for), increases in Learning Difficulties expenditure of 0.7m (due to additional high cost patients), and an overspend in Mental Health Adults 0.2m and Mental Health Contracts 0.2m being offset by a large underspend in Mental Health Older people of 0.7m (due to delayed start and reduced costs for the Care Home and Home First schemes) v. Other Programme (including Reserves) Other Programme costs are under budget by 4.7m, largely due to impact of Earmarked Reserves held in Month 9 as per planning assumptions. vi. Primary Care Primary Care costs are above planned expenditure by 2.3m due to overspends in Prescribing of 1.7m (which is based on the 7 months actual costs (April October 2016) and two months estimated accruals) and net overspends in Co-commissioning and Local Enhanced Services of 1.0m offset by underspends in Commissioning schemes ( 0.4m) Primary Care Year to Date Budget '000 Year to Date Actual '000 Year to Date Variance '000 CENTRAL DRUGS COMMISSIONING SCHEMES 2,627 2, LOCAL ENHANCED SERVICES 14,053 12,464-1,589 OUT OF HOURS 3,209 3, OXYGEN PRESCRIBING 65,659 67,336 1,678 PRIMARY CARE IT 1,853 1, PRC DELEGATED CO-COMMISSIONING 46,345 49,006 2, , ,716 2,268 vii. Running Costs 49 Running costs are showing an under spend against planned levels of 1.3m for the year to date. This is mainly due to the Page 11 of 27

24 Running cost reserve not being utilised in line with financial plan assumptions c) Forecast Outturn Position as at Month 9 (December) The CCG is currently reporting a balanced position against its revised forecast outturn position of 8.017m surplus as per the table below. In line with the changes to CCG financial reporting as described earlier (regarding surplus and headroom) this results in a deterioration of the surplus position from 14.4m and results in an in-year deficit position of 6.410m (excluding 1% headroom in order to deliver 16.4m cumulative surplus). 2016/ / /17 Annual Budget M9 Forecast Outturn M9 Forecast Variance m m m ALLOCATION (869,517) (869,517) - ACUTE TOTAL 417, ,312 5,793 COMMUNITY HEALTH SERVICES TOTAL 94,540 95, CONTINUING CARE TOTAL 31,372 35,014 3,642 MENTAL HEALTH TOTAL 81,454 82,838 1,384 OTHER PROGRAMME ( INC RESERVES ) TOTAL 40,309 35,939 (5,116) PRIMARY CARE TOTAL 179, ,971 1,692 PROGRAMME COSTS TOTAL 844, ,471 8,252 RUNNING COSTS TOTAL 10,617 8,776 (1,841) (SURPLUS) / DEFICIT (14,427) (7,270) 6, Within the forecast outturn assumptions and delivery of the 8.017m there remains an expectation of delivery of both phase 1 ( 6.5m) and phase 2 ( 7.4m) of financial recovery plan solutions. These mitigations are described within the financial recovery plan shared with NHS England with the majority being implemented within quarter 3 of the financial year to address year to date operational performance issues but are subject to levels of risk as identified in section e) Key Variances and Exceptional Items i. Acute Contracts The net acute commissioning forecast outturn position as at Month 9 is a 5.8m over performance. In line with the year to Page 12 of 27

25 date position, acute contract performance are forecast to be over planned levels by 5.7m, Non Contracted Activity over by 0.3m offset by other underspends of 0.2m on winter resilience funding. The main contract forecast over performance areas are as per the table below with main variances being seen against Royal Liverpool and Broadgreen Hospitals, Aintree, Liverpool Womens, Alder Hey and St Helens and Knowsley contracts The forecast position includes an assumption that the financial recovery solution are delivered as per the financial recovery plan. ACUTE COMMISSIONING 2016/17 Budget ' /17 Forecast '000 Forecast Variance '000 R LIV/BRG UNI HOSP NHST 200,286, ,457,379 1,170,411 NW AMBUL SVC NHST 20,796,036 21,238, ,000 AINTREE UNI HOSP NHS FT 77,537,371 78,919,610 1,382,239 LIVP WOMENS NHS FT 38,668,983 39,966,052 1,297,069 ALDER HEY CHILDRENS FT 28,235,940 29,990,459 1,754,519 ST HEL/KNOWS TEACH NHST 18,754,520 20,117,151 1,362,631 SPIRE HEALTHCARE LTD 12,262,311 12,364, ,584 LIVP HRT/CHST HOSP NHS FT 6,089,376 6,547, ,853 NON CONTRACT 4,254,600 4,302,315 47,715 WALTON CENTRE NHS FT 2,016,642 2,244, ,040 SOUTHPORT/ORMSKIRK NHST 1,022, ,951 (37,167) WIRRAL UNIV TEACH HOSP NHS FT 711,579 1,047, ,673 ONE TO ONE LTD 682, ,609 (9,196) WARRINGTON/HALTON NHSFT 598, ,805 (74,487) WRIGHT/WGN/LEIGH NHS FT 386, ,223 (162,979) COUNTESS OF CHESTER FT 245, , C MANC UNI HOS NHS FT 238, , ,263 FAIRFIELD INDEPENDENT HOSPITAL 219, ,109 (17,864) RENACRES HOSPITAL 211, ,089 8,199 UNI HOSP SMAN NHS FT 204, ,371 3,526 SALFORD ROYAL NHSFT 204, ,284 95,482 NHS ST HELENS CCG 0 (1,500,000) (1,500,000) SMT SAVINGS 0 (1,300,000) (1,300,000) TOTAL ACUTE COMMISSIONING 413,629, ,368,942 5,739,790 ii. Community Health Contracts The net community health commissioning forecast outturn position as at Month 9 is a 0.3m over performance consisting of contract over performance of 0.8m, and a favourable position Page 13 of 27 51

26 across intermediate / palliative and long term conditions / digital of 0.5m. With regards to Community Health Services contracts, these are over planned by 0.8m, again in line with year to date position regarding contract over performance in Spa Medica and AQP Physiotherapy & Podiatry Contracts as per the table below COMMUNITY SERVICES 2016/17 Budget ' /17 Forecast '000 Forecast Variance '000 LPOOL COMM HC NFT - SLA 66,845,993 67,849,993 1,004,000 AINTREE UNI HOSP NHS FT - Diabetes 3,640,452 3,640,452 0 LPOOL COMM HC NFT - Anticoag 2,106,108 1,110,235 (995,873) SPECSAVERS HEARCARE LTD 945, ,000 0 SPAMEDICA 350, , ,000 BPAS 235, ,000 90,000 STROKE ASSOCIATION 0 232, ,000 INJURY CARE CLINICS LTD 0 218, ,000 WIRRAL COMM NFT 0 65,000 65,000 PRIORY MEDICAL CENTRE 0 120, ,000 BOOTS HEARINGCARE LTD 0 62,000 62,000 OTHER 98,500 26,500 (72,000) TOTAL COMMUNITY 74,221,053 75,344,180 1,123,127 iii. Continuing Care Continuing Care, Health Packages (Fully / Joint Funded) and Funded Nursing Care costs are forecasted over budgeted levels by 3.6m, this is predominantly as a result of in year pressures driven by increases to domiciliary care costs and increased FNC rates as instructed during quarter one of this financial year. iv. Mental Health Contracts The net mental health commissioning forecast outturn position as at Month 9 (December), is a 1.2m over performance consistent with the year to date performance position, with regards to commitments against CAMHS and Learning Disabilities over and above planned expenditure levels. Contract areas are as per below table but are block contract values Page 14 of 27 52

27 MENTAL HEALTH CONTRACTS 2016/17 Budget ' /17 Forecast '000 Forecast Variance '000 MERSEY CARE NHST 60,003,840 60,178, ,000 MERSEY CARE NHST - IAPT 4,971,768 4,971, BOROUGHS PART NHS FT 637, ,048 (1,020) LANCASHIRE CARE NHSFT 139, ,776 0 CHESH/WIRRAL PART NHSFT 133, ,920 0 TOTAL MENTAL HEALTH 65,886,372 66,060, ,980 *Mersey Care 175k pressure consists of A&E Liaison 40k Extension (CCG share of 3 way split) and Mental Health Liaison 135k (Apr June) v. Other Programme (including Reserves) The reserves held by the CCG are as per the below table, it is important to note the treatment of the 1% non-recurrent headroom reserve with the month 9 reporting position Reserves December (M9) November October (M7) (M8) 1% Non-recurrent (*1) 8,362 8,362 8,362 Commissioning Reserve (*2 ) (2,082) (2,082) (2,082) Running Costs (*3) 1,663 1,663 1,663 Total 7,943 7,943 7,943 The assumptions regarding utilisation of reserves are as per the below points 1) 1% Non-recurrent Reserve anticipated to be released by NHS England later in financial year to remain with CCG position 2) As per below table with regards to budget and forecast outturn position of commissioning reserve Budget Forecast Outturn NPFIT 5.0m 4.6m Commissioning Reserve ( 7.4m)* ( 8.1m*) (equivalent to financial recovery plan requirements) Quality Premium Income ( 0.9m) ( 0.9m) Assumption (15/16) Other Assumptions 0.3m ( 2.1m) ( 4.4m) 3) Not anticipated to be required 53 Page 15 of 27

28 vi. Primary Care Planned expenditure in Primary Care is forecast to be overspent by 1.7m by the end of the financial year as per the table below. The forecast outturn position for Prescribing currently stands at 1.025m over performance against planned levels at the end of the financial year. This is an improvement of 214k on the forecast out turn position reported at month 8 when a forecast over performance of 1.24m was reported. The forecast position reflects a range of anticipated savings, some of which have already commenced as part of the Finance and Effectiveness Plan. The PRC Delegated Co-commissioning forecast is 3.1m above budget due to the increase in patients in 2016/17. PRIMARY CARE 2016/17 Budget ' /17 Forecast '000 Forecast Variance '000 PRESCRIBING 87,543,000 88,568,153 1,025,153 PRC DELEGATED CO-COMMISSIONING 61,793,310 64,928,749 3,135,439 LOCAL ENHANCED SERVICES 18,737,786 16,911,254-1,826,532 OUT OF HOURS 4,278,256 4,259,389-18,867 COMMISSIONING SCHEMES 3,520,144 2,992, ,769 PRIMARY CARE IT 2,470,000 2,382,105-87,895 OXYGEN 871, ,393-7,114 CENTRAL DRUGS 64,632 64,632 0 TOTAL PRIMARY CARE 179,278, ,971,051 1,692,416 d) Financial Recovery The delivery of the planned surplus position will depend on a combination of solutions as identified within the financial recovery plan as shared with NHS England. These solutions are assumed to reduce CCG forecast outturn expenditure assumptions in order to deliver the required surplus position. Phase One of the financial recovery process (as shown in the table below) initially generated circa 6.54m of adjustments to planned / likely expenditure assumptions within the financial year. 54 Page 16 of 27

29 Financial Recovery Categories Senior Management Lead In-Year Activity / Expenditure Impact Slippage Programme Deferral Acute Activity - Referral & Outpatient Reviews 300,000 Chery Mould Prescribing Expenditure ' FEP' 500,000 Chery Mould Programme Expenditure Digital agenda 1,000,000 Tony Woods Review of Healthcare Packages 240,000 Kerry Ll oyd Programme Expenditure Physical Activity 750,000 Carole Hill Winter Resilience Funding 160,000 Ian Davies Grants Programme - Year 2 Requirements 370,000 Tony Woods Inhaler Project 42,000 Tony Woods Clinical Sessions 50,000 Carole Hill CLARC Contributions 300,000 Tony Woods Excess Treatment Costs 90,000 Tony Woods GP Specification Recovery 348,000 Chery Mould Primary Care IT (gold standard) 87,000 Chery Mould 16/17 CQUINS 1,000,000 Jane Lunt Care Homes Model implementation 750,000 Tony Woods Falls / Stroke 400,000 Tony Woods Vacancy Freeze / Secondments / Fixed Term Clinical Sessions 150,000 Ian Davies 6,537,000 The table below shows the additional solutions considered as Phase 2 of the 2016/17 financial recovery process and are included within the financial recovery plan as at the end of December These additional solutions identify an additional 7.4m of potential expenditure reductions based on information as at the end of December 2016 and are required in order to deliver the forecast outturn surplus position. 55 Page 17 of 27

30 Solution Initiative Additional Target ( ) Senior Management Lead SMT Review (5% Target) 3,000,000 All SMT Contract Challenges 350,000 Derek Rothwell Demand Management 350,000 Cheryl Mould Acting As One 100,000 Katherine Sheerin Provider Contracts 500,000 Tom Jackson Prescribing Expenditure 700,000 Cheryl Mould Outturn Assumptions 1,000,000 Tom Jackson Review Contract Agreements 1,000,000 Derek Rothwell Unidentified 400,000 All SMT 7,400, As per previous months reporting, both phase 1 and 2 solutions have assumed to be delivered (or further mitigations realised to offset any non-delivery) within the forecast outturn position in line with business rules. Should these solutions not be delivered, clearly this places the CCG at risk of non-delivery of NHS England Business Planning Rules and subsequent impact upon its assurance rating. d) Risks There are a number of risks to delivery of the CCG forecast outturn position and its ability to deliver against NHS England Business Planning Rules for the 2016/17 financial year. Financial Recovery Plan Phase 1 Phase one confirmed savings as at the end of December were 5.512m as per the table below, the remaining solutions have been assessed for risk of delivery as per the RAG rating column. A number of the solutions required further clarification of savings values but remain on track for delivery, whilst others require further detailed monitoring in order to assess in year impact (e.g. referral Page 18 of 27

31 and outpatient activity, prescribing) against forecast outturn assumptions Financial Recovery Categories Senior Management Lead Confirmed Savings at End of December (M9) 16/17 Risk of Delivery as at End of December Acute Activity - Referral & Outpatient Reviews 300,000 Chery Mould 210,000 Prescribing Expenditure ' FEP' 500,000 Chery Mould 333,333 Programme Expenditure Digital agenda 1,000,000 Tony Woods 750,000 Achieved Review of Healthcare Packages 240,000 Kerry Lloyd 0 Programme Expenditure Physical Activity 750,000 Carole Hill 750,000 Achieved Winter Resilience Funding 160,000 Ian Davies 160,000 Achieved Grants Programme - Year 2 Requirements 370,000 Tony Woods 370,000 Achieved Inhaler Project 42,000 Tony Woods 42,000 Achieved CLARC Contributions 300,000 Tony Woods 300,000 Achieved Excess Treatment Costs 90,000 Tony Woods 80,000 Achieved GP Specification Recovery 348,000 Chery Mould 348,000 Achieved Primary Care IT (gold standard) 87,000 Chery Mould 87,000 Achieved 16/17 CQUINS 1,000,000 Jane Lunt 618,968 Achieved Care Homes Model implementation 750,000 Tony Woods 863,089 Achieved Falls / Stroke 400,000 Tony Woods 400,000 Achieved Vacancy Freeze / Secondments / Fixed Term Clinical Sessions 200,000 Ian Davies/Carole Hill 200,000 Achieved 6,537,000 5,512,390 Page 19 of 27 57

32 Phase 2 Phase Two potential savings identified additional solutions of 7.4m of potential expenditure reductions are required in order to deliver the forecast outturn surplus position. As per the table below, based on information at the end of December 2016, approximately 2.64m of the 7.4m was identified as part of the financial recovery discussions. Further work is required in order further progress detailed project initiation documents and gain further confidence in successful implementation of savings assumptions for the financial year. Additional Solution Additional Target Confirmed Savings End of December 2016 Identify Additional opportunities (Slippage / Deferral / Cease Expenditure on BAU) through SMT Reviews (Nov-December) 3,000, m confirmed as per reviews conducted to end of November (Digital, Primary Care / Corporate, Integrated) Contract Challenges 350, m challenges re specialised drugs included within CCG billing Demand Management 350,000 Targeting Referrals & AQP Activity for Q4 Acting As One 100,000 Targeting Devices / Drug Pass through Costs for Q4 Provider Contracts 500,000 Liverpool Women's 0.4m discussion continue with other providers during December Prescribing Expenditure 700,000 Impact on December March Prescribing Expenditure ( 0.2m Inhaler Project, 0.04m Rebates) Outturn Assumptions 1,000,000 NHS Property Services re Void Costs 0.2m, Resolution of Prior Year Issues (LCH 0.2m) Review Contract Agreements 1,000,000 EPR Contract (NPFIT), Grant Agreements Unidentified 400, Page 20 of 27

33 7,400, m Summary of CCG Financial Risks to delivery At month 9 reporting, the equivalent 7.4m additional solutions required have increased to 8.1m due to in month over performance against areas as outlined in this report. In order to deliver the planned surplus position, the below table shows the level of mitigations required at each relevant reporting point. These are referred to as solutions as per financial recovery plan. Planning Gap Month 6 Increase to 1% + 1% Month 7 Acute Contracts Other Net Month 7 Movements Month 7 Acute Contracts (Royal M7 & NCA s) Mental Health Packages Quality Premium (15/16) Month 8 Month 9 3.4m 2.0m 1.6m 0.4m 7.4m ( 5.4m like for like on basis of 14.4m surplus) 1.1m 0.4m ( 0.8m) 8.1m 8.1m This CCG financial outturn position assumes that the full value of phase 1 and 2 are delivered and that there are no further adverse movements in forecast outturn positions beyond the month 8 reporting position. Budget holder meetings are still taking place during December to review financial assumptions as part of Phase 2 Recovery plan approach and to revise unidentified recovery plan elements (was 0.4m, now 1.1m due to month 8 operational pressures increase) February Update Based on information available at the beginning of february (Month 10 Financial Position is still being calculated at the time of writing) it would appear that the likelihood of the CCG delivering the target 59 Page 21 of 27

34 surplus position of 1% + 1% (cumulative 16.4m surplus) has decreased. Early indications being that there has been increases to a range of healthcare expenditure areas (including secondary care, prescribing, mental health / learning disability packages costs) together with lower than anticipated impact of the CCG financial recovery solutions as per phase II of its plans for the financial year A full report will be produced for month 10 reporting to finance, procurement and contracting committee s as per normal timescales. Based on early forecast assumptions and in line with risk adjusted positions submitted to NHS England, the CCG s expectation is that the overall position (including the 1% headroom) will be closer to a 1% surplus but with a number of outturn assumptions still being queried at this stage with partners there does remain an element of risk to delivery. Potential Forecast Outturn position range from a 6m to 10m surplus depending upon the final values and again further information will be provided as part of normal month 10 reporting arrangements. e) Statement of Financial Position The table below shows the statement of financial position for the CCG as at December 2016 including relevant assets and liabilities. Dec-16 Nov-16 Total Non-Current Assets 0 0 Cash 59, ,500 Accounts Receivable 10,582,186 7,726,560 Current Assets 10,642,164 7,827,060 TOTAL ASSETS 10,642,164 7,827,060 Accounts Payable 73,740,655 51,095,971 Total Current Liabilities 73,740,655 51,095,971 Retained Earnings incl. In Year -63,098,490-43,268,910 Total Taxpayers Equity -63,098,490-43,268,910 TOTAL EQUITY + LIABILITIES 10,642,165 7,827, Cash Target Page 22 of 27

35 The target for the month of December 2016 was achieved with a cash balance of 59k at the end of the month below the 1.25% target % Cash Target 10.00% 8.00% 6.00% 4.00% Target Actual 2.00% 0.00% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 f) Better Payment Practice Code Under the Better Payments Practice Code (BPPC), CCG s are expected to pay 95% of all creditors within 30 days of the receipt of invoices. Under the Better Payments Practice Code (BPPC), CCG s are expected to pay 95% of all creditors within 30 days of the receipt of invoices. The December 16 year to date figure shows that this target was achieved for NHS and NON NHS for Values and NON NHS for Number of invoices. The target for December 16 on NHS (number) was not achieved at 93.94% (Oct %), and still not for the year to date due to the impact of prior months, as previously reported. Action to improve performance has been implemented and it is anticipated that the target for 2016/17 will be achieved. 61 Page 23 of 27

36 6. STATUTORY REQUIREMENTS (only applicable to strategy & commissioning papers) 6.1 Does this require public engagement or has public engagement been carried out? Not Applicable 6.2 Does the public sector equality duty apply? Yes/no. Not Applicable 6.3 Explain how you have/will maximise social value in the proposal: describe the impact on each of the following areas showing how this is constructed to achieve the most: a) Economic wellbeing b) Social wellbeing c) Environmental wellbeing Not Applicable 6.4 Taking the above into account, describe the impact on improving health outcomes and reducing inequalities Not Applicable 7. DESCRIBE HOW THIS PROMOTES FINANCIAL SUSTAINABILITY Supports the achievement of Statutory Financial Duties. 8. CONCLUSION The purpose of this report is to provide the Governing Body with an update on the CCG s financial performance against its planned surplus and elements of business planning rules for 2016/17, particularly regarding the amendments in respect of 1% nonrecurrent headroom. Tom Jackson Chief Finance Officer 7 th February Page 24 of 27

37 Appendix One Year to Date Budget Performance as at December 2017 Annual Year to Date Year to Date Year to Date Forecast Forecast Budget Budget Actual Variance Variance 000's 000's 000's 000's 000's 000's ACUTE ACUTE COMMISSIONING 413, , ,123 3, ,369 5,740 ACUTE NCAS/OATS 3,231 2,423 3, , ACUTE END OF LIFE ACUTE COLLABORATIVE COMMISSIONING 0 0 (0) (0) 0 0 ACUTE HIGH COST DRUGS (93) 242 (93) ACUTE WINTER RESILIENCE (48) (291) 170 (154) ACUTE TOTAL 417, , ,279 3, ,312 5,793 COMMUNITY HEALTH SERVICES COMMUNITY SERVICES 74,221 56,369 57, ,344 1,123 COMMUNITY HEALTH SERVICES INTERMEDIATE CARE 9,961 7,695 7, , COMMUNITY HEALTH SERVICES PALLIATIVE CARE COMMUNITY HEALTH SERVICES CARERS COMMUNITY HEALTH SERVICES HOSPICES 3,837 2,840 2,833 (7) 3,777 (59) COMMUNITY HEALTH SERVICES LONG TERM CONDITIONS 5,735 4,302 3,426 (875) 4,970 (765) COMMUNITY HEALTH SERVICES TOTAL 94,540 71,790 72, , CONTINUING CARE FUNDED NURSING CARE 4,424 3,318 4,670 1,352 6,227 1,803 CONTINUING CARE CHC ADULT FULLY FUNDED 20,242 15,303 16,739 1,437 21,936 1,694 CONTINUING CARE CHC CHILDREN 4,090 3,068 2,990 (78) 3,938 (153) CONTINUING CARE CONTINUING HEALTHCARE ASSESSMENT & SUPPORT (30) 328 (30) CONTINUING CARE CHC ADULT JOINT FUNDED 2,258 1,692 1, , CONTINUING CARE TOTAL 31,372 23,649 26,553 2,904 35,014 3,642 MENTAL HEALTH CHILD AND ADOLESCENT MENTAL HEALTH 1,501 1,235 2, ,688 1,188 MENTAL HEALTH LEARNING DIFFICULTIES 3,852 2,889 3, , MENTAL HEALTH MENTAL HEALTH SERVICES - OTHER 1, ,146 (15) MENTAL HEALTH MENTAL HEALTH CONTRACTS 65,886 49,285 49, , MENTAL HEALTH DEMENTIA

38 MENTAL HEALTH MENTAL HEALTH SERVICES - ADVOCACY MENTAL HEALTH MENTAL CAPACITY ACT MENTAL HEALTH MENTAL HEALTH SERVICES - COLLABORATIVE COMMISSIONING MENTAL HEALTH MENTAL HEALTH SERVICES - NOT CONTRACTED ACTIVITY (53) 201 (62) MENTAL HEALTH MENTAL HEALTH SERVICES - ADULTS 5,206 3,904 4, , MENTAL HEALTH MENTAL HEALTH SERVICES - OLDER PEOPLE 2,980 2,235 1,511 (725) 2,007 (973) MENTAL HEALTH TOTAL 81,454 61,064 62,241 1,177 82,838 1,384 OTHER EXCEPTIONS & PRIOR APPROVALS 3,188 2,391 2, ,099 (89) OTHER COMMISSIONING - NON ACUTE 14,635 10,976 11, , OTHER REABLEMENT 2,626 1,969 2, , OTHER NHS 111 1,563 1,173 1,168 (5) 1,391 (172) OTHER PATIENT TRANSPORT OTHER RECHARGES NHS PROPERTY SERVICES LTD 5,650 4,238 3,650 (587) 4,867 (783) OTHER QUALITY PREMIUM PROGRAMME (655) 0 (873) OTHER SAFEGUARDING 1, (29) 978 (33) OTHER CLINICAL LEADS 1,563 1,142 1,061 (81) 1,483 (80) OTHER PROGRAMME PROJECTS 1,618 1, (255) 1,271 (347) OTHER COUNSELLING SERVICES 1, (165) 689 (311) OTHER NON RECURRENT PROGRAMMES (162) 81 (219) OTHER NON RECURRENT RESERVE 8, ,362 0 OTHER COMMISSIONING RESERVE (2,083) 3,563 0 (3,563) (5,126) (3,043) OTHER TOTAL 40,309 29,056 24,357 (4,699) 35,192 (5,116) PRIMARY CARE PRC DELEGATED CO-COMMISSIONING 61,793 46,345 49,006 2,661 64,929 3,135 PRIMARY CARE PRESCRIBING 87,543 65,659 67,336 1,678 88,568 1,025 PRIMARY CARE OUT OF HOURS 4,278 3,209 3,195 (14) 4,259 (19) PRIMARY CARE OXYGEN (7) PRIMARY CARE CENTRAL DRUGS (3) 65 0 PRIMARY CARE PRIMARY CARE IT 2,470 1,853 1,787 (65) 2,382 (88) PRIMARY CARE COMMISSIONING SCHEMES 3,520 2,627 2,222 (405) 2,992 (528) 64 Page 26 of 27

39 PRIMARY CARE LOCAL ENHANCED SERVICES 18,738 14,053 12,464 (1,589) 16,911 (1,827) PRIMARY CARE TOTAL 179, , ,716 2, ,971 1,692 PROGRAMME COSTS TOTAL 844, , ,279 5, ,725 8,252 RUNNING COSTS ESTATES AND FACILITIES RUNNING COSTS INNOVATION FUND RUNNING COSTS OPERATIONS MANAGEMENT RUNNING COSTS COMMISSIONING (2) RUNNING COSTS COMMUNICATIONS & PR (2) 122 (18) RUNNING COSTS STRATEGY & DEVELOPMENT (2) 52 (2) RUNNING COSTS FINANCE 1, (27) 971 (54) RUNNING COSTS ADMINISTRATION & BUSINESS SUPPORT (19) 786 (24) RUNNING COSTS CEO/ BOARD OFFICE 2,259 1,694 1, ,231 (28) RUNNING COSTS CONTRACT MANAGEMENT RUNNING COSTS BUSINESS INFORMATICS 1, (118) 978 (143) RUNNING COSTS CORPORATE COSTS & SERVICES 1,922 1,442 1,382 (60) 1,823 (99) RUNNING COSTS GENERAL RESERVE - ADMIN 1,663 1,256 0 (1,256) 0 (1,663) RUNNING COSTS TOTAL 10,617 7,966 6,640 (1,326) 8,776 (1,841) 855, , ,919 4, ,500 6,410 CONFIRMED (803,160) (602,345) 0 (602,345) 0 (803,160) POTENTIAL (66,357) (49,768) 0 (49,768) 0 (66,357) ALLOCATIONS (869,517) (652,113) 0 (652,113) 0 (869,517) 65 Page 27 of 27

40 66

41 Report no: GB NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY TUESDAY 14 TH FEBRUARY 2017 Title of Report Lead Governor Senior Management Team Lead Report Author Summary Recommendation Relevant standards/targets CCG Corporate Performance Report February 2017 Dr Nadim Fazlani Ian Davies, Chief Operating Officer Stephen Hendry, Senior Operations and Governance Manager The purpose of this paper is to report to the Governing Body the areas of the CCG s performance in terms of its delivery of key NHS Constitutional measures, quality standards/performance and financial targets for November 2016 and December That Liverpool CCG Governing Body: Notes the performance of the CCG in the delivery of key national performance indicators and the recovery actions taken to improve performance; Determines the level of assurances given in terms of mitigating actions where risks to CCG strategic objectives are highlighted. CCG Improvement and Assessment Framework 2016/17; Delivering the Forward View: NHS planning guidance 2016/ /21; NHS England/NHS Improvement Strengthening Financial Performance & Accountability in 2016/17 Page 1 of 63 67

42 CCG CORPORATE PERFORMANCE REPORT (FEBRUARY 2017) 1. PURPOSE The purpose of this paper is to report to the Governing Body the areas of the CCG s performance in terms of its delivery against key NHS Constitutional measures, NHS Planning Guidance 2016/17, quality standards/performance and financial targets for November 2016 and December RECOMMENDATIONS That Liverpool CCG Governing Body: Notes the performance of the CCG in the delivery of key national performance indicators and the recovery actions taken to improve performance; Determines if there are acceptable levels of assurances given in terms of mitigating actions where risks to CCG strategic objectives are highlighted. 3. BACKGROUND The CCG is held to account by NHS England for corporate performance against delivery of key indicators as defined in the CCG Improvement and Assessment Framework 2016/2017. The new framework supports the NHS Planning Guidance for 2016/17 and aligns key objectives and priorities for the NHS for the financial year; linking heavily to Sustainability and Transformation Plans (STP) and the triple aim of improving the health and wellbeing of the population. Under the Improvement and Assessment Framework 2016/17 CCGs will be rated in 29 areas (underpinned by 60 indicators) which are located in four domains: 68 Better Health - how the CCG is contributing towards improving the health and wellbeing of its population and bending the demand curve; Better Care - care redesign, performance of constitutional standards and outcomes; Sustainability - how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends; Page 2 of 63

43 Leadership - assesses the quality of the CCG s leadership, the quality of its plans, how the CCG works with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity (for example in managing conflicts of interest) For the first time patients are now able to view their CCG s ratings on the mynhs website (part of the NHS Choices web resource). Ultimately, the CCG has to be assured that the services we commission are delivering the required NHS Constitutional and quality standards and meet the local system priorities for 2016/17. This is largely achieved through the now well established governance frameworks and committee structures in place which monitor performance and provide assurances to the Governing Body that key risks to strategic objectives and operational delivery continue to be effectively managed. The reporting of quarterly indicators and analysis against key NHS/Public Health/local outcomes to the Governing Body will continue in 2016/17 with the aim of aligning reporting requirements and measurements with the key Healthy Liverpool Programme (HLP) areas of transformation. Due to the way in which these indicators are currently measured, reporting for the majority of these data sets will be on a quarterly and/or annual basis, by exception or as and when key data is made available. The timing of some data flows continue to impact on corporate reporting schedules and this report updates the Governing Body with a combination of performance data from November 2016 and up to the end of December Headline commentary is provided below to draw the Governing Body s attention to specific areas of performance which represent risks to delivery, and to the relevant assurances on internal control measures in place to mitigate those risks. 4. BETTER CARE DOMAIN - NHS CONSTITUTIONAL MEASURES NHS Liverpool CCG is committed to ensuring that performance against constitutional measures and outcomes is consistently and rigorously maintained. Although not all of the indicators within the Better Care domain will be reflected in the Corporate Performance Reports for 2016/17, NHS England aims to develop operational support tools to support CCGs (and NHS England s local teams) to identify trends, 69 Page 3 of 63

44 outliers and enable a more thorough analysis of the CCG Improvement Assessment Framework (CCG IAF) indicators which will form an integral part of future reporting. 4.1 Elective Access & Waiting Times During 2016/17 achievement of recovery milestones for access standards is a priority. Standards relating to A&E and ambulance waits, referral to treatment, 62-day cancer waits (including securing adequate diagnostic capacity) along with mental health access standards account for four of the nine National must dos which every local system is expected to achieve for the financial year Good Performance Referral to Treatment (52 Weeks) Indicator Referral to Treatment Incomplete pathway (52 Weeks) RED TREND Narrative Mandate: no-one waits more than 52 weeks to receive treatment from the date of referral There were 0 (zero) Liverpool CCG patients reported to be waiting over 52 weeks in December Year-to-date Liverpool CCG has reported a total of four patients waiting up to 52 weeks (all of whom have now been treated). At provider catchment level, the latest published data available is for November 2016 which again reports as 0 (zero) patients waiting 52 weeks or over. Assurance on CCG Control Measures Liverpool CCG will continue to robustly monitor any breaches which occur against the 52 week RTT standard Areas for Improvement Diagnostic Waiting Times Indicator Diagnostics - % patients waiting 6 weeks or more for a diagnostic test RED TREND Narrative Mandate: no-one waits more than 6 weeks for a diagnostic test from the date of referral Liverpool CCG failed the 1% standard for December 2016 with performance at 3.02% (this represents the poorest performance reported during 2016/17). As at December 2016, there were 195 patients waiting over 6 weeks, 10 of which were over 13 weeks. 159 (81.5%) of the patients waiting in excess of 6 week waiters were in endoscopy. Analysis of the CCG position at provider level shows that Page 4 of 63 70

45 performance is predominantly affected by the Royal Liverpool Hospital (153 breaches) with Aintree University Hospital reporting 28 breaches of the standard. A further analysis of the +13 week waiters shows that five are at the Royal Liverpool Hospital (all endoscopy); four are at Central Manchester Hospital (in physiological measurements in echocardiography) whilst a further 13-week case has been reported by Liverpool Women s Hospital ( urodynamics ). In terms of year-to-date position (April to December 2016) the CCG remains compliant with the 1% standard with performance at % At provider catchment level, the latest published data available is for November The Royal Liverpool Hospital failed to achieve 1% standard in November with performance at 1.165%. In total, there were 48 patients waiting longer than the 6-week national standard (comprised of 21 in gastroscopy and 21 colonoscopy). The Trust has cited capacity issues (particularly in endoscopy) as the main as the main issues in achievement of the diagnostics target Liverpool Women s Hospital also failed the diagnostics target in November with performance at 1.44%. In total there were 9 patients that waited longer than the standard. All breaches were in urodynamics and have been attributed to a lack of capacity to perform cystometries. The Trust has confirmed that a new consultant has taken up post and another consultant s time has been freed up in order to increase capacity in this area and reduce waiting times. All other Liverpool Providers achieved the standard in November Assurance on CCG Control Measures In terms of the Royal Liverpool Hospital, a lack of capacity remains the primary reason for endoscopy breaches and the Trust is developing a business case to address this shortfall. The Trust is also pressing ahead with a number of initiatives to increase capacity within the endoscopy service, which includes in-sourcing support from Medinet (a company working alongside NHS organisations to improve waiting times). If successful, this could remove the backlog potentially within 3-4 months. The possible outsourcing of activity to other acute trusts so far has been unsuccessful, with both Aintree Hospitals and Whiston Hospital declining to take on the additional work. Liverpool CCG continues to work with the Trust to analyse demand, with plans underway to focus on Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS) pathways which aim to reduce endoscopy demand for those patients who ultimately end up with an IBS diagnosis. 71 Page 5 of 63

46 4.1.3 Areas for Improvement - Patients waiting 18 weeks or less from referral to hospital treatment (Incomplete Pathways) Indicator Referral to Treatment Incomplete pathway (18 Weeks 92% target) RED TREND Narrative The NHS Constitutional Standard which stipulates that over 92% of patients on non-emergency pathways do not wait in excess of 18 weeks from referral to treatment (including patient choice) is also one of the National must dos for 2016/17 and a key component of how the local system will reduce unwarranted variation between CCG referral rates to better manage demand. At CCG level the 92% standard was not met in December 2016 with performance reported at 90.9%. This also represents a decline in performance from November s position of 91.6%. Although the target was marginally missed in December by 1.1% the CCG has received an overall red rating against this key constitutional measure for the month. As at December 2016 there were 2703 patients waiting over 18 weeks, with 166 patients within this cohort waiting over 36 weeks. Specialties with the largest volumes of long waiters (+18 weeks) were General Surgery (526), Trauma & Orthopaedics (541) and Ophthalmology (554). The cumulative year-to-date performance currently stands at 91.81%. At provider level, the latest available published data is for November 2016 which shows performance across the catchment area as generally sub-par. The Royal Liverpool Hospital failed to achieve the 92% standard in November 2016 with performance at 89.94% (although this is a marginal improvement in performance from the 89.84% reported by the Trust in October 2016). Performance in November equates to 2,809 patients waiting over 18 weeks for treatment. As has been the case during the latter half of 2016, the poorest performance against the standard are within General Surgery (82.8%), Trauma & Orthopaedics, (82%) and Oral Surgery (86%). Early indications for December 2016 suggest that RTT performance has fallen to 88.72%, although this will obviously be confirmed in the March 2017 Performance Report. Overall issues affecting Trust performance continue with familiar themes of large numbers of medical outliers who are ready for discharge, lack of resources to staff waiting list initiatives, planned additional theatre session and a lack of beds. In addition, there has been numerous cancellations of elective admissions due to the high escalation status of the hospital with particularly long waits emerging for highly specialist services. Page 6 of 63 72

47 Longer diagnostic waits are also having a negative impact on the achievement of the RTT standard. The Trust is also undertaking a full capacity and demand exercise within the next 10 weeks across the all specialities to fully understand the position and has submitted a request to access some of the additional funding available for RTT from NHS England. A provisional allocation of 339k is to be used in General Surgery (colorectal) and T&O (hip and knee replacements) as NHS England have stipulated that the additional allocation is to be used to outsource activity and not to fund waiting list initiatives. The provider will also utilise some of this funding to validate the waiting list and contact all patients and ensure they are still want surgery and are fit for surgery. Aintree University Hospital also failed to achieve the 92% standard in November with performance at 90.21% (a slight improvement on October 2016 performance of 89.2 %). This equates to 1630 patients waiting over 18 weeks for treatment. The specialties within the Trust which are delivering the poorest performance against the standard are Dermatology (22.6%), Ophthalmology (81.9%) and Oral Surgery (75.7%). Nationally the performance for November 2016 is 90.5%. Assurance on CCG Control Measures CCG continues to support and facilitate the relationship between the Royal Liverpool and Spire Liverpool and has actively encouraged the Trust to out-source activity wherever possible. A programme of peer review in relation to referrals has commenced in primary care (review prior to the decision to refer) alongside of which the CCG is considering a referral management service for key specialities. The CCG is working closely with providers and General Practices in Liverpool to reduce Gastroenterology referrals through improved pathways and better primary care management. The CCG has also reviewed Ophthalmology pathways with the aim of reducing post-operative follow ups in a hospital setting and utilising the capacity within community ophthalmic services (which is actually in line with best practice). The Royal Liverpool s overall recovery plan for RTT continues to be rigorously monitored both internally by the provider and by the CCG, with regular monthly meetings taking place to assure delivery of optimal performance. Additional monies for RTT have recently been made available by NHS England and LCCG has encouraged the Royal Liverpool (and other local providers) to apply. 73 Page 7 of 63

48 4.2 Cancer Waiting Times Good Performance All Cancer Measures Indicator Narrative Cancer Waiting Times The CCG achieved all nine cancer standards in November This represents a real positive in terms of performance against TREND cancer waiting times, with the CCG achieving across all nine GREEN indicators both in-month and year-to-date. Performance against the specific measures are summarised below: % Patients seen within two weeks for an urgent GP referral for suspected cancer LCCG achieved 97.59% against a target of 93% At provider level, only Alder Hey failed to meet the 93% standard with performance reported at 87.5%. However, in patient terms this equated to one breach (Dermatology) and in this particular case the patient was inappropriately triaged. % of patients seen within 2 weeks for an urgent referral for breast symptoms LCCG achieved 96.33% against a target of 93% % of patients receiving definitive treatment within 1 month of a cancer diagnosis LCCG achieved 98.96% against a target of 96% At provider level, Liverpool Heart and Chest Hospital failed to meet this standard with performance reported at 92.86% against the 96% standard. A total of 3 patients waited over 31 days in this period % of patients receiving subsequent treatment for cancer within 31 days (Surgery) LCCG achieved 100% against a target of 94% % of patients receiving subsequent treatment for cancer within 31 days (drug treatment) LCCG achieved 100% against a target of 98% % of patients receiving subsequent treatment for cancer within 31 days (radiotherapy treatment) LCCG achieved 98.98% against a target of 94% % of patients receiving 1st definitive treatment for cancer within 2 months (62 days) LCCG achieved 88.63% against a target of 85%. Year-to-date the CCG remains above the 85% target with 74 Page 8 of 63

49 performance at 86.3% At provider level, Liverpool Women s failed to meet this standard with performance reported at 83.78% against the 85% target. In total there were three patients who waited longer than 62 days, all of whom were complex cases and were treated in the same month. % of patients receiving treatment for cancer within 62 days from an NHS Cancer Screening Service LCCG achieved 90.91% against a target of 90%. At provider level, Liverpool Women s failed to meet this standard with performance reported at 83.33% against the 90% target. In total there were 0.5 patient breaches that were due to 1 complex patient, whose management plan changed during pathway. % of patients receiving treatment for cancer within 62 days upgrade their priority CCG achieved 87.5% against a local target of 85%. At provider level, Liverpool Heart and Chest Hospital failed to meet this standard with performance reported at 75% against the 85% standard 4.3 Urgent & Emergency Care Areas for Improvement - Ambulance Waits Indicator Ambulance Response Times ( Red Response Rates) RED TREND Narrative Ambulance activity has remained high up to the end of December Overall incident growth in the city has actually slowed, with a fall of 2.1% in the number of incidents in December against plan. This compares very favourably with the higher 1.2% increase in incidents for the North West overall during the month. Red activity has, however continued to be above plan and expected levels, although we have seen a reduction in growth to 4.1% in December compared to the 6.3% in October, with the North West 7.8% above plan in-month. Performance in December 2016 has remained significantly challenged as a result of Red demand and continued lengthening of hospital turnaround delays showing little improvement. Consequently, performance in Liverpool remains challenged with none of the three national targets met in month, Page 9 of 63 75

50 although cumulatively (year-to-date) Red 1 performance is still being met: December 2016: - Red 1: 8-minute response 67.21% against 75% target (remains above North West performance of 61.63%); Red 2: 8-minute response 63.53% against 75% target (remains above North West performance of 57.31%); All Reds: 19-minute response 87.92% against 95% target (remains above North West performance of 85.42%) Despite the higher than planned number of incidents the service continues to make good progress in reducing conveyance to hospital, with the following December performance seen in Liverpool: 'Hear & Treat' is at 14.73%; 'See & Treat' at 22.09% and 'See & Convey' at 63.18% of incidents, with a continuation of the reducing trajectory planned through the year for the numbers of people conveyed to hospital. Assurance on CCG Control Measures There is no doubt that performance continues to be disappointing with the three national performance measures not being met (a situation mirrored across most of England). Demand for the emergency ambulance service continues to be at unprecedented levels and significantly above the previous annual average growth of circa 2.5%. The actual distance from the national targets for performance in the city, i.e. the time after the national targets at which they are met is as follows: In December 2016 Red 1 was met at 9 mins 15 secs; Red 2 at 11 mins; and all Reds A19 at 34 mins. The length of these performance tails are closely monitored to assess the impact of any worsening performance. In response to the continuing pressures commissioners have agreed a remedial action plan to seek to recover Red performance and in particular reduce the significant variation between CCGs. These initiatives include the following areas of action: Managing handover & turnaround targeted intervention at poorly performing Trusts including the development of surge management plans, with stepped escalation; enhanced senior management presence in the Regional Health Control Desk to provide tactical oversight; and further joint work supported by ECIP; Health Care Professional Bureau the introduction of a bureau function to improve the assessment of HCP referrals and direct the most appropriate resources to match individual s needs. High volume Nursing Home referrals - targeted intervention including the offer of staff training and train the trainer initiatives to help educate and inform home staff as to the most appropriate use of ambulance resources, targeted at 47 high volume users across the North West; Management of inter hospital transfers further development and roll out of a transfer matrix to successfully manage inter facility transfers, considering patient acuity, urgency and the cohorting of patients as a means of better utilising available resources; Clinical Assessment Service (previously known as the Integrated Virtual Clinical Hub) further expansion and development of the CAS to increase the availability 24/7 of 76 Page 10 of 63

51 additional clinical support to 111 and 999 calls and frontline staff, with the intention of further increasing hear & treat and also conveyance to AED alternatives, where available Areas for Improvement: Percentage of patients admitted, transferred or discharged from A&E within 4 hours Indicator A&E Waits - % of patients who spend 4 hours or less in A&E (cumulative) 95% threshold RED TREND *CCG performance is calculated based on CCG A&E mapping table produced by NHS England. Provider activity described relates to Royal Liverpool Hospital, Liverpool Women s Hospital, Alder Hey Children s Hospital and Aintree Hospital. Narrative Liverpool CCG continues to underperform against the 95% A&E target (all types) with November 2016 performance showing that 88.53% of patients spent less than 4hrs in A&E against the national standard of 95% (all types). This represents the lowest performance point of 2016/17 and a further decline on October 2016 performance at 90.1%. The 2016/17 year-to-date position for LCCG currently stands at 90.08%. November 2016 performance at provider level shows that the Royal Liverpool Hospital (87.67%), Aintree University Hospital (81.10%) and Alder Hey (91.66%) all failed the 95% threshold (all types). Only Liverpool Women s Hospital achieved the monthly target in November 2016 (99.52%). In England, only 11 out of the total 138 trusts achieved the Type 1 A&E performance standard of 95% during the month of November. The average national performance for November 2016 was 82.7 % for Type 1 and 88.4% for all types. Analysis of Type 1 activity enables a closer focus on the site specific issues of A&E Departments and is considered the true marker of a trust s performance against the 95% standard. The aggregation of Type 2 (Trust specific) and Type 3 activity (e.g. Walk-in Centre services) with Type 1/site specific performance therefore can present an inaccurate picture of a provider s position. The Royal Liverpool includes both Type 2 and Type 3 A&E attendances in its performance analysis whilst Aintree Hospital has only Type 3 activity to aggregate with site specific A&E performance. Alder Hey, however, only counts Type 1 performance in its activity. The year-to-date position for Liverpool trusts who provide Type 1 activity sees both the Royal Liverpool and Aintree continuing to fail the national 4-hour target, as illustrated in the table below: Page 11 of 63 77

52 Even when aggregating Type 2 and Type 3 activity both the Royal Liverpool and Aintree Hospitals are still some way short of the 95% target. Assurance on CCG Control Measures Achievement of the 4hr A&E target remains a priority, although the urgent care system has been under consistent pressure since December 2016 which will be reflected in the March 2017 Performance Report. The findings of the Emergency Care Improvement Programme (ECIP) system diagnostic, which encompassed both Acute Trusts have been formally received by the CCG and will be presented at the February 2017 CCG Governing Body meeting. ECIP will continue to support delivery of sustainable improvement in performance with responsibility for the implementation and oversight of the action plan (resulting from the system-wide diagnostic) falling under the remit of the North Mersey AED Delivery Board. The main areas of focus for the action plan include: System leadership; Assessment prior to admission; Doing today s work today, and; Discharge to assess Type 1 Type 2 Type 3 Total performance. Alder Hey Children s Hospital 95.17% 95.17% Aintree Hospital 71.89% % 85.52% Liverpool Women s Hospital 98.47% 98.47% Royal Liverpool Hospital 74.57% 99.79% % 90.05% Maintaining the system-wide focus, all partners continue to explore actions to relieve service pressures and enable consistent flow throughout hospitals. Some important steps have included commissioning additional capacity in Intermediate Care, supporting Community Equipment and domiciliary provision, the roll out of the Home First scheme (which is discussed in more detail in Section 8 (8.5.2) of this report) and further actions to reduce ambulance conveyance to AED. As previously discussed the matter of 4-hour performance is a symptom very much of whole system pressures and solutions lie in that whole system working together to transform the way in which urgent and emergency care is both perceived and used by the public. Through the AED Delivery Board and with the support of ECIP we aim to make sustainable performance improvements in 2017/18 through acting as one and changing the way in which our services are provided and delivered. 78 Page 12 of 63

53 5. BETTER CARE - MENTAL HEALTH 5.1 Good Performance Dementia Diagnosis Indicator Estimated Dementia Diagnosis: % of people aged over 65 GREEN TREND Narrative LCCG continues to achieve the Dementia Diagnosis measure with performance reported at 75.9% against the 70% target in December Although this is a slight decline on November s performance of 76.4%, LCCG achievement of the standard has been consistently positive during 2016/ Good Performance Early Intervention in Psychosis (EIP) Indicator Proportion of people experiencing first episode psychosis (FEP) or an at risk mental state that wait 2 weeks or less to start a NICE recommended package of care GREEN TREND Narrative Liverpool CCG performance against the EIP measure saw 75% of patients treated within 2 weeks of referral for first episode psychosis against the 50% standard during November At provider level, Mersey Care achieved 75% in November 2016 against the 50% standard. Nationally, the proportion of people treated within the 2-week standard was 77.6%. Analysis at CCG level of patients on incomplete pathways shows 76% of patients waiting over 2 weeks as at the end of November This equates to 32 out of 42 patients who are still waiting to start treatment and who had already waited over the 2- week standard. At provider level (Mersey Care) 67.8% of patients were reported as waiting over 2 weeks as at the end of November. This equates to 38 out of 56 patients still waiting to start treatment having already waited over 2 weeks. Nationally, the percentage of people who were still waiting over 2 weeks at the end of November was 50.4%. Page 13 of 63 79

54 5.1.3 Good Performance - Proportion of Patients on Care Planned Approach (CPA) Indicator Proportion of patients on (CPA) discharged from inpatient care who are followed up within 7 days GREEN TREND Narrative For Quarter 2 (1 st July 30 th Sept 2016) Liverpool CCG continues to achieve the 95% standard with performance reported at 96.4%. Quarter 2 data at provider level shows that Mersey Care's performance for the period was 97.2% against the 95% standard Good Performance Improving Access to Psychological Therapies (IAPT) 6-week and 18-week Referral to Treatment Indicator % of patients who received their first treatment appointment within 6 weeks **National data GREEN TREND Narrative National data for October 16/17 for the percentage of patients who received their first treatment appointment within 6 weeks of referral is % against a target of 75%. Performance throughout 2016/17 is on an upward trajectory and is significantly above the 75% target The YTD position is currently reported at 85.5% % of patients who received their first treatment within 18 weeks **National data GREEN TREND National data for October 16/17 for percentage of patients who received their first treatment within 18 weeks of referral is 96.64% against a target of 95%. Performance over the last quarter has improved significantly, and for the last 3 months the CCG has achieved the 95% target YTD performance is currently reported at 92.58% Page 14 of 63 80

55 5.1.5 Areas for Improvement - IAPT Access & Recovery (Quarterly Measures) Indicator IAPT (Access) -% of people who receive psychological therapies (Quarterly Measure 3.75%) Narrative National performance for Quarter 2 (July to Sept 2016) shows that the CCG as performing below the target of 3.75% with performance at 2.70% (a small decline in performance on the Q1 position of 2.9%). RED TREND The indicator is measured nationally using financial quarters (the period also used for CCG assessment) although national data is also published based on rolling quarters. Data reported in the dashboard relates to national quarterly performance data. IAPT (Recovery) - % of people who finish treatment having attended at least two treatment contacts and are moving to recovery **National data RED TREND The latest rolling quarter data is for the period Aug to Oct 2016 states performance to be 2.7% and there is no change on Q2 performance levels. Due to the publication of national data being several months behind, this indicator is also monitored using local data supplied by the provider in order to present a more current position Based on local data submitted for the latest rolling quarter (Oct, Nov and Dec 2016) the CCG remains below the standard of 3.75% with performance at 2.4%. National performance for Quarter 2 (July to Sept 2016) shows that the CCG is performing some way below the 50% target at 33.6%. Similar to the access indicator above, this represents a decline on the Q1 position of 34.8%. The indicator is measured nationally using financial quarters (the period also used for CCG assessment), however national data is also published based on rolling quarters. The latest rolling quarter data is for the period Aug to Oct 2016 and shows performance to be 32.8%. Again, this is a decline in performance compared to Q2 levels. Due to the publication of national data being several months behind, this indicator is also monitored using local data supplied by the provider in order to present a more current position Based on the local data submitted for the latest rolling quarter (Oct, Nov and Dec 2016) the CCG remains significantly below the standard of 50% with performance at 31.5%. Assurance on CCG Control Measures At the request of Liverpool CCG, the IAPT Intensive Support Team (IST) undertook a deep dive of the service in summer of 2016, following which an action plan was produced to address the numerous recommendations. One of the main areas targeted was the internal waiting list which at the end of August 2016 stood at 3,216 patients awaiting second treatment. The IST is returning to 81 Page 15 of 63

56 Liverpool on 15 th February to review progress against the recommendations and also sense check the capacity and demand modelling undertaken by the service in respect of future sustainability. A more detailed analysis of historical performance and mitigating actions taken by the CCG can be found in Section 8 of this report (Integrated Performance Outcomes). 6. CLINICAL QUALITY, PATIENT SAFETY AND ENSURING A POSITIVE EXPERIENCE OF CARE Commissioning high quality, person-centered, safe and effective healthcare for the people of Liverpool is a key priority for the CCG. In line with the recommendations of the National Quality Board (NQB) the CCG s Quality, Safety and Outcomes Committee has established a Quality Early Warning Dashboard to provide the CCG with a robust system which identifies issues and risks relating to patient quality and safety at the earliest opportunity. The dashboard covers all NHS Trusts within the Merseyside area and includes Risk Profiles for each organisation issued by the Care Quality Commission (CQC) and Monitor Risk and Financial Ratings. Where risks or themes are identified they will be actively managed through established CCG governance arrangements and overseen by the Quality, Safety and Outcomes Committee, relevant Clinical Performance and Quality Group Meetings and through collaborative commissioning arrangements with other Merseyside CCGs. This section of the report summarises key performance areas of the NHS Outcomes Framework in Domain 4 (ensuring that people have a positive experience of care and Domain 5 - treating and caring for people in a safe environment and protecting them from avoidable harm. 6.1 NHS Outcomes Framework Domain 4 Ensuring people have a positive experience of care Areas for Improvement Indicator Mixed sex accommodation breaches RED TREND Narrative Performance during December 2016 showed that the CCG had 0 (zero) breaches of the mixed sex accommodation indicator The year to date position for 2016/17 is 8 mixed sex accommodation breaches for the CCG against a zero tolerance plan. There were also 0 (zero) breaches reported by Liverpool providers during December Page 16 of 63 82

57 Assurance on CCG Control Measures Liverpool CCG continues to robustly monitor any breaches of the Mixed Sex Accommodation indicator at Trust CPQG meetings. 6.2 NHS Outcomes Framework Domain 5 treating and caring for people in a safe environment and protecting them from avoidable harm Areas for Improvement - MRSA Indicator Incidence of Healthcare Acquired Infections MRSA Monthly plan tolerance of 0; Annual plan of 0 for 2016/17 RED TREND Narrative There were two reported incidences of MRSA assigned to Liverpool CCG during December The year-to-date position for 2016/17 is now 8 cases of MRSA. The breakdown of MRSA cases assigned to Liverpool CCG is below 2016/17 April May June July Aug Sep Oct Nov Dec YTD Monthly Actual - Trust Assigned Monthly Actual - CCG Assigned Monthly Actual - Third Party Assigned Total One case of MRSA was also reported by Aintree Hospitals during December Assurance on CCG Control Measures Both CCG identified MRSA bacteraemia cases underwent a rigorous post infection review (PIR) coordinated by the CCG. One case was considered unavoidable after the PIR whilst the other was determined as avoidable with lessons learnt to be presented at the CCG s Quality, Safety & Outcomes Committee (QSOC) by the HCAI programme lead. The case reported by Aintree Hospitals during December 2016 also underwent a PIR meeting, which was attended by the CCG HCAI programme lead. No clear lapses of care were identified, although the patient had received intensive treatment within Aintree and it was therefore not considered appropriate for to be taken to NHS England as a Third Party attribution. The Zero tolerance objective remains in place and all cases of MRSA BSI are subjected to a robust Post Infection Review (PIR) which aims to identify the root cause and any lapses in care that have contributed to the case. The Quality, Safety and Outcomes Committee will be assured that robust Post Infection Reviews are completed for each with clear learning and action plans developed. An example of learning is being taken forward by a GP Clinical Lead who is reviewing EMIS to enable the documentation and identification of MRSA status where there has been an episode of bacteraemia. 83 Page 17 of 63

58 6.2.3 Areas for Improvement C.difficile Indicator Incidence of Healthcare Acquired Infections C.difficile Annual plan of 138 for 2016/17 Narrative There were 10 new cases of C.diff reported in December 2016 for Liverpool CCG against a plan of 11. This brings the year to date position to 129 against a plan of 105. A total of 10 new cases of C.diff have been reported during December 2016 across the Liverpool providers: RED TREND Royal Liverpool and Broadgreen Hospital during December 2016 there has been 3 new reported cases of iff which takes the year to date total to 42 against a plan of 33; Aintree Hospital during December 2016 there were 5 reported cases of C.diff, which takes the year to date total to 36 against a plan of 35; Liverpool Heart and Chest during December, there were 2 reported cases of C.diff. This takes the YTD total to 3 against a plan of 3; Aintree Hospital during October 2016 there were three reported cases of C.diff which takes the year to date total to 27 against a plan of 27. Assurance on CCG Control Measures Through the NHS England appeals process four cases have been successfully appealed by the Royal Liverpool to date in 2016/17 - bringing the Trust s provisional total to 38. A further appeal meeting to review 3 cases is planned for early February The Trust continues work to reduce Clostridium difficile Infection (CDI), with the CDI steering group reporting progress regularly. The two cases reported by Liverpool Heart and Chest underwent Root Cause Analysis (RCA) process and although there were no apparent links between their occurrences, poor standards of documentation in both were considered to be contributory in terms of lapses in care. The CCG continues to adopt a multifactorial approach to all Health Care Associated Infections (HCAI) and the HCAI programme lead has recently developed a revised RCA tool which is currently being piloted by the Liverpool Community Health Infection Prevention team. One of the aims of this pilot is to identify lessons learned which can be then fed into Primary care quality groups. Where two or more CDI cases occur in Liverpool GP practices within the same financial year a post infection review meeting will be carried out and led by the CCG. Additional work streams also continue to be implemented with the aim of supporting shared learning and understanding across providers. The trajectory presented does not account for the number of cases where a review has been completed and an appeal lodged. For an appeal to be upheld there has to be clear evidence that there were no lapses in care; where this is agreed cases are separated from the numbers and a revised total applied. Appeals were processed during w/c 28 th November 2016 for five cases attributed to the Royal Liverpool Hospital, the outcome of which saw four of the five cases upheld (i.e. the Trust s appeal against these cases 84 Page 18 of 63

59 were agreed with and totals adjusted accordingly). 7. CCG QUALITY PREMIUM (EXCEPTION REPORT) The Quality Premium for 2016/17 consists of a number of indicators including National measures (worth 70% of premium) and 3 local priorities (worth 30% of premium) which are subject to achievement of NHS Constitution measures. As in previous years, CCGs may face having their quality premium reduced if NHS Constitution measures are not met. The premium will be reduced by 25% for each constitution measure not met during 2016/17. Quality Premium achievement in 2016/17 is worth over 2.5million for Liverpool CCG. The table below illustrates the total cost available for each measure. Liverpool CCG Quality Premium 2016/17 Measure Area Summary Current Target Trend % of QP National 1 National 2 National 3 National 4 Local 1 Cancer E- Referrals GP Patient Survey Antibiotic prescribing Local measure Cancers diagnosed at early stage no update (data for 2015 still to be published) Increase in the proportion of GP referrals made by e- referrals latest data August 2016 Overall experience of making a GP appointment- latest data July 2015 to March 2016 Antimicrobial resistance (AMR) Improving antibiotic prescribing in primary care latest data September 2016 Number of coamoxiclav, cephalosporins & quinolones (reduced from 2014/15 value) latest data September 2016 Reduction in emergency admissions for alcohol related liver disease (per 100,000) Potential Value 48.5% 60% 20% 513, % 80% 20% 513, % 85% 20% 513, % 10% or below 10% 256, % 256, Page 19 of 63

60 Local 2 Local 3 Local measure Local measure latest data April 2015 to March 2016 Access to IAPT services: People entering IAPT services as a % of those estimated to have anxiety/depression latest data June to August 2016 Reduction in emergency admissions due to falls in people aged 65+ (rate per 100,000) 2.82% 3.75% 10% 256,727 3,371 3,452 10% 256,727 2,567,270 For 2016/17, a number of Liverpool providers have agreed improvement trajectories for delivery of RTT, 4hr A&E, 62-day Cancer waits and Red 1 Ambulance response times. For the purpose of the Quality Premium, LCCG is measured against the targets agreed between providers and NHS Improvement. A full analysis of Quarter 2 performance against the above Quality Premium targets will be provided in March Liverpool CCG s achievement of the NHS Constitutional Quality Premium measures will be assessed in Quarter 4 (where possible). The monthly Corporate Performance Report provides updates in terms of mitigating actions, progress with improvement plans and any residual risks arising from poor performance against national Constitutional measures. The quarterly produced Integrated Performance Report also monitors the local QP indicators (and some of the national indicators) and is included in Section 8 below. 8. INTEGRATED PERFORMANCE OUTCOMES INDICATORS (JANUARY 2017 UPDATE) The Integrated Performance Framework has been developed using measures from NHS, Adult Social Care and Public Health Outcome Frameworks, along with additional local indicators. This section is intended to provide clear and comparative information on progress against local priorities for quality improvement and to demonstrate where gains in health outcomes are being achieved for the population of Liverpool. The Integrated Performance Framework is structured around the following themes and ambitions: 86 Page 20 of 63

61 Over Arching Indicators Domain 1: Preventing People from dying prematurely: Reduce the potential years of life lost from causes considered amenable to health care by 21.4% by 2018/19. During 2014, Liverpool CCG reported a 3.4% increase in the number of years of life lost through causes considered amendable to health care with a rate of 2,643 per 100,000 population. In order for Liverpool to achieve the 2018 ambition an average annual reduction trend of 6.4% is required. No national update is available for this indicator. Domain 2 - Enhancing quality of life for people with long-term conditions improving health-related quality of life for people with long-term conditions. During the period July to March 2016, Liverpool reported a 1.6% increase in health reported quality of life for people with long term conditions. Liverpool s rate increased by 1.6% from 66.2% in July to March 15 to 67.8% in Jul to March However, this remains below the target of 69.5% 87 Domain 3 - Helping people to recover from episodes of ill health or following injury: Reduction in the rate of Composite Emergency Admissions. Latest data for 2014/15 reported a 9.8% increase in avoidable emergency admission rate compared to 2013/14 with a rate of 2,680 per 100,000 population. The composite emergency admission measure is a subset of four measures covering admissions for conditions deemed as avoidable (highlighted as sub measures within dashboard). Due to the timeliness of the national published data, local data is also used to monitor this indicator in a timelier manner and uses local SUS data flows, applying the national criteria and methodologies where possible. Latest local data for the period November 15 to October 16 shows that the rate has decreased from 2,410 in 2015/16 to 2,234 admissions per 100,000. Better Care Fund measure for non-elective emergency admissions on the Health & Wellbeing Footprint: Latest data for Quarter 2 shows that the number of non-elective admissions is reported to be 14,430 and is 0.64% above the quarter 2 plan of 14,337. This is an improved position on Q1 2016/17 and Q4 2015/16 reported levels of 14,834 and 14,852 respectively. Domain 4 - Ensuring that people have a positive experience of care Patient experience of primary care and Inpatient care average Page 21 of 63

62 number of negative responses per 100 patients (Selected questions). No updates are available for these indicators. Only measures where updated data has become available since the last update are included below. For commentary relating to other measures included within the attached dashboard please refer to previous Integrated Performance Report updates. 8.1 Children s Programme Please note that updates are not available for the following indicators: Ante-natal assessments within 13 weeks, breastfeeding initiation rate and hospital admissions caused by injuries in young people Good Performance Indicator Breast feeding prevalence at 6-8 weeks GREEN TREND Narrative Performance for Quarter /17 is reported at 32.6% against the target of 32%. Performance in this period also represents a 5.5% increase on Q4 2015/16 (27.1%). Despite improved performance against this measure Liverpool is still ranked 7 out of 7 of the core cities. The latest peer average performance is 46.2% (no data was published by Public Health England for Birmingham) Children receiving face to face NBV with a Health Visitor within 14 days TREND Children receiving a 6-8 week review by 8 weeks by a Health Visitor TREND Performance for Quarter /17 for children receiving a face to face new born visit with a health visitor within 14 days is reported to be 83.7%. This is a very slight (0.3%) increase on the Q1 position of 83.4%. Performance for this indicator has been on an upward trend since Q3 2015/16. Performance for Q2 2016/17 for children receiving a 6 to 8-week review by 8 weeks by a health visitor is 91.6%. This is an increase of 0.7% on the Q1 reported performance of 90.9%. Performance for this indicator has also been on an upward trend since Q3 2015/16. Page 22 of 63 88

63 8.1.2 Areas Requiring Improvement Indicator The rate of stillbirths and deaths within 28 days of birth per 1,000 live births and stillbirths RED TREND MMR2 uptake - 2 doses (5 year olds) Narrative This indicator monitors the rate of stillbirths and deaths within 28 days of birth per 1,000 live births and stillbirths - reported at CCG of residence level by calendar year. Based on data from Office of National Statistics (ONS) for the year 2014, Liverpool CCG is significantly above the national average rate of 7.1 per 1000 live births for this indictor with a rate of 9.5 per 1000 live births. The CCG is ranked 11 th out of 15 core city CCGs. This is, however a decline in performance compared to 2013 which reported that the rate for Liverpool CCG was 7.9 (much closer to the national average of 7.3 per 1000 live births). Performance for Q1 2016/17 is reported as 88.9% (6.1% below the target of 95%). RED TREND Despite underperforming against this measure, Q1 marks a slight improvement (0.9%) in performance on the 87.8% achieved in Q4. Liverpool s performance is slightly better than the core city average of 85.2% Maternal smoking at delivery RED TREND Performance for Q1 2016/17 is reported as 14.6% (3.2% below the national average of 11.4%). This is a slight improvement on the Q4 reported performance of 15.8%. Despite the slight improvement, Liverpool CCG remains amongst the bottom performing of the core cities (ranked 13 th out of 15). The latest peer average performance is 11.9% Assurance on CCG Control Measures Rate of stillbirths and deaths this is being considered in the context of the Maternity Vanguard and the Better Births national guidelines. Any plans and trajectories will be developed and highlights shared once available. MMR 2 uptake - Performance is red as a result of the transition of delivery of childhood vaccinations into General Practice. This was an expected consequence of a change in provider, and mirrors other areas who have done the same, although it should be noted that Liverpool s performance didn t drop as much as other areas (locally or nationally). Performance however is improving (88.3% in Q1; 89.2% in Q2) and there is dedicated resource in place to target specific families and improve uptake over coming months. Maternal Smoking at Time of Delivery Liverpool Women s Hospital has now procured CO monitors as a tool to increase referrals and quit rates. Issues regarding referrals have been raised at the CQPG and arrangements are being made for a secure method for referral. A meeting has been arranged with SFL (the Stop Smoking service provider). 89 Page 23 of 63

64 8.2 Long Term Conditions Programme Good Performance Indicator Primary Care: Reduction in CHD admissions to hospital (link to increase in cardiac rehab completion and increase in smoking quitters) GREEN TREND Narrative The latest rolling 12 months data for the period November 2015 to October 2016 shows that Liverpool CCG has observed a decrease in the rate of CHD admissions, with a rate of per 100,000 population when compared to (2015/16 financial year data). This is also below the 2016/17 planned rate of admissions per 100,000 population. Reduction in heart failure admissions to hospital (link to patients prescribed beta blocker GREEN Reduction in stroke admissions to hospital (link to increasing pulse check and anti-coag) GREEN Reduction in COPD admissions to hospital (Link to increase in pulmonary rehabilitation completion rate) GREEN TREND TREND TREND Through increasing the number of heart failure patients on beta blockers Liverpool s ambition is to reduce heart failure admissions by 40 between 2014/15 and 2018/19. The latest rolling 12 months of data for the period November 2015 to October 2016 shows that Liverpool CCG has observed a decrease in the amount of heart failure admissions with a rate of per 100,000 population (compared to 2015/16 financial year data). This is also below 2016/17 planned rates of 131 admissions per 100,000 population. A prevention sub group is now in place as part of the CVD redesign. The group is in the process of developing a Cardiology Prevention Strategy which will look to include prescribing advice and recommendations. Liverpool s ambition is to reduce stroke admissions through increasing pulse checks and anti-coagulation monitoring. The latest rolling 12 months of data for the period November 2015 to October 2016 shows that Liverpool CCG has seen a decrease in the rate of stroke admissions, with a rate of per 100,000 population compared to (2015/16 financial year data). This is also below the 2016/17 planned rate of admissions per 100,000 population Liverpool CCG s ambition is to reduce COPD admissions through increasing completion of pulmonary rehabilitation. The latest rolling 12 months of data for the period November 2015 to October 2016 shows that Liverpool CCG has observed a decrease in the rate of COPD admissions with a rate of per 100,000 population compared to (2015/16 financial year data). This is also below 2016/17 planned rate of admissions per 100,000 population. Page 24 of 63 90

65 Primary Care: % patient over 65 receiving a pulse check (excluding established AF) (Reference impact on stroke admissions) GREEN Primary Care: People with COPD and MRC Dyspnoea scale >=3 offered pulmonary rehabilitation GREEN Proportion of people who are feeling supported to manage their condition TREND TREND TREND Improvements have been reported for this measure, which has been identified as impacting on reducing mortality and reducing emergency hospital admissions. Latest data for November 2016 shows that the percentage of patients over 65 receiving a pulse check has improved by 0.9% since the last reporting period with a rate of 74.7% (compared to a plan of 68.5%). Performance for this indicator is consistently above the target of 70% and is on an upward trajectory throughout 2016/17. Latest data for November 2016 shows that the percentage of people with COPD and MRC Dyspnoea scale >=3 who are offered pulmonary rehabilitation has remained the same since the last reporting period (rate of 74.7%) although this is still above the plan of 68.5%. Performance for this indicator has been consistently above the target of 55.8% with an average performance of 68% in 2016/17 (April to November 2016) Latest data for the proportion of people who are feeling supported to manage their condition for the period July 15 to March 16 is reported to be 66.3%. This is a 0.5% increase on the previous reporting period (July 14 to March 15) in which performance stood at 65.7% Liverpool CCG is currently amongst the top performing of the core cities (ranked 3 rd out of 15). Performance is 1.6% above the peer average whilst the latest peer average performance is 64.7%. In the previous reporting period Liverpool CCG was ranked 6 th out of 15 core cities Areas Requiring Improvement Indicator Primary Care: % of CHD patients treated with a Statin Narrative Latest data for November 2016 reports that performance has remained at the same level for the number of CHD patients treated with a statin. RED TREND Performance is maintained at 84.4% from the previous reporting period % below the 97.2% target. 91 Page 25 of 63

66 Primary Care: % of Heart Failure patients treated with a beta blocker (Reference impact on Heart Failure admissions) RED TREND Latest data reported for November 2016 shows a slight increase (0.2%) in the number of Heart Failure patients treated with a beta blocker from 71.7% in the previous reporting period to 71.9%. However, this is 11.2% below the 83.1% target. Average performance in 2016/17 is currently at 71.44% Primary Care: People with Diabetes who have received 8 care processes RED Primary Care: People with Diabetes diagnosed less than 1 year referred to structured education RED TREND TREND Performance for November 2016 remains below plan, currently standing at 64.4% against the target of 70%. This is a 5% improvement on the previous month s performance which stood at 59.4% and this measure remains as a priority across all localities in Liverpool. Please note that from September 2016 the 9 Care Processes were revised to reflect 8 Care Processes, with retinal screening omitted from the search. This is due to retinal screening now being measured on a three yearly basis rather than an annual measure. Performance remains below the target of 80.8%. Latest rates for November 2016 stand at 78.6% compared to a plan of 80.8% (a slight decline in performance compared to the previous month s performance of 79.9%). Performance in November 2016 is the lowest to-date during 2016/17. Average performance for 2016/17 currently stands at 79.8%. The Liverpool Diabetes Partnership (LDP) will continue to build upon relationships with primary care to improve holistic and preventative diabetes care across all settings. Assurance on CCG Control Measures % of CHD patients treated with a Statin - practices have completed a significant amount of work in relation to this measure. All practices are below the performance target of 97.2%, although patient views on statins are historically set due to negative press which is reflected in the lower uptake in Childwall, Gateacre & Allerton and Woolton Neighbourhoods. There is also less uptake in areas of deprivation (particularly in Picton and Kensington Neighbourhoods). Targeted practices are to be offered MMT search to enable work on this indicator. % of Heart Failure patients treated with a beta blocker - Titration of medications in this complex group of patients requires several visits and specialist involvement in some cases (i.e. multiple co-morbidities). Despite being some way below target, performance is showing an upward trend. People with Diabetes who have received 8 care processes the CCG is continuing to build relationships between practices and the LDP Service and identify those practices with lower performance to offer support. ACR remains a predominant area for dropped performance, although this has seen an improvement. ACR nurse / admin support information has been 92 Page 26 of 63

67 targeted to these practices. People with Diabetes diagnosed less than 1 year referred to structured education analysis of performance against this measure cannot find the cause of the below-par achievement. However, the following actions are to be taken by the CCG: Performance to be discussed at city-wide nurse meeting on 9 th February 2017, advising referral part of care and should be done for all; GP Neighbourhood leads to oversee this indicator and discuss with nurses in those practices with low referral rates; Practice managers also targeted with communication to promote referral of all newly diagnosed persons. Liverpool Diabetes Partnership are already working with the primary care nurses and advising the practices re-referring for education. However, LDP will now obtain a list of newly diagnosed patients from each practice and send a joint letter from LDP and the practice advising the patient they have been referred. 8.3 Mental Health Programme Good Performance Indicator People with serious mental illness (SMI) who have received the complete list of physical checks (Local PCQF) GREEN The proportion of patients on Care Programme Approach discharged from inpatient care that are followed up within 7 days. GREEN TREND TREND Narrative National data: there has been no update on national data since the previous report. Performance is at 41.7% for 2014/15 Local data: Using local data flows, performance continues to be positive month by month and current performance (November 2016) stands at 45.5% - 7.8% higher than the target of 37.7%. Whilst performance has improved overall, at practice level performance varies significantly with the highest performing practice achieving 100% and lowest performing practice reporting 18.5%. The average of the bottom 25 performing practices is 30.6%. Liverpool CCG will continue to target poor performing practices to ensure that improvement continues. Performance for Quarter /17 remains above plan at 96.4% against the 95% target. However, this is a slight decrease on Q1 2016/17 performance of 1.7% when the CCG achieved 98.1%. Page 27 of 63 93

68 Proportion of adults in contact with secondary mental health services living independently, with or without support GREEN TREND Final published performance for 2015/16 shows that Liverpool above the national reported position of 58.6% with performance at 67.7% However, this is a decline on the previous reporting period of 0.6%. Liverpool CCG is ranked 4 out 8 core cities which has an average performance of 59.4% Areas Requiring Improvement Indicator 2016/17 Quality Premium Local Indicator Access to IAPT services: % of people who receive physiological therapies as a percentage of those estimated to have anxiety or depression RED TREND Narrative In line with operational plans the recommendation is to achieve a National access rate of 15% by March National data: Source HSCIC For people entering IAPT the latest national published data in Quarter 2 (July, Aug & Sep 2016) reports performance at 2.7% for the period, below the quarterly target of 3.75%. Actual performance for Quarter /17 was reported at 2.93%. Access rates have steadily reduced below the National Standard in recent quarters and this trend is continuing in 2016/17. The 2016/17 target for this indicator is to achieve 15%. For the period April to September 2016 the CCG s position is 5.62%, which is below the half year target of 7.5%. Local data (Local data flow from Provider) Local data is used to monitor this indicator in a timelier manner than the national published data. Based on the local data submitted for the latest rolling quarter (Aug, Sep & Oct 2016), the Page 28 of 63 94

69 CCG remains below the standard of 3.75% with performance at 2.73% (consistent with the national performance data). Based on current performance, achievement of this Quality Premium indicator is likely to be a challenge in 2016/17. Recovery IAPT: Percentage of people who are moving to recovery of those who have completed treatment RED TREND ** please note that local data is to be used an indication of the direction of performance and the CCG will be assessed on nationally published data Latest national data for Quarter 2 (Jun to Sep 2016) shows Liverpool is experiencing a slight improvement in performance for the percentage of people who are moving to recovery (of those who have completed treatment). Performance at Quarter 2 is reported to be 35% compared with 34.1% at Q1 2016/17. However, this remains significantly below the target of 50%. Assurance on CCG Control Measures Although people have been receiving a first treatment appointment in a timely manner and the service is exceeding the national targets, historically patients go on to experience long waits for second appointments (referred to as internal or hidden waits). This, combined with the waits inherited from the previous provider (Inclusion Matters Liverpool) means that in real terms, people are actually waiting significant lengths of time to access treatment. In terms of access, the 2016/17 year-to-date access position at the end of Quarter 3 is 8.02% (compared to a national target of 11.25%). For Recovery, the 2016/17 Q3 position is 31.51% against a national target of 50%. Waiting times for Q3 2016/17 are: 83.48% of people accessing treatment within 6 weeks against a national target of 75% 98.37% of people accessing treatment within 18 weeks against a national target of 95% At the December 2016 Governing Body meeting it was agreed that a comparison between Talk Liverpool (TL) Performance and that of the previous provider, Inclusion Matters Liverpool (IML) may provide some additional context in regard to current performance against IAPT standards and as a measure of improvement. To make this statistically relevant the first three quarters of the last three financial years have been used in the analysis (this is because IML was in contract close down for the final quarter of 2014/15 and therefore we would expect to see performance drop whilst they undertook activities associated with this). It also correlates with the most recent performance information available (i.e. Quarters 1-3 of 2016/17). The comparisons are below and based on the nationally published data. Access Year Q1 Q2 Q3 Provider 2014/ % 2.63% 2.82% IML 2015/ % 2.24% 3.88% TL 2016/ % 2.70% 2.40% TL The chart below shows the performance trend between April 2014 and December 2016: 95 Page 29 of 63

70 IAPT Performance (Access) Apr 14-Dec 16 3% 2% 2% 1% 1% 0% It is worth noting that Q1 performance and Q2 performance for 2015/16 contain data errors and it is therefore not a comprehensive analysis. This data error was due to the Q1 national data set counting all patients transferred from IML to Talk Liverpool as entering treatment, which meant that they were essentially counted twice (hence the spike in performance. A data submission error then occurred in Q2 which gave a nil return for Liverpool patients accessing treatment in September, an inevitable consequence of which was a visible drop in performance. Data errors aside, there has been a slight improvement in overall performance since the transfer of the contract to Talk Liverpool. In respect of waiting times, comparisons between the two contracts are summarised below: Access within 6 weeks of referral Year Q1 Q2 Q3 Provider 2014/ % 70.00% 73.00% IML 2015/ % 58.89% 70.53% TL 2016/ % 91.94% 83.48% TL Access within 18 weeks of referral Year Q1 Q2 Q3 Provider 2014/ % 95.00% 95.00% IML 2015/ % 78.89% 87.37% TL 2016/ % 96.77% 98.37% TL Performance trends for the completion of treatment during the period April 2014 and December 2016 are presented in the chart below: 96 Page 30 of 63

71 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Apr-14 IAPT Performance in completion of treatment in 6 and 18 weeks. Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec weeks 6 weeks As described earlier, although patients have received timely first treatment appointments they go on to experience long waits for second appointments (referred to as hidden waits ). Following the recommendations of the IAPT Intensive Support Team an interim pathway was developed to address this situation and was launched at the end of November Latest contract reporting shows that at the end of Dec 2016 the waiting list had reduced to 2066 and was on target to hit the trajectory for all people to enter treatment by the end of May as per the trajectory below: October November December January February March April May Target Reduction Actual WL Numbers 161/7 WL Numbers 15/16 Although the interim pathway has been relatively successful in addressing the issue, resources have been mostly directed at the waiting list backlog and this has had some impact on the number of new people accessing the service. As the first cohorts of patients were due to be discharged from the service at the end of January 2017 data is not yet available in respect of recovery or the number of patients completing the course. In addition to the interim pathway, work has been undertaken to focus on operational and clinical improvements within the service to ensure that it is sustainable and that the waits do not build up again once they are cleared. As mentioned earlier in the report, the IAPT Intensive Support Team is 97 Page 31 of 63

72 is returning to Liverpool on 15 th February to review progress against the recommendations and also sense check the capacity and demand modelling undertaken by the service in respect of future sustainability. 8.4 Cancer Programme Please note that updates are not available for the following indicators: Percentage of cancers detected at stage 1 and 2, and for cancer screening coverage for breast cervical and bowel cancers Areas requiring improvements Indicator One-year survival from all cancers Narrative Latest national data published is for the period Dec 2013 to Dec 2014 (the year of diagnosis being calendar year 2013). AMBER TREND Analysis of this data shows that the one-year net survival (%) for adults diagnosed with cancer aged years was 69.5%. This is an improvement of 0.8% when compared to 2012 performance of 68.7%. Liverpool CCG is 0.5% lower than the national average for this measure but has demonstrated improvement on previous years. Liverpool CCG is currently ranked 9 th out of 15 core cities and performance is equal to the peer average. The highest peer performance is at 72.2%, whilst the lowest peer performance is at 66.9%. Assurance on CCG Control Measures One-year survival is often used as a proxy measure for earlier stage at diagnosis. If a cancer is diagnosed earlier, it is more responsive to treatment and patients are more likely to survive for more than one year. This is important because research has shown that once a cancer patient has survived for a year, England is almost as good as the Nordic countries (who have some of the best cancer survival rates in Europe) in ensuring that they survive for at least five years (APPG cancer report, 2014). Five-year survival rates can be used as proxy measure for quality of treatment services. Small year-on-year changes in the survival estimates for a given CCG can mean big changes in its ranking. Interpretation should therefore focus on trends. It is positive that the Liverpool trend continues to improve. There is variation in one-year survival rates by cancer type. Breast cancer has a 96% one-year survival rate in England, compared with 21% for pancreas. One-year survival for all cancers in Liverpool is now identical to the England rate (both 70.4% in 2014). For breast, colorectal and lung cancers combined Liverpool has a higher one-year survival rate than England (72.3% compared with 71.5% in 2014). Liverpool has higher one-year survival rates for breast cancer at 97.5% compared with 96.5% (this is statistically significant) and lung cancer at 38.5% compared with 36.8%). For colorectal Liverpool is marginally lower, although this is not a significant difference (76.9% compared with 98 Page 32 of 63

73 77.2%). There is a link between method of diagnosis and length of survival. People diagnosed through screening and through managed presentation (e.g. referred under a two week wait clinic) have better one-year survival rates overall than those who are diagnosed as an emergency presentation. To improve cancer one-year survival, the aim is to: a) Diagnose cancer at an earlier stage; b) Diagnose cancer through planned, rather than unplanned routes Diagnosing cancer early - Lung cancer accounts for one third of deaths from cancer in the city; over one third of lung cancer diagnoses are made in A&E, and most lung cancers are diagnosed at the later stages of cancer (stage 3 or 4) when outcomes are poorer. The Liverpool Healthy Lung Programme has been running for 9 months, and through a risk stratification approach, low dose CT scanning is offered proactively to populations at higher risk of lung cancer. The programme is still in pilot stages, however the cancers detected to date are typically at the early stages of lung cancer (stage 1 or 2) and where treatment options are much improved. Finding more people at earlier stages of lung cancer (which accounts for a high proportion of cancer deaths overall in the city) will contribute to one-year cancer survival rates in the city. The programme has also been piloting the Breathe Freely healthy lung events (over 2,000 people have attended). These events are open to all and aim to promote positive messages about lung cancer and lung health in general. It is known that there is a significant fear and fatalism amongst people of both the disease and the perceived treatment options (which could be contributing to the high number of people being diagnosed at the later stages of lung cancer). Cancer screening - Bowel cancer screening uptake is slowly increasing, although remains at under 50%. Activities to improve uptake include the development of a toolkit, a media campaign aimed at first time responders, a project aiming to increase uptake in black and ethnic minority communities, a brief intervention initiative incorporated into the safe and well visits undertaken by Merseyside Fire and Rescue Service and hopeful inclusion in GP specification for April 2017 onwards. Improving bowel cancer screening performance will directly improve one-year survival rates; because of the incidence of colorectal cancer in the city, earlier diagnosis of bowel cancer will positively impact on cancer mortality rates. Bowelscope, a one off test at the age of 55, will complete roll out across the city in Spring Cervical screening performance continues to deteriorate in line with the national trend. A package of support is offered to primary care teams, and cervical screening is included in GP specification from NHS England is leading a review of breast screening services (due to deteriorating performance). Liverpool CCG will support the implementation of any recommendations arising from this review which is due to be published in February The CCG is also working with partners to promote positive stories of cancer survival, and good local services, to help reduce fear and fatalism which stop people contacting their GP with symptoms suspicious of cancer. More work needs to be done with communities to support people to know the possible signs of cancer, risk factors for cancer, and encourage people to see their GP. The CCG Cancer Team are active in reviewing pathways with specialist services, to reduce steps in clinical pathways where appropriate and aiming to reduce pathway duration to enable faster 99 Page 33 of 63

74 treatment. This includes change at speciality level (e.g. iron deficiency anaemia; colorectal pathways; GP access to diagnostic tests) and system change (e.g. emerging work at STP level on imaging, pathology and endoscopy). Elements of this pathway work should increase the number of cancers diagnosed at Stage 3 rather than at Stage 4, which also contributes to increased survival. This work also includes alternatives to emergency admission. 8.5 Healthy Ageing Please note that updates are not available for the following indicators: Social care quality of life, proportion of people who use services and their carers', who reported that they had as much social contact as they would like, emergency admissions due to falls in people aged 65 and over and hip fractures in people aged over Good Performance Indicator 2016/17 Better Care Fund Measure Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services GREEN TREND Narrative Liverpool has reported an improvement in performance during the latest quarter (Q1 2016/17) with performance standing at 84.7% (compared to 78.6% reported in Q4 2015/16). This is currently above the 2016/17 BCF target of 75% 2016/17 Better Care Fund Measure Estimated diagnosis rate for people with dementia GREEN TREND Liverpool has reported a steady increase in dementia diagnosis rates during 2016/17 and figures reported for September 2016 showed performance at 76.5% against a target of 70%. Emergency Admissions from Care homes GREEN TREND The latest rolling 12 months of data for November 15 to October 2016 shows that Liverpool CCG has reported a decrease in the rate of emergency admissions to care homes with a rate of per 100,000 compared to for the year 2015/16. This is below the 2016/17 plan of 3,510.9 admissions per 100,000 Page 34 of

75 2016/17 Quality Premium Local Indicator Reduction in Emergency admissions due to injuries due falls in people aged 65 and over GREEN TREND The recommendation for 2016/17 for Liverpool is to reduce to a rate of 3,452 per 100,000 population (a reduction of 7 non elective admissions from injuries due to falls in people aged over 65). National data: (source Public Health Outcomes Framework) The baseline from which this quality premium indicator was set was on national published data for 2014/15 for Liverpool. This showed that there had been a notable increase in the rate of injuries sustained through falls for over 65 s from 2,790 per 100,000 in 2013/14 to 3,462 in 2014/15. Using this data, Liverpool is ranked in the bottom percentile nationally for rates of falls and fall related injuries and is currently ranked 8 th out of 8 core cities. The peer average during 2014/15 was 2,559 admissions per 100,000. National data for 2015/16 has yet to be published. Local Data: (source SUS) Local data is also used to monitor the indicator in a timelier manner and uses local SUS data flows - applying the national criteria and methodologies where possible. Whilst local data monitors Liverpool CCG activity/rates, the national data reports a rate for Liverpool (as a Local Authority population). Local data aims to replicate the national methodology as closely as possible, and although it is expected that analysis of Liverpool CCG activity will be reflective of a Liverpool position (and trends mirrored) it is important to note these differences. The current position (based on a rolling 12 months of data for the period November 2015 to October 2016) is positive and shows that Liverpool CCG s current rate is at 3,304 per 100,000. This is an improved position on the 2015/16 rate of 3,458 per 100,000. The table below shows the crude rate for the periods 2014/15, 2015/16 and the latest rolling 12 months (November 2015 to October 2016). 14/15 15/16 rolling 12 months (Nov 15 to Oct 16) Page 35 of

76 Number of admissions due to falls 2,477 2,422 2,336 rate per 100,000 3,574 3,458 3,304 Using this methodology, Liverpool CCG has seen a decrease in the rate on the 2014/15 baseline and based on these figures Liverpool CCG is achieving the target rate of 3,452 per 100,000 with a current rate 3,304 per 100,000. The period analysed is also now contains 7 months of 2016/17 and is therefore more reflective of 2016/17 (the previous update only used 3 months of 2016/17 in the rolling 12-month period). When analysing the volumes of activity (actual number of admissions) in 2014/15, 2015/16 and 2016/17, this also demonstrates that the number of admissions due to falls has decreased from 2,477 in 2014/15 to 2,422 in 2015/16 and a further reduction of 86 to 2,336 has been observed in the latest rolling 12- month period. The chart below shows that the volumes of emergency admissions due to falls in people aged 65 + whilst relatively flat, is on a downward trend and supports the decrease in rates that has been observed. 300 No of Falls 65+ : source SUS Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Based on all the above, indications remain that Liverpool is on track to achieve the target rate for 2016/17. ** please note that local data is to be used an indication of the direction of performance and the CCG will be assessed on nationally published data (which may use slightly different methodologies Page 36 of

77 8.5.2 Areas Required for Improvement Indicator 2016/17 Better Care Fund Delayed transfers of care from hospital (Health and Social Care) RED TREND Narrative The 2016/17 target is an improvement of 5% on the 2015/16 performance level of 1,035 bed days delayed per month. Based on projected growth in recorded delays during 2016/17 to 2017/18 the relative performance gain is an estimated is 9%. Estimated growth increasing monthly averages to 1,063 bed days delayed. The 2016/17 target is set to mitigate a 4% growth in delays and improve by a further 5% on current volumes. During 2016/17, an increase to-date in the rate of delayed transfers of care compared to 2015/16 has been observed. In Q the reported rate was 1,469 per 100,000. This was against a Q1 2016/17 plan of 715 per 100,000. Q2 2016/17 data shows an improvement on Q1 with the rate reported to be 1382 per 100,000. However, this remains significantly above the planned rate for Q2 of and significantly above the Q2 2015/16 actual rate of 735. For the last two quarters of 2015/16 rates were also being reported above planned levels with rates increasing significantly in Q3 (1039 per 100,000) and Q4 (1456 per 100,000). Levels reported in 2016/17 to date are consistent with the latter quarters of 2015/16 Page 37 of

78 Primary Care: People with Dementia prescribed antipsychotic medication RED TREND Performance rates continue to be poor against the <5% target. Performance for November 2016 is reported at 12.3% which is a slight decrease of 0.3% on October 2016 (12.6%). Performance during 2016/17 to date averages 12.18%. 2016/17 Better Care Fund Measure Permanent admissions to residential and nursing care homes, per 100,000 population RED TREND The delivery of the BCF plan in 2016/17 is to reduce the rate of permanent admissions of older people (aged 65 and over) to residential and nursing care homes. Performance at Q2 2016/17 reports an increase in rate of permanent admissions to care homes. The rate at Q2 2016/17 was per 100,000, this is above the 2016/17 target of 766. This is also an increase on Q1 2016/17 where performance was reported at per 100,000. Assurance on CCG Control Measures To note: as per definition changes during 2014/15, this is a measure of the intention to admit rather than actual admissions. Delayed transfers of care (DTOC) - The CCG continues to work with partners to bring about improvements in patient flow throughout the urgent care system and reduce both the numbers of patients occupying an acute bed who are considered ready for discharge (RFD) and formal DTOCs which form a subset of this overall cohort. Throughout 2016/17 the CCG has supported the Rapid Improvement Event (RIE) programme at both Royal Liverpool & Broadgreen University Hospital and Aintree University Hospital. This evidence based approach is based on upon a 90-day improvement cycle and has seen a number of initiatives put in place to improve: Internal trust processes (Delivery of daily consultant led ward/board rounds, Implementation of the SAFER care bundle approach to discharge planning, RED/GREEN day analysis of inpatient stays to optimise inpatient stays, Review and Implementation of standardised patient choice policy). Discharge pathways into community (Discharge to Assess through Home 1 st implementation, Significant redesign of pathways and Intermediate Care resource to provide a flexible approach with emphasis on supporting patients to return to usual place of residence on discharge). In addition to this work the CCGs facilitation of ECIP system diagnostic and its active role in the establishment of both the North Mersey and Southport AEDB and North Mersey AEDB operational sub group ensure that further development of plans to reduce DTOC, and monitoring of associated outcome measures, is undertaken in a coordinated and transparent manner. The CCG s approach to implementing a Discharge to Assess culture is clearly set out within 104 Page 38 of 63

79 these plans and is based on delivery of increasingly integrated health and social care provision to ensure that the Home 1 st approach - building on the scheme implemented from 1 st November 2016 which is now averaging 15 discharges a week (up from 8 a week in Nov / Dec), is extended and expanded to include the full range of community based disciplines and support available. People with Dementia prescribed antipsychotic medication - At the close of the 2015/16 GP specification process, the Validation Committee reviewed submissions from practices that were not meeting the KPI. These indicated that patients had been reviewed and, in most cases, a clinical decision to continue prescribing made (usually following a consultation with the mental health specialist teams as treatment was for a diagnosed psychotic illness). The KPI remained in the specification with the expectation that patients would receive an annual review to ensure that treatment remained appropriate. Permanent admissions to residential and nursing care homes, per 100,000 population as summarised in relation to DTOC above, the Home First pathway is now established and working alongside the Emergency Response Team/Frailty Service to take patients from Aintree Hospitals and the Royal Liverpool into the pathway. As stated above, a key measure to minimise delayed transfers of care and enable people to live independently is the development of discharge pathways into the community setting and the significant redesign of pathways and Intermediate Care resources to support patients to ultimately return to their usual place of residence on discharge. 8.6 Prevention Updates are not available for the indicators percentage of eligible population receiving an invite for health check or the percentage of those invited who receive a health check Areas Requiring Improvement Indicator Smoking quitters TREND Chlamydia detection rate (15-24 year olds) AMBER TREND Narrative Latest data for Quarter /17 for the number of smoking quitters shows that performance has decreased by 12.5% to 37.5% from the previous quarter s performance of 50%. Liverpool is ranked 6 th out of 7 core cities, which has a peer average performance of 45.6%. Latest performance data (2015) for Chlamydia detection rates for year olds shows that rate has reduced to 2151 per 100,000 from the previous year s rate of 2248 per 100,000. Performance is also below the national target of < 2300 per 100,000. Liverpool is ranked as amber on the Public Health Website for this indicator. The North West rate is 2328 per 100,000 and the England rate is 1887 per 100,000. Liverpool is therefore above Page 39 of

80 2016/17 Quality Premium Local Indicator Emergency admissions for alcohol related liver disease (trend score based on performance based on local data) RED TREND the England value but below the value for the North West. This has been identified as a key priority area for the reduction of emergency admissions under the governance arrangements of the Healthy Liverpool Community Programme. The recommendation for 2016/17 is for Liverpool to reduce to a rate of 56.2 per 100,000 and over time close the gap between our rate and peer average. This equates to a reduction of 17 alcohol related liver disease admissions in 2016/17 from a 2015/16 baseline. National data: (source HSCIC) Latest national data shows that for the period April 2015 to March 2016 there has been a notable increase in the rate of emergency admissions for alcohol related liver disease with rates increasing from 52.5 in 2014/15 to 60.3 in October 2014 to September 2015 (period on which QP target was set) to 66.6 for the full year 2015/16. This equates to 261 alcohol related liver disease admissions in 2015/16, an increase of 53 on the previous year. The graph below using national data illustrates the increasing trend in both the rate and volume of emergency admissions for alcohol related liver disease: 300 Emergency admissions for alcohol related liver disease - source HSCIC / / /15 Rate number Liverpool CCG is currently ranked 15 th out of 15 core cities. The best performing core city has a rate of 21.8 admissions per 100,000. The peer average is 35.6 admissions per 100,000. Local data: (source SUS) Local data is also used to monitor the indicator in a timelier manner and uses local SUS data flows, applying the national criteria and methodologies where possible. Page 40 of

81 The current position is based on rolling 12-month data for the period November 2015 to October Based on this period, Liverpool CCG s current rate is per 100,000 (an improvement in performance on the financial year data 2015/16 which reported a rate of per 100,000). However, this is still some way off the 2016/17 target of The table below shows the crude rate using local data for the periods 2014/15, 2015/16 and the latest rolling 12-month period (November 2015 to October 2016). Whilst the volumes differ slightly to the nationally published figures, the trend up to 2015/16 is mirrored (2016/17 national data is not yet available for a comparison: Apr - Oct number of alcohol related admissions 14/ / / / /16 rolling 12 months (Nov 15 to Oct 16) Number of admissions for alcohol related liver disease rate per 100, Using this methodology, both 2015/16 and the latest rolling 12 months (incorporating 7 months of 2016/17 data) show an increase in the rate compared to 2014/15. However, the latest rolling 12 months demonstrates a small improvement on the 2015/16 position. Analysis of volumes of activity (actual number of admissions) highlights that the number of admissions for alcohol related liver disease has increased from 208 in 2014/15 to 258 in 2015/16 and to 256 in the latest period analysed. The chart below illustrates the increasing trend in the volumes of emergency admissions for alcohol related liver disease by month: Page 41 of

82 35 Number of alcohol related admissions - source SUS Oct-16 Aug-16 Jun-16 Apr-16 Feb-16 Dec-15 Oct-15 Aug-15 Jun-15 Apr-15 Feb-15 Dec-14 Oct-14 Aug-14 Jun-14 Apr-14 When comparing the same period (April to October) in 2014/15, 2015/16 and 2016/17, the data also demonstrates the reported increase in admissions. However, 2016/17 data shows a decrease on 2015/16 volumes but is still significantly higher than the 2014/15 volumes. Hospital admissions for alcohol related conditions per 100,000 narrow measure TREND Successful completion of drug treatment - opiate users TREND ** please note that local data is to be used an indication of direction of performance and the CCG will be assessed on nationally published data (which may use slightly different methodologies) Performance for Quarter /17 shows a decline in performance compared with Q4 2015/16 with the rate of hospital admissions for alcohol related conditions per 100,000 (narrow measure) increasing from to per 100,000. Liverpool is ranked 7 out 7 of the core cities where the peer average is per 100,000 Latest reported performance for Quarter /17 for the successful completion of drug treatment (opiate users) has decreased by 1.1% to 5.2% from the previous quarter s performance of 6.3%. Liverpool is currently ranked 5 out of 7 core cities, which has a peer average performance of 5.6%. Successful completion of drug treatment non-opiate users TREND Latest reported performance for Quarter /17 for the successful completion of drug treatment (non-opiate users) has decreased by 5.9% to 47.1% from the previous quarter s performance of 53%. Despite the decline in performance, Liverpool is currently ranked 2nd out of 7 core cities, which has a peer average performance of 34%. Page 42 of

83 Assurance on CCG Control Measures Stop Smoking - A new provider for the Stop Smoking service commenced in July As expected, the service took some time adjust and reorganise the staffing. This has affected the numbers of people using the service (which has also been affected by the rise in e-cigarette users). The new service is offering universal provision, whilst also targeting groups which are known to be still smoking. Chlamydia - The prevalence of chlamydia has remained relatively stable and the target of 2,300 per 100,000 population is expected to be met. The introduction of a new type of clinic in young people s service (Test and Go) has helped to increase the number of chlamydia tests offered to young people. Emergency admissions for alcohol related liver disease - Public Health has expressed reservations about the suitability of this as a target. Although commentary states that the goal is to close the gap between our rate and peer average over time this will prove difficult given the chronic nature of alcohol liver disease which results from excessive consumption over an extended length of time. Local Alcohol Profiles for England data (LAPE) highlight that in 2005, Liverpool recorded the highest level of alcohol related hospital admissions out of the 326 Local Authorities in England. Rates of admissions were significantly higher than, for example Bristol and Sheffield - core cities who are amongst Liverpool CCG peers that performance is monitored against. Whilst the Liverpool alcohol related hospital admission ranking has improved over the past decade, the legacy of previous high risk consumption in Liverpool (which 12 years ago resulted in its position at the top of alcohol related hospital admissions rankings) is likely to now manifest itself in a higher level of population at risk of chronic liver disease (compared to Sheffield and Bristol for example). Given that emergency admissions for liver disease are also included in the other chosen indicator - Hospital admissions for alcohol related conditions per 100,000 narrow measure it is also important to note that there is also an element of double counting across the two indicators. Public Health feel the latter indicator will be more responsive to the interventions currently being implemented under the governance of the Liverpool Alcohol Strategy Group and a more accurate gauge of the progress made in Liverpool to combat alcohol misuse. Moving forward it is also felt that reporting 12-month rolling data would avoid issues with seasonal variations. There are complex and multi factual reasons for emergency admissions related to alcohol and related liver diseases and the successful completion of drug programmes and detox. As part of the Complex Needs programme of work these are being further explored and understood. The Complex Needs programme of work covers a number of key areas with embedded objectives and outcomes, which have been identified over the past 3 months as an integrated programme of work. The programme is currently defining the scope via the Complex Needs Group and the Alcohol Treatment and Recovery Group with key themes (as described below) ensuring that the key areas of work align to Healthy Liverpool and also current financial objectives for the CCG; Alcohol Related Brain Injury currently no pathway exists to assess or identify this impact, discussions are taking place to explore the development of a pilot with Waves of Hope; Primary Care assessment/advice and brief intervention GP referrals to community alcohol services (LCAS) remain low as does identification of homeless/complex needs; There is no specific pathway for community rehab and recover services (non NHS) (LCC are currently leading on a redesign of these services with providers substance misuse 109 Page 43 of 63

84 project group). Completion of a stepped type model with housing providers with a SPA is being explored; Attending acute Frequent Attender meetings and aligning with CCTs (also using risk stratification) with a view to supporting many Frequent Attenders in the community; Exploring primary care provision and best practice national models such as Pathway (a model of care for homeless/complex needs working from Primary care into Secondary Care). A resource has been identified in the Royal Liverpool working in partnership with the CCG piece together a data picture of homeless attendance/admission; Lack of psycho-social intervention for this complex cohort. The lead Health Psychologist at Aintree Hospitals has undertaken an audit of 83 individuals classed as frequently attending. This found that with follow up after 3 sessions of psychological intervention it reduced frequent attendances by almost half; Working with LCC colleagues to explore how housing/hostel providers can be used more effectively for those with complex needs; Working with Urgent Care and MADE in the Royal Liverpool to limit barriers for discharge for complex individuals (i.e. around discharge to hostel provision) which could affect further frequent attendances and admission; Explore an End of Life pathway for patients with liver disease. It should be taken into account that the presented indicators relate to admission or contact and within this cohort there may be one individual attending times over a 6-month period. An example of this was highlighted at the last Alcohol MDT in the Royal Liverpool where two patients were discussed; one patient had attended 29 times within the 6-month period with the other patient attending attended 22 times over the same. It is therefore extremely likely that the alcohol related indicators are actually a low number of individuals who are attending frequently. Successful completion of drug treatment (opiate users) the latest National Drug Treatment Monitoring System (NDTMS) figures for the 12-month period up to September 2016 show successful completion of drug treatment (opiate users) at 5.8%, representing a slight reduction of 0.2% against the NDTMS baseline figure of 12 months to March Successful completion of drug treatment (non-opiate users) the latest NDTMS figures for the 12-month period up to September 2016 show successful completion of drug treatment (non-opiate users) at 50.2%, representing a slight increase of 0.2% against the NDTMS baseline figure of 12- months to March Patient Experience Please note that an update is not available for the indicator Overall experience of making a GP appointment Areas Requiring Improvement Indicator 2016/17 Quality Premium National Indicator Increase in the proportion of Narrative In order for Liverpool CCG to achieve the Quality Premium for this indicator, either 80% has to be met by March 2017 or March 2016 performance (58%) has to be exceeded by 20%. Page 44 of

85 GP referrals made by e- referrals The latest performance for Liverpool CCG for September 2016 is 57.1%. Performance is reported to be better than the national position which for September 2016 stood at 51.1%. RED TREND The CCG has consistently been above the national average throughout 2015/16 and 2016/17 to date. However, the gap has narrowed during 2016/17. Analysis of historical trends shows that performance has declined since April 2015 when performance peaked at 71%. The average proportion of GP referrals made by e-referrals during April to September 2016/17 is 56%; this compares to an average of 67% during the same period in 2015/16. % of GP referrals made by e-referrals 80% 70% 60% 50% 40% 30% 20% 10% 0% Sep-16 Aug-16 Jul-16 Jun-16 May-16 Apr-16 Mar-16 Feb-16 Jan-16 Dec-15 Nov-15 Oct-15 Sep-15 Aug-15 Jul-15 Jun-15 May-15 Apr-15 England LCCG On current performance levels, achievement of this Quality Premium Indicator is likely to be challenging. Assurance on CCG Control Measures Continued sub-optimal performance is understood to be still due to a combination of the on-going issues associated with the implementation of the new NHS e-referrals system and capacity issues within each of the providers. As reported previously, these capacity issues cause an increase in ASIs (appointment slot issues) which has a negative impact on the CCG s utilisation. If providers book ASIs outside of the e-referrals system, they are not included in the overall count for the Quality Premium as they are not classed as a direct booking. Leads from the CCG s Choice/NHS e-referrals Team have continued to meet with colleagues at the Royal Liverpool, Liverpool Heart and Chest, Alder Hey, Aintree Hospitals and Spire Liverpool with the support of the national team (NHS Digital) Service Implementation Manager and the clinical lead to explore the requirements of the Service Delivery Improvement Plan (SDIP). Providers have commenced the reviewing of DOS (directory of services), which will ensure that GPs can clearly identify the appropriate services for their patients and ultimately reduce the number of referrals which are rejected or redirected. The CCG continues to work closely with specialties such as haematology with the aim of launching Advice & Guidance at the earliest opportunity during Page 45 of 63

86 8. CARE QUALITY COMMISSION INSPECTIONS/ISSUES/NOTICES Where providers are not meeting essential standards, the CQC has a range of enforcement powers to protect the health, safety and welfare of people who use the service (and others, where appropriate). When the CQC propose to take enforcement action, the decision is open to challenge by the provider through a range of internal and external appeal processes. 8.1 The Walton Centre for Neurology Overall Rating Outstanding The CQC carried out an announced inspection at the Trust between 5th April 2016 and 8 th April An unannounced inspection was also undertaken on 21 st April 2016 of Chavasse, Lipton, Dott and Caton wards in addition to theatres, critical care and the Complex Rehabilitation Unit (CRU). Following these inspections, the Walton Centre received an overall Outstanding rating from the CQC and was rated as Outstanding against Effective and Caring domains. Key findings from the CQC report included the following: All areas inspected were visibly clean and well organised. The Walton Centre was rated as the overall top acute trust in England in relation to the patient-led assessments of the care environment (PLACE) in The Trust scored 99% for cleanliness and 98% for condition, appearance and maintenance; Ward and theatre managers carried out daily staff monitoring and escalated staffing shortfalls to matrons and senior managers; End of life care was the responsibility of all staff across the trust and was not restricted to the end of life care (EOLC) team; Consultants made up 54% of the medical and surgical workforce across the Trust which was higher than the England average of 39%. There were less middle grade doctors at 4% compared with the England average of 9%, and the number of registrars within the service was higher than the England average at 41% (compared to the England average of 38%); Regular multidisciplinary mortality and morbidity committee meetings took place which fed into the monthly mortality and morbidity seminars. Mortality rates were lower (better) than average mortality rates at similar units between April 2012 and 112 Page 46 of 63

87 March 2015, as reported in the Neurosurgical National Audit Programme. Several areas of outstanding practice were noted during the inspection, which included: There were numerous examples of outstanding care in medical services where patients individual needs were met using alternative approaches to rehabilitation pathways which involved patients and their families. This included developing a garden area where family were encouraged to attend and garden with the patient; The use of functional magnetic resonance (MR) scanning in the diagnosis and treatment of patients. It was usually used for research purposes in other trusts but the trust was developing a range of applications that would improve diagnosis and outcomes for patients; The introduction of the nationally recognised rehabilitation network was considered as outstanding practice due to the focussed approach to rehabilitation and ability to move a patient to the most appropriate setting for care in a timely manner across the hub and spoke model; The interactive TIMS theatre live tracking system was an innovative system which allowed live tracking of patients through their theatre journey. This system also allowed consultants to book their own patients on to theatre lists while in clinic. A number of other organisations had visited the centre to benchmark against this system. The full inspection report can be downloaded from the CQC website: Page 47 of 63

88 8.2 North West Ambulance Service (NWAS) Overall Rating Requires Improvement NWAS is one of 10 ambulance trusts in England and provides emergency medical services across the North West region, which has a population of over seven million people. The Trust employs 5,409 whole time equivalent (WTE) staff who are based at ambulance stations and support offices across the North West. There are 109 ambulance stations distributed across the region, three emergency operations centres, one support centre, two patient transport service control centres, and two Hazardous Area Response Team (HART) buildings. The Trust also provides, along with urgent care and out of hours partners, the NHS 111 Service for the North West Region. The CQC undertook an announced focused inspection of NWAS between 23 rd and 26 th May 2016, with an unannounced inspection taking place on 6 th June The inspection was carried out as part of the CQC s comprehensive inspection programme and encompassed three core services of Emergency Operations Centres, Urgent and Emergency Care and Patient Transport Services (PTS). The NHS 111 service was also inspected during the visit. Key findings of the inspection are summarised below: Emergency Operations Centre: GOOD Emergency & Urgent Care: REQUIRES IMPROVEMENT Patient Transport Service: GOOD NHS 111: GOOD Trust Overall: REQUIRES IMPROVEMENT This is the first CQC inspection of NWAS to be rated and the Trust was pleased to receive a rating of Good in relation to care but was disappointed to receive an overall rating of requires improvement. Prior to the announced inspection, the CQC reviewed a range of information that it held and asked other organisations to share what they knew about the Trust. Interviews also took place with staff and patients. CQC also observed how people were cared for, talked to carers and/or family members, and reviewed patients records of personal care and treatment. 114 Page 48 of 63

89 Ratings were provided for each of NWAS core functions and found that the Trust s NHS 111, patient transport services and emergency operations centres were good, however, the emergency and urgent care service requires improvement. In terms of quality, the ratings for care, responsiveness and effectiveness were good, whilst other areas of quality that were inspected were rated as requires improvement Quality ratings: Safe: Requires Improvement Effective: Good Well-led: Requires Improvement Caring: Good Responsive: Good Unfortunately, this means that the Trust has received an overall rating of requires improvement which is disappointing. Outstanding practice was noted in other areas, including the delivery of the Trust s Hazardous Area Response Teams (HART), the implementation of community care pathways and use of new technology to map public defibrillator locations and sharing that information with control centres so they could be used to help patients in the community. NWAS has accepted the comments in the report relating to improvements required for procedures, guidelines and training, however the inspection took place almost ten months ago and the majority of the points highlighted have already been addressed. For the remainder, the Trust are working to a robust action plan which is being monitored by the Executive team and commissioners. These relate to the Trust s duty of candour and safeguarding of adults procedures and policies, together with the need to increase the recording and learning from incidents. Significant developments have already been made in areas such as the recruitment of paramedics, which is a national issue not unique to NWAS. The Trust has improved in house training for existing EMTs to become Paramedics with a clear progression plan. So far 49 have started the diploma programme with a further 77 on a clear progression route. An intensive recruitment drive has also resulted in the employment of 51 paramedics from Poland and Finland. 115 Page 49 of 63

90 The full inspection report can be downloaded from the CQC website: The Clatterbridge Cancer Centre Overall Rating Outstanding The CQC undertook an announced inspection of the Clatterbridge Cancer Centre and the Aintree Radiotherapy site between 7 th and 9 th June An unannounced inspection followed on 21 st June 2016 which assessed core services including medical care services (oncology), End of Life, outpatients/diagnostics, chemotherapy and radiotherapy. Overall, the Trust was rated as Outstanding and Good for the domains of safe, effective and responsive. Key findings from the inspection included the following: There was a clear trust strategy plan for 2014 to 2019 which had been refreshed in February This was supported by the establishment of a Transformation Programme Office to support the delivery of the transformation agenda; The Trust was led and managed by a visible executive team. This team were well known to staff who also spoke highly of the commitment shown to continually improve services by putting patients and people close to them at the centre of decision making; The NHS staff survey 2015 showed the trust performed better than the national average for 12 indicators and as expected in a further seven. The overall staff engagement score for the trust was 3.98, which was in line with the national average score of 3.94 for specialist acute trust; There was a very positive and supportive culture across all wards and departments. Staff were very proud of their hospital and the work they did. They were enthusiastic and passionate about the care they provided and the achievements they have accomplished. There was a tangible sense of willingness to go the extra mile and do the very best for their patients; The service participated in the National Chemotherapy Multi- Disciplinary Team (MDT) Peer Review (2014) being compliant with 35 out of 36 standards and scoring 97.6% overall. The service scored 100% overall compliance with the 19 standards for intrathecal chemotherapy in the National Chemotherapy MDT Peer Review (2014). 116 Page 50 of 63

91 The CQC report highlighted several areas of outstanding practice, which included: The End of Life service had developed a simulation based training programme to develop the skills and knowledge of staff throughout the hospital. This involved simulating difficult situations so that staff developed their confidence when dealing with patients and relatives at the end of life; All staff were committed to facilitating the requests of patients at the end of life. As an example, there had been a number of weddings organised within a short period of time at the request of patients. A number of the Trust s staff were involved in facilitating these; The Radiotherapy service had developed and used vac bags to help immobilise patients during treatment in addition to making individual head rests for patients to make them more comfortable; The Chemotherapy at Home project was outstanding and provided patients with treatment in their own homes. This service was seen as an embodiment of the Trust as a whole and its vision of providing the best cancer care to their patients; The positivity and compassion shown by Chemotherapy staff, which was also reflected in the feedback from patients was outstanding. It was clear that all levels of staff continuously strived to provide outstanding care to their patients. The full inspection report can be downloaded from the CQC website: CQC Inspections of Liverpool GP Practices The following reports have been published by the Care Quality Commission into the public domain between December 2016 and February Old Swan Health Centre Overall Rating Good (Reinspection) A comprehensive inspection carried out on 30 th June 2016 found a breach in legal requirements (Regulation 19 of the Health & Social Care 117 Page 51 of 63

92 Act 2012 Fit and proper persons employed) which the practice was requested by the CQC to immediately remedy. A follow-up focused inspection on 20 th December 2016 determined that the practice had addressed the issues identified and appropriate Disclosure and Barring Service (DBS) checks had been carried out for all staff. In addition, the practice had purchased a defibrillator, put monitoring systems in place for uncollected prescriptions and had made a number of other improvements to achieve an overall Good rating. The full inspection report can be downloaded from the CQC website: Page 52 of 63

93 8.4.2 Grassendale Medical Centre - Overall Rating Good (Reinspection) An announced comprehensive inspection of the practice on 12 th May 2016 found it to be in breach of Regulation 19 (Fit and proper persons employed and Regulation 12 (Safe care and treatment) of the Health & Social Care Act A focused follow-up inspection carried out on 23 rd December 2016 confirmed that the practice had implemented the required improvement actions and addressed the issues identified in the previous inspection. The practice had carried out health and safety risk assessments and DBS checks had been carried out for all staff, whilst monitoring systems for managing and mitigating safety risks had been improved. The full inspection report can be downloaded from the CQC website: Westmorland GP Centre - Overall Rating Good (Reinspection) Following a comprehensive announced inspection of the practice on 17 th June 2016, the CQC found it to be in breach of Regulation 12 (Safe care and treatment) of the Health & Social Care Act A focussed inspection was carried out on 20 th December 2016 which confirmed that all areas of concern had been addressed. The practice had systems in place for the authorisation of practice nurses to administer vaccinations and had employed the services of an external HR company. The full inspection report can be downloaded from the CQC website: 9. SUSTAINABILITY - CCG FINANCIAL POSITION Due to the changing need and complexity of financial reporting requirements the CCG Financial Position is now issued as a separate report. 119 Page 53 of 63

94 10. STATUTORY REQUIREMENTS (only applicable to strategy & commissioning papers) This section is not applicable to the CCG Corporate Performance Report. 11. DESCRIBE HOW THIS PROMOTES FINANCIAL SUSTAINABILITY The report provides evidence of the progress being made across the health economy in terms of CCG and local provider performance against NHS Constitutional/National Indicators and Outcomes Measures. The report highlights whether local providers are contributing to overall financial sustainability by measuring performance against activity, quality and value for money and individual contractual requirements. 12. CONCLUSION Where performance is at variance to plan action is underway with Trusts to deliver corrective action to improve performance with contractual levers utilised to support improvements. These improvements are actively led by CCG Clinicians. Stephen Hendry Senior Operations & Governance Manager 6 th February Page 54 of 63

95 Liverpool CCG - Performance Report (CCG Level) Metric Q1 Q2 Q3 Q4 YTD Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Preventing People from Dying Prematurely Cancer Waiting Times 191: % Patients seen within two weeks for an urgent GP referral for suspected cancer RAG G G G G G G G G G (MONTHLY) Actual % % 94.31% 95.19% 94.89% 97.31% 96.06% 97.59% 95.8% The percentage of patients first seen by a specialist within two weeks when urgently referred by their GP or dentist with suspected cancer Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 17: % of patients seen within 2 weeks for an urgent referral for breast symptoms (MONTHLY) Two week wait standard for patients referred with 'breast symptoms' not currently covered by two week waits for suspected breast cancer 535: % of patients receiving definitive treatment within 1 month of a cancer diagnosis (MONTHLY) The percentage of patients receiving their first definitive treatment within one month (31 days) of a decision to treat (as a proxy for diagnosis) for cancer 26: % of patients receiving subsequent treatment for cancer within 31 days (Surgery) (MONTHLY) 31-Day Standard for Subsequent Cancer Treatments where the treatment function is (Surgery) 1170: % of patients receiving subsequent treatment for cancer within 31 days (Drug Treatments) (MONTHLY) 31-Day Standard for Subsequent Cancer Treatments (Drug Treatments) 25: % of patients receiving subsequent treatment for cancer within 31 days (Radiotherapy Treatments) (MONTHLY) 31-Day Standard for Subsequent Cancer Treatments where the treatment function is (Radiotherapy) 539: % of patients receiving 1st definitive treatment for cancer within 2 months (62 days) (MONTHLY) The % of patients receiving their first definitive treatment for cancer within two months (62 days) of GP or dentist urgent referral for suspected cancer 540: % of patients receiving treatment for cancer within 62 days from an NHS Cancer Screening Service (MONTHLY) Percentage of patients receiving first definitive treatment following referral from an NHS Cancer Screening Service within 62 days. 541: % of patients receiving treatment for cancer within 62 days upgrade their priority (MONTHLY) % of patients treated for cancer who were not originally referred via an urgent GP/GDP referral for suspected cancer, but have been seen by a clinician who suspects cancer, who has upgraded their priority. RAG G G G G R R G G G Actual % % 93.40% 97.04% 92.78% 92.18% 95.56% 96.33% 94.5% Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% RAG G G G G G G G G G Actual % % 98.84% 97.57% 98.85% 99.09% 97.62% 98.96% 98.41% Target 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% RAG G G G G G G G G G Actual % % % 100% 96% 100% 100% 100% 99.04% Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% RAG G G R G G R G G G Actual % % 97.56% 100% 100% 93.59% 98.65% 100% 98.63% Target 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% RAG G G R G G G G G G Actual % % 91.30% 100% 95.30% 97.40% 95.52% 98.98% 96.92% Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% RAG R R G R G G G G G Actual % % 86.36% 84.06% 88.16% 87.21% 89.47% 88.63% 86.30% Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% RAG G G R G G G R G G Actual % % 80.00% 100% 100% 90.91% 88.89% 90.91% 93.94% Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% RAG G G R G R G G G G Actual % % 80.00% 88.89% 83.30% 100% 100% 87.50% 92.39% Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 15/16 and 16/17 Trend Page 55 of

96 Metric Q1 Q2 Q3 Q4 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Ambulance 1887: Category A Calls Response Time (Red1) Number of Category A (Red 1) calls resulting in an emergency response arriving at the scene of the incident within 8 minutes 1889: Category A (Red 2) 8 Minute Response Time Number of Category A (Red 2) calls resulting in an emergency response arriving at the scene of the incident within 8 minutes 546: Category A calls responded to within 19 minutes Category A calls responded to within 19 minutes Enhancing Quality of Life for People with Long Term Conditions Mental Health 138: Proportion of patients on (CPA) discharged from inpatient care who are followed up within 7 days The proportion of those patients on Care Programme Approach discharged from inpatient care who are followed up within 7 days IAPT E.A.3: % of people who receive psychological therapies - Access E.A.S.2: % of people who finish treatment having attended at least two treatment contacts and are moving to recovery - Recovery E.H.1 - A1: % of patients who received their first treatment appointment within 6 weeks of referral E.H.1 - A2: % of patients who received their first treatment appointment within 18 weeks of referral Helping People to Recover from Episodes of Ill Health or Following Injury Dementia Diagnosis Estimated diagnosis rates RAG G G G G G R R R G Actual 85.92% 87.00% 79.60% 82.02% 80.40% 72.68% 67.83% 69.23% 77.86% Target 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% RAG G G R R R R R R R Actual 75.38% 77.20% 73.40% 67.61% 73.02% 66.50% 68.13% 66.70% 70.88% Target 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% RAG R G R R R R R R R Actual 94.94% 95.10% 92.80% 91.06% 94.71% 92.62% 91.59% 89.89% 92.78% Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% RAG G G G Actual % 96.36% 97.22% Target 95.00% 95.00% 95.00% 95.00% 95.00% RAG Actual Target R 2.90% 3.75% R 2.70% 3.75% 3.75% 3.75% 15.00% RAG Actual Target R 34.8% 50.0% R 33.6% 50.0% 50.0% 50.0% 50.00% RAG G G G G G G G G Actual 76.15% 81.20% 81.50% 87.20% 90% 91.94% 90.76% 85.50% Target 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% RAG R R R R A G G R Actual 87.16% 90.00% 89.90% 93.10% 94.6% 96.77% 96.64% 92.58% Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% RAG G G G G G G G G G G Actual 73.8% 74.5% 75.0% 75.7% 76.10% 76.50% 76.50% 76.36% 75.95% 75.9% Target 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% YTD 15/16 and 16/17 Trend Page 56 of

97 Metric Q1 Q2 Q3 Q4 YTD Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Early Intervention in Psychosis early intervention in Psychosis waiting times: The proportion of people experiencing first RAG G G R G G G G G G episode psychosis (FEP) or an at risk mental state that wait two weeks or less to start a Actual 55.50% 55.50% 41.60% 57.15% 62.50% 61.50% 57.14% 75% 58.92% NICE-recommended package of care. Target 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Ensuring that People Have a Positive Experience of Care EMSA 1067: Mixed sex accommodation breaches - All Providers No. of MSA breaches for the reporting month in question for all providers 1812: Mixed Sex Accommodation - MSA Breach Rate MSA Breach Rate (MSA Breaches per 1,000 FCE's) Referral to Treatment (RTT) & Diagnostics 1291: Referral to Treatment RTT (Incomplete) Percentage of patients waiting at period end (RTT) for incomplete pathways (Commissioner) 2004: Referral to Treatment RTT - No of Incomplete Pathways Waiting >52 weeks The number of patients waiting at period end for incomplete pathways >52 weeks 1828: % of patients waiting 6 weeks or more for a diagnostic test The % of patients waiting 6 weeks or more for a diagnostic test Treating and Caring for People in a Safe Environment and Protect them from Avoidable Harm HCAI 497: Number of MRSA Bacteraemias Incidence of MRSA bacteraemia (Commissioner) 24: Number of C.Difficile infections Incidence of Clostridium Difficile (Commissioner) Accident & Emergency 431: 4-Hour A&E Waiting Time Target (Monthly Aggregate for Total Provider) % of patients who spent less than four hours in A&E (Total Acute position from Unify Weekly SitReps) RAG R R G G R G R R G R Actual Target RAG R R G G R G R R G R Actual Target RAG G G A A R R R R R R Actual 92.9% 92.6% 92.0% 92% 91.70% 91.28% 91.19% 91.60% 90.91% 91.81% Target 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% G R G G R R G R G R Actual Target RAG G G G G G R G G R G Actual 0.476% 0.509% 0.464% 0.53% 0.99% 1.04% 0.41% 0.82% 3.02% 0.919% Target 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% RAG R R R R R R R R R R YTD Target RAG R R R R R R R R R R YTD Target RAG R R G R R R R R R Actual 90.87% 91.31% 92.10% 91.93% 91.18% 90.37% 90.10% 88.53% 90.80% Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 15/16 and 16/17 Trend Page 57 of

98 Provider Level Performance Report Metric Period Target ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITALS NHS TRUST AINTREE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST ALDER HEY CHILDREN'S NHS FOUNDATIO N TRUST LIVERPOOL HEART AND CHEST HOSPITAL NHS FOUNDATIO N TRUST LIVERPOOL WOMEN'S NHS FOUNDATION TRUST LIVERPOOL COMMUNITY HEALTH MERSEYCAR E NHS TRUST THE WALTON CENTRE SPIRE LIVERPOO L Preventing People from Dying Prematurely Cancer Waiting Times 2005: % Patients seen within two weeks for an urgent GP referral for suspected cancer (MONTHLY) The % of patients first seen by a specialist within two weeks when urgently referred by their GP or dentist with suspected cancer 2006: % of patients seen within 2 weeks for an urgent referral for breast symptoms (MONTHLY) Two week wait standard for patients referred with 'breast symptoms' not currently covered by two week waits for suspected breast cancer 2007: % of patients receiving definitive treatment within 1 month of a cancer diagnosis (MONTHLY) The percentage of patients receiving their first definitive treatment within one month (31 days) of a decision to treat (as a proxy for diagnosis) for cancer 2009: % of patients receiving subsequent treatment for cancer within 31 days (Drug Treatments) (MONTHLY) 31-Day Standard for Subsequent Cancer Treatments (Drug Treatments) 2008: % of patients receiving subsequent treatment for cancer within 31 days (Surgery) (MONTHLY) 31-Day Standard for Subsequent Cancer Treatments where the treatment function is (Surgery) 2010: % of patients receiving subsequent treatment for cancer within 31 days (Radiotherapy Treatments) (MONTHLY) 31-Day Standard for Subsequent Cancer Treatments where the treatment function is (Radiotherapy) 2011: % of patients receiving 1st definitive treatment for cancer within 2 months (62 days) (MONTHLY) The % of patients receiving their first definitive treatment for cancer within two months (62 days) of GP or dentist urgent referral for suspected cancer 2012: % of patients receiving treatment for cancer within 62 days from an NHS Cancer Screening Service (MONTHLY) Percentage of patients receiving first definitive treatment following referral from an NHS Cancer Screening Service within 62 days. Nov Nov Nov Nov Nov Nov Nov Nov % 97.55% 96.32% 87.50% % 96.89% % 93% 93.46% 95.97% 96% 98.65% 98.52% 92.86% % % 98% % % 94% % % % % % 94% % 85% 85.58% 87.29% 95.65% 83.78% 90% % % 83.33% 2013: % of patients receiving treatment for cancer within 62 days upgrade their priority (MONTHLY) % of patients treated for cancer who were not originally referred via an urgent GP/GDP referral for suspected cancer, but have been seen by a clinician who suspects cancer Nov % % 91.84% 75.00% % Page 58 of

99 Metric Period Target ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITALS NHS TRUST AINTREE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST ALDER HEY CHILDREN'S NHS FOUNDATIO N TRUST LIVERPOOL HEART AND CHEST HOSPITAL NHS FOUNDATIO N TRUST LIVERPOOL WOMEN'S NHS FOUNDATION TRUST LIVERPOOL COMMUNITY HEALTH MERSEYCAR E NHS TRUST THE WALTON CENTRE SPIRE LIVERPOO L Enhancing Quality of Life for people with long term conditions Mental Health 138: Proportion of patients on (CPA) discharged from inpatient Q care who are followed up within 7 days % 97.20% Helping People to Recover from Episodes of Ill Health or Following Injury Early Intervention in Psychosis (EIP) early intervention in Psychosis waiting times: The proportion of people experiencing first episode psychosis (FEP) or an at risk mental state that wait two weeks or less to start a NICE-recommended Ensuring that People Have a Positive Experience of Care EMSA 1067: Mixed sex accommodation breaches No. of MSA breaches for the reporting month in question for all providers 1812: Mixed Sex Accommodation - MSA Breach Rate MSA Breach Rate (MSA Breaches per 1,000 FCE's) Referral to Treatment (RTT) & Diagnostics 2014: % of patients waiting 6 weeks or more for a diagnosic test The % of patients waiting 6 weeks or more for a diagnosic test 2000: Referral to Treatment RTT (Incomplete) Percentage of patients waiting at period end (RTT) for incomplete pathways (Provider) 2004: Referral to Treatment RTT - No of Incomplete Pathways Waiting >52 weeks Cancelled Operations 1983: Urgent Operations cancelled for a 2nd time Number of urgent operations that are cancelled by the trust for nonclinical reasons, which have already been previously cancelled once for 1982: % of Cancellations for non clinical reasons who are treated within 28 days Patients who have ops cancelled, on or after the day of admission (Inc. day of surgery), for non-clinical reasons to be offered a binding date within 28 days, or treatment to be funded at the time and hospital of patient s choice. Nov % 75.00% Dec Dec Nov Nov Nov Nov Q % 1.165% 0.78% 0.91% 0.46% 1.44% 0.00% 0.58% 0.00% 92.00% 89.94% 90.21% 92.09% 92.41% 92.68% 96.30% 96.50% % 0 24% 0 0 1% 125 Page 59 of 63

100 Metric Period Target ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITALS NHS TRUST AINTREE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST ALDER HEY CHILDREN'S NHS FOUNDATIO N TRUST LIVERPOOL HEART AND CHEST HOSPITAL NHS FOUNDATIO N TRUST LIVERPOOL WOMEN'S NHS FOUNDATION TRUST LIVERPOOL COMMUNITY HEALTH MERSEYCAR E NHS TRUST THE WALTON CENTRE SPIRE LIVERPOO L Treating and Caring for People in a Safe Environment and Protect them from Avoidable Harm Accident & Emergency 431: 4-Hour A&E Waiting Time Target (Monthly Aggregate for Total Provider) % of patients who spent less than four hours in A&E (Total Acute position 1926: A&E Attendances: Type 1 Number of attendances Type 1 A&E depts 1927: A&E Attendances: All Types Number of attendances at all A&E depts 1928: 12 Hour Trolley waits in A&E Total number of patients who have waited over 12 hours in A&E from decision to admit to admission Hospital Acquired Infections MRSA 497: Number of MRSA Bacteraemias Incidence of MRSA bacteraemia (Provider) Cdifficile 24: Number of C.Difficile infections Incidence of Clostridium Difficile (Provider) Nov Nov Nov-16 (YTD) Nov Dec-16 (YTD) Dec-16 (YTD) 95.00% 87.7% 81.1% 92.0% 99.5% 7,498 6,607 5, , ,648 38,307 8, Local Local Page 60 of 63

101 Liverpool Health and Social Care Integrated Performance Report Liverpool Latest Value Key Direction of Travel Key: Performance is worse than target/plan Performance shows an improvement on previous reporting period Core Cities (CCG peers are mapped to CCGs that fall within core Performance is/has met target/plan Performance shows no change since previous reporting period city boundaries) Performance is better than target/plan Performance shows a decline on previous reporting period B'ham Mcr Newcastle Sheffield Target/Plan not available Previous reporting period not available for comparison Bristol Leeds Nottingham Better Care Fund Scheme Project HLP Outcome 1 Domain 1 HLP Outcome 2 Domain 2 CCG outcome CCG Framework Priority Domain Domain 3 HLP Outcome 1 HLP Outcome 2 Indicator Name Metric Reporting Period Target Previous Latest Potential years of life lost (PYLL) from causes considered amenable to healthcare Liverpool Direction Trend of travel over time Previous Latest Core City Trend over time Min Max Liverpool Ranking previous Years /12 8/12 Health-related quality of life for people with long-term conditions Percentage Jul 15- Mar /15 15/15 HLP Rate per Outcome 3a Reducing avoidable emergency admissions (composite measure) 100,000 Healthy Liverpool Programme Priorities Liverpool Value 2014/ Core City Benchmark Liverpool Ranking current Domain 3 HLP Local Data Reducing avoidable emergency admissions (composite Outcome 3a measure) Rate per 100,000 Nov 15-Oct 16 (rolling 12 months) HLP Outcome 3a Domain 3 HLP Non Elective Emergency Admissions (MAR Activity, HWB Footprint Outcome 3b LCCG, KCCG and SSCCG) -BCF measure Total admissions Q2 2016/17 14,337 14,834 14,430 Domain 4 HLP Patient experience of primary care - average number of negative Outcome 4a responses per 100 patients (Selected questions) Per 100 patients 2014/15 < Domain 4 HLP Patient experience of hospital care - average number of negative Outcome 4b responses per 100 patients (Selected questions) Per 100 patients Childrens Domain 1. The rate of stillbirths and deaths within 28 days of birth per 1,000 live births and stillbirths Rate per /15 11/15 Domain 1. Antenatal assessments within 13 weeks Percentage Q3 2015/ /12 5/12 Domain 1. Maternal smoking at delivery Percentage Q1 2016/ /15 13/15 Domain 1. Breast feeding prevalence at 6-8 weeks Percentage Q1 2016/17 > /8 7/7 Domain 1. Breastfeeding - breastfeeding initiation Percentage 2014/ /7 Domain 1. MMR2 uptake - 2 doses (5 year olds) Percentage Q1 2016/ /7 3/7 Self Care & Prevention Accident Prevention Domain 1. Hospital admissions caused by injuries in young people (15-24 years) Crude Rate Per 100, / Domain 1 Children receiving face to face NBV with a Health Visitor within 14 days Percentage Q2 2016/ Domain 1 Children receiving a 6-8 week review by 8 weeks by a Health Visitor Percentage Q2 2016/ Page 61 of

102 Better Care Fund Scheme Self Care & Prevention Self Care & Prevention Project Self-Care CCG outcome CCG Framework Priority Domain Domain 1 and 3. Domain 1 and 3. Domain 1 and 3. Self-Care Domain 1. Impact on emergency admissions Impact on emergency admissions Impact on emergency admissions Impact on emergency admissions Indicator Name Metric Reporting Period Target Previous Latest Reduction in CHD admissions to hospital *Link to increase in cardiac rehab complition rate and increase in smoking quitters Reduction in heart failure admissions to hospital - Patients prescribed beta blocker Reduction in stroke admissions to hospital - Increasing pulse checks and anti-coag Reduction in COPD admissions to hospital *Link to increase in pulmonary rehab complition rate Long Term Conditions Rate per 100,000 Rate per 100,000 Rate per 100,000 Rate per 100,000 Nov 15-Oct 16 (rolling 12 months) Nov 15-Oct 16 (rolling 12 months) Nov 15-Oct 16 (rolling 12 months) Nov 15-Oct 16 (rolling 12 months) Liverpool Value Liverpool Direction Trend of travel over time Previous Latest Core City Trend over time Core City Benchmark Min Max Liverpool Ranking previous Liverpool Ranking current Domain 1. % patient over 65 receiving a pulse check (excluding established AF) Percentage Nov Domain 1. % of CHD patients treated with a Statin Percentage Nov Domain 1. % of Heart Failure patients treated with a beta blocker Percentage Nov Domain 1. People with COPD and MRC Dyspnoea scale >=3 offered pulmonary rehabilitation Percentage Nov Domain 1. People with Diabetes who have received 8 care processes Percentage Nov Self Care & Prevention Domain 1. Self-Care Domain 1. Mental Health Transformation Primary Care Domain 1. Care Primary Locality Mental Health Transformation Primary Care Domain 1. Care Primary Locality Mental Health NHS Transformation General Mental Health Domain 1. Constitution People with Diabetes diagnosed less than 1 year referred to structured education 2.2 Proportion of people who are feeling supported to manage their condition People with serious mental illness (SMI) who have received the complete list of physical checks (National Data) Local Data People with serious mental illness (SMI) who have received the complete list of physical checks (PCQF) The proportion of patients on Care Programme Approach discharged from inpatient care who are followed up within 7 days Mental Health Proportion of adults in contact with secondary mental health services Transformation General Mental Health Domain 2. living independently, with or without support Mental Health Transformation Phychological Therapies Domain 2. Quality 2016/17 Premium Mental Health Transformation Phychological Therapies Domain 2. Quality 2016/17 Premium Mental Health NHS Transformation Phychological Therapies Domain 1. Constitution Access to IAPT services: People entering IAPT services as a % of those estimated to have anxiety/depression Local data: Access to IAPT services: People entering IAPT services as a % of those estimated to have anxiety/depression IAPT Rate of recovery: % of people who are "moving to recovery" of those who have completed IAPT treatment Percentage Nov Percentage Jul 15- Mar /15 3/15 Mental Health Programme Percentage 2014/ /15 2/15 Percentage Nov Percentage Q2 2016/ /15 7/15 Percentage 2015/ /8 4/8 Percentage Q2 2016/ % /15 Percentage Rolling quarter (Aug, Sep & Oct 16) 3.75% Percentage Q2 2016/17 50% /15 Mental Health Percentage of referrals to IAPT services which indicated a reliable Transformation Phychological Therapies Domain 2. recovery following completion of treatment Percentage January 2015 to December / Page 62 of 63

103 Better Care Fund Scheme Project CCG outcome CCG Framework Priority Domain Liverpool Value Liverpool Direction Indicator Name Metric Reporting Period Target Previous Latest Trend of travel over time Cancer Programme 2013 (year of diagnosis) Domain One-year survival from all cancers Years Domain /17 Quality Premium Previous Latest Core City Benchmark Core City Trend over time Min Max Liverpool Ranking previous Liverpool Ranking current /15 9/ Percentage of cancers detected at stage 1 and 2 Percentage /16 12/15 Self Care & Prevention Self Care & Prevention Self Care & Prevention Health Improvement Domain 1. Cancer screening coverage - breast cancer Percentage Health Improvement Domain 1. Cancer screening coverage - cervical cancer Percentage Health Improvement Domain 1. Cancer screening coverage - bowel cancer Percentage Healthy Ageing Programme Healthy Ageing Reablement Domain 3. National BCF measure Delayed Transfers of Care (delayed days) from hospital per 100,000 population (aged 18+). Rate per 100,000 Q2 2016/ Healthy Ageing Reablement Domain 3. National BCF measure Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services Percentage Q1 2016/ Healthy Ageing Dementia Domain 3. National BCF measure Estimated diagnosis rate for people with dementia Percentage Q2 2016/ % 76.5% Healthy Ageing Dementia Domain 1. People with Dementia prescribed antipsychotic medication Percentage Nov-16 < National BCF Healthy Ageing Carers Domain 4. measure Social care-related quality of life Percentage 2015/ Healthy Ageing Carers Domain 4. Proportion of people who use services and their carers, who reported that they had as much social contact as they would like Percentage 2015/ Healthy Ageing Care Homes Domain 3. Permanent admissions to residential and nursing care homes, per Rate per 100,000 population 100,000 Q2 2016/ National BCF measure Healthy Ageing Care Homes Domain 3. Emergency admissions from care homes Rate per Nov 15-Oct ,000 (rolling 12 months) Healthy Ageing Reablement Domain 3. Emergency admissions due to falls in people aged 65 and over Rate per 100, / /8 8/8 2016/17 Quality Premium Healthy Ageing Reablement Domain 3. Local data: Emergency admissions due to falls in people aged 65 and Rate per Nov 15-Oct 16 over 100,000 (rolling 12 months) /17 Quality Premium Healthy Ageing Reablement Domain 3. Hip fractures in people aged 65 and over Rate per 100, / /8 7/8 Prevention Self Care & Prevention Self Care & Prevention Self Care & Prevention Self Care & Prevention Self Care & Prevention Self Care & Prevention Self Care & Prevention Self Care & Prevention Self Care & Prevention Tobacco Control Domain 1. Smoking quitters Percentage Q1 2016/ /7 6/7 Domain 1. Percentage of eligible population receiving an invite for health check Percentage Q3 2015/ /7 6/7 Domain 1. Percentage of those invited who receive a healthcheck Percentage Q3 2015/ /7 6/7 Domain 1 Alcohol Domain 1. Alcohol Domain 1. Alcohol Domain 1. Chlamydia detection rate (15-24 year olds) 2016/17 Quality Premium Emergency admissions for alcohol related liver disease 2016/17 Quality Premium local data. Emergency admissions for alcohol related liver disease Hospital admissions for alcohol related conditions per 100,000 narrow measure Rate per 100,000 Rate per 100,000 Rate per 100,000 Rate per 100, > Apr 2015 to March 2015 (Provisional) Nov 15-Oct 16 (rolling 12 months) /15 15/ Q1 2016/ /7 7/7 Domain 1. successful completion of drug treatment - opiate users Percentage Q2 2016/ /7 5/7 Domain 1. Successful completion of drug treatment - non opiate users Percentage Q2 2016/ /7 2/7 Patient/Carers Experience Domain /17 Quality Premium Increase in the proportion of GP referrals made by e-referrals Percentage Sep-16 80%/+22% 56% 57% Domain 4. Overall experience of making a GP appointment: either achieve 85% 2016/17 Quality respondants who said they had a good experience of making an Premium appointment or 3% increase on percentage of respondants who said they had a good experience Percentage Jul 15- Mar % or 85% /12 Page 63 of

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105 Report no: GB NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY TUESDAY 14 TH FEBRUARY 2017 Title of Report Lead Governor Senior Management Team Lead Report Author Summary Recommendation Relevant standards/targets Emergency Care Improvement Programme: Whole System Enquiry Visit Liverpool & South Sefton Health Economy. Katherine Sheerin Chief Officer Ian Davies, Chief Operating Officer Ian Davies, Chief Operating Officer A review of the North Mersey health economy was conducted by the national ECIP team between the 31/10/16 and 4/11/16. This report presents the findings of that review and the suggested actions. That Liverpool CCG Governing Body: Notes the contents of the ECIP review. Urgent and emergency care NHS Constitutional standards. Page 1 of

106 EMERGENCY CARE IMPROVEMENT PROGRAMME WHOLE SYSTEM ENQUIRY VISIT LIVERPOOL AND SOUTH SEFTON HEALTH ECONOMY. 1. PURPOSE To present to the Governing Body the findings of the ECIP review of the Liverpool and South Sefton local health and social care system. 2. RECOMMENDATIONS That Liverpool CCG Governing Body: Notes the contents of the ECIP review. 3. BACKGROUND The urgent and emergency care local health and social care system has been under some considerable pressure for some time, evidenced by the poor performance against the national 4 hour target in AED, lengthening ambulance turnaround times and the high numbers of people with delayed transfers of care / ready for discharge. Despite considerable local efforts and increased joint working, pressures have continued and as part of the national support programme ECIP have been brought into the local system to carry out a comprehensive diagnostic enquiry visit assessment and to make recommendations for action. After some unavoidable delay, the final ECIP report has now been received and under the auspices of the North Mersey AED Delivery Board an action plan will now be urgently developed across the system to progress the ECIP recommendations, with ongoing support from the ECIP team over the coming months to support subsequent implementation and expected service improvement. The attached ECIP report contains a focus upon high impact changes, which along with good, accountable leadership for each work stream, will enable the urgent and emergency care systems across Liverpool and South Sefton to make significant and sustainable improvements to its urgent care services. 132 Page 2 of 26

107 4. STATUTORY REQUIREMENTS (only applicable to strategy & commissioning papers) NHS Constitutional Standards for urgent and emergency care. 4.1 Does this require public engagement or has public engagement been carried out? No i. If no explain why: it is not expected that the recommendations will require additional public engagement: As the action plans are developed this will be kept under review and any subsequent requirement identified, appropriately discharged. ii. If yes attach either the engagement plan or the engagement report as an appendix. Summarise key engagement issues/learning and how responded to. 4.2 Does the public sector equality duty apply? Yes. iii. If no please state why iv. If yes summarise equalities issues, action taken/to be taken and attach engagement EIA (or separate EIA if no engagement required). If completed state how EIA is/has affected final proposal: As the action plans are developed this will be kept under review and any subsequent requirement identified, appropriately discharged. 4.3 Explain how you have/will maximise social value in the proposal: describe the impact on each of the following areas showing how this is constructed to achieve the most: a) Economic wellbeing b) Social wellbeing c) Environmental wellbeing An effective health and social care urgent and emergency care system will have a beneficial impact upon the wellbeing of the city and its population, specifically ensuring that resources are utilised in an effective and efficient manner to meet individual s needs. 133 Page 3 of 26

108 4.4 Taking the above into account, describe the impact on improving health outcomes and reducing inequalities It is expected that implementation and delivery of the ECIP recommendations will have a positive impact upon improving outcomes of those with urgent and emergency care needs, alongside reducing health inequalities. 5. DESCRIBE HOW THIS PROMOTES FINANCIAL SUSTAINABILITY Poor performance of the health and social care urgent and emergency care system has a detrimental impact upon financial stability and sustainability. The delivery and sustainability of a redesigned urgent and emergency care system is expected to support and promote financial sustainability. 6. CONCLUSION The ECIP report is presented to the Governing Body for their consideration. Ian Davies Chief Operating Officer 16 th January Page 4 of 26

109 ECIP Whole System Enquiry Visit Liverpool and South Sefton Economy Introduction The review was conducted from Tuesday 31st October to Friday 4th November (inclusive) across all parts of the local health and social care system. We would like to acknowledge how welcome the team were made to feel by all staff we met. The review was well organised by staff locally. Everybody was very engaged, open and honest. Our feedback session to the system was conducted on the 28 th of November at your request, The following members of the ECIP North Region team were involved in the whole system enquiry: Claire Old, Improvement Manager and site lead Karen McCracken- Associate Improvement Manager and associate site lead Steve Christian, Senior Improvement Manager Dr Kevin Reynard, North Clinical Lead and ED Consultant Dr Nick Roper, Consultant in Acute Medicine Dr Sally Briggs, Consultant in Elderly Medicine Steve Barnard, Improvement Manager Dennis Holmes, Social Care Lead Jeremy Pease, Improvement Manager Teresa Emery, Improvement Manager Cathy Howe, Improvement Manager Marie Herring, Improvement Manager Jerry Penn-Ashman, Ambulance Advisor Les Porter, Associate Improvement Manager Claire Price, Associate Improvement Manager We wish to assure all concerned, in particular the teams we met, that in our evaluation we have acted independently and trust that all concerned will view observations and recommendations in a constructive manner. During the course of the week, our team spent time in clinical areas, led various activities with teams, and engaged with clinicians and leaders in a variety of settings. We also reviewed the data and information supplied by the system. The observations and recommendations in this report are a result of these interactions and are based on the themes that emerged. Local Context Our review encompassed the two systems surrounding Aintree University Hospitals Foundation Trust (AH), which has 684 beds, and Royal Liverpool and Broadgreen University Hospitals, (L&BH) with 750 beds. Liverpool Clinical Commissioning Group (LCCG) is the lead commissioner for L&BH and South Sefton Clinical Commissioning Group (SSCCG) is the main commissioner for AH. However, due to the proximity of Southport and Ormskirk Hospitals NHS Trust, there is also a close relationship between this acute trust and Southport and Formby Clinical Commissioning Group (S&FCCG). These three systems together form the basis of the A&E Delivery Board. This, in addition to the same number of councils (Liverpool City Council, 135 Page 5 of 26

110 Sefton Council and Knowsley and Halton), adds to the complexity of health and social care provision, making it challenging for patients and health and care staff to navigate the system and access services. At all stages of the patient journey, this creates some organisational boundaries between services, duplication of effort, confusion and frustration for staff and delays for patients. Evidence Base Case for Change As a starting point it is essential that everyone across the system understands that poor patient flow leads to a reduction in high quality care, and therefore the requirement to make improvements at pace. Flow in both systems is clearly compromised; patients spend too long in the emergency department and too long in acute care. Improving flow throughout the system, so that patients only receive acute care when, and for as long as it is clinically needed, must be the focus for the whole system. Research into poor patient flow (resulting in crowded emergency departments and high bed occupancy) has established links with a number of adverse patient outcomes and evidence suggests: For patients who are seen and discharged from an A&E, the longer they have waited to be seen, the higher the chance they will die during the following 7 days (Guttmann et al, 2013). The longer a patient spends in the Emergency Department (ED), the longer they stay in the hospital (Liew et al, 2003). Ten days in hospital leads to the equivalent of 10 years ageing in the muscles of people over 80 (Giles et al, 2004). Delays in transfer from ED to higher dependency units increase mortality and length of stay (Chalfin et al, 2007). Once a hospital is over 90% bed occupancy it reaches a tipping point in its resilience (Forster et al, 2003). Lowering levels of bed occupancy is associated with decreased in hospital mortality and improved performance on the 4-hour target (Boden et al, 2015). Key Information from ECIP Data Pack Emergency Department (ED) Attendances Aintree Overall attendances in the Emergency Department have increased by +5.6% from March to August 2015 compared with the same period in 2016 (40,263 to 42,537). Ambulance attendances have increased in the aforementioned time period (+6.6%; 14,987 to 15,974) and walk in attendances have increased by +5.1% (25,276 to 26,653). 136 Page 6 of 26

111 Liverpool Overall attendances in the Emergency Department have increased by +0.2% from April to September 2015 compared with the same period in 2016 (46,308 to 46,406). Ambulance attendances have increased in the aforementioned time period (+0.9%; 17,552 to 17,707) and walk in attendances have decreased by -0.2% (28,756 to 28,699). Patient flow Aintree The performance around the time to treatment metric (time from arrival to seen by a clinical decision maker) has historically been very low at around 15% of patients treated within 60 minutes of arrival. In addition, analysing this by time of day of arrival, we can see that there is significant variation with patients arriving at 9am being seen, on average, within 60 minutes. However, patients arriving around 1am are seen within 100 minutes as can be seen from the graph below. Patients Time to treatment % Attends Avg SD -3 SD +3 1 Beyond 2 Sigma 9 on one side of Avg 6 trending up / down 2 of 3 beyond 2 Sigma 4 of 5 beyond 2 Sigma 15 within 1 Sigma 30-Sep 31-Oct 30-Nov 31-Dec 31-Jan 28-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-Dec 31-Jan 29-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 8 outside 1 Sigma Graph 1 Time to treatment performance by day TTT Monday Tuesday Wednesday Thursday Friday Saturday Sunday TTT Axis Title :00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21: Page 7 of 26

112 Liverpool The performance around the time to treatment metric (time from arrival to seen by a clinical decision maker) has historically been low at around 42% of patients treated within 60 minutes of arrival. Analysing this by time of day of arrival, we can see that there is significant variation with patients arriving at 9am being seen, on average, within 50 minutes. However, patients arriving around 1am are seen within 150 minutes as can be seen from the graph below Time to treatment % Attends Avg SD SD +3 Patients Beyond 2 Sigma 9 on one side of Avg 6 trending up / down of 3 beyond 2 Sigma 4 of 5 beyond 2 Sigma 0 15 within 1 Sigma 30-Oct 30-Nov 31-Dec 31-Jan 28-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-Dec 31-Jan 29-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 8 outside 1 Sigma Graph 1 Time to treatment performance by day TTT Monday Tuesday Wednesday Thursday Friday Saturday Sunday TTT Axis Title :00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 Length of Stay (LoS) Aintree In this system 32% of patients have a zero day length of stay (LoS), often referred to as ambulatory, shown in Graph 2. This is good compared with the National profile of 30%. This is mirrored in the proportion of patients staying between 0-2 days shown in Graph 4 (short stay / assessment patients). In 138 Page 8 of 26

113 this system, 60% of patients on average have a 0-2 day LoS, whereas the national average is 65-70% Day LoS % Attends Avg SD -3 SD +3 1 Beyond 2 Sigma Patients on one side of Avg 6 trending up / down 2 of 3 beyond 2 Sigma 4 of 5 beyond 2 Sigma 0 15 within 1 Sigma 30-Sep 31-Oct 30-Nov 31-Dec 31-Jan 28-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-Dec 31-Jan 29-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 8 outside 1 Sigma Graph 2 Proportion of patients with 0 day length of stay % Short Stay LoS % Attends Avg SD SD Beyond 2 Sigma Patients on one side of Avg 6 trending up / down 2 of 3 beyond 2 Sigma 4 of 5 beyond 2 Sigma 0 15 within 1 Sigma 30-Sep 31-Oct 30-Nov 31-Dec 31-Jan 28-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-Dec 31-Jan 29-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 8 outside 1 Sigma Graph 3 Proportion of patients with a Short Stay (0-2 midnights) % Liverpool In this system 32% of patients have a zero day length of stay (LoS), often referred to as ambulatory, shown in Graph 2. This is good compared with the National profile of 30%. This is mirrored in the proportion of patients staying between 0-2 days shown in Graph 4 (short stay / assessment patients). In this system, 58% of patients on average have a 0-2 day LoS, whereas the national average is 65-70%. 139 Page 9 of 26

114 Day LoS % Attends Avg SD -3 SD +3 1 Beyond 2 Sigma Patients on one side of Avg 6 trending up / down 2 of 3 beyond 2 Sigma 4 of 5 beyond 2 Sigma 0 15 within 1 Sigma 30-Oct 30-Nov 31-Dec 31-Jan 28-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-Dec 31-Jan 29-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 8 outside 1 Sigma Graph 2 Proportion of patients with 0 day length of stay % Patients Short Stay LoS % Attends Avg SD -3 SD +3 1 Beyond 2 Sigma 9 on one side of Avg 6 trending up / down 2 of 3 beyond 2 Sigma 4 of 5 beyond 2 Sigma 0 15 within 1 Sigma 30-Oct 30-Nov 31-Dec 31-Jan 28-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-Dec 31-Jan 29-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 8 outside 1 Sigma Graph 3 Proportion of patients with a Short Stay (0-2 midnights) % Discharges Aintree Graph 4 shows the discharge profile for this system is shown by time of day. The initial peak of discharges peak at 6pm which is later than we would expect Admission and Discharge profile 2000 Patients Admissions Discharges Hour Graph 4 Admission and Discharge profile Page 10 of

115 Graph 5 shows that discharges are heavily weighted to a Friday (peak at 120) compared with Saturday (80) and a low on Sunday of 70. This variation impacts on flow of patients through the emergency floor over the weekend and also impacts negatively on patient outcome, with patients admitted over the weekend having a longer LoS than patients admitted on a Monday. Day of week profile - Admission/Discharge Admissions Discharges Admissions Discharges 0 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Day of week 0 Graph 5 Admission / Discharge by day of week Liverpool Graph 4 shows the discharge profile for this system is shown by time of day. The initial peak of discharges peak at 4pm which is later than we would expect Admission and Discharge profile 2000 Patients Admissions Discharges Hour Graph 4 Admission and Discharge profile Graph 5 shows that discharges are heavily weighted to a Friday (peak at 120) compared with Saturday (80) and a low on Sunday of 70. This variation impacts on flow of patients through the emergency floor over the weekend and also impacts negatively on patient outcome, with patients admitted over the weekend having a longer LoS than patients admitted on a Monday. 141 Page 11 of 26

116 Day of week profile - Admission/Discharge Admissions Discharges Admissions Discharges 0 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Day of week 0 Graph 5 Admission / Discharge by day of week Patient Outcome Aintree If we look at the time in the Emergency Department for the patients who are admitted we can see, from the graph below, that there is a significant peak of patients leading up the 4 hour mark (which is common picture across the country). If we overlay the length of stay (in days), we can see that as the time in department increases so does the length of stay. Patients admitted within 4 hours having a length of stay of 4.1, whereas patients admitted after 4 hours have a length of stay of 6.4 days. Time in Department for Attendances (Admitted) patients compared with LoS Attendances (Admitted) LoS Patients LoS (Days) Graph 8 Time in department against length of stay Time in department (Minutes) 0 Liverpool If we look at the time in the Emergency Department for the patients who are admitted we can see, from the graph below, that there is a significant peak of patients leading up the 4 hour mark (which is common picture across the country). If we overlay the length of stay (in days), we can see that as the time in department increases so does the length of stay. Patients admitted within 4 hours having a length of stay of 4.2, whereas patients admitted after 4 hours have a length of stay of 6.5 days. 142 Page 12 of 26

117 Time in Department for Attendances (Admitted) patients compared with LoS Attendances (Admitted) LoS Patients LoS (Days) Graph 6 Time in department against length of stay Time in department (Minutes) 0 As we have said in our meetings together where we have shared this data, we have used it to shape the quick wins, and we have also triangulated the data with our 6 A s audits and length of stay (LOS) reviews. Given that you have elected to work as a system, sharing data and the intended and unintended consequences of any change on both systems, is essential. Priorities We recommend that the system focuses on four key priority areas: 1. Leadership 2. Assessment prior to admission 3. Doing today s work today 4. Discharge to assess These priorities align with the national A&E Plan and will allow the system to concentrate on a limited number of actions that will have a high impact on performance. System Leadership Commissioning There are significant differences of opinion and direction of travel between commissioners, which manifests itself in a lack of consistency in decision making in relation to service developments, changes and delivery. This results in some major challenges in ensuring the smooth and timely movement of patients around systems and in particular out of hospital. There is an obvious commissioning focus on the functioning of ED at both units and it is recommended that a more holistic view of the patient journey and the potential for improvement is taken: failure of A&E access standards is a system issue, not just an ED problem. Whilst we have recognised that improvements can be made in systems, processes and the environments in ED, commissioners could really benefit patient care and flow by a concentration on alternatives to admission and timely discharge. There needs to be a re-focussing of commissioning strategies to drive integration of services across all providers and stakeholders. This is particularly important given the current procurement process at Liverpool Community Health (LCH) where services are being split 143 Page 13 of 26

118 into bundles of core and non-core. One, perhaps unintended, consequence of this move is the potential breakup of the Community Respiratory Team who provide significant support across both systems in early supported discharge and hospital at home. The whole move in relation to LCH is proving very disruptive across systems and it is imperative that stability in integrated system provision is achieved as soon as possible through the new provider. This will take considerable skill and commitment. It is appropriate to highlight within this section the importance of inclusion in commissioning strategies of mental health services and current difficulties must be resolved around the provision of Liaison Psychiatry in particular. It is understood that Mersey Care are bidding to take on some of the services currently provided by LCH and whether they are successful or not the continued development of integrated mental health in primary care provision is imperative. This should be driven through commissioning rather than through a business development agenda in Mersey Care. There does not appear to be an accepted or well-understood plan for community beds, particularly intermediate care beds resulting in a lack of clarity around where responsibility for intermediate care sits. The Royal Liverpool Hospital are planning to reduce their bed base in the new hospital by 100 beds and at the same time Liverpool council have plans to build three 50-bedded nursing/residential facilities. It is recommended that further consideration is given to this and that there is a strong drive to further develop the Home First" philosophy at pace. It is positive in this context, that there is strong clinical support for the Home First approach across clinicians in both primary and secondary care. As we detailed in the feedback session, acute beds in the Royal Liverpool Hospital are being reduced, however the results of the length of stay review indicate a unique usage pattern, with a higher than normal number of patients in the not-fit category, and a younger population usage (for example in Stroke). We caution the system in the reduction of beds until a re-evaluation of the assumptions is undertaken based on this system s unique circumstances. Closing beds ahead of process improvements can seriously destabilise systems and must be done with great care, particularly where hospitals are running at high occupancy levels. It is essential that occupancy can be shown to have fallen significantly on run charts before beds are considered for closure. We would suggest that the Citywide telephone triage service needs further consideration, as it would appear to be a duplication of services offered through the national 111 services. In other applications of telephone technology, the local tele health service is very popular and successful with both staff and patients. Currently 700 patients benefit from this service with a capacity for Commissioners should look at the opportunities of expanding this service as soon as feasible. In many other health systems, the federation of practices has been successful particularly if this is developed on a locality basis. It is recommended that the current plan to federate across all 90+ practices is revisited and perhaps a more locality based solution developed. The A&E Delivery Board The new A&E Delivery Board provides an opportunity to redefine how system leaders hold each other to account for delivery and align themselves to one vision for urgent care. The 144 Page 14 of 26

119 group needs to develop one version of the truth in terms of performance across the system and agree the high impact actions and shared risks. This will lead to agreement on the processes that cause patient delays. System leaders need to develop strong professional relationships at a sub-regional level. There are several sources though which formal team development can be procured and ECIP would be happy to support this if required by the system. It would also be beneficial for the system to develop a memorandum of understanding or shared principles that articulate a shared purpose and shared values: How we do things round here. Equally, we would recommend that system leaders engage fully in urgent care work across the system, spending time in each other s organisations, to fully understand the whole system aspects of urgent and emergency care across the system. Sharing the responsibility for actions necessary in escalation would be enhanced by this level of understanding. The system should be focused on a number of priority areas delivering small, incremental gains. It is important that an improvement-based approach is adopted and systematically used with a focus on learning, scaling and sustaining. There should be an emphasis on 90 day improvement plans and reducing unnecessary bureaucracy. The system governance processes should be designed to support this approach. We also suggest that PMO and transformational resources would be maximised if all organisations contributed to a shared team. Developing system leadership recommendations Consolidation of existing resources and development of more simple pathways across the system, a plea from staff for post-code neutral discharge pathways. Develop a sub-regional strategy for urgent and emergency care (including workforce). Establishment of a fully functioning A&E Delivery Board, with focused work plan Adopt a cross system 90-day improvement-based approach, consolidating all system resources into one team. Agree a shared purpose and shared values at a system level. Assessment prior to admission 6 A s Review- Liverpool A 6A s review was completed in Liverpool by a multi-disciplinary team led by a GP. The team looked at 25 cases, which identified that 20% of cases reviewed could have had an admission avoided if existing services had been utilised or had capacity. As a comparison nationally, this figure is fairly low. The review highlighted: ED is the default admission point when everyone else is busy. 145 Page 15 of 26

120 There is a lack of confidence of GPs in the IV community service. The pathway is not good for patients who overdose: patients are admitted to medical inpatients rather than CDU and then wait a long time for a psychiatric review. There are a high number of young strokes and we observed some delays for CT scanning. Alternatives to ED such as Walk-In centres have been a success. There were delays observed in getting a patient out of ITU to step down which is a waste of resources. Internal delays were observed e.g., outpatient ultrasound wait is 6 weeks, so patients are admitted or kept in to secure a slot. Nursing homes can take a long time to assess (one patient waited 14 days). There is a need for direct admission to specialties to avoid ED. Protocols are sometimes not followed for admission in ED, for example a patient was admitted without checking with a senior clinician. 6A s review- Aintree No GP attended the audit and there were limited attendees. Only a small number of patients were reviewed as a result. It was agreed that the audit needed repeating with a GP and more patients to estimate the potential for avoiding admissions. Despite that the findings were: The ability for frailty services to pull is limited with no frailty score recorded. Internal professional standards for review in ED do not appear to be applied. The ability to discharge from ED is limited because of variation in the availability of alternative services. A breakdown in communication was observed in advance care plans. Mental health capacity assessments are causing delays. Bed flow is a concern- when patients are admitted into the wrong pathway or wrong specialty which can cause significant delays Ambulance non-conveyance and handover Whilst it is recognised this is a priority for both Trusts: Both sites struggle with ambulance handover Average turnaround is 40 minutes and significant delays have been recorded over the last few months. 146 Page 16 of 26

121 AH has a large RAT area but no reverse queueing at peak times RLBUHT has no active triage or intervention further down the queue than fourth. ED We observed: Committed and caring staff who were welcoming and open. Whilst we accept that a new hospital is planned for Liverpool, patients are currently treated in a sub-optimal physical environment. Aintree pit-stop is effective when running as planned. The pit-stop proforma is excellent and prompts transfer to ambulatory care and frailty, but delivery can be variable. RLBUHT run nurse led triage. We did not observe frailty assessment in either ED Assessment prior to admission recommendations If one ED model is to be adopted, pace could be improved by using the best of both systems and developing relationships between the two units. The current suggestion of Consultants from both sites contributing to the trauma rota at Aintree is a good start, but the teams are some distance from being a truly integrated team at all levels. Increase the pace of ED integration and process changes; develop new integrated ED operational methods now before the new hospital opens. Our ECIP ED Clinical Lead will share our deep dive with clinical teams and support the development of integrated improvement plans. Work with the ECIP Ambulance lead to improve integrated handover processes. It is imperative that departments take responsibility for queuing ED patients and the release of crews. Solutions for queue management should be sought until flow can be established to make this unnecessary. Streaming can occur from the ambulance service and on-site GP provision which could be maximised further. Encourage crews to transfer to chairs where appropriate on arrival to ED. Embed regular 6A audits within your system with peer review of both sites. Streaming to mental health services was reported to be a major issue. There is confusion about ongoing overnight support and this needs clarification. Introduce frailty scoring at the front door and initiate comprehensive geriatric assessment within one hour. Today s Work Today Overall, the two acute trusts have followed Safer Faster Better recommendations and developed SAFER and Red to Green methodology, which is commendable. We met really committed and innovative clinicians and managers who wanted to use evidence based 147 Page 17 of 26

122 improvement processes. Our recommendation to you would be around being very clear on what is expected of everyone in terms of internal professional standards and response times, as the variation in individual operation is resulting in a lack of credibility in the process and delays in patient discharge. The push from clinicians to mirror operating models across the two Trusts will be made easier if both trusts adopt similar operative models, as clinicians can then work across sites adhering to the same standards. The success of Productive Ward initiatives shows that where things like equipment and policy are the same in ward environments, risk of mistakes and resultant harm are reduced. As a concept, if SAFER bundles and your Purple to Gold initiatives were the same with the same expectations and internal professional standards, expectations would be clear wherever clinicians are working. We would recommend ECIP support a more in-depth review of site management processes and meetings. We saw variation in the way bed meetings were conducted and in resultant actions and expectations. The full capacity protocol operation is unclear in both the executive sign up and in the operationalisation. Acute Medicine In our Acute Medicine Deep Dive, our ECIP Acute Consultant noted: Aintree: Overarching impression was of a well organised, well led and functional unit & team. Looking at their development plans and recent work it may be that this has come about as a result of their improvement work. The CD we met had been in post for 6 weeks and had been brought in to lead the developments and appeared to have a good grip on what was happening both day to day and overall. Liverpool: Overarching impression was of an under pressure unit and organisation where the abnormal had been normalised. E.g. had a standing ward round to see all the patients bedded overnight in ED, because there always were a significant number. The AMU seemed relatively protected from this, meaning that all of that pressure was being borne by ED, other than the medical input. The estate is not ideal but could do more e.g. ambulatory care needs to be larger and blocked from bedding down. There is a need for a clear plan for processes such as huddles/board rounds. There is also a need for links to information systems such as bed management (no clear overview of current and pending activity for the floor). We recommend that our ECIP lead shares the findings of his deep dive with the acute medicine teams and assists in the development of a shared model across both sites. Frailty Model In the deep dive conducted by our ECIP frailty lead, she concluded: 1. There is a need for closer working between clinical teams at both sites to learn from each other s expertise. 148 Page 18 of 26

123 2. There is a need for a review of community provision to standardise the discharge to assess approach, intermediate care offer. 3. There is a need to ensure that frailty identification is embedded and to develop plans to support patients not in core areas. 4. There is a need to ensure robust CGA is initiated within an hour of attendance whether in ED, AMU or acute frailty unit. We recommend that our ECIP frailty lead shares the findings of her deep dive with the frailty teams and assists in the development of a shared model across both sites. Today s work today recommendations Consider a common SAFER bundle and Red to Green /Purple to Gold process. With the support of ECIP, complete a review of site management processes and bed management information systems. We recommend that our ECIP lead shares the findings of his deep dive with the acute medicine team and assists in the development of a shared model across both sites. We recommend that our ECIP frailty lead shares the findings of her deep dive with the frailty teams and assists in the development of a shared model across both sites. We recommend the introduction of a frailty score and comprehensive geriatric assessment within an hour of attendance whether in ED, AMU or the acute frailty unit. We recommend an increased focus on the establishment and implementation of common internal professional standards developed by the clinical teams; particularly focussed on improving early pull from assessment units to speciality inpatient wards and escalation of inpatient delays. The full capacity protocol operation is unclear in both the executive sign up and in the operationalisation. We recommend it is reviewed. We recommend that a common patient choice policy is adopted. We found numerous issues associated with variable application and over prescription from clinicians of long-term care. Raising patient and relative expectations by clinicians without having the correct background information was seen as a huge frustration by staff. Discharge to assess Stranded patients can be identified as those with a length of stay (LOS) of seven days or more. The aim of any review of these patients is to understand what the plan is and what is the next thing that these patients are waiting for on the day of review. Our findings in Aintree and the Royal Liverpool Hospital were starkly different. 149 Page 19 of 26

124 Aintree: We reviewed 274 patients who had a length of stay of over 7 days. The adult acute bed base is 680 beds and we suggest that trusts should aim for max 20% of their patients over 7 days, whereas Aintree has nearly 50% of their patients over 7 days. 158 of the patients were classified as fit and 116 as not fit which is a normal pattern. The aim of the exercise was to give the top 5-6 reasons that will help the trust to target their stranded patients. The top reason for patients to be fit and still in hospital was ongoing therapy (N.B. influenced by the presence of Aintree2Home beds on site) then: Waiting for a domiciliary care package (19) Waiting for external assessment (16) Pt or family choice (18) (? Over prescription as detailed above) Waiting for community placement (12) Waiting for residential/nursing Home (10) Liverpool We reviewed 317 patients which equated to nearly 42% of patients over 7 days in an adult acute bed base of 750 beds.120 patients were classified as fit and 197 not fit which is a very abnormal distribution. Of the trusts we have reviewed in the country, there is no other trust where there are more not fit than fit patients. This pattern was a repeat of when we did this review the last time in Liverpool Hospital. This causes us concern if you are losing 100 acute beds (although this is not a scientific enough tool to be a modelling tool). For this reason, we recommend that you review your demand and capacity modelling. In the fit category, the highest number of patients were waiting for internal CHC process (12) and then: Choice(10) Ready for home today(12) Waiting for internal assessments/results(8) Equipment and adaptations(7) In the not fit category the highest number of patients were waiting for an internal test (42) followed by: No clear plan (11) Active ongoing treatment (78) News score above 5 (26) IV Therapy (15) 150 Page 20 of 26

125 Discharge to assess recommendations Consider community employment of HCAs until domiciliary care market developed DTOC meetings turn into Get me Home meetings Home First at pace (though well done for this initiative) MADE events to educate on alternatives SAFER at pace Conduct and internal waits audit Review thinking on IV pathways Review location of social work and discharge teams in Aintree (not together at present). Consider if being risk averse (use of voluntary sector rather than professionals) Choice- banners as you come in the hospital about pathways through the system (behavioural insights team say people start to believe things when you say it over and over again) For adaptations and equipment- consider a handyman or voluntary sector We suggest you review the TTO process using our ECIP Rapid Improvement Guide, our ECIP Pharmacy Lead can help to assess and support TTO process ECIP to assist MADE events ECIP to support Home First and D2A at pace ECIP to assist review of the Full Capacity and Patient Choice Protocol. Continue to implement SAFER and Red to Green (purple to gold) at pace. ECIP to assist PDSA of therapists at the front door. A plea from your staff for services to BE POSTCODE NEUTRAL on discharge. Community Overarching issues: There is significant variation and fragmentation of community services across the system with no common core offer across Liverpool and South Sefton. There are multiple points of access to community services. There are different names for services that provide broadly similar offers across the geographical patch, which makes navigating the services difficult and confusing for patients and referrers. There are significant delays in Fast Track funding for end of life patients, with approximately 3 patients a week dying in acute setting whilst waiting for funding decisions. South Sefton locality community services are delivered by Liverpool Community Health but have been developed in isolation to the Liverpool based community services, which is a 151 Page 21 of 26

126 historic organisational issue but also due to different commissioning arrangements. Whilst the services are now addressing some of the silo working there is still significant variation in provision across the system with different levels of service offers and names for example The Intensive Community Care Team (ICCT) is available 7 days a week in Liverpool with some overnight provision that is not replicated in South Sefton. This leads to fragmentation of services and inequity of access for patients. There are also up to three different routes of access, which complicates access particularly for urgent care services, which is likely to lead to ED being the default place of attendance. It is recommended that a core community offer and commissioning strategy for community services should be developed across Liverpool and South Sefton. A collaborative approach should be adopted, commissioners working with health and social care partners including the voluntary and community sector, patients and carers to develop the community offer. This needs to ensure that there is one name with a common language and capacity to ensure ease of access and a timely response, seven days a week and into the late evenings for step up and step down care. Best practice and the A&E Delivery plan mandates Discharge to Assess and trusted assessor type models, which needs to be a key component of the community services. The benefits of the Liverpool and Aintree adopting this approach are two fold, it will greatly reduce delays in discharge and a home first approach where clinically appropriate will improve outcomes for patients. Some community services in-reach into the acute frailty model in Liverpool, which is good practice however there are further opportunities across the system to increase integrated approaches including: It is recommended that a core community offer and commissioning strategy for community services should be developed across Liverpool and South Sefton. South Sefton have a CQUIN with community nurses working in ED to support admission avoidance, it is recommended that these nurses align to the acute frailty unit to support an integrated approach to early assessment and discharge to assess. The Liverpool Community Frailty Team (CFT) currently provides in-reach to the acute frailty model in Liverpool. It is recommended that this team works with the community matrons in Liverpool who are case managing and supporting admission avoidance from care homes. This would enable the CFT to access valuable information from the community matron s records, which should help to reduce the need for admission and increase earlier discharges. The community teams currently use EMIS as an electronic record and the CFT could look to gain access to these within the Royal Liverpool Hospital. Mobile working is developing within the community and this should be considered for the CFT and also the community nurses working in ED/the acute frailty pathway at Aintree Hospital. The ICCT that is currently being established needs to be developed at pace to ensure that it is fully mobilised and working at capacity to support admission avoidance and maintaining people in the community. The extension of mobile working and the ability to print off care plans and have these available in the person s own home. Also increasing the number of care plans on ERRIS will support increasing the number of people not transferred to hospital by the ambulance services. The community are currently providing intravenous antibiotics, which is good practice however these are generally prescribed as twice daily. It is recommended that the system works together with microbiology to develop 152 Page 22 of 26

127 alternative pathways for single dose IV antibiotic prescribing, changing to oral doses as soon as clinically appropriate. Other options are to train patients to administer their own antibiotics, which other areas have introduced for children. This will enable better use of the community resources. Liverpool are currently developing delivery of tele health models of care, it is recommended that you develop this as a system wide model across Liverpool and South Sefton. Community nursing services are currently providing heparin injections twice daily for housebound patients with DVTs. A good example of a community based DVT service was observed at the Old Swan Walk in Centre (WIC), which is currently provides once daily injections which could be adopted by community nursing. This could be further developed to consider novel oral anticoagulants licensed for the treatment of DVT in order to release community nurse capacity. It is recommended that the system looks to developing the availability of the DVT pathway across all WICs in Liverpool and South Sefton. The process for completing CHC documentation seems to be complex and time consuming, particularly when community staff are completing Decision Support Tools (DSTs) for patients not known to them. It was estimated for one clinic that it took up to 1.5 w.t.e. of district nurse time each week on completing DSTs. It is recommended that the process is reviewed to make this leaner and makes use of electronic patient record information (which is currently faxed) and best practice that the multi-disciplinary team member who best knows the person should complete the documentation. This process should be standardised across all community providers, it is understood that Mersey Care do not completed DSTs, which then falls to the district nurses to complete. The community teams felt that there would be benefit of having an equipment amnesty. The Emergency Response Team mooted they could not discharge patients due to availability of social care. It is recommended that this is reviewed to identify which patients can be stepped down from social care alongside implementation of discharge to assess and addressing over prescription of support required on discharge and patient and carer expectations. The system should also look work with the voluntary sector to identify opportunities for stepping down patients into alternative services. Community teams felt there was value in developing better links with services provided from the Innovations Centre with the localities to improve communication and integrated working. The impact of reducing the variation in provision and improving access to community services 7 days a week and outside of core hours, particularly in South Sefton, will help to improve admission avoidance approaches in the community. This, alongside the development of a discharge to assess model which will reduce Length of Stay (LoS) and increase opportunities for admission avoidance, will improve patient experience and outcomes. The challenges of the current financial constraints across the system are recognised, however there are opportunities to enable better utilisation of community resources. The system should explore these further enabling the reinvestment of efficiencies into extending the provision in the community. 153 Page 23 of 26

128 On the Aintree site, it was reported that there were significant delays in Fast Track funding for end of life patients, with approximately 3 patients a week dying in acute setting whilst waiting for funding decisions. It is recommended that the process for agreeing funding is reviewed to ensure that the preferred place of care is accessed in a timely way. Walk in Centres Visits to some of the walk in centres (WIC) identified some good practice within the service and enthusiasm with the team at Litherland to develop services further into an ambulatory care community service. However, across the sites there is significant variation in the service offer. It is recommended that the good practice is spread across all sites enabling a consistent offer and in opening hours and service provision across all WICs. This will enable ambulance crews and 111 to divert more patients from ED services to WICs. We recommend that opportunities for developing the core offer in WICs are explored further for commissioning across the system including: Litherland WIC has significant issues with GP cover and the service is currently exploring opportunities with the Out of Hours Providers to extend GP cover. It is understood that there is a GP acute visiting service provided by the OOH provider across some parts of the system. This may provide opportunities for working with other local CCGs to enable coverage of a few services across the geographical patch, which will afford efficiencies whilst improving access to out of hospital services. The Old Swan WIC provided a DVT pathway, which could be extended across all WICs. Litherland are keen to expand to ambulatory care models in community and extend x-ray provision for children, which could be established with Alder Hey Hospital where the service already has some joint governance arrangements. WIC staff do not seem to be accessing data with the exception of Litherland. It is recommended that staff make better use of data to understand current activity and flow to inform service development opportunities. It was noted that reception staff currently receive patients in the waiting area and inform nursing staff if there is a patient requiring urgent review. We recommend that written guidance is provided for reception staff to improve governance on identifying and highlighting poorly patients to nursing staff. Some of the attendances at the WIC maybe due to poor primary care access and we recommend that commissioners review data on the presentations at WICs based on GP practice to understand this further with a view to improving primary care access and developing capacity to increase the core offer for WIC as identified above. In addition the WICs need to send notifications to GP practices of attendances so that they are aware of attendance and any relevant clinical issues, this is particularly priority for paediatric attendances. General Practice In the time available we only had the opportunity to visit one general practice in Sefton and we were unable to schedule a visit in the time available to the Out of Hours GP service. We 154 Page 24 of 26

129 know that the area has the same workforce challenges in terms of recruitment of GPs and practice staff from our stakeholder discussions, however we will share any further findings at a later date. Social Care. The Royal Liverpool acute trust chief interface is with Liverpool City Council, relationships between the Trust and the Council were overwhelmingly described as good at both a strategic and operational level. The existence of one coterminous Clinical Commissioning Group for the City assists in providing this sense of strategic coherence in the City. As with very many Local Authorities, Liverpool City Council has seen significant reductions in central government funding over the last seven years and, consequently, the adult social care budget in the City has reportedly been reduced by almost 50% in that time. The Council has described the great efforts that have been made to ensure its ability to continue to deliver statutory services but, by implication, this has meant that it s funding for a range of nonstatutory services has had to be sacrificed. The Council does not expect its funding situation to improve with further central government funding reductions of up to 90M expected over the next 3 financial years. Against that backdrop, the Council is eager to ensure that it maximises opportunities for strategic partnering in the future delivery of adult social care services, believing that this represents the most efficient means of sustaining its statutory service offer, including its current deployment of social work staff in both Hospital and Community settings. As part of this overall strategic intention, the system is committed to moving away from bed based care and support (in both acute and community settings), towards home first solutions for people. The first practical steps accompanying this strategic intent had just been taken at the commencement of fieldwork. The Aintree trust main interface is with Sefton Council as well as with the City of Liverpool which it neighbours. Both Trusts also interface, to a greater or lesser extent, with Knowsley and Halton Councils. On balance, the strategic and operational complexities created for each Trust in managing relationships with multiple Local Authorities, seems to be more of an issue for the Aintree system. Sefton Council is also coterminous with Sefton and Southport Clinical commissioning group but also has a significant interface with the Southport and Ormskirk Acute Trust. Sefton Council has, like its neighbour, faced substantial central government funding reductions and, like its neighbour, has sought to protect its statutory services. In contrast to Liverpool, and perhaps because of the differing financial circumstances of the respective CCG s, more strained strategic and operational relationships appear to exist within this system. The strategic strain is not limited to disputes between the CCG and Local Authority, disputes are also played out between the CCG and acute trust. This strategic strain links directly into operational tensions. This is best characterised by regular disputes in relation to the funding of care for patients likely to have continuing healthcare needs on the one hand and disputes over funding an intermediate care pathway on the other. This strategic and operational strain is played out in the acute setting and is likely to be observable in the outcome of the length of stay review. In contrast to the Liverpool system, it was difficult to discern an overall system strategy, rather a set of individual organisational objectives primarily geared towards short term individual financial sustainability. 155 Page 25 of 26

130 With this in mind, there appear to be significant opportunities for onward shared learning between the Liverpool and Aintree systems both strategically and operationally and the establishment of the newly constituted A & E Board provides a vehicle potentially capable of accelerating this process. Conclusion The recommendations in this report reflect the need for the system to concentrate on a limited number of priorities that will result in a simplified urgent care pathway. These recommendations are rooted in the clear evidence described in Safer, Faster, Better and are being delivered in an increasing number of systems around England. They also reflect the priorities in the national A&E Plan. ECIP will provide practical support for the next twelve months including learning events, access to data and information and onsite support from a team of clinical experts. We will be working as experts working alongside experts, using improvement methodology to drive sustainable improvements. The system is now asked to develop and agree a focused delivery plan to ensure that improvement is made at pace. Claire Old Dr Kevin Reynard Steve Christian Improvement Manager, Clinical Lead, North, Senior Improvement Manager, ECIP ECIP ECIP 156 Page 26 of 26

131 Report no: GB NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY TUESDAY 14 TH FEBRUARY 2017 Title of Report Lead Governor Senior Management Team Lead Report Author Summary NHS RightCare Programme Dr Maurice Smith Tony Woods, Programme Director Community Services and Digital Care Gina Perigo, Programme Lead NHS RightCare is a programme committed to reducing unwarranted variation to improve people s health and outcomes. It ensures that the right person has the right care, in the right place, at the right time, making the best use of available resources. It s important to note that NHS Liverpool CCG will be expected to: review, understand and address areas of unwarranted variation within the September 2016 Commissioning for Value (CfV) pack by the end of 2017/18. This will involve working through several cycles of the RightCare approach, focussing on multiple pathways have completed this approach for 40% of the opportunities highlighted by the end of 2017/18 and plan to address 80% of the opportunities by 2018/19 Page 1 of 9 157

132 Recommendation Relevant standards/targets That Liverpool CCG Governing Body: provides system leadership across the local health economy (LHE) to facilitate the NHS RightCare approach being embedded successfully approves the pathways that have been identified as the key priorities for the first cycle based on review of the CfV packs in relation to the opportunity to improve quality and reduce the spending profile, which are: - Circulation Problems - Respiratory System Problems - Neurological System Problems supports the development of effective business processes to help deliver effective and sustainable change, particularly in relation to decision making and prioritisation. Note: The opportunity value identified for review is 18,731,000 which accounts for 45.5% of the total opportunity outlined within the CfV pack. Progress against the selected pathways will be assessed through robust evaluation and within the CCG Improvement and Assessment Framework (IAF). The IAF includes two NHS RightCare indicators, which will assess whether CCGs improve in terms of spend and outcomes in the areas they select as NHS RightCare priorities under the programme. Page 2 of 9 158

133 NHS RIGHTCARE PROGRAMME 1. PURPOSE The purpose of this report is to provide an overview of the NHS RightCare Programme and requirements for CCGs, now that NHS Liverpool CCG is part of wave two. 2. RECOMMENDATIONS That Liverpool CCG Governing Body: provides system leadership across the local health economy (LHE) to facilitate the NHS RightCare approach being embedded successfully approves the clinical pathways that have been identified as the key priorities for the first cycle based on review of the CfV packs in relation to the opportunity to improve quality and reduce the spending profile, which are: - Circulation Problems - Respiratory System Problems - Neurological System Problems supports the development of effective business processes to help deliver effective and sustainable change, particularly in relation to decision making and prioritisation Note: The opportunity value identified for review is 18,731,000 which accounts for 45.5% of the total opportunity outlined within the CfV pack. 3. BACKGROUND NHS RightCare is a programme committed to reducing unwarranted variation to improve people s health and outcomes. It ensures that the right person has the right care, in the right place, at the right time, making the best use of available resources. NHS RightCare ensures local health economies: make the best use of resources to optimise value better value for patients, the population and the tax payer 159 Page 3 of 9

134 understand how they are doing by identifying variation in spend and health outcomes with demographically similar populations and more widely across health economies in England get talking about the same issues - about key opportunities to improve population healthcare, developing viable solutions and removing barriers to success focus on the areas of greatest opportunity by identifying priority programmes which offer the best opportunities to improve healthcare for populations. use best practice and optimised processes to make sustainable improvements to care pathways to reduce unwarranted variation Following the launch of the programme in February 2016 and a successful rollout to the first cohort of 65 CCGs, this has resulted in quantifiable reductions in unwarranted variation, improvement in patient outcomes and a drive to increase value. NHS RightCare launched Wave 2 of the programme in October Participating in the RightCare programme brings with it access to the following resources: A dedicated RightCare Delivery Partner Analytical support from an expert central team Access to clinicians and managers across England who have successfully implemented RightCare, for knowledge transfer Central support and products relating to Intelligence (Commissioning for Value, Knowledge Management), networking, peer learning and sharing of best practice 4. WAVE 2 REQUIREMENTS NHS Liverpool CCG is now part of Wave Two of the NHS RightCare Programme and is expected to provide system leadership across the LHE to facilitate the NHS RightCare approach being embedded successfully. As NHS RightCare is a population-based approach, it s a crucial role ensuring all stakeholders are aligned and supportive. Practically, the programme will be expecting three firm products from NHS Liverpool CCG as we work through the NHS Right Care Approach with our Delivery Partner on a handful of priority pathways: 1. Capturing emerging opportunities: quantifying the main opportunities the LHE will pursue in their first cycle of improvement to reduce 160 Page 4 of 9

135 unwarranted variation and increase value, based on Commissioning for Value and local intelligence and data. Gateway one submission is due on the 24th of February Capturing approved business cases: stakeholder-agreed case for change and plan for action. Gateway two submission due on the 14 th of July 2017.This return will add detail to the emerging opportunities, including timeframes for returns and the full scope of improvements being targeted in cycle one. 3. Establishing quarterly reporting to 2020: commencing in January 2018 This will involve working through several cycles of the RightCare approach, focussing on multiple pathways and have completed this approach for 40% of the opportunities highlighted by the end of 2017/18 and plan to address 80% of the opportunities by 2018/19. To facilitate the process the following roles and leads have been identified as requested by NHS RightCare; Dr Maurice Smith - Clinical Lead, Tony Woods - Executive Lead, Gina Perigo - Operational Lead, and a Liverpool RightCare Working Group has been established. Priorities (Opportunities) for Cycle 1 The CfV pack provides a review of the indicative data across the10 highest spending programmes of care highlighting the top priorities. Each CCG is compared to the 10 most demographically similar CCGs, which is used to identify opportunities to improve population healthcare. LCCG is benchmarked against the following CCGs: NHS Salford CCG NHS Bristol CCG NHS Brighton and Hove CCG NHS Hull CCG NHS Sheffield CCG NHS Sunderland CCG NHS Newcastle Gateshead CCG NHS South Tees CCG NHS Stoke on Trent CCG NHS South Manchester CCG The scale of opportunity has been calculated based on NHS Liverpool CCG performing at a similar rate to the average of the top 5 CCGs within the RightCare peer group. 161 Page 5 of 9

136 The following pathways, Circulation, Respiratory and Neurological System Problems have been identified as the priorities for the first cycle based on a review of the CfV packs carried out by the Liverpool RightCare working group. The opportunities have been selected based on where the Liverpool health economy: is an outlier and is most likely to yield the greatest improvement for health outcomes and financial sustainability is aligned to the North Mersey Local Delivery System priorities and plans has strong clinical leadership and engagement has a significant level of resource to support implementation of the improvement plans Table 1. Right Care Opportunities (Disease area) As detailed in table 1, Respiratory and Circulation disease areas offer the greatest opportunities in relation to spend, bed days saved and potential lives saved. Both programmes already have well established integrated delivery groups working through proposed opportunities across a number of work streams. The work streams are clinically led with clinical representation from each North Mersey provider. Both areas equate to 36% of the total opportunity. A third area would be required to take Liverpool over the 40% threshold. Given the crossover of work between circulatory and neurological, it is proposed that Neurological be selected as the third area for phase 1. Chest Pain and Syncope and Collapse which currently fall under Neurological offer the greatest opportunity within the neurological 162 Page 6 of 9

137 disease; both areas are currently being reviewed as part of the circulation redesign. Gastrointestinal is recognised as a significant opportunity for the LHE. However, it is proposed that this be reviewed in the second cycle while preparatory work commences to identify clinical and managerial leadership across the North Mersey local delivery system, to ensure that LHE is in a position to optimise the opportunities available for transformation and improvement. Progress against the selected priorities will be assessed through robust evaluation and within the CCG Improvement and Assessment Framework (IAF). The IAF includes two NHS RightCare indicators, which will assess whether CCGs improve in terms of spend and outcomes in the areas they select as NHS RightCare priorities under the programme. NHS Rightcare Approach NHS Rightcare Approach has been designed to maximise value at population and individual levels and consists of the three phases, see figure 1. Figure Page 7 of 9

138 The RightCare approach aims to ensure healthcare systems are focusing change resources on the areas of greatest opportunity and impact. This applies both to the full optimal system design process where Commissioning for Value information identifies areas of greatest opportunity for a full service review (Where to Look) as well as to any other transformation ideas that support the sustainability of the system. Phase two of the approach emphasizes the need for clinical leadership and active engagement of all relevant stakeholders with patients at the centre of the engagement process, to ensure optimal clinical redesign and delivery (What to Change). Effective business processes (How to Change) are a key ingredient for the RightCare methodology. They are essential when generating, considering and developing ideas to maximise value, to help deliver effective and sustainable change, through the development of robust plans and effective decision making and prioritisation processes. CCGs will be expected to report on a small number of approach milestones, the NHS RightCare Oversight Group has indicated that they intend to monitor these qualitatively. 5. STATUTORY REQUIREMENTS (only applicable to strategy & commissioning papers) N/A 5.1 Does this require public engagement or has public engagement been carried out? Yes / No 5.2 Does the public sector equality duty apply? Yes/no. 164 Page 8 of 9

139 5.3 Explain how you have/will maximise social value in the proposal: describe the impact on each of the following areas showing how this is constructed to achieve the most: a) Economic wellbeing b) Social wellbeing c) Environmental wellbeing 5.4 Taking the above into account, describe the impact on improving health outcomes and reducing inequalities 6. DESCRIBE HOW THIS PROMOTES FINANCIAL SUSTAINABILITY The NHS Five Year Forward View modelled the need for the health system to generate 22bn of efficiencies by 2020/21. The NHS RightCare programme is a critical part of NHS England s approach to driving allocative efficiency in order to meet this need. 7. CONCLUSION The NHS RightCare programme will support NHS Liverpool CCG to maximise value, reduce unwarranted variation and improve population healthcare improvements. 165 Page 9 of 9

140 166

141 NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY TUESDAY 14 TH FEBRUARY 2017 Report no: GB Title of Report Lead Governor Senior Management Team Lead Report Author Summary Recommendation Review of Orthopaedic Services Dr Fiona Lemmens Tom Jackson, Healthy Liverpool SRO Carole Hill, Healthy Liverpool Programme Director The purpose of this paper is to present the case for change for the reconfiguration of adult acute orthopaedic services in the city, and to provide an overview of the process and timescales to develop proposals, engage, consult and a decision regarding the future provision of these services. That Liverpool CCG Governing Body: Notes and approves the clinical and financial case for reconfiguring orthopaedic services, provided by the city s two adult acute trusts; Notes the joint commitment of commissioners and providers to identify a proposed solution which improves the quality of services and ensures clinical and financial sustainability; Approves the process and timescales for proposal development, patient and public engagement and formal consultation, leading to a decision regarding the future delivery of orthopaedic services. 167 Page 1 of 14

142 Impact on improving health outcomes, reducing inequalities and promoting financial sustainability Relevant Standards or targets This project supports the achievement of the Healthy Liverpool Programme objectives to improve health outcomes, reduce health inequalities and to deliver clinical and financial sustainability. NHS Constitution Targets Healthy Liverpool aims 168 Page 2 of 14

143 REVIEW OF ORTHOPAEDICS SERVICES 1. PURPOSE The purpose of this paper it to present the case for change for the city s orthopaedic service, aligned to the Healthy Liverpool hospitals vision to establish a centralised university teaching hospital campus with single-service, city-wide delivery, delivered through centres of academic, clinical and service excellence. This model for hospital services will see delivery of specialised and general services delivered from a network of centres, including the centralised campus site and neighbouring District General Hospitals, alongside the shift to more services being provided by hospitals in neighbourhoods across the city. This will bring health and academia together in one location, allowing maximum advantage of the city s research and development capabilities. 2. RECOMMENDATIONS That Liverpool CCG Governing Body: Notes and endorses the clinical and financial case for reconfiguring orthopaedic services, provided by the city s two adult acute trusts; Notes the joint commitment of commissioners and providers to identify a proposed solution which improves the quality of services and ensures clinical and financial sustainability; Approves the process and timescales for proposal development, patient and public engagement and formal consultation, leading to a decision regarding the future delivery of orthopaedic services. 3. CONTEXT AND CHALLENGES It is widely accepted that the North Mersey hospital system has too many hospital trusts delivering care from too many sites to be either clinically or financially sustainable in a resource constrained system. The 2013 Liverpool Mayoral Health Commission advocated the: " reduction of duplication and unnecessary competition (particularly in secondary care) and for the restructuring of care in all settings to improve the patient pathway and quality of 169 Page 3 of 14

144 care. This recommendation was supported as the direction of travel by Healthy Liverpool. The challenges for the North Mersey hospital system are significant and if left unaddressed will undermine service delivery, sustainability and health outcomes. The economic climate in which the NHS operates means that new and innovative models are required to deliver better services at lower cost, in order to ensure clinical and financial sustainability for the hospital system, and meet the future needs of the population. There is also a requirements to create financial and workforce capacity to enable a shift of care from acute to community settings. The Healthy Liverpool plan for hospital care to be delivered as a single service, by single teams, across the city is the proposed approach to reduce variation and improve patient care, also enabling solutions to the fundamental shared challenges around improving outcomes, ensuring that the system has the right workforce capacity and skills and financial sustainability. By transforming hospital services we aim to: A single service will be underpinned by: Single clinical leadership and unified governance arrangements Combined medical and senior nursing workforce; delivering standardised patient pathways Standard operating procedures and clinical policies A single performance management framework Combined training, education and research arrangements A single shared patient record Single point of referral The case for change for single service, city wide adult acute services has been clearly articulated in the Healthy Liverpool Prospectus and subsequent Blueprint. The aims set out in the Prospectus were to: Have the best hospital care system in the country; Have all patients receive the right care in the right place first time; Have a safe health care system that is sustainable clinically and financially into the future; Maximise patient outcomes and experience. Transformation will adopt the following principles: Services will be delivered by single teams; 170 Page 4 of 14

145 Services will be of high quality, delivered to consistent best practice standards and unwarranted variation will be eliminated; Services will be local whenever practicable, central where necessary; Services will be delivered by a workforce that is sustainable, motivated and champions improved patient care, experience and outcomes. The programme will also adopt the principle: Getting It Right First Time (G.I.R.F.T. - The national review of adult elective orthopaedic services in England, Professor Briggs, 2015). 1 This recommends: Reconfiguration to facilitate delivery of subspecialisation, critical mass and minimal volumes. This is to ensure both quality and financial sustainability; Early, intense and frequent rehabilitation to increase function, improve quality of life, reduce rate of falls and decrease length of stay; Ring fenced beds, laminar flow theatres and dedicated specialist theatre teams to reduce infection rates, improve outcomes and reduce variability. The university hospital trusts and specialist trusts across in the region have been working together more closely over recent years. AUH and RLBUH have come together to deliver Major Trauma services, joint venture partnerships have been established for both Vascular and Clinical Laboratory Services. AUH, RLBUH and LWH have also collaborated to produce the full business case for a single IT system and Electronic Patient Record (EPR). These partnerships, and other joint work under the Healthy Liverpool Programme, have highlighted a consistent clinical view that joint working is essential to improve patient outcomes and to sustain clinical services in the local health economy. The clinicians have recommended that organisational merger would be most likely to facilitate these improvements in care. Proposals for delivery of the single service, system wide model of care are guided by the following service configurations: AUH is now established as the single receiving site for major trauma in Cheshire and Merseyside. This fixed point has led to the potential for increased volumes of complex trauma to be transported to this site alongside major trauma cases. The next step following major trauma delivery is to address the implications of elective inpatient services at AUH Page 5 of 14

146 Both Trusts are committed to establishing safe and sustainable clinical rotas, ensuring compliant 24/7 service provision. For example, consultant, trainee medical staff and Allied Health Professionals need to be supported in maintaining the required skills and competencies to deliver elective, urgent and major trauma care. The new Royal Liverpool Hospital is emerging as a specialist centre, with a particular focus on complex inpatient surgical cancer services. 4. ORTHOPAEDICS RECONFIGURATION PROPOSAL In moving forward with the delivery of single service, system wide services, AUH and RLUHBT have proposed the establishment of a unified Liverpool Orthopaedic and Trauma Service (LOATS). This proposed reconfiguration would be informed by the following principles and benefits: Development of a single elective orthopaedic centre. This will allow for the delivery of high quality and high volume services and sub-specialist service delivery. Transfer of all orthopaedic trauma, including spinal trauma, to the AUH site. Services and pathways will be standardised to best practice and unwarranted variation will be eliminated. Decreased waiting times for inpatient orthopaedic trauma and flexibility in dealing with ambulatory orthopaedic trauma and elective cases will reduce overall waiting times and length of stay. This will be delivered and supported by a combined consultant rota. It should be noted that spinal elective inpatient services that currently are provided on the Royal Liverpool Hospital site remain outside of the scope of this work. Work with NHS England seeks to further the collaboration with The Walton Centre NHS Foundation Trust and explore delivery of the Neuro Vanguard Model across the city. If any options under this proposal impact upon other services, it would require further work to establish a case for change and establishment of due process for those services. 172 Page 6 of 14

147 It is recognised that Liverpool CCG has a strategy to deliver an integrated citywide musculoskeletal service (MSK) delivery model. Currently there is variation in practice across the city and evidence from NHS RightCare Commissioning for Value (2016) also details several areas where spend in MSK care is high against benchmark CCGs. The LOATS proposal will address unwarranted variation by standardisation of care pathways (including diagnostics) and embed NHSE Shared Decision Making principles. Liverpool CCG, under the umbrella of the Healthy Liverpool Programme, will colead a review of orthopaedic services in the city; to identify option(s) and ultimately a proposed solution(s) that will deliver the best care in a way that is clinically and financially sustainable. This project will be delivered in close collaboration with other North Mersey Commissioners South Sefton and Knowsley CCGs, and with both adult acute trusts. 5. THE CLINICAL CASE FOR CHANGE The Healthy Liverpool vision is to have the best hospital services in the city. The principles that guide this are that all patients receive right care in the right place first time; services must be of high quality and delivered to best quality practice standards; continuity and coordination of care will be maximised and any necessary transfer of care optimised to reduce the risks and improve the experience of patients; delivery of care seven days a week. National Standards for Orthopaedic Care There is good evidence of improved outcomes from specialisation in orthopaedics and also with increased volume of service delivery. This is clearly articulated by the British Orthopaedic Association and the Royal College of Surgeons who are in the process of setting standards for minimum delivery, both of individual surgeons and of orthopaedic services. The anticipated national specification for specialised orthopaedic services is predicated to set out the following standards for the delivery of care from specialised orthopaedic centres: A defined ward area is available for specialist orthopaedic patients i.e. ring fenced orthopaedic beds. A complete theatre inventory of specialised orthopaedic equipment with relevant implant components being available on site. Only in exceptional 173 Page 7 of 14

148 circumstances (less than 10%) should instrumentation and implant sets be loaned. A defined theatre suite for orthopaedic procedures with appropriate fully trained orthopaedic theatre staff. All surgical Consultants to have the required expertise and volumes in the said specialist orthopaedic procedure and this can be demonstrated using the latest research and guidelines for each procedure category. Access to critical care or high dependency care beds when required. The service is delivered by an appropriately trained and resourced multidisciplinary team. Acts as a tertiary provider of specialised orthopaedic service by its role in receiving and treating secondary referrals from across the network. When the revised national service specification is published it is widely accepted that the current AUH/RLUHBT arrangements will no longer meet the new standards. The formation of a new, unified orthopaedic service will enable full compliance. In addition, the ability for surrounding District General Hospital (DGH) orthopaedic departments to offer highly complex or sub-specialist service provision within the new specification will be hugely challenging. The establishment of LOATS would ensure that, the RLUHBT and AUH hospitals are collectively designated as a specialised orthopaedic centre. This is fundamental to excellent patient care as it will ensure that the service attracts and retains specialists, protects research and development and ensures that specialist services continue to be delivered within the city. 6. THE FINANCIAL CASE FOR CHANGE The large number of Trusts in Liverpool presents challenges for our health economy. Historically, trusts have competed with each other, with some key services duplicated, leading to inefficiencies and a shortage of clinical expertise, impacting on workforce sustainability, training and education. Our priority is to secure long-term clinical and financial sustainability of services in the city, rather than protect the status quo for service delivery. This is crucial to achieving our aim to have the best hospital care system in the country. 174 Page 8 of 14

149 Nationally, trauma and orthopaedic surgeons make up 33% of the surgical workforce and provide 25% of all surgical interventions within secondary care. The total annual NHS MSK spend is 10 billion, the third highest behind cardiac and mental health, of which 80% is spent in hospitals. Locally, the LOATS proposal is a key element of the single service system wide reconfiguration of services, which in totality is estimated to save in the order of 70 million by Detailed modelling of the financial benefits of this proposal will be developed in the pre-consultation business case. 7. REVIEW OF ORTHOPAEDIC SERVICES NHS Liverpool CCG will work with other commissioners, RLUHBT and AUH and other relevant providers, to propose a solution. A commissioner and trust-led review will now commence to identify and evaluate all possible options in order to identify a preferred option/s that will enable long term clinical and financial sustainability for orthopaedic services. The question to be answered by the review is: What is the optimal configuration of orthopaedic services that will deliver clinically & financially sustainable safe services in the future, maximising patient outcomes and experience? The review will include the following deliverables: 1. A robust options appraisal process reviewing need and evidence; considering a long list of possible options and evaluating them against a range of criteria, including (but not exclusively) clinical standards, clinical dependencies, health outcomes, patient experience, activity and finance, access, equalities impact, estates, workforce, deliverability and affordability. 2. The options appraisal will inform the development of one or more options that are considered to deliver clinical and financial sustainability. 3. A preferred option or options will inform the production of a pre-consultation business case, which will be required to meet the exacting requirements of the NHS England assurance process. NHS England assurance process for service reconfiguration ensures we have: 175 Page 9 of 14

150 Strong public and patient engagement Consistency with current and prospective need for patient choice Clear, clinical evidence base Support from commissioners 4. The effectiveness of the preferred option will be measured by Get it Right First Time (GIRFT) outcomes: Short Term: Reductions in: prostheses costs, loan kit costs, readmission rates, length of stay and surgical site infection. Medium Term: Reductions in: national variation for procedures, outliers in national registries and infection/complication rates. Long Term: Reductions in: revisions surgery, readmissions and litigation numbers and rates. 8. GOVERNANCE Commissioners are required to follow a structured assurance process when leading service reconfiguration, as set out in the NHS England guidance: Planning, assuring and delivering service change for patients: There will be a planned and managed approach from the start which establishes clear roles, a shared approach between organisations; ensuring alignment with commissioning intentions and plans. Self-assurance will be put in place as part of the programme governance to ensure the proposal is robust and supported before it is subject to the external assurance process conducted by NHS England. Committees in Common A Committees in Common (CIC) has been established for developing Healthy Liverpool service reconfiguration proposals and for the purposes of supporting system wide decision making. CIC enable formal decisions to be made in a joined up way by groups of CCGs where it makes sense to work together across a larger geographical footprint. In this case the CIC consists of NHS Liverpool, South Sefton, Southport and Formby and Knowsley CCGs, which represent the majority of patients who use these services. Local Authorities (Knowsley, 176 Page 10 of 14

151 Liverpool and Sefton) and NHS England (Specialised Commissioning) are also represented on the CIC. The key recommendations to be made to CCG Governing Bodies by the CIC for this process include: Endorse the case for change and vision for the services, recommended by clinical leaders; Endorse the process for solutions development; options development and appraisal; Endorse the programme assurance process; Endorse the process for scrutiny by local authority OSCs; Recommend a pre-consultation business case for approval by CCG Governing Bodies, which will then go to NHS England for external assurance. This would include a preferred option/s; Ensure the 4 tests for service reconfiguration have been met Review the findings from formal public consultation to inform a recommended decision; Make a final recommendation on the future configuration of these services for approval by CCG governing bodies, informed by the Pre-consultation Business Case, which will inform a Decision-making Business Case, which includes findings from consultation. Endorse an implementation plan with a benefits realisation timetable and milestones. Oversight Group An Orthopaedic Executive Oversight Group has been established, tasked with ensuring effective clinical engagement, developing the clinical and financial evidence base, including relevant clinical standards and formulating the proposed clinical model. 9. ENGAGEMENT AND COMMUNICATIONS Patients, public and key stakeholders have already participated in the Healthy Liverpool Hospitals single service pre-consultation engagement, done in the Summer of 2015, and will continue to be involved throughout every stage of this process. Liverpool CCG, RLBUHT and AUH will work together on a joined-up approach to a communications and engagement programme over the coming months to ensure an open and transparent approach. Central to effective involvement will be providing clarity over the issues and opportunities for real involvement. Patient and Public Involvement Robust and ongoing communications, engagement and formal public consultation form part of this process. Subject to NHS England being assured 177 Page 11 of 14

152 about the proposal there would be a formal public consultation on a preferred option for the future delivery of orthopaedics. It is anticipated that a formal public consultation could commence as early as June Health Scrutiny NHS bodies have a legal duty to consult with local authority Health Overview and Scrutiny Committees (OSCs). Early stage discussions will take place with local OSCs (Liverpool, Sefton and Knowsley) to ensure that the plans for engagement and consultation process meet statutory requirements and to satisfy OSCs that the case for change is sound. At a later stage, OSCs will also review the proposal to be consulted on, to ensure that the consultation process is robust and meets statutory requirements, along with best practice approaches. It is also good practice to enable Health and Wellbeing Boards to feed into the development of proposals. 10. KEY MILESTONES The process for major service reconfiguration is clearly set out in the NHS guidance and requires a planned journey through defined stages which are illustrated below: 178 Page 12 of 14

153 11. STATUTORY REQUIREMENTS 11.1 Does this require public engagement or has public engagement been carried out? Yes, the proposal developed will be subject to formal public consultation Does the public sector equality duty apply? Yes/no. All service change proposals, including those related to healthy Liverpool schemes, include an Equality Impact Assessment, which is an essential step in the engagement development process. The CCG recognises its duty to engage with people who have protected characteristics 2 and will ensure the views and experiences of vulnerable groups help shape the improvement of services. We will ensure that Liverpool s diverse population has access to appropriate mechanisms to facilitate meaningful relationships and good engagement Explain how you have/will maximise social value in the proposal: describe the impact on each of the following areas showing how this is constructed to achieve the most: a) Economic wellbeing b) Social wellbeing c) Environmental wellbeing Liverpool CCG s social commitment to social value will ensure that this proposal is developed through engagement with patients and other stakeholders. The design process will have due regard for these three factors in order to deliver an effective service, particularly for those experiencing health inequalities Taking the above into account, describe the impact on improving health outcomes and reducing inequalities Healthy Liverpool has identified clear intentions for the delivery of improved health outcomes and reduced inequalities through the transformation schemes within the programme, including the hospital transformation programme. The 2 The Equality Act 2010 makes it unlawful to discriminate against people with a protected characteristic. The protected characteristics relate to Age, Disability, Gender Reassignment, Pregnancy and Maternity, Marriage and Civil Partnership, Race, Religion or belief, Sex and Sexual Orientation 179 Page 13 of 14

154 outcomes set out in the Healthy Liverpool Blueprint and progress in delivering these outcomes is tracked and reported. 12. DESCRIBE HOW THIS PROMOTES FINANCIAL SUSTAINABILITY Healthy Liverpool was established to deliver the recommendations of the Liverpool Mayoral Health Commission. Healthy Liverpool s objectives are to ensure long term clinical and financial sustainability for the city s health and care services. Proposed hospital reconfigurations such as this will evidence how they deliver the triple aim of better health, better care and better value. 13. CONCLUSION This paper sets out a clear case for change for orthopaedic services. It does not seek at this stage to provide any solutions, but rather to set out a clear and robust process, over a defined timescale, which will identify one or more options for change that will deliver high quality, safe and clinical services that are also financially sustainable. All parties, commissioners and providers, are aligned in their commitment to ensuring that orthopaedic services continue to be delivered locally and that new models of care must deliver improved quality and safety, as well as positive patient experience. 180 Page 14 of 14

155 Report no: GB NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY TUESDAY 14 TH FEBRUARY 2017 Title of Report Lead Governor Senior Management Team Lead Report Author Summary Armed Forces Covenant Katherine Sheerin, Chief Officer Ian Davies, Chief Operating Officer Richard Houghton, Primary Care Support Manager The purpose of this paper is to provide the Governing Body with an understanding of the Armed Forces Covenant and ask that they agree to formally sign up to the Covenant on behalf of NHS Liverpool CCG Recommendation Relevant standards/targets That Liverpool CCG Governing Body: Notes the contents of this report Approves the formal signing of the Armed Forces Covenant The Armed Forces Covenant Page 1 of 9 181

156 ARMED FORCES COVENANT 1. PURPOSE This report presents to the Governing Body the Armed Forces Covenant and sets out to recommend that NHS Liverpool CCG formally signs the Covenant. 2. RECOMMENDATIONS That Liverpool CCG Governing Body: Notes the content of this report Approves the formal signing of the Armed Forces Covenant 3. BACKGROUND The Armed Forces Covenant 1 (established in 2011) is a promise by the nation to ensure that those who serve, those who have served, and their families are treated fairly. It is an agreement between the armed forces community, the nation and the government. It encapsulates the moral obligation to those who serve, have served, their families and the bereaved. The covenant s twin underlying principles are that: Members of the armed forces community should face no disadvantage compared to other citizens in the provision of public and commercial services; And that special consideration is appropriate in some cases, especially for those who have given the most such as the injured or the bereaved 2 In terms of health and wellbeing, the Covenant states that: 1 es_covenant.pdf Page 2 of 9

157 Veterans receive their healthcare from the NHS, and should receive priority treatment where it relates to a condition which results from their service in the Armed Forces, subject to clinical need. Those injured in Service, whether physically or mentally, should be cared for in a way which reflects the Nation s moral obligation to them, whilst respecting individual wishes. For those with concerns about their mental health, where symptoms may not present for some time after leaving Service, they should be able to access services with health professionals who have an understanding of Armed Forces culture. In signing the Covenant the CCG pledges itself to: 1. Support our employees who choose to be members of the Reserve forces, including by accommodating their training and deployment where possible 2. Promoting the fact that we are an armed forces-friendly organisation 3. Seeking to support the employment of veterans young and old; 4. Striving to support the employment of Service spouses and partners 5. Endeavouring to offer a degree of flexibility in granting leave for Service spouses and partners before, during and after a partner s deployment 6. Aiming to actively participate in Armed Forces Day And specific local commitments: 7. To continue to encourage General Practices to be proactive in identifying military veterans within their practice population, for both new registrations and existing patients 8. To continue to work with local veteran organisations and charities to raise awareness in the veteran community of the importance of identification within General Practice 183 Page 3 of 9

158 9. To work with Local Government to ensure the Health and Well Being of current or veteran service personnel and their families is supported 10. To ensure services commissioned support the needs of those who serve, have served, or their immediate families 4. PROGRESS TO DATE Local Context On 27 th March 2012 Liverpool City Council signed the first Armed Forces Covenant on Merseyside. The covenant was signed by representatives from the Armed Forces community, public, private, voluntary and community sectors. Subsequently in July 2015, Liverpool City Council, in partnership with Liverpool CCG, published its Joint Strategic Needs Assessment for Military Veterans. This JSNA made a number of recommendations that included: 1. Continue to encourage General Practices to be proactive in identifying military veterans within their practice population, for both new registrations and existing patients. 2. Continue to work with local veteran organisations and charities to raise awareness in the veteran community of the importance of identification within General Practice. 3. Consider awareness raising sessions with General Practice staff to ensure they are aware of the importance of identifying this population group, perhaps as part of a wider protected time event on identifying other population groups e.g. ethnic minorities. 4. Consider awareness raising sessions with schools in the city to ensure they are aware of the importance of identifying children who come from military families. 5. Establish regular reporting of the number of patients identified as veterans to the Making it Happen Group Page 4 of 9

159 The Making it Happen for Veterans Group has been established to bring together the armed forces communities, commissioners and providers of public services, civilian communities and private, voluntary and charitable sector communities to oversee the strategic delivery of the Liverpool Armed Forces Community Covenant. The Making it Happen Group has a number of task groups which report to it, looking at: Housing Employment, Education and Training Health & Wellbeing Liverpool CCG leads the Health and Wellbeing agenda as mandated from the Making It Happen Group. It seeks to understand the size and composition of the local veteran population to ensure that health needs of veterans can be fully understood and services commissioned with veteran health needs in mind. National Context The Health & Social Care Act gave the Secretary of State the power to require NHS England to commission services for members of the Armed Forces and their families 4. From 1 st April 2015, GMS Regulations allow for a serving member of the armed forces of the Crown, who has received written authorisation from DMS, to register with a GP in whose practice area they live or work during the period in respect of which that written authorisation is given, for a period of up to two years. During early 2016, NHS England conducted an audit of their current Veteran s mental health services to capture and build on best practice, ensuring Veterans receive the high quality services. NHS England sought the views and experiences of the people that access these services first hand, through a national engagement exercise launched in January Opinions were gathered from a wide range of stakeholders including Veterans who have or have had a mental health illness, their families and carers, service charities, commissioners and providers who offer treatment and Page 5 of 9

160 support in this area. The engagement closed at the end of March 2016, with nearly 1,300 people and organisations responding. The feedback highlighted a number of common themes including: the need for a greater awareness of the dedicated Veteran mental health services available; long referral/waiting times; transfer of care, particularly around the discharge process; the need to ask have you served? the need for greater clarity over where to go for help; the need to understand an Armed Forces background From April 2016, NHS England have embedded a question into normal mental health data collection, that will require all providers of NHS funded mental health care to help identify Veterans and Service dependents using their services. 5. STATUTORY REQUIREMENTS (only applicable to strategy & commissioning papers) Armed Forces Act 2011: Annual duty to report on progress against the covenant to Parliament (including on health issues) NHS Mental Health Strategy 2011: Includes specific provision for military veterans Health & Social Care Act 2012: Duty of NHS England to commission health services on behalf of the Armed Forces 5.1 Does this require public engagement or has public engagement been carried out? Yes /No i. If no explain why ii. If yes attach either the engagement plan or the engagement report as an appendix. Summarise key engagement issues/learning and how responded to. Locally a Veterans engagement exercise was undertaken by the CCG Social Value and Engagement Team, during This exercise highlighted the following points. 186 Page 6 of 9

161 Veteran s experiences of accessing health support services were mixed and variable. Some individuals have had excellent support from specific organisations, particularly where the organisation offered dedicated services for veterans. Their experience of however of primary care, in particular GP services, was overwhelmingly negative. There were issues with initially accessing a GP and with the transfer of medical information leading in some cases to a break in care. Veterans felt that some GPs lacked an understanding of their needs and were not always aware of relevant services to which to refer them. Participants in the exercise thought there was not enough information about services available to them. For those Veterans who reported having good experiences of services, they felt they had stumbled on the services almost by accident. Some also noted that psychologists did not always have appropriate training in conflict and trauma-related mental health issues experienced by Veterans. Key barriers to accessing services included: Lack of awareness of suitable services (on their part and on their GP s) or understanding or skills to see these out A sense of scepticism about the capacity of these services to understand or meet their needs A strong culture amongst veterans to keep their health issues (especially mental health) to themselves and to see seeking help as a weakness. The final report from this engagement exercise will be presented to the Primary Care Commissioning Committee and shared with the contracting team and respective clinical leads to support the development of an action plan to respond to the concerns and difficulties raised by Veterans. 5.2 Does the public sector equality duty apply? Yes. i. If no please state why ii. If yes summarise equalities issues, action taken/to be taken and attach engagement EIA (or separate EIA if no engagement required). If completed state how EIA is/has affected final proposal. 187 Page 7 of 9

162 Individual service changes and developments will be subject to an EIA, as appropriate and required. 5.3 Explain how you have/will maximise social value in the proposal: describe the impact on each of the following areas showing how this is constructed to achieve the most: a) Economic wellbeing b) Social wellbeing c) Environmental wellbeing The adoption of the Armed Forces Covenant will over time have a beneficial impact upon the wellbeing of those who have served and the communities in which they now live. 5.4 Taking the above into account, describe the impact on improving health outcomes and reducing inequalities The overall aim is to improve the health outcomes for Veterans and reduce the inequalities and variability of service response that many experience today in the city. By supporting the Covenant the CCG makes a clear and public statement that it is committed to these aims and will be held accountable for their delivery. 6. DESCRIBE HOW THIS PROMOTES FINANCIAL SUSTAINABILITY By improving the services commissioned and delivered to Veterans it is envisaged that those services will be provided in a more effective and cost efficient manner. 7. CONCLUSION At present, Liverpool CCG is not signed up formally to the Armed Forces Covenant and this omission should be remedied with the CCG formally declaring its support to the Armed Forces Covenant and the pledge it represents. The City of Liverpool will also host the National Armed Forces Day on Saturday 24 th June With Liverpool CCG already working hard to support military veteran health within the city, by signing the Covenant, it would formally cement our pledge to this agenda. 188 Page 8 of 9

163 Richard Houghton Primary Care Support Manager Ian Davies Chief Operating Officer 6 th February 2017 Page 9 of 9 189

164 190

165 Report no: GB NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY TUESDAY 14 TH FEBRUARY 2017 Title of Report Lead Governor Senior Management Team Lead Report Author Summary Recommendation Relevant standards/targets Secondment Policy Professor Maureen Williams Ian Davies, Head of Operations & Corporate Performance Lisa Doran, HR/OD Lead Liverpool CCG s Secondment Policy sets out the organisation s approach to secondments and aims to provide a clear and fair process. That Liverpool CCG Governing Body: approves the attached Policy as recommended by the HR Committee on 24th January Current employment legislation Agenda for Change NHS Employment Checks Standards NHSLA Risk Management Standards Page 1 of 3 191

166 SECONDMENT POLICY 1. PURPOSE The purpose of this paper is to provide the Governing Body with a Secondment Policy for approval. 2. RECOMMENDATIONS That Liverpool CCG Governing Body: approves the Policy. 3. BACKGROUND Since April 2013, Liverpool CCG has developed its HR policies through a process of prioritisation. LCCG has taken a consultative approach to the development of its HR policies, irrespective of whether the policy is contractual or not. This is a new CCG HR policy. Existing secondments in the CCG all have formal agreements in place that outline the terms of that secondment. This Policy includes good practice principles that a secondment agreement doesn't have, for example objective setting, eligibility and reflective learning and sharing. The CCG currently has 18 employees on internal secondment and 5 workers in on secondment from another employer. Secondments provide a flexible solution to resourcing and are likely to continue to be used in the CCG in the future. The draft Policy has been shared with all staff, giving the opportunity for comments/queries/suggestions to be made by all. All comments/queries have been responded to and suggestions have been considered and changes made where necessary/appropriate. 4. STATUTORY REQUIREMENTS (only applicable to strategy & commissioning papers) N/A 192 Page 2 of 3

167 4.1 Does this require public engagement or has public engagement been carried out? Yes / No i. If no explain why ii. If yes attach either the engagement plan or the engagement report as an appendix. Summarise key engagement issues/learning and how responded to. 4.2 Does the public sector equality duty apply? Yes/no. i. If no please state why ii. If yes summarise equalities issues, action taken/to be taken and attach engagement EIA (or separate EIA if no engagement required). If completed state how EIA is/has affected final proposal. 4.3 Explain how you have/will maximise social value in the proposal: describe the impact on each of the following areas showing how this is constructed to achieve the most: a) Economic wellbeing b) Social wellbeing c) Environmental wellbeing 4.4 Taking the above into account, describe the impact on improving health outcomes and reducing inequalities 5. DESCRIBE HOW THIS PROMOTES FINANCIAL SUSTAINABILITY The Policy sets out the CCG's approach to secondments. Secondments allow a flexible approach to resourcing an assignment that is fixed term in its nature and as an alternative to a Fixed Term Contract (FTC). Ordinarily a secondment has less financial risk than a FTC. 6. CONCLUSION The proposed policy was considered by HR Committee on 24th January The HR Committee recommends that the attached policy is approved by the Governing Body. 193 Page 3 of 3

168 194

169 Liverpool Clinical Commissioning Group Secondment Policy 195

170 Version: Ratified by: Date ratified: Name of originator/author: Name of Lead: Date issued: Review date: Target audience: V1 HR Committee HR/OD Chief Operating Officer Organisation wide Any changes made to this policy should be outlined in the below Review and Amendment Log. In the event of any changes to relevant legislation or statutory procedures this policy will be automatically updated to ensure compliancy without consultation. Such changes will be communicated. Version No Type of Change Date Description of change 196

171 CONTENTS 1. Policy Statement 2. Aims and Objectives 3. Scope 4. Main Policy Content 4.1. Definition of Terms 4.2. General 4.3. Employee (Secondee) 4.4. Host Employer/Manager 4.5. Seconding Employer/ Manager 4.6. Early termination of the secondment 4.7. Special Consideration for External Secondments 4.8. Guidance for Staff and Managers 5. Roles and Responsibilities 5.1. Chief Operating Officer 5.2. Employees 5.3. Human Resources 6. Associated Documentation and References 6.1. Relevant Legislation 6.2. Associated Policies and Guidance Documents 6.3 Useful Contacts 7. Policy Governance 197

172 7.1. Equality and Diversity 7.2. Management and Review 198

173 1. Policy Statement Secondments allow a flexible resourcing solution and can often be an alternative to a fixed term contract. A secondment can also offer an individual the opportunity to widen their personal and career development through the enhancement of their existing skills by gaining experience in a different role and/or working environment. 2. Aims and Objective This aim of this policy is to provide a clear understanding of the CCG s approach to secondments and to clarify the procedure to be followed to facilitate a secondment. 3. Scope This policy is applicable to all staff employed by the CCG. It will also apply to the management of staff from external organisations who may wish to apply for and undertake a secondment in the CCG. 4. Policy 4.1 Definition of Terms Secondment: A secondment is a fixed term opportunity Secondee: The employee taking up the secondment opportunity. Seconding Employer/Manager: The employee s substantive employer/manager i.e. for the original post prior to secondment Host Employer/ Manager: The organisation the secondment is in. The secondment manager. Internal Secondment: A CCG employee seconded to another role within the CCG. External Secondment: a) An individual not employed by the CCG seconded to the CCG. Or b) A CCG employee seconded to an external organisation

174 4.2. General Principles Throughout the duration of the secondment, the Secondee remains employed by the seconding organisation and the secondment period will be considered as continuous employment with the seconding organisation. All secondment opportunities must be advertised. Secondments must be for a fixed term period and will usually last a minimum of 3 months and a maximum of 12 months. In exceptional circumstances secondments may be extended beyond 12 months with the agreement of the seconding manager and a member of SMT. Secondments can be either full time or part time. In some cases, part time secondments may be completed by the employee by splitting their time between the secondment and their substantive post. All parties must understand and agree the purpose of the secondment at the outset. 4.3 Completion of Secondment Upon completion of the secondment, where this does not exceed 12 months, the employee should return to their substantive post, with the exception of organisational change. Should the substantive post not exist upon return, then the principles of the organisational change policy will apply. Should the secondment exceed 12 months then it cannot be guaranteed that the employee will return to their substantive post. However this should be made clear to the employee before the secondment or extension of the secondment is agreed by the employee. In this situation the employee will, at the end of the secondment, return to a post commensurate with the skills and grade of the employee Employee (Secondee) In order to be eligible to apply for a secondment opportunity, an employee must: Seek support from their substantive manager prior to application for the secondment. Have been in their current post for a minimum of 12 months based on the closing date on the advertisement for the secondment post. The employee can be on a permanent or a fixed term contract to apply for a secondment opportunity so long as their contract is beyond the secondment end date. Should not be subject to any formal procedure e.g. disciplinary investigation. Secondment opportunities will not be unreasonably refused. There may, however be service or operational requirements, which could lead to an application being declined

175 Any issues relating to a management decision of not approving a secondment should be raised with the substantive manager in the first instance. To progress formally with an appeal against a decision, the Grievance Policy and Procedure should be followed. If the line manager supports the application and the employee is successful, the secondee must highlight to the host manager any adjustments required to support their integration into the workplace prior to the start of the secondment e.g. reasonable adjustments under the Equality Act 2010 Existing flexible working arrangements will not be automatically transferred to the the secondment. A new flexible working request should be made to the host manager/employer. Once in post, clear objectives should be agreed between the host manager and the secondee and any training needs identified. The objectives and training must be reviewed regularly between the secondee and the host manager (the Review Form in Appendix 2 can be used as an example). The secondee is responsible for ensuring that they attend all mandatory/statutory training appropriate to the secondment role as directed by the host employer. 4.4 Host Employer/Manager Once a successful candidate has been appointed to the secondment post, the host employer is responsible for: Completing a Secondment Agreement stating the details and duration of the secondment. All parties should receive a copy of the completed agreement. HR Advice should be sought. Requesting any specific needs or adjustments to support the secondee s integration into the workplace and implementing these adjustments in advance of the secondment start date. Ensuring that a local induction programme is prepared covering all mandatory/statutory training relevant to the post. Agreeing objectives with the secondee. Ensuring Regular review meetings take place to assess the secondee s performance against agreed objectives. Having a final review meeting with the secondee to assess whether the secondment objectives have been met, upon reaching the end of the secondment. Any areas of concern throughout the secondment should be highlighted by the Host Employer to the Seconding Employer

176 4.5 Seconding Employer/ Manager An employee should seek the support of their line manager prior to applying for a secondment role. Managers have the right to refuse to support an employee s secondment application and must give reasons for doing so. A secondment should not be unreasonably refused. The seconding manager must ensure that: The main objectives of the secondment are agreed with the secondee. Regular contact is identified and agreed with the secondee HR are aware and the correct HR forms are completed (please contact HR for guidance). Upon the employee s return to the department, the seconding manager should evaluate the learning outcomes of the secondment with the employee. 4.6 Early termination of the secondment The seconding employer, host employer and employee have the right to terminate the secondment agreement early by giving one month s notice to all parties (unless specified otherwise in the secondment agreement). This will be for situations such as, but not limited to: Performance, conduct or disciplinary issues Organisational Change/ Business Need The secondment is not as subscribed The secondment has not met the terms of the agreement. If the secondee remains absent by reason of ill health for more than 4 weeks during the period of secondment any party may terminate this agreement by written notice sent to all parties

177 4.7 Special Consideration for External Secondments The CCG recognises that external organisations may have their own Secondment Policy in place which may differ from the CCG s. In these circumstances, the seconding organisation should share their secondment policy with the host organisation and an agreement must be reached on areas which may differ in the policy such as notice periods and review meetings. This should be confirmed in writing. The Seconding Employer and Host Employer must reach agreement regarding method and payments of salary, travel and other costs prior to the secondment (advice on options must be sought from HR). Line managers must contact HR for support and advice on secondment agreements Guidance for Staff and Managers Agreement All three parties must agree in writing the terms and conditions of the secondment, including such items as: pay and salary progression; (the rate for the job will apply from the outset and protection, where necessary, will apply), working pattern, annual leave, performance development plan and review. ESR/ Payroll The secondee will remain on the payroll of their employer during the secondment. Recharge Arrangements should be made with Finance whenever necessary. Maternity, Parental or Adoption leave If during the period of secondment, the secondee needs to start maternity, parental or adoption leave or planned sickness absence (greater than 4 weeks), and the secondment is for 12 months or less, then the secondee would return to their original department. This will enable the secondment to be fulfilled by somebody else. If the secondment is for 12 months or more, then the host employer will have responsibility for the leave/absence. Extension of Secondments If, at the end of the seconded period there is an opportunity for it to be extended this must only be done agreement from all parties involved, i.e. the seconding manager, the secondee and the host manager. Where possible, the extension of the secondment must be planned at least one month in advance by all parties

178 It must be confirmed in writing by the host manager to both the secondee and the seconding manager. If, at the end of the seconded period, the post becomes permanent, then it must be advertised in line with the CCG s Recruitment & Selection Policy. Recording annual leave, sickness and other absences The hosting manager will be responsible for the recording of annual leave, sickness absence and other absence and providing this information on a monthly basis to the seconding department. The seconding manager will be responsible for liaising with payroll to ensure that the secondee is paid appropriately and that these details are properly recorded. Secondments into the CCG from external organisations should be provided with similar information by the hosting manager upon request. All sickness absence will be managed by the host organisation in line with the seconding organisation s sickness policy. Capability, Disciplinary and Grievance issues The host manager is responsible for the day to day management of the secondee but if during the seconded period there are performance, disciplinary or grievance issues, the seconding manager must be notified. In these instances the host employer reserves the right to terminate the secondment giving appropriate notice. If the host employer does not wish to terminate the secondment any issues must be dealt with in accordance with seconding employer s policy in conjunction with the hosting manager, the secondee and where necessary, Human Resources. Any disciplinary issues should be investigated by the seconding manager. If it is found that disciplinary action should be taken, this will be conducted by the seconding employer. Secondments into the CCG from external organisations should be managed with the assistance of the employing organisation and respecting their policies. Contact should be made with the seconding manager and Human Resources. 5. Roles and Responsibilities 5.1 Chief Operating Officer The Chief Operating Officer is responsible for ensuring that this Policy is fully implemented

179 5.2. Employees All employees are required to comply with this policy Human Resources To provide support and advice to staff on any aspect of their employment, terms and conditions of service. To promote the policy and give general guidance and support to managers. To promote consistency policy application across the CCG in order to achieve a balance between organisational requirements and individual needs. 6. Associated Documentation and References 6.1 Relevant Legislation Employment Act 2008 Equality Act Associated Policies and Guidance Documents To support effective implementation and understanding the following Policies and processes are signposted for additional guidance. Recruitment & Selection Policy Performance Development Plan and Review Capability Sickness Absence Study Leave Statutory and Mandatory Training 6.3. Useful Contacts Human Resources Telephone: /

180 7. Policy Governance 7.1 Equality and Diversity The CCG is committed to an environment that promotes equality and embraces diversity in its performance as an employer. It will adhere to legal and performance requirements and will mainstream equality and diversity principles through its policies, procedures and processes. This policy should be implemented with due regard to this commitment. To ensure that the implementation of this policy does not have an adverse impact in response to the requirements of the Equality Act 2010 this policy has been screened for relevance during the policy development process and a full impact assessment conducted where necessary. The CCG will take action when necessary to address any unexpected or unwarranted disparities and monitor workforce and employment practices to ensure that this policy is fairly implemented. 7.2 Management and Review of Policy HR will be responsible for the management of this policy. In addition, the effectiveness of this policy will be monitored and the policy may be reviewed and amended at any time if is deemed necessary. Notification of any changes to policies will be communicated to all staff. Staff should be aware that the CCG intranet site version of this document is the only version that is maintained and controlled. Any printed copies should be viewed as uncontrolled and as such may not necessarily contain the latest updates and amendments

181 NHS LIVERPOOL CLINICAL COMMISSIONING GROUP HR COMMITTEE Minutes of meeting held on Tuesday 15 th November 2016 at 2pm Meeting room 3, 3 rd Floor, The Department, Lewis s Building PRESENT: Professor Maureen Williams Dave Antrobus Moira Cain Katherine Sheerin Dr Shamim Rose Chair Lay Member Patient Engagement Governing Body Member - Practice Nurse Chief Officer Governing Body Member GP IN ATTENDANCE: Ian Davies Lisa Doran Stephen Hendry Sallyanne Hunter Paula Jones APOLOGIES: Dr Maurice Smith Chief Operating Officer HR / OD Lead Senior Operations & Governance Manager Customer Relations Lead Committee Secretary Minutes Governing Body Member GP 1.1 WELCOME & INTRODUCTIONS The Chair welcomed everyone to the meeting and introductions were made. The Committee welcomed the Customer Relations Lead to the meeting who was attending due to her expertise in health and safety and as such for any questions around the operational policies in item 2.1. The Chief Operating Officer noted that he needed to leave the meeting early to attend another meeting. 1.2 DECLARATIONS OF INTEREST No declarations of interest were noted specific to items on the agenda. 207 Page 1 of 7

182 1.3 MINUTES OF PREVIOUS MEETING HELD ON TUESDAY 3 RD MAY 2016 The minutes of the previous meeting held on 3 rd May 2016 were previously circulated and agreed as a correct record subject to the following amendments: The location of the meeting needed to be change to remove the reference to Arthouse Square. It was noted that the date of next meeting in the minutes of 2 nd August 2016 was postponed. 1.4 MATTERS ARISING NOT ALREADY ON THE AGENDA: Action Point One it was noted that the Organisational Development Plan was on the Agenda Action Point Two the Senior Operations & Governance Manager updated the HR Committee that new statutory Guidance from NHS England on Conflicts of Interest had been received in June 2016 and the CCG s Policy had been updated accordingly. This had then been approved at the CCG Governing Body Action Point Three it was noted that the Social Media Policy had been approved by a virtual meeting of the HR Committee/ thread on 1 st August 2016 and then had been signed off by the Governing Body at the August 2016 Governing Body meeting Action Point Four the HR/OD Lead updated the HR Committee that the Well Being Charter was being pulled together by the Staff Listening Group and would be completed by March The Chair asked for it to come to the HR Committee first before being sent to the Governing Body. 208 Page 2 of 7

183 Section 2: Items for Decision 2.1 POLICIES FOR APPROVAL - HR The process for policy review/approval was discussed as the Chief Operating Officer suggested that as the policies in this item were operational they should be approved by the Operational Management Group. The Chair had been thinking along the lines non-controversial policy changes being done virtually rather than needing to come back to the HR Committee/relevant committee and then going to the Governing Body due to the potentially high numbers involved. The Senior Operations & Governance Manager explained that the policies were coming to the HR Committee as they had an impact on staff. These policies had been in place last year but had not been approved, they had now been developed and localised from national templates and there was now a compendium of health and safety policies: (i) Display Screen Equipment Policy (ii) Fire Safety Policy (iii) Health & Safety Policy (iv) Incident Reporting Policy (v) Lone Worker Policy (vi) Moving and Handling Policy (vii) Security Management Policy (viii) Violence, Aggression and Abuse Policy Also, NHS Protect needed to have written evidence that the policies had been approved and implemented. The Customer Relations Lead noted that there might be additions such as a Young Persons Policy. All of the policies above had been consulted on with staff prior to the move last year into The Department. Now the CCG needed to progress and embed the policies and carry out the required risk assessments for Lone Workers as those starting early and working late in a building only occupied so far by the CCG fell into this category. It was also noted that there was an increasing number of aggressive contacts, mostly by telephone, as the CCG has delegated authority for the commissioning of primary care. Page 3 of 7

184 For Fire Safety it was noted that each employee had the duty to complete their mandatory training but that it would be advisable to strengthen the knowledge of the evacuation procedure by regular six monthly drills and recruit new Fire Marshalls to fill vacancies. There was also a need to carry out more Personal Evacuation Plans particularly re regular visiting public with health issues. At the request of the Chair it was agreed that the Customer Relations Lead would bring back an Action Plan re embedding the policies into practice and timelines to the next meeting. The Chair noted that this time the Policies would to go to the Governing Body meeting in December for final ratification but between now and the next HR Committee meeting she would consider the process for approval of policies and which policies should be approved at which committee or Governing Body meeting. The Chief Officer pointed out an error in the Violence, Aggression and Abuse Management Policy which referred to the Deputy Chair as the nominated Security Management Director and that it had been agreed that this should be the Chief Finance Officer. The Senior Operations & Governance Manager commented that staff should be encouraged to take a zero tolerance approach to aggressive behaviour and input to the incident database, a system of recorded message to say that calls were recorded was deemed to be too complex and expensive and that the use of the incident reporting process was the best option. More advanced Conflict Resolution training was to be looked at by the Customer Relations Lead for certain staff roles. The HR/OD Lead suggested that a better way for communicating a high number of policies to staff would perhaps be by giving headlines for each at the Floor Meeting. There was a discussion around the Display Equipment Policy and the eyesight test/glasses voucher scheme which the committee agreed was important to implement. 210 Page 4 of 7

185 The Liverpool CCG HR Committee: Noted and approves all the attached Policies Recommended all the attached Policies to the Governing Body for final approval Agreed that the Chair would look into a future process of changes and updates to policies which are of a noncontroversial, nature or not new policies, being approved virtually by HRC prior to submission to GB. 2.2 RECRUITMENT POLICY & PROCEDURE - HR The HR/OD Lead presented the revised Recruitment Policy and Procedure to the HR Committee for approval. The changes made to the Policy were purely operational and the policy was shorter and set out the process to be followed. There was nothing new or contentious. The Chair asked about the exceptions which needed to made in the recruitment process and it was confirmed by the HR/OD Lead that exceptions were dealt with in section 4.10 of the Policy which noted that any exception could be instructed by the Chief Officer or Chief Finance Officer. The Chair asked for this section to be strengthened to note that this instruction needed to be in writing for there to be an audit trail to follow. The Chief Officer stressed the importance of the CCG Social Value aims and the desire to, where possible, recruit local people who reflected the composition of the local population. The HR/OD Lead agreed to strengthen this and come up with a form of words to be inserted into the policy and would send this to members virtually for ratification; this would be inserted prior to the Policy being sent to the December 2016 Governing Body meeting for approval. The Lay Member for Patient Engagement noted the review date of April 2017, it was noted that the aim was to have the same review dates for policies, review did not mean that the policy would be changed/updated merely reviewed. 211 Page 5 of 7

186 The Liverpool CCG HR Committee: Noted the content of the policy Approved the Recruitment Policy subject to the amendments requested. Section 3: Items for Discussion None Section 4: Items for Information 4.1 ORGANISATIONAL DEVELOPMENT ACTION PLAN HR The HR/OD Lead presented the Organisational Development Action Plan to the HR Committee for noting. The Organisational Development Plan itself had been approved by the HR Committee in 2014 but as the organisation had matured since the Plan was originally drafted it was recently reviewed to ensure it was still fit for purpose. Intelligence had been gathered from the 2015 staff survey, staff events, Senior Management Team sessions and the Staff Listening Group and collated to identify issues and look at how to make improvements. This was cross-checked against the original plan and any necessary amendments were being made, however not a great deal had to be changed. The Staff Listening Group (SLG) was supporting the work on the Action Plan, a column had been added to the Action Plan for themes and SLG sub-groups had been set up to look at themes of which there were five: Culture, Team, Engagement, Development and Governance. It was noted that this was a living document and would need to respond to changes in the organisation. The Chair asked for an update to come back to the committee in six months time and that this should be a regular agenda item every six months. The HR/OD Lead noted that it would be good to give staff feedback on the issues they had raised to see that they were being considered and acted upon. 212 Page 6 of 7

187 The Liverpool CCG HR Committee: Noted the updated action plan and looked forward to receiving an update in six months time 5. ANY OTHER BUSINESS The HR/OD Lead updated the HR Committee on progress towards having a workplace union representative recruited to replace Joan Bennett and who would be invited to the HR Committee. Two people had come forward and the relevant paperwork had been completed and sent to the Unison Office but there had been no further progress, the delay was with Unison not the CCG. She was meeting with the Unison Regional Representative later in the week and would investigate the delay. In response to a question from the Chair about the numbers of union members amongst the staff she responded that to her knowledge there were around 30 staff, of the total 150/160, who were members of Unison. 6. DATE AND TIME OF NEXT MEETING to be confirmed. 213 Page 7 of 7

188 214

189 NHS LIVERPOOL CLINICAL COMMISSIONING GROUP FINANCE PROCUREMENT AND CONTRACTING COMMITTEE MINUTES OF MEETING HELD ON TUESDAY 20 TH DECEMBER PM TO 5PM ROOM 1, LIVERPOOL CCG, THE DEPARTMENT, LIVERPOOL, L1 2SA Present Nadim Fazlani (NF) Chair Katherine Sheerin (KS) Chief Officer Maureen Williams (MW) GB Member -Lay Member Governance/Deputy Chair Dave Antrobus (DA) GB Member Patient Engagement Lay Member Tom Jackson (TJ) Chief Finance Officer Maurice Smith (MS) GB Member GP Tina Atkins (TA) Practice Manager In Attendance Mark Bakewell (MB) Derek Rothwell (DR) Ian Davies (ID) Jane Lunt (JL) Tony Woods (TW) Laura Middleton (LM) Paula Jones Deputy Chief Finance Officer Head of Contracts, Procurement & BI Chief Operating Officer Head of Quality/Chief Nurse (up until and including item 4.1) Programme Director Digital & Community Care PriceWaterhouseCoopers (observing) Committee Secretary Apologies None Part 1: Introductions and Apologies NF chaired the meeting and introductions were made and apologies were noted. He welcomed Laura Middleton to the meeting who was part of the PriceWaterhouseCoopers Team carrying out the Capacity and Capability Review for the CCG. 215 Page 1 of 10

190 1.1 Declarations of Interest There were no declarations of interest made specific to the agenda. 1.2 Minutes and action points from the meeting on 22 nd November The minutes of the meeting on 22 nd November 2016 were accepted as an accurate record of the discussions which had taken place subject to the following amendments: Item 2.1 Better Care Fund Assessment 2017/18 ID clarified that it was the Autumn Statement which was due out 23 rd November, 2016, with regards to the Better Care Fund Assessment. As mentioned later in that section by ID the national guidance was not yet received on the Better Care Fund and so as stated correctly in the minutes the CCG s two year operational plan would need to be submitted without the section on the Better Care Fund. From item 3.1 Finance Update Month 7 October ID pointed at that Clare Duggan s title at NHS England was Director of Commissioning Operations Cheshire & Merseyside. From item 3.2 Contract Update November 2016 it was noted that the second bullet on page 10 needed to be clarified by DR on the situation re performance at Spire. 1.3 Matters Arising Not already on the Agenda Action Point One MW updated the Finance Procurement & Contracting Committee that the action around policy approval was ongoing and she was discussing the matter with ID. It was agreed that although the action had been initiated at the Finance Procurement & Contracting Committee the issue affected all committees and so the solution would go to the Governing Body rather than come back to the Committee Action Point Two - It was noted that the Care Homes Model/Transforming Care paper was to be brought to the January 2017 meeting. 216 Page 2 of 10

191 1.3.3 Action Point Three - It was noted that action to bring the Better Care fund to the Quality Safety & Outcomes Committee and then back to the Finance Procurement & Contracting Committee in January 2017 for sign off and possibly Primary Care Commissioning Committee was only attributable to Dyane Aspinall and not Tony Woods Action Point Four ID noted that the Emergency Care Improvement Programme Report ( ECIP ) had been received in draft and the final report was not yet available it would come to the Financial Recovery Oversight Group and the Finance Procurement & Contracting Committee in due course Action Points Five and Six re Telehealth and Supportive End of Live Care Service procurements approved in principle from the procurement aspect but awaiting more information on the financial position of the CCG as at end of December 2016 the financial position was to be discussed at the Governing Body Strategic Development Session on 21 st December Part 2: Updates There were no items for discussion in this section. Part 3: Performance 3.1 Finance Update November 2016 Month 8 Report No: FPCC The Deputy Chief Finance Officer (MB) presented a paper to the Finance Procurement & Contracting Committee, summarising the CCG s financial performance for the month of November 2016 (month 8), in respect of NHS England Business Planning Rules regarding in-year surplus position and treatment of non-recurrent headroom and an assessment of the risk to the delivery of the forecast surplus position given current/required mitigating actions as identified within the Financial Recovery Plan shared with NHS England. He highlighted: Page 3 of 10

192 As per previous months reporting that there had been a change in the CCG approach to reporting in relation to NHS England Business Rules during October, resulting in a revised target of a 1% surplus ( 8m) rather than 1.7% ( 14.4m) and the re-establishment of the non-recurrent headroom of 1% ( 8.362m), resulting a in a revised targeted cumulative surplus position of 16.4m for the financial year. The month 8 position had deteriorated by 700k mostly due to increases in the cost of care packages from the Local Authority around Learning Disability and Mental Health. Each Month the CCG carried out a self-assessment process month 8 was amber with over-performance across providers. The Better Payments Practice Code performance was still amber and under the 95% target but performance had improved. There was no change to revenue resources. Year to date the CCG was reporting over performance of 5m against budgeted expenditure as at November Acute contracts: Net position was 2.6m over planned levels - Aintree and the Royal had some issues re over performance due to winter resilience and high cost drugs (predominantly information was as at month 7). Community Health Contracts: currently over plan by 300k driven by over performance in Spa Medica, Any Qualified Provider Physio and Podiatry contracts and cost pressure in intermediate and palliative care offset against savings in Long Term Conditions and the Digital Programme. Continuing Care: Over budget by 2.5m mainly due to increases in the cost of Funded Care packages and Funded Nursing Care over which we had little control. Ways of developing planning assumptions would be looked at in the Governing Body Strategic Development Session on 21 st December ID asked if there was any feel for possible further charges increases during 2017/18, the response was that this could not be ruled out. 218 Page 4 of 10

193 Mental Health: over budget by 800k due to additional Children s and Adolescents Mental Health expenditure of 700k, increases in Learning Disability spending and adult mental health offset by large underspend in older people. Underspend in other programme areas (National Programme For IT monies held in reserve). Primary Care: over plan by 2.9m due to prescribing overspend, the year to date figures should actually be lower when the Financial Recovery Plan mitigations were applied. Year to date forecast was for an in-year deficit of 6.4m against delivery of an 8m surplus. Phase One savings were 6.5m, Phase Two had 8.1m (raised from 7.4m at Month 7) of savings and delivery of these was included in the figure. Financial Recovery Plan had been shared with NHS England the risks to delivery of the Plan were around the level of mitigations required at each reporting point: Month 6 3.4m of mitigations were required which had increased month 8 to 8.1m on a like for like basis due to the change in the required surplus position. Cash Target the CCG was below the cash target, Better Payment Practice Code performance was just below the 95% target but this should be achieved by the year end. No official news received as yet on the 1% non-recurrent headroom figure, the Committee would be kept informed The Finance Procurement & Contracting Committee was being asked to note: the current financial position and risks associated with delivery of the forecast outturn position, the stated assumptions regarding proposed recovery solutions to deliver the required business rules based on current forecast outturn assumptions of 8.1m (was 7.4m at Month 7), 219 Page 5 of 10

194 that an immediate cessation of all un-committed CCG expenditure has been approved until the end of December 2016 with a further financial review taking place at that point to address in year and 2 year planning requirements (2017/18 and 2018/19), The financial recovery oversight group (FROG) continues to meet on a weekly basis to support the monitoring of the initial solutions identified within the recovery plan. The Finance Procurement and Contracting Committee commented as follows: MS commented that self-assessment felt more like red than amber. The Chair reminded the Finance Procurement & Contracting Committee that the Governing Body had agreed to deliver Business Rules. Therefore this was the 16.4m (1% plus 1%). TJ responded that the decision did not need to be made now, the CCG was close to achieving the desired forecast outturn surplus although there was always risk given that there were four months of the year remaining and the situation could deteriorate. By the beginning of January 2017 we would be in a better position to make assumptions. Again this would be discussed in detail at the Governing Body Strategic Development Session. Discussions around what had been delivered by the CCG financially in 2016/17 would not be held until March/April of 2017 so it was difficult to plan for the next year. The Chief Officer noted that if the CCG did not deliver Business Rules it would be rated as Requires Improvement. The NHS Liverpool CCG Finance Procurement & Contracting Committee: Noted the current financial position and risks associated with delivery of the forecast outturn position, Noted the stated assumptions regarding proposed recovery solutions to deliver the required business rules based on current forecast outturn assumptions of 8.1m (was 7.4m at Month 7) 220 Page 6 of 10

195 Noted that an immediate cessation of all un-committed CCG expenditure has been approved until the end of December 2016 with a further financial review taking place at that point to address in year and 2 year planning requirements (2017/18 and 2018/19) Noted the financial recovery oversight group (FROG) continues to meet on a weekly basis to support the monitoring of the initial solutions identified within the recovery plan. Part 4: Strategy & Commissioning 4.1 Children & Adolescents Mental Health Services ( CAMHS ) Waiting List Plan Report No: FPCC JL presented a paper to the Finance Procurement & Contracting Committee to share the CAMHS waiting list plan, outlining the objectives of the national CAMHS waiting list funding and to gain approval of the tender waiver for one of the CAMHS provider, the Young Persons Advisory Service ( YPAS ). In August 2015 NHS England had asked all CCGS to submit a plan to transform CAMHS in order to access recurrent funding which had been committed nationally. A national report Future in Mind had outlined the requirements for CCGs in partnership with health and social care to promote resilience, prevention and early intervention, improve access, care for the most vulnerable, be accountable and transparent and develop the workforce. Liverpool was recognised as having good performance in the area of CAMHS and worked well with health and wellbeing partners and the voluntary sector. The current average waiting list was 12.5 weeks which was better than the national average of 17 weeks. However in order to maintain progress and transform the service the national funding was required. YPAS worked with children and young people at early help and specialist levels of need and was an existing provider in the CAHMS partnership working. There were robust governance and performance monitoring arrangements in place with YPAS, timeframes did not allow for a procurement exercise as the national funding available on a nonrecurrent basis until 31 st March Page 7 of 10

196 MW noted the importance of this service for young people but wondered about the effect going forward and mixed messages if funding was put into the provider now when the situation might change from 1 st April She was also concerned about the high levels of agency staff. JL responded that to access this funding we needed to act quickly, and that all the staff used were verified and qualified for their posts. KS was concerned about the ability of YPAS to scale up and deliver in time. JL responded that she was assured that they would be able to do so. The work that YPAS carried out from other funding was separate to this. KS noted that the Chair of YPAS was an employee of Liverpool CCG and this needed to be made clear. She also asked for confirmation that what was requested to be delivered by YPAS for the funding could be achieved in time for the year end. JL responded that YPAS had been part of the CAMHS network for many years. In response to the earlier query about mixed messages to the provider it was vital to have open and honest relationships with providers so they understood how the CCG needed to approach funding and the pressures it was subject to. DA was concerned about the viability of YPAS given their funding from the Grant process. NF referred to the wider issue of funding going forward for this area given the additional savings to be found for the Financial Recovery Plan under Pot C of other areas after Secondary Care and Primary Care. JL responded to the Committee noting that it was clear that these monies were intended only to reduce the waiting list, the CCG would be clear that YPAS had a contractual responsibility to deliver and would be performance managed and treated in exactly the same was Alder Hey. MW asked for it to be made clear to YPAS that we were paying retrospectively for results upfront. The NHS Liverpool CCG Finance Procurement & Contracting Committee: Noted the contents of this report. Considered current control measures and whether action plans provided sufficient assurance on mitigating actions. Agreed that the risk scores accurately reflect the level of risk that the CCG is exposed to given current controls and assurances. 222 Page 8 of 10

197 Noted the purpose of the non-recurring national waiting list funding Approved the tender waiver form for YPAS in order to progress the waiting list initiative. Part 5: Governance 5.1 Finance, Contracting & Business Intelligence Risk Register Report No: FPCC The Finance Contracting and Procurement Committee considered the Finance, Contracting & Business Intelligence Risk Register. DA referred to risk F05 around the production of a number of bespoke financial reports to various stakeholders and asked if it should be removed. MB commented that the ledger system had been re-organised to make it easier to manipulate re data extraction and management. It was agreed that this Risk Register should function in the same manner as the Corporate Risk Register re removal of risks process and so MB and ID would discuss this outside of the meeting. The NHS Liverpool CCG Finance Procurement & Contracting Committee: Noted the contents of this report. Considered current control measures and whether action plans provide sufficient assurance on mitigating actions. Agreed that the risk scores accurately reflect the level of risk that the CCG is exposed to given current controls and assurances. Agreed that this should mirror the process for the Corporate Risk Register. 6. Any Other Business MS noted that the Telehealth and End of Life Procurements approved in principle at the November 2016 meeting were still not in the public domain re the preferred provider outcome due to the halt in non-committed financial expenditure which would continue into January However the minutes of the November 2016 meeting were due to be presented to the January Page 9 of 10

198 Governing Body for noting therefore consideration needed to be given at the time of sending out the Governing Body January 2017 papers as to whether or not include the minutes or include a redacted version. 7. Date and time of next meeting Tuesday 24 th January 2017 Room 2 10am The Department Lewis s Building L1 2SA. 224 Page 10 of 10

199 Minutes of the Healthy Liverpool Programme Board Wednesday 21 December 2016 Present Tom Jackson (Chair) Chief Finance Officer / Integrated Programme SRO Dave Antrobus Lay Member/Patient Engagement/Vice Chair Simon Bowers GP/Governing Body Member/Clinical Director, Digital Care Chris Grant Programme Director, Hospitals Carole Hill Integrated Programme Director Katherine Sheerin Chief Officer Maurice Smith GP / Governing Body Member / Clinical Director, Living Well In Attendance Andrea Astbury Peter Kirkbride Sue Lavell Helen Murphy Gina Perigo Kate Warriner Jackie Dobbins Programme Manager, Community Clatterbridge Cancer Centre Integrated Programme Manager Programme Manager, Hospitals Programme Manager, Living Well Programme Manager, Digital PMO Project Support Officer/Minutes Apologies Janet Bliss GP/Governing Body Member/Clinical Director, Community Sandra Davies Director of Public Health / Programme Director, Living well Nadim Fazlani GP/Governing Body Chair Paul Fitzpatrick Healthy Liverpool Estates Lead Samih Kalikeche Liverpool City Council, Director of Adult Services and Health Dr Fiona Lemmens GP/Governing Body Member/Clinical Director Urgent Care / Hospitals Jane Lunt Chief Nurse/Head of Quality/Governing Body Member Tony Woods Programme Director, Community and Digital Care 1.0 Welcome, Introductions and Apologies 1.1 The Chair welcomed everyone to the meeting. Apologies were noted as above. 2.0 Minutes of the Last Meeting 2.1 The minutes of the last meeting held on 30 November 2016 were agreed as an accurate record. 3.0 Matters Arising EPR Business Case - an action for Kate Warriner to produce an executive summary on Centres of Global Digital Excellence for presentation to the Healthy Liverpool Programme Board was deferred to the next meeting. Action: Kate Warriner to present an executive summary on Centres of Global 225