CCG Governing Body. Thursday 10 May 2018, 13:00 16:30. Room G02A&B, 160 Tooley Street, London SE1 2QH AGENDA. Time Item ENC Presented by

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1 CCG Governing Body Thursday 10 May 2018, 13:00 16:30 Room G02A&B, 160 Tooley Street, London SE1 2QH AGENDA Time Item ENC Presented by Chair s Welcome - Dr. Heaversedge Introductions and apologies for absence - Dr. Heaversedge Public open space - Members of the public OPEN: Southwark CCG Governing Body Meeting in Public Provider presentation London Ambulance Service Presentation Darren Farmer Assistant Director of Operations, LAS Southwark showcase at patient story Patient story: engagement on care coordination Items for Assurance Minutes and action log from the meeting on 8 March 2018 A (i, ii) Dr Heaversedge Managing Director s Report B Ross Graves Items for Decision Report of the CCG s prime committees: March, April 2018: i. EPEC terms of reference April 2018 ii. IG&P Committee Terms of Reference 2018/19 iii. Nursing home AQP framework D D (ii) D (iii) Dr Heaversedge Chair: Dr Jonty Heaversedge 1 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

2 D (iv) Standing Items for Assurance Update on the latest CCG position: i. Performance and quality ii. Finance and risk Appended documents for reference: i. CCG IAF Assurance Report (M1) iii. CCG Finance Report (M12) iv. CCG BAF and Risk Report (M1) Presentation and discussion E (i) E (ii) E (iii-a,b) Ross Graves & Noel Baxter Malcolm Hines & Dr. Heaversedge Item for Assurance Annual Public Health Report 2017 C Dr Pinder Items for Reference and Information Minutes of CCG committees - 10 Integrated Governance & Performance Committee (February; March 2018) Commissioning Strategy Committee (March 2018) Primary Care Commissioning Committee (January 2018) F (i - ii) G H Engagement & Patient Experience Committee (April 2018) I Audit Committee (December 2017; March 2018) J (i-ii) Closing Items Any Other Business: Items to be notified to the secretary at least 48 hours before the meeting in accordance with Standing Orders Dr. Heaversedge Public Open Space Dr. Heaversedge 16:30 CLOSE Items f Note: Extended Public Open Space to be held 17:30-18:30, Room 132AB Date of Next Meeting: 2.00pm to 5.30 pm, 12 July 2018 Chair: Dr Jonty Heaversedge 2 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

3 CCG GOVERNING BODY 8 March 2018 Southwark CCG, 160 Tooley Street, SE1 2QH Minutes GOVERNING BODY MEMBERS PRESENT: Dr Noel Baxter (NB) Andrew Bland (AB) Jane Cliffe (JC) Professor Ami David (AD) Joy Ellery (JE) Professor Kevin Fenton (KF) Dr Richard Gibbs (RGi) Caroline Gilmartin (CG) Ross Graves (RG) Dr Jonty Heaversedge (JH) Malcolm Hines (MH) Mark Kewley (MK) Dr Michael Khan (MKh) Kate Moriarty-Baker (KMB) Andrew Nebel (AN) Robert Park (RP) Dr Yvonneke Roe (YR) Genette Laws (GL) Stephen Whittle (SW) Dr Nancy Kuchemann (NK) IN ATTENDANCE: Kieran Swann (KS) Professor Julia Wendon (JW) Andrea Cornfield (AC) Olivia Stevens (OS) APOLOGIES: Ian Abbs (IA) Linda Drake (LD) Dr Robert Davidson (RD) Dr Emily Gibbs (EG) Clinical Lead Chief Officer Southwark LMC Governing Body Nurse Member Lay member Director of Health and Wellbeing (Southwark Council) Lay Member, (Deputy Chair) Director of Integrated Commissioning Interim Managing Director CCG Chair (Meeting Chair) Chief Financial Officer Director of Transformation Secondary Care Doctor Member Interim Director of Quality & Chief Nurse Lay Member Lay Member Clinical Lead Director of Commissioning, Southwark Council Healthwatch Southwark Clinical Lead Head of Governance & Assurance Medical Director, King s College Hospital MIND Women s Forum MIND Women s Forum Co-opted member (Guy s and St Thomas ) Practice Nurse Member Clinical Lead Clinical Lead Chair: Dr Jonty Heaversedge The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 1

4 1 Chair s Welcome JH welcomed attendees to the meeting. Introductions were made and apologies received (as above). Southwark showcase JH reflected on his experience of visiting the MIND women s forum and welcomed the MIND team for the item, which he noted was a regular slot to allow Southwark organisations to talk to the Governing Body about the work they do. 2 Andrea Cornfield (AC) talked to a presentation on the MIND Women s Forum peer support group. She described the purpose of the group as being to provide a nurturing and therapeutic environment for people to meet together with professional facilitators. She described some of the aims of the group as being to widen members social interaction and reduce isolation in a safe and non-judgemental environment. She also explained that the group enabled women to access other opportunities, services and support. AC talked through some of the experiences of the women attending the group; described examples of the challenges they faced; talked about the activities the group do together; highlighted the positive outcomes some group members achieve; and noted the impact that the social interaction, sense of shared experience and solidarity had brought. On behalf of the Governing Body JH thanked the MIND team for their presentation and shared his reflection on the powerful impact of their work. Public Open Space JH welcomed questions from the members of the public in attendance. He stated that there would be an opportunity for further discussion with Governing Body members after the meeting. 3 Elizabeth Rylance-Watson (ERW) (Southwark resident and member of Southwark Pensioners Action Group) made a suggestion to ensure that the Dulwich Health Centre made space available for the use of voluntary sector. She also asked for the papers to be made legible. ERW asked about the CCG s Risk Report risk IC-35 and requested an update on the status of this risk. She asked for Southwark s position on mental health expenditure; asked about mental health bed pressures; and requested broad reports with mental health data so that CCG areas could see performance and expenditure information across neighbouring CCG areas. CG stated that the CCG was not reporting financial pressures in mental health and was projecting no overspend in 2017/18 for these budget areas. JH responded to agree on the point relating to the voluntary sector space and Dulwich. JH agreed to put MIND in touch with the Dulwich team Action JH. Chair: Dr Jonty Heaversedge The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 2

5 JH agreed to respond at a later date on the questions relating to bed pressures Action JH. JH said that as STP lead AB would consider the requirement for STP-level data packs on information. AB explained the STP s governance set-up and noted that the Strategic Partnership Group of the STP will meet in public monthly and utilise information on mental health services that speaks to all eleven STP organisations. CG said that the CCG and Council were working through the arrangements together with SLaM to resolve the financial issues highlighted in the risk ERW asked about. A member of the public commented that the papers for the Governing Body were voluminous. She reflected on her experience on her attending a meeting at King s and asked whether their clinical coding systems meant the trust was under-charging the CCG for activity the trust undertakes. AB responded to say that the extent of any issues related to clinical coding were of a different order of magnitude to the financial challenge faced by the trust. JH agreed to look at the way the CCG published papers Action JH. Introduction and apologies for absence 4 Committee members were asked to declare any conflict of interest or change to the register of interest. The register was circulated for signing. No members declared a change to their interest with the exception of Andrew Bland. AB declared an interest related to his role as Accountable Officer for Greenwich CCG and for his designate role as AO for Lewisham, Bromley and Bexley CCGs, the Greenwich charitable fund, and leadership role for the STP. Minutes and action log from the last meeting on 11 January AN noted that he was not present at the last meeting. The action log was reviewed and all actions were noted as being complete or not yet due. It was noted that KF would report to the Governing Body in July on the determinants of and possible preventative responses to emergency admissions. CCG Operating Plan trajectories and CCG Budget 2018/19 March 2018 draft version 6 RGr introduced the item noting that the Governing Body signed-off a two year operating plan last year. He explained that the document included in the papers highlighted the changes to that plan to reflect actual performance and the refreshed planning guidance of 2 February He said that the second document included the full detailed activity and performance trajectories for this year. He noted the planning documents represented a formal opportunity for the planning assumptions to be reviewed and endorsed by the Governing Body. MH talked the Governing Body through the budgetary framework, highlighting the CCG s uplift and additional resources made available via the last HM Government Budget. He confirmed that this equalled an additional 3m for the CCG, with an expectation that this funds additional acute activity growth and performance improvement, the detail of which MH referenced in the paper. He continued by reporting that the CCG was planning to meet the Chair: Dr Jonty Heaversedge The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 3

6 national investment standard for mental health, which stipulates that the CCG should increase its funding on these services by no less than the increase of it s general allocation. MH highlighted the table on page 4 that set out the overview of the CCG s financial plan. He also described the plan for the use of national sustainability funding to support NHS trusts and Foundation Trusts. MH confirmed that CCG would additionally bid for external funds (e.g. Transformation or local charity funding) to support its work, but no assumptions on this were included in the CCG s financial plan. MH described the CCG s QIPP plan, which was detailed on pages 9-10 of the Budget Framework paper. He noted that the figures included in the table were subject to some further revisions as contract variations are agreed with trusts and he noted that the CCG had currently identified 15.5m of the 16.5m requirement. MH said that the CCG would operate with a lower level of reserves than in previous years. He noted that this is planned to be 5.5m (50% of the position for 2016/17). He explained potential in-year risk and the risk of re-set contracts in future years, which he noted were recorded on page 12 of the document. MH described the process of developing the budget for 2018/19 and recommended it to the Governing Body to endorse and recommend to the Council of Members for approval. SW asked RGr and MH what they thought the key pressure points were for patients. He also highlighted the planned trajectory for children s access to community mental health services being lower than national targets. MH highlighted pressure points and risks relating to: elective waiting times; A&E performance; demand for continuing care services; and an inherited shortfall last year on primary care budgets. AB added that A&E and cancer pathway targets represented pinchpoints, which requires action across multiple providers as well as investment. The Governing Body discussed the RAG-rating system used in the operating planning paper and it was explained that this indicated where a planning trajectory had been altered and / or whether it was set to achieve the required national standard or not. CG explained that the trajectory for children s access to community mental health services currently planned to deliver at less than national standards but that the CCG and Council were completing a joint review in this area, with the aim of exceeding the trajectory included in the Operating Plan. JH confirmed that the plan was set for a realistic level of ambition and that the CCG was looking to exceed these plans in year. RG noted his support for the operating plan and financial framework. He highlighted a theme he drew from the papers, which is that the CCG is part of a winder NHS system and not an island. He highlighted examples of this in the budget framework and noted the requirements for the CCG to support the STP area and its member organisations to achieve financial balance. RG noted the plan for the CCG to increase its surplus in 18/19 by 650k, which he said was an additional requirement to be used to support SEL CCG collective financial balance. He asked MH to confirm whether the Governing Body should monitor the in-year financial position of the other STP CCGs as part of its assurance processes. AB confirmed that STP footprints have now been set a STP control total by NHS England and he explained that the 650k additional surplus was the CCG s contribution to that STP CCG total. He noted that the Governing Body has been involved in considering the Chair: Dr Jonty Heaversedge The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 4

7 regulatory STP CCG control total requirements as these have been developed and he described the previous and current arrangements in place under the Collaborative Framework in south east London to enable risk-sharing between CCGs. He noted that these locally-agreed arrangements have now been stipulated as mandatory by NHS England. RP asked for assurance that all CCGs are undertaking their actions to deliver a collective CCG control total. It was agreed that a plan for CCG oversight of this would be developed and reported back to the Governing Body Action MH. AB said that the CCG team has done well to identify QIPP opportunities totalling 15.5m, though he also noted that there remained a 1m QIPP gap. He also described the likely significant non-acute pressures and risks in the new financial year. JH agreed that 18/19 was a year of high-risk in respect of delivery of the CCG s financial plan. The Governing Body endorsed the Operating Plan and Budget Framework 2018/19 and recommended to the Council of Members for approval. Report of the CCG s prime committees: December 2017, January & February 2018 JH introduced the report, explaining that it recorded the work of the CCG s prime committees and identified items for discussion, assurance and decision. 7 JH reminded members that the papers being referred to the Governing Body for decision had been thoroughly reviewed and discussed at CCG committees. He noted that the Governing Body was asked to agree the Operating Plan and Budgetary Framework, which he said had been completed with conclusion of the previous item. The Governing Body noted the content of the prime committee report and the decisions that have been made by the delegated committees. Provider presentation: King s College Hospital NHS Foundation Trust JH welcomed Professor Julia Wendon (JW), KCH Medical Director to the Governing Body. JW talked about some of the pressures faced by the trust at present and highlighted A&E and emergency activity; financial and workforce. She went through a slide-pack of supplementary information describing the trust s approach to monitoring outcome indicators. 8 She noted that the trust s mortality rate for a range of admissions was comparatively good as were re-admissions rates; treatment targets for diabetes; management if asthma; care for patients with sepsis; and practice guidance for managing heart failure. She said that the data indicated that King s clinicians deliver high quality care in these areas, and explained how King s performed across a range of outcomes indicators and audits. JW flagged the importance of working with public health and community colleagues to reduce late-stage presentation. JW went into some further detail about learning from deaths and the process of mortality monitoring at the trust. She described the trust s open approach to managing and addressing safety issues, highlighting recent work in anaesthesia and surgical safety. JW talked about the importance of staff morale and described some of the work that the trust Chair: Dr Jonty Heaversedge The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 5

8 leadership was doing with clinical teams and the organisation s clinical leadership to support this. She discussed the trust s use of clinical data to engage clinical teams and support operational improvement. JW described some further work to improve the management of sepsis. It was flagged that the trust has a requires improvement rating from the CQC, and it was reported that the commission was visiting every month and that a further inspection is due this calendar year. She noted that the trust has improved some scores since its previous CQC review. JW described some of the trust s planned work including falls reduction; outcomes for patients receiving a hip replacement; EPR roll-out; theatre utilisation; care for people with mental health; RTT performance, RCA and 52 week breaches (flagging the reduction achieved); and the trust s work with Carter-Briggs to look at productivity across a range of specialties. JW described the arrangements in place to manage the trust s emergency department and patient flow throughout the trust. NK asked about the trust s plans for mental health. JW said that there is a joint mental health board with SLaM, which looked at the quality of care for patients with mental health presentations in emergency department; the management of patients with alcohol or substance misuse admissions; and work to meet the physical health needs of inpatients in SLaM. JE asked JW to talk about King s work on workforce retention. NB asked for JW s view on the sustainability of the trust s performance in respect of outcomes; how the trust could give assurance around safety in ED; and the trusts response to their staff survey results. JW said that the trust s vacancy rate is slowly reducing for both nursing and medical roles. She said that the trust would be looking at providing more training and development opportunities for nursing staff to support their professional development and aide retention. She noted that PRUH medical gaps were more than at Denmark Hill and she said the trust was looking at rotating clinicians across sights. In response to the staff survey results, JW acknowledged that there is further work to do to communicate with staff and to address issues identified about bullying and flexible working. KF asked about the risk of EU staff departing the trust and JW described some of the steps the trust is taking to recognise the contribution of EU and other front-line staff. JW responded to NB s question on quality and outcomes by saying that this remained the trust s foremost priority. She described some of the work the trust would need to do internally and with partners to maintain and improve patient outcomes. The Governing Body discussed the trust s development of productive relationships between clinical and non-clinical leaders and staff. She talked about some of the opportunities to bring together management, finance and clinical colleagues in divisional units. RP asked whether there was an understanding at King s of the need for pan-stp solutions to the financial problems at King s. JW described some of the trust s work across the region and said that the group talked about the opportunities in partnership working. Chair: Dr Jonty Heaversedge The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 6

9 AN asked what the trust s solution is to the on-going under-performance of RTT and A&E YR fed-back the positive view of her patients experience of King s in terms of the quality of care they receive. JW responded to say that cancer and diagnostic performance is reasonably good and has improved. She described the position on RTT as being long-term and said that the trust will work backwards from the longest waiters. She said the trust was challenged to manage RTT performance and patient-flow within its constrained capacity and said that dropping the occupancy rate would support improved performance. She talked about the culture of the organisation and the trust s plans to improve patient flow. JH reflected on the importance of a partnership-led response to the challenges faced by the trust and he expressed the Governing Body s commitment to identifying shared solutions. JH noted the resignation today of Nick Moberly and stated the Governing Boy s recognition of his hard work and commitment to King s and focus on care quality and partnership working. Managing Director s Report RGr introduced the report, taking the paper as read. He took the Governing Body through three items of business. The first was a requirement for the Governing Body to endorse the proposal approved by the CCG s Commissioning Strategy Committee on the Healthy London Partnership 2018/19 budget and operational plan. For the second item, RGr asked the Governing Body to formally note the CCG s assurance rating for EPRR. As the third item for decision RGr asked the Governing Body to delegate an action to the Chief Financial Officer and Accountable Officer to sign and seal the deed of accession relating to the Strategic Partnering Agreement underpinning the Lambeth Southwark and Lewisham Local Improvement Finance Trust arrangements. This is required in advance of the Stage 2 business case approval for the new Dulwich Health Centre. 9 The Governing Body noted that under the Transfer Scheme (paragraph 5(7)) the former Primary Care Trusts' rights and liabilities in connection with the Strategic Partnering Agreement dated 6 December 2005 (as referred to in the Deed of Accession) ("the SPA") were transferred to Community Health Partnerships Limited on the condition that NHS Southwark Clinical Commissioning Group and others accede to the SPA subject to the limitations set out in the Transfer Scheme. The Governing Body noted that as a report under the Transfer Scheme, NHS Southwark Clinical Commissioning Group would execute the Deed of Accession in accordance with the section 6.1 of the Standing Orders (Appendix 3 of the Constitution) and the Scheme of Reservation & Delegation (Appendix D of the Constitution) and accordingly NHS Southwark Clinical Commissioning Group would formally be a party to the SPA. The Governing Body approved NHS Southwark Clinical Commissioning Group acceding to the SPA on the terms of the Deed of Accession and authorised the seal to be affixed to the Deed of Accession in accordance with the Standing Orders as described above. AB noted his endorsement of the Healthy London Partnership proposal and noted that the savings on the previous cost to the CCG would be invested to undertake work at a STP or at CCG level. Chair: Dr Jonty Heaversedge The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 7

10 The Governing Body discussed the STP s approach to digital development and noted the appointment of Dr. Jack Baker as Chief Clinical Information Officer for the south east London programme. RG noted his appreciation that the CCG would be launching the community dermatology and ophthalmology services. KF asked whether HLP was a sustainable programme in light of funding reductions. He asked how the resources being transferred to STP areas would be accessible to use and for public health work on prevention. AB said that the recommendation was to reduce funding at a lower level; he noted HLP had been able to offset this reduction by attracting other funding sources; he asserted his view that the programme was now more focused and sustainable. AB said that STP SROs areas will be asked to coordinate a conversation about the local expenditure of resource being made available at a sub-regional level. He said that local areas would be engaged to determine opportunities that made sense for them. JH suggested that a case for investment / use of available resources would be welcome. The Governing Body noted NHS England s rating of full compliance for Emergency Preparedness, Resilience, and Response and the CCG s action plan. The Governing Body formally endorsed the Commissioning Strategy Committee s approval of the Healthy London Partnership proposal for 2018/19. The Governing Body noted the contents of the Managing Director s Report. Director of Health and Wellbeing Report It was agreed that KF would present his Annual Public Health Report at the next Governing Body meeting Action RW to schedule. KF talked to the document included in the papers, which highlighted who worked for the team; what the public health team did; the department s strategic priorities and key updates on particular areas of work; and the governance structure within which the team worked. He also highlighted the the Southwark Health Profile document and noted that he would cover this in greater detail at the May Governing Body meeting. 10 RP asked about the work the public health team has done on social regeneration and he asked KF to comment on the involvement he has had on the new developments in the borough. KF noted that social regeneration work is a major priority and he has been working with the Council planning and regeneration teams to look at health and the healthy and wellbeing of communities within new developments and existing communities in the borough. KF described some of the data related to this area and described how it would be used to create an evidence base to better inform planning decisions and design. JE asked whether there were measures of social isolation in the population. KF confirmed that there were data available from national data sets and that local research could be adapted from a regular residents survey. He said that this was a priority for his team and he was included in his Annual Public Health Report. Chair: Dr Jonty Heaversedge The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 8

11 Update on the latest CCG position: KMB highlighted the major quality issues and the work being completed in her directorate to identify and address these. She highlighted her team s work on workforce and summarised some of the activities relating to the training and development sessions run by the CCG for general practice clinical staff in Southwark. She also said that the CCG has recently established a network for locum clinicians working in Southwark, which aimed to improve rates of recruitment and retention. 11 KMB took Governing Body members through a short presentation looking at the national and local recruitment and vacancy rates at local providers. She highlighted work by the CCG s team on training related to duty of candour ; audits undertaken on patient safety in emergency department noting that these show clinical standards are being maintained ; serious incidents; and discharge to assess for continuing care, where she described the CCG s high levels of performance to support effective discharge to assess processes for patients. The Governing Body noted the CCG s latest position on quality, performance, finance and risk. The Governing Body noted the extreme risks and changes to the BAF as described in the CCG Risk Register and BAF. Minutes of CCG committees 12 The Governing Body noted the minutes of the following meetings: Integrated Governance & Performance Committee (Nov 2017; Jan 2018) Commissioning Strategy Committee (January 2018) Primary Care Commissioning Committee (November 2017) Engagement & Patient Experience Committee (January 2018) Joint Commissioning Strategy Committee Summary (November 2017) 13 Any other Business None 14 Public Open Space Martin Dadswell (Southwark resident) noted that the Canada Water Residents Association was running an event on social regeneration this evening. KF said the public team was involved in this work. Tutiette Thomas (patient, service user, and carer) commented that Lambeth CCG ran a good project looking at outcomes for service users and carers using a co-production approach. She suggested there may be learning for Southwark CCG in this. CG highlighted the CCG and Council s Joint Mental Health Strategy and highlighted the commitment to implementing the strategy through co-production. MK agreed that the principle of co- Chair: Dr Jonty Heaversedge The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 9

12 production was vital in helping the CCG understand patients experience of care. He gave the example of recent work on 3+ Long Term Conditions, which won a national award for coproduction. Tutiette Thomas asked what the oversight arrangements were for the GSTT community nursing team; whether mental health placements have a time limit in terms of communicating a decision; and whether the King s Parkinson s Centre could share its expertise within the local community and whether the CCG could also visit. JH agreed to pass on the point on the Parkinson s Centre to King s and said that he would feedback the request for the CCG to attend the Southwark and Lambeth Parkinson s group to the CCG s Head of Engagement Action JH. CG said that there were different mental health panels and that she would be able to answer specific questions outside of the meeting if that was acceptable. She said that GSTT had organisational responsibility for oversight of the community team and this was monitored by commissioners via contract monitoring and CQRG meetings, which are coordinated by Lambeth CCG. NB explained the quality-monitoring arrangements in place. Elizabeth Rylance-Watson commented on her observations of a recent Health Select Committee discussion on the NHS workforce and the development of Accountable Care Systems. She asked the CCG to establish a specific risk register relating to workforce. JH noted that this issue was discussed by the clinical programme board for the STP earlier in the week and that workforce collaboration was a fundamental issue for the STP to get right. AB commented that he would play-in this comment to the provider federation board and workforce part of a review of the STP s governance arrangements. 15 Date of the next Governing Body Meeting: 2.00pm to 5.30 pm, 10 May 2018, 160 Tooley Street. Chair: Dr Jonty Heaversedge The best possible health outcomes for Southwark people Chief Officer: Andrew Bland 10

13 Action Log: Governing Body Meeting March2018 Outstanding action from last Governing Body meeting Meeting Date Agenda item Action Point Update Date to be completed Lead Status January 2018 Update on latest CCG position Convene group with a number of clinical leads to review approach, and if appropriate identify the top 5-9 indicators for determinants and mitigating factors influencing emergency admissions. To report back to GB Completion date revised to July Work has commenced jointly between Kevin Fenton and Noel Baxter to develop indicators. July 2018 KF In progress and not yet due March 2018 March 2018 Public Open Space Operating Plan and Budget Framework 2018/19 Review the CCG s publishing of Governing Body papers with the CCG corporate team A plan for CCG oversight of how it will receive assurance that all CCGs are undertaking their actions to deliver a collective CCG control total to be reported back to the Governing Body. Review of Governing Body meetings to be conducted at GB seminar. To include review of papers. MH to provide update to May 2018 GB July 2018 JH In progress May 2018 MH Due Chair: Dr Jonty Heaversedge 1 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

14 Meeting Date Agenda item Action Point Update Date to be completed Lead Status March 2018 Public open space Pass on a question to King s Medical Director about whether the King s Parkinson s Centre could share its expertise within the local community. Explore whether the CCG could also visit a Southwark & Lambeth Parkinson s group. JH to provide update to May 2018 GB May 2018 JH Due Actions closed since the last Governing Body meeting Meeting Date Agenda item Action Point Update Date completed Lead Status March 2018 Director of Health and Wellbeing Report Schedule 30 minutes for Annual Public Health Report at the May 2018 meeting. Scheduled. May 2018 RW Complete March 2018 Public Open Space Make data available on mental health bed pressures. As part of developing the delivery plan for Southwark Joint Mental Health and Wellbeing Strategy the CCG and Council are developing a dashboard for mental health performance that will be shared as part of planning (June and July 2018). In the meantime Southwark performance in the context of London regional performance can be accessed via the Healthy London Partnership May 2018 JH Complete Chair: Dr Jonty Heaversedge 2 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

15 Meeting Date March 2018 Agenda item Action Point Update Public Open Space Put MIND in touch with the Dulwich team regarding potential use of space at the health centre for voluntary sector organisations. Mental Health Dashboard here: In developing the service model for the new Dulwich health Centre we were very mindful of the valuable role played by a range of voluntary sector organisations working in the borough especially in supporting people living with long term conditions. In discussion with a number of representatives from these organisations we agreed with them that the best option would be to include a centrally located information point that could be operated by a range of organisations on a rota basis. It is our intention to address how this might work in practice when we are closer to the time when the centre is operational, but our starting position is a model that links organisations to the clinics happening in the centre, so that (for instance) Diabetes UK were there on the day when the diabetes clinics are happening. Date completed Lead Status May 2018 JH Complete Chair: Dr Jonty Heaversedge 3 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

16 Southwark CCG Committee Report ITEM FOR DISCUSSION / ASSURANCE CCG Committee Governing Body Month May Year 2018 Item title: Managing Director s Report 8 March 2018 Enclosure number: B Any know conflict of interest No The item is being presented to the committee for (select only one): Discussion Assurance Chair: Dr Jonty Heaversedge 1 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

17 Report Author Responsible Director Name Ross Graves Name Ross Graves Job title Managing Director Job title Managing Director Directorate N/A Directorate N/A 1. Purpose of the paper (why does the committee need to discuss / receive assurance?) The Managing Director s Report provides the Governing Body with an update on major developments in local health system and within the commissioning portfolio. 2. Describe the issue being presented to the committee for discussion or assurance This report gives focus to the following items, which the Governing Body are asked to note: South east London (SEL) CCGs CCG 360 o Survey Strategic and operational planning Forward View into Action Our Healthier South East London System resilience and performance Primary Care CQC and econsult Estates programme The Governing Body is asked to formally approve the below items: Primary care services to care homes and nursing homes: As per the CCG s Standing Financial Instructions the Governing Body is asked to approve awarding this contract to the successful bidder with a contract start date of 01 June Chair: Dr Jonty Heaversedge 2 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

18 3. What stakeholder engagement has taken place? Each area of the report has been the overseen by the relevant committee of the Governing Body including the Senior Management Team of the CCG. Clinical lead portfolio holders have been involved in each area. Supporting information / documents Please append any relevant documents including detailed reports; options appraisals; background documents; national guidance etc. Appendix # Name of document i CCG Managing Director s Report May 2018 Date paper completed Thursday, 03 May 2018 Chair: Dr Jonty Heaversedge 3 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

19 Managing Director s Report 02 May NHS Southwark CCG Development 1.1 South east London (SEL) CCGs April has marked the start of the new CCG leadership arrangements agreed in September We are pleased that the majority of executive posts have now been appointed and are now working to their new responsibilities. This structure includes executives which will support individual CCGs, and also some which will work across several or all six organisations. In all cases the aim is to support both our local and collective priorities. Within these arrangements, five CCGs (Bexley, Bromley, Greenwich, Lewisham and Southwark) agreed to appoint a single Chief Financial Officer (CFO) and two Directors of Finance that would report to that CFO one for Bexley, Bromley and Southwark CCGs, and one for Greenwich and Lewisham CCGs. In addition a third Director of Financial Strategy post was established working across all six CCGs and again, reporting to the single CFO. Importantly, no changes were proposed or agreed for the financial leadership of NHS Lambeth CCG. At the current time, the three Director of Finance positions have been recruited to and started in post from 1 April. Recruitment is continuing for the position of CFO for south east London CCGs. Until this post has been recruited to, Malcolm Hines will be Acting CFO for Bexley, Bromley and Southwark CCGs and David Maloney will be Acting CFO for Greenwich and Lewisham CCGs. To ensure consistent terminology within and outside of South East London and to best communicate our collaboration, the South East London CCG Executive group and our CCG Chairs have supported changes to our naming conventions. Therefore, all CCGs will now be referred to as members of the NHS South East London Commissioning Alliance. Over the last few months, the CCG review has focused on supporting the implementation of the new executive structure and governance and also the development of approaches to best support collaborative working. This includes: Supporting the CCG Organisational Development (OD) leads to scope and deliver the first phase of an OD programme. This has included interviews with the new leadership and wider members of the CCGs, and the delivery of two facilitated sessions to support effective working across the south east London executive. This programme of work will continue and expand in the new financial year. Continued discussions with the CSU regarding the most effective approach to acute and integrated urgent care (IUC) contracting and also ensuring best value for money for their services. The establishment of a Quality Leads group which meets monthly to discuss issues and opportunities that can be approached collaboratively. Chair: Dr Jonty Heaversedge 1 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

20 CCG Governing Bodies will now all meet within a two week window, a new weekly South East London Executive Group has been established and there will be monthly meetings with the South East London CCG Chairs and members of the Executive. The next phase of the CCG Review started in mid-april The focus of this phase will be ensuring the best use of our collective resources to deliver local priorities as well as identifying opportunities for collaboration. 1.2 CCG 360 o Survey The fifth annual survey carried out by Ipsos MORI on behalf of NHS England took place earlier this year. NHS Southwark CCG had a total response rate across all stakeholder groups of 88% and a member response rate of 89%. Overall, the CCG s results are positive with scores consistently higher than the national, regional and cluster average in most areas. Areas where the CCG has improved scores compared to the previous year include involving the right individuals and organisations when commissioning / decommissioning services, having confidence in the leadership of the CCG to deliver its plans and priorities, having confidence in the CCG to deliver improved outcomes for patients, having confidence in the CCG to act on feedback it receives about the quality of services and feeling that comments have been considered when commenting on the CCG s plans and priorities. There are a few areas where the CCG has lower scores than in 2017 and these include having clear and visible leadership of the CCG and whether the CCG has effectively communicated its plans and priorities. One more member practice responded to the survey compared to compared to 33, out of a total of 38. However, member practice scores rose in a number of areas when considering absolute numbers and these include ability to influence the CCG s decisionmaking process, having confidence in the clinical leadership of the CCG, familiarity with the financial situation of the CCG and agreeing that representatives from member practices are able to take a leadership role within the CCG if they want to. Areas where members practice respondents scores are lower than last year in terms of absolute numbers include understanding the financial implications of the CCG s plans, understanding the implications of the CCG s plans for service improvement and understanding the referral and activity implications of the CCG s plans. The results were discussed at the locality meetings with member practices in April to help identify any actions before being presented and discussed at the commissioning strategy committee in June The full results from Ipsos MORI are published on the CCG website. 2. Taking forward system-wide transformation in Southwark 2.1 Strategic and operational planning Chair: Dr Jonty Heaversedge 2 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

21 The final accounts for have now been prepared and are currently going through audit examination. The outturn for the year shows a small surplus, after technical adjustments, and the release of the ½% contingency reserve held all year under NHSE rules. The final outturn is a cumulative surplus of 11,074k, and an in year surplus of 530,000 after taking out these technical adjustments, largely relating to drugs in short supply and national contracts. The CCG has, subject to audit, continued to maintain its record of achieving its financial duties each year. The CCG has also been negotiating its contracts for , the second year of a two year agreement for all acute and mental health services. These agreements have been managed within available resources. The agreements reached include mechanisms for managing in year risk for both types of services. The Mental Health Investment Standard has been met with an overall increase just above the growth uplift of 3.33% for the year. 2.2 Forward View into Action Commissioning Development The CCG and Southwark Council have been developing an integrated approach to outcome based commissioning, adapting the Bridges to Health and Wellbeing population segmentation model (which has been operating in trailblazer areas for integration such as Stockport) to reflect the unique demographics of Southwark and ensuring that the model is an holistic rather than clinical model, in a way that factors in the wider determinants of health and wellbeing. We are working over the course of May and June to prioritise initial areas of focus for mobilisation, using stakeholder feedback to refine our approach. This will involve facilitating and over time embedding a different, more coordinated and integrated way of working across the system towards population health and care outcomes. Work has highlighted both the value of an inclusive approach across health, social care and public health when scoping key areas of focus along with the importance of language when characterising & describing emerging cross-cutting groups of service users to ensure key areas of focus are meaningful and can be easily recognised by key stakeholders across social care as well as health. Next steps on this work are to hold a joint plenary Commissioning Development Group workshop during May / June to feed into an extraordinary meeting of the CCG and Council s Joint Commissioning Strategy Committee during June which will sign off a recommended approach to phasing and prioritisation. System Development Work continues to develop our model for community based care across the borough. Local Care Networks (LCNs) are our model for delivering integrated, community-based care to populations of 100 to 150k residents, bringing together Southwark s seven neighbourhood footprints. To date, LCNs have brought together provider partners with the voluntary and community sectors and have developed a care coordination pathway for 3+ long term conditions that has been rolled out across all GP practices in Southwark. Chair: Dr Jonty Heaversedge 3 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

22 From the start of June we will mobilise refreshed arrangements for community based care in Southwark. These arrangements will consist of a Southwark Community based Care Board acting as a partnership board that will bring together commissioners and providers and will provide oversight of our Local Care Network programme as well as our evolving commissioning arrangements as these shift towards commissioning for population outcomes. At the same time we are working with partners across the system to further explore options for closer partnership working through strengthened and more formalised partnership and contractual arrangement that would support the development of our LCNs. 2.3 Our Healthier South East London The Healthier South East London programme work streams are currently agreeing 2018/2019 priorities building on 2017/2018 activities and achievements and aligned with NHS planning guidance. Recent highlights include: Cancer - Following a successful pilot, the Rapid Access Diagnostic Clinic based at Guy s Hospital has extended its service to patients from Bexley, Bromley, Greenwich and Lewisham. Community Based Care Supported direct booking of extended access appointments by NHS 111 to improve access for patients who call 111 and need an urgent primary care appointment. This is available across Southwark, Lambeth and Lewisham, with Bromley going live in April. Direct booking options are being developed for Bexley and Greenwich to go live in spring/summer 2018 Digital - Improved record sharing across SEL went live in March. This links the two clinical portals - the Local Care Record and ConnectCare together, giving care professionals real-time access to patient records irrespective of where the care is being provided in SEL. From April 2018, Dr Harpal Harrar has been the STP Primary Care Digital lead on a one day a week basis. Dr Harrar is a GP from the Sandmere Practice in Lambeth and is also a member of NHS Lambeth CCG s Governing Body Maternity Submission of a second version of the local Better Births Implementation Plan to NHS England at the end of January. The implementation of some sections of the plan has started already, including: supporting commissioners and Maternity Voices Partnerships (MVPs) in agreeing local resourcing arrangements; working to develop services so that more women are offered continuity of carer; and a number of projects which are aiming to link up digital maternity systems across service providers Planned Care: Orthopaedics the SEL Orthopaedic Clinical Network will be talking to patients over the spring, to ensure their views are captured and reflected as part of understanding the current service at each site. This engagement will be taken forward with the OHSEL PPAG and with provider trust public engagement groups New Joint Senior Responsible Officer (SRO), Urgent & Emergency Care Programme - At the end of January 2018, Dr Simon Eccles left his post of Joint SRO, Urgent & Emergency Care Programme to take up a national role as Chief Clinical Information Officer for NHS England. We would like to offer our thanks to Simon for all of his hard work. Tricia Fitzgerald, Director of Nursing at King s College Hospital NHS Foundation Trust, has been appointed as the new Joint SRO, Urgent & Emergency Care, taking up the role on 1 March System Resilience 3.1 Accident and Emergency 4 Hour Standard Chair: Dr Jonty Heaversedge 4 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

23 Performance for both GSTT and KCH - Denmark Hill have remained below the 95% national standard for patients being treated, admitted, transferred or discharged within 4 hours. Performance for GSTT slipped against the planned trajectory for the Trust, achieving 85.1% for March for all types which is a decrease on February performance of 87.4%. Bed pressures remain high at St Thomas and work is being done on updating and re-launching the Trust-wide full capacity protocol with clinical MDT support. The new Majors re-build section of the Emergency Department has fully opened with the CDU building works to be completed in May With the new opening of the area, the team is currently trialling a new Rapid Assessment Team (RAT) model for quick assessment in the ED. The Trust is also piloting additional SELDOC GP shifts overnight in the UCC to help protect UCC performance overnight. The Trust held a One Team engagement week in March to support the front door and improve speciality response times to ED referrals. The Clinical and Operational Management team for the Acute Assessment Unit also continue work on the Care Redesign Programme to review and create new acute ambulatory pathways. Performance for KCH continues to track below the planned trajectory for the Trust. A&E performance for March was 71.2% for all types. Poor performance on the Denmark Hill site is contributed to flow issues throughout the hospital, high numbers of unfilled clinical shifts (doctors and nurses) and low numbers of discharges. The UCC Working Group has moved into an implementation phase and has started to make changes within the UCC to improve performance. Due to this work, in mid-march the UCC started to achieve over 90% performance against the 4 hour target. The Trust also held another Multi Agency Discharge Event (MADE) the week prior to the Easter bank holiday to help create capacity over the weekend. The event was successful in discharging 93 patients on the day of the event and setting up 37 patients to be discharged the following day by 10am. Besides weekly telephone conferences with KCH for weekend planning, senior management from the CCG are also attending daily 8:00am meetings at Denmark Hill to help escalate any issues quickly. The KCH Emergency Pathway Board continues to meet weekly with regular attendance by the CCG, ICDT, Transformation Nous and NHS Improvement to help facilitate improvements on site. Besides external support from Transformation Nous and NHS Improvement, the Emergency Care Improvement Programme (ECIP) team also started on site in April to help make improvements along the emergency pathway. 3.2 London Ambulance Service At this time, LAS is only releasing STP level data for the Ambulance Response Programme (ARP). In March 2018, LAS struggled to meet the response time targets for most patients in South East London. While the targets were missed in March, the performance has continued to improve since the launch of the ARP programme in November In May, CCGs will start to receive ambulance response times for their areas. LAS is also in the process of releasing their new strategic overview for 2018/ /23. The organisation would like to be a world class ambulance service for a world class city: London s primary integrator of urgent and emergency care on scene, on phone and on line. In their draft report, LAS plans to enable the most appropriate patient care by: 1. Using their influence and working with partners to ensure a consistent approach to urgent and emergency care LAS will invest substantially in providing coordination in Chair: Dr Jonty Heaversedge 5 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

24 the strategy, design and development of urgent and emergency care in London, including urgent/integrated care centres supported by analytics. 2. Acting as a multi-channel single point of access and triage to the urgent and emergency care system across London LAS will build on their recognised excellence to move towards acting as the integrated entry point to the emergency and urgent care system via 999, 111 and digital/online means. This will enable LAS to ensure that patients receive the most appropriate care and that there is consistency across London. 3. Providing a high quality and efficient differentiated clinical service that better matches care to patient urgent and emergency needs This will enable LAS to use staff and vehicles in the most effective way by preventing escalation and helping to manage demand on the system as a whole. LAS have selected a number of patient groups for whom changing the way they respond will deliver a significant improvement in the quality of care and patient experience. This includes falls, mental health, maternity and end of life care. 3.3 Integrated Urgent Care (formally NHS 111) The procurement process for the new Integrated Urgent Care service ended in April 2018 with reports being sent to all SEL CCGs in May detailing the process and the outcome of the bids. The process and selection of bidder will be presented to NHS England in the beginning of June for final sign off. The new service is intended to be in place by mid- October The new specification will move the current referral 111 service to a consult and complete model. The service will have pharmacists, advanced nurse practitioners and GPs working in the service with the ability to prescribe and directly book primary care appointments in-hours and out-of-hours. The service will also link with mental health providers in South East London. The new service intends to increase calls closed with self-care advice from trusted healthcare professionals, decrease callers referred to A&Es, refer patients to the most appropriate service for their needs and improve the patient experience. 3.4 Referral to Treatment (RTT) Standard RTT performance for Southwark CCG did not meet the trajectory of 86.9% for February 2018, reaching 84.9%. However, this was a small improvement from 84.6% in January The compliant specialties were Dermatology, General Medicine, Geriatric Medicine, Thoracic Medicine and Rheumatology. All other specialties did not meet the 18 week standard. RTT performance for Southwark CCG at KCH in February 2018 was 80.5%; the compliant specialties were General Medicine, Gynaecology, Geriatric Medicine, Thoracic Medicine and Rheumatology. This is an improvement from 79.5% in January 2018 and the overall performance for KCH at Southwark CCG has improved since April The Trust has implemented a new RTT governance structure with an RTT Delivery Group meeting weekly with each of the DH and PRUH teams. An RTT Recovery Lead also joined the Trust in Q4 (2017/18) for a period of 9 months to focus on demand and capacity alignment, and longwait PTL review with each of the key services. RTT performance for Southwark CCG at GSTT in February 2018 was 88.0%; this was a decline in performance from 88.4% in January The specialties that were noncompliant were, Cardiology, ENT, Gastroenterology, General Medicine, General Surgery, Gynaecology, Plastic Surgery and Trauma and Orthopaedics (T&O). Demand and capacity plans for each service have also been revised to focus on RTT recovery. A revised recovery Chair: Dr Jonty Heaversedge 6 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

25 trajectory for RTT was submitted to NHS Improvement in November 2017, and the Trust submitted a more detailed plan to NHS Improvement on 22nd December A new Red2Green (R2G) report has been rolled out to all services and is being used at weekly Patient Tracking List (PTL) meetings as part of long waiter management. The R2G report is designed to track those patients whose pathways are at 40 weeks or over. Newly established planning and performance meetings for each directorate are now in place at the Trust. These meetings will be fed back to the Chief Operating Officer for oversight. The number of patients waiting over 52 weeks for Southwark CCG in February 2018 was 45; this was a decline compared to January However, despite the recent increase, there has been an overall downward trend of patients waiting over 52 weeks for elective care since April Of these 45 breaches, forty three occurred at KCH (13 in General Surgery, 1 in Gynaecology, 1 in General Medicine, 13 in Trauma and Orthopaedics (T&O), 4 in Ophthalmology, 1 in Urology and 10 in Other. The remaining two breaches for Southwark CCG occurred at GSTT (1 in Other) and Imperial College (1 in Trauma and Orthopaedics (T&O). To further support performance and reduce waiting times, we are pleased to announce that the new community service models for Ophthalmology and Dermatology have launched. The Optometrist Triage Service will ensure that everyone who needs treatment for an eye condition in Southwark is seen in the right place, first time. Rather than referring patients directly to secondary care for routine eye conditions, GPs will be requested to refer patients to the Optometrist Triage Service. The referral will be reviewed and triaged by an optometrist who will decide which is the most appropriate service for the patient to be referred to. The community dermatology service will manage a broad range of skin conditions and strengthen the dermatology offering in Southwark by providing a specialist led intermediary service. All routine dermatology referrals from GPs in Southwark will be referred to the service and specialists will review them to ensure that patients and are seen in the right setting, first time. 3.5 Cancer Waits Southwark CCG met the national Two Week Wait (2WW) standard and trajectory of 93.0% in February 2018, achieving 95.8% for all cancers. This was an improvement in performance compared to 94.7% in January Southwark CCG did not meet their trajectory of 87.5% for Cancer 62 Day performance in February 2018, reaching 64.3%. This was a significant drop in performance compared to 82.8% in January The high performance in January 2018 was in part due to fewer than expected breaches in January. These delayed breaches are reflected in the February figures, and to some extend will be reflected in the March performance figures. These breaches relate to patients who delayed their diagnostic/treatment around the Christmas and New Year period, and were therefore treated later. The dip in February was therefore expected and was flagged to us in advance. There were 15 breaches in February Of the 15 breaches, 1 was due to delay in workup, 1 was due to patient being unfit to commence treatment, 1 was due to other medical condition prioritised, 3 were due to administrative issues, 2 were due to inter-trust with no information and 7 were due to patient choice. South East London (SEL) acute providers submitted revised Cancer Recovery Plans together with revised trajectories, which were approved by regulators in November The Return to Trajectory plans outline how the Trusts will return to recovery by March Chair: Dr Jonty Heaversedge 7 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

26 As part of the SEL cancer delivery plan, additional funding was provided to support performance improvement. This includes additional diagnostic capacity, implementation of Straight to Test (STT), training radiographers in reporting and Multidisciplinary Team (MDT) Co-ordinators to track patients on the pathways. A new Standard Operating Procedure (SOP) for Inter Trust Transfers (ITT) has been implemented across South East London Trusts since 11 December 2017 and it is expected that this will improve performance of ITT. 3.6 Electronic Referral System (e-rs) Southwark CCG s e-rs utilisation in March 2018 was 61% - this ranks Southwark 9th out of the 32 CCGs in London. Both GSTT and KCH have made good progress in their paper switch-off programmes. GSTT completed their paper switch-off programme on 1 April, with their fourth tranche of specialties becoming e-rs only. The switch-off has been successful with few issues reported. Denmark Hill have completed phases 1 and 2 of their paper switch-off programme, and 20 specialties are now e-rs only. The next set of specialties is due to become e-rs only on 1 July. The CCG will work closely with the trust to ensure the programme continues to deliver on time and ensure timely communications are shared with primary care. In Primary Care, there are a number of GP IT Facilitators available to provide e-rs training to practices. Practice level information is being used to identify and support GP practices which may benefit from additional training. Resources for GPs (including training guides developed by the GP IT Facilitators) are available on the Members and Staff Zone and regular updates are provided in the Planned Care Newsletter. 4. Primary Care 4.1 CQC The CQC inspection process is a national programme and on 1 April 2015 the CQC began inspecting GP practices in Southwark. 37 of Southwark s 38 GP practices have now been inspected and have had their reports published. The practice that has not been inspected is being inspected in May Full reports are available on the CQC website ( ). 30 practices in Southwark have been rated as good. Five practices are rated as requires improvement. The CCG is monitoring closely these practices action plans to ensure that the improvements required that were highlighted during CQC inspections are made. As the delegated commissioner of general practice services, the CCG has issued remedial breach notices to practices where inspection reports have highlighted breaches in the general practice contract. The CCG has also supported practices to make improvements in areas such as infection control, medicines management processes, reporting and investigation of incidents and safeguarding. GP Forward View resilience funding was also prioritised for practices with poor CQC ratings to support them with the implementation of their action plan which enabled practices to recruit additional management resources. In Q1 of 2017/18 CQC has published two practice reports which has seen them taken out of special measures and rated as good overall after follow up inspections highlighted that both practices had made significant improvements. Chair: Dr Jonty Heaversedge 8 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

27 Forest Hill Group Practice The practice was previously inspected in June 2017 when it was placed in special measures and given an overall rating of inadequate. An announced inspection was carried out on 8 February 2018 which saw that concerns from the previous inspection had been addressed and significant improvements had been made. The practice is now rated as good overall. It was also noted that leadership and management had improved. The practice had clear systems to manage risks and safety incidents, it had reviewed the effectiveness of the care it provided and had a strong focus on continuous learning and improvement at all levels. The inspection highlighted some areas where further improvements could be made including improving access to appointments and telephone access. The CCG is continuing to monitor access at the practice closely. The practice has recruited four new salaried GPs (one of which will be joining the practice in May). In addition, two primary care pharmacists have also been recruited to provide care and support for patients with long term conditions. Trafalgar Surgery The practice was previously inspected in April 2017 and was inadequate overall. The rating applied to being safe and well-led. It was re-inspected in on 30 January 2018 and rated Good overall. The practice was noted to have made improvements in many areas. The inspection found that the practice had a clear system to manage risk and safety incidents ensuring that lessons learned were shared and saw improvements. Patients were provided information about how to make complaints and an easy and accessible appointment system was in use. There was a strong focus on continuous learning and improvements. The CCG continues to work with the practice to provide support as required. In addition to this, Sternhall Lane Surgery had a third inspection on 14 March 2018 and are now rated as good overall. The practice was previously rated as requires improvement, but at its most recent inspection the CQC noted that the practice had made clear improvements to manage risk and identify learning from safety incidents and complaints. The CQC found that the practice should make improvements in continuing to engage with the premises owner in regards to making improvements which the CCG has confirmed they will support the practice with. 4.2 econsult We are pleased to announce the introduction of an online consultation platform for Southwark - econsult. The platform will enable patients to consult with their own NHS GP simply by completing a quick online form. It helps GPs to deliver better access to registered NHS patients by providing a round-the-clock portal where patients can enter their symptoms and receive instant self-help advice, together with signposting to NHS 111, pharmacies and other healthcare services. econsult is starting to work with our local GP practices, GP federations and Patient Participation Groups (PPG) to implement this locally. This is one of the digital initiatives that we are working on with our practices and our patients and we will continue to work with both on further developing our digital offer locally. Items for the Governing Body to formally approve 5. Primary care services to care homes and nursing homes NHS Southwark CCG recently re-procured the extended primary care services to care homes with nursing beds contracts. As part of this procurement the CCG has extended this Chair: Dr Jonty Heaversedge 9 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

28 service offer to larger residential homes in Southwark recognising the complexities of residential and their increasing health needs. The aim of the procurement is to: provide high quality care for residents of care homes with nursing beds through high quality care services supported by a multi-disciplinary team approach, to provide a proactive clinical leadership to support services both provided by and provided to the home; to review the needs of residents of CQC registered homes and the model of service provision required within identified resources. There are a total of nine nursing and residential homes included in this procurement: The CCG followed a procurement process supported by our procurement team at the Commissioning Support Unit. We have appointed a successful bidder and the Procurement Ratification Report was approved by the Primary Care Commissioning Committee (PCCC) on 24 April. As per the CCG s Standing Financial Instructions the Governing Body is asked to approve awarding this contract to the successful bidder with a contract start date of 01 June The contract is for three years with an option to extend for two years. The full five year contract value is 1,805,000. Chair: Dr Jonty Heaversedge 10 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

29 1. Summary of prime committee meetings since the last Governing Body Committee meetings included in this report Integrated Governance & Performance Committee Commissioning Strategy Committee Joint Commissioning Strategy Committee Engagement and Patient Experience Committee South East London Committee in Common SCCG Primary Care Commissioning Committee Remuneration Committee Audit Committee 22 March March April March March 2018 Meeting Date 26 April 2018 Chair: Dr Jonty Heaversedge 1 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

30 2. Summary of the principal role of CCG prime committees Committee Principal role of the committee Chair Integrated Governance & Performance Committee Commissioning Strategy Committee Joint Commissioning Strategy Committee Engagement and Patient Experience Committee The overarching duty of the committee is to act to oversee governance in an integrated way, with all aspects of commissioning and provider activities scrutinised using an approach that considers finance, quality, safety and performance together. Assurance of the effective functioning of the CCG and its main contracted providers. Provision of assurance to the CCG Governing Body for safeguarding; information governance; health and safety and equality and diversity management. Responsible for assuring the Governing Body on the monitoring of the CCG s risk management and Board Assurance Framework. Oversees the development and implementation of the CCG s strategic plans and commissioning intentions, taking into account information received from Localities and the Council of Members on commissioning strategy and priorities; scrutinises the on-going efficacy of commissioned services where service developments are identified; works with Member Practices to implement plans and undertake designated actions in the localities; receives reports from strategic programme boards charged with overseeing major commissioning programmes. Sets direction and provides guidance on the development of strategic plans that are shared between NHS Southwark Clinical Commissioning Group and Southwark Council. Provides a joint forum for the senior leadership of the two organisations to discuss the local approach to strategic issues and oversee the key partnership strategies for children and young people, mental health, and older adults and complex needs, within the overarching Joint Southwark Five Year Forward View for Health and Social Care. Responsible for monitoring, advising and providing assurance on patient engagement ensuring statutory duties are met and building on local good practice and report to the Governing Body on progress in implementing the engagement strategy and advising of any major deviation from engagement plans. Andrew Nebel, Lay Member, NHS Southwark CCG Dr. Jonty Heaversedge, Chair, NHS Southwark CCG Dr. Jonty Heaversedge, Chair, NHS Southwark CCG & David Quirke- Thornton, Strategic Director, Children's and Adults Services, Southwark Council Joy Ellery, Lay Member, NHS Southwark CCG Chair: Dr Jonty Heaversedge 2 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

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

32 3. Recommendations to the Governing Body for decision/approval The Governing Body should review the papers referenced and formally approve the recommendation made by the stated committee. This decision will be recorded in the minutes of the Governing Body meeting. No. Committee name Meeting date Agenda item Recommendation for decision Associated documents 1. Engagement and Patient Experience Committee 20 April 2018 EPEC terms of reference April 2018 The committee approved the EPEC TORs and recommended them to the Governing body for agreement. ENC D (ii) 2. Integrated Governance and Performance Committee 22 March 2018 IG&P Committee Terms of Reference 2018/19 The committee approved the terms of reference, and recommended them to the Governing Body for agreement. ENC D (iii) 3. Integrated Governance and Performance Committee 26 April 2018 Nursing home AQP decision The committee recommended the re-signing of the contract to the Governing Body. ENC D (iv) Chair: Dr Jonty Heaversedge 4 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

33 4. Action taken under delegation: Governing Body to note for assurance The Governing Body should note the below items, where a prime committee made a decision under the scheme of delegation as set out in the CCG Constitution. No. Committee name Meeting date Agenda item Action taken under delegation by the committee 1. Integrated Governance & Performance Committee 22 March 2018 CCG Risk Report & Board Assurance Framework (M12) The committee noted the STP strategic risks. 2. Integrated Governance & Performance Committee 22 March 2018 CCG Quality Update The committee noted the current quality and safety issues, and the assurance and improvement activities described. 3. Integrated Governance & Performance Committee 22 March 2018 CCG Quality Update The committee noted the SCRs, MARs and SARs which involved the CCG during 2017, and were assured by the approach undertaken by the SCR or the SAR sub-groups of the Southwark Safeguarding Board. 4. Integrated Governance & Performance Committee 22 March 2018 Operating Plan 2018/19 The committee endorsed the draft Operating Plan 2018/19 ahead of its presentation to the Council of Members for approval on 28 March Integrated Governance & Performance Committee 22 March 2018 Risk Management Framework and Corporate Objectives for The committee approved the Risk Management Framework and Corporate Objectives 2018/19. Chair: Dr Jonty Heaversedge 5 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

34 No. Committee name Meeting date Agenda item Action taken under delegation by the committee 6. Integrated Governance & Performance Committee 22 March 2018 IG toolkit submission report The committee reviewed the assurance statement and approved the final IG Toolkit position. 7. Integrated Governance & Performance Committee 22 March 2018 Any other business The committee was informed that in February 2018 the PCCC voting members at the Primary Care Programme Board agreed the proposed contract model and that officers can start the patient and stakeholder engagement. 8. Integrated Governance & Performance Committee 26 April 2018 Matters arising The committee noted that decisions made at the last IGP had been signed off by the Chief Financial Officer. 9. Integrated Governance & Performance Committee 26 April 2018 CCG Quality Update The committee noted the current quality and safety issues, and outlined quality assurance and improvement activity described in the quality update. 10. Integrated Governance & Performance Committee 26 April 2018 Flexible working policy The committee agreed the updated policy. Chair: Dr Jonty Heaversedge 6 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

35 No. Committee name Meeting date Agenda item Action taken under delegation by the committee 11. Commissioning Strategy Committee 1 March 2018 Locality Reports: January & February 2018 The committee received updates from the North and South Southwark Localities. 12. Commissioning Strategy Committee 1 March 2018 Planned care referral optimisation review and next steps The committee agreed to cease the Peer Review scheme and to continue the extended trials of Visual DX and Consultant Connect. 13. Commissioning Strategy Committee 1 March 2018 Care at Home The committee approved the proposal and supported the recommendation to participate in the procurement of a framework of providers to deliver care packages for children and young people s continuing care needs. 14. Commissioning Strategy Committee 1 March 2018 Evaluation of the HIV care transition services The Committee noted the positive findings of the initial evaluation of current services post de-commissioning of specialist HIV services. 15. Commissioning Strategy Committee 1 March 2018 Evaluation of the HIV care transition services The committee agreed that the full evaluation will be presented back to CSC in early in 2018/19. Chair: Dr Jonty Heaversedge 7 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

36 No. Committee name Meeting date Agenda item Action taken under delegation by the committee 16. Commissioning Strategy Committee 1 March 2018 Update on Walworth Town Hall The committee registered its support for the expression of interest for the Walworth Town Hall site. 17. Audit Committee 28 March 2018 Internal Audit Progress Report The committee accepted the Internal Audit Progress Report. 18. Audit Committee 28 March 2018 Internal Audit Progress Report The committee approved the audit reports presented for Continuing Care, Primary Care Commissioning and Information Governance Toolkit. 19. Audit Committee 28 March 2018 Internal Audit Progress Report The committee approved the draft Head of Internal Audit Opinion for submission with the Annual Report. 20. Audit Committee 28 March 2018 Internal Audit Progress Report The committee accepted the internal audit progress report. Chair: Dr Jonty Heaversedge 8 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

37 No. Committee name Meeting date Agenda item Action taken under delegation by the committee 21. Audit Committee 28 March 2018 External Audit Plan (KPMG): The committee approved the external audit plan for The committee received assurance on service auditor report for Capita. 22. Audit Committee 28 March 2018 Counter Fraud Report (TIAA) The committee accepted the Counter Fraud Services Progress Report, Annual Plan 18/19 and the Self-Review Tool assessment. 23. Audit Committee 28 March 2018 Chief Financial Officer s Report The committee approved the DRAFT Annual Report and Annual Governance Statement for submission. 24. Audit Committee 28 March 2018 Chief Financial Officer s Report The committee approved the Accounting Policies 25. Audit Committee 28 March 2018 Chief Financial Officer s Report The committee approved the Waivers and Tender Ratification Report for the period Jan-Mar Chair: Dr Jonty Heaversedge 9 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

38 No. Committee name Meeting date Agenda item Action taken under delegation by the committee 26. Audit Committee 28 March 2018 Chief Financial Officer s Report The committee approved the registers for declaration of interests, gifts and hospitality and procurement decisions. 27. Engagement and Patient Experience Committee 20 April 2018 Draft engagement guide The committee provided feedback on the draft engagement guide for CCG staff. 28. Primary Care Commissioning Committee 21 March 2018 Sternhall Lane Surgery Relocation Business Case The committee agreed that the current proposal to move in to the Lister Primary Care Centre does not fit with the CCG s strategy for primary care at this time. 29. Primary Care Commissioning Committee 21 March 2018 Primary Care Finance Report month /18 The committee received the Primary Care Finance Report month / Primary Care Commissioning Committee 21 March 2018 Quality Improvement Report The committee received the Quality Improvement Report. Chair: Dr Jonty Heaversedge 10 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

39 No. Committee name Meeting date Agenda item Action taken under delegation by the committee 31. Primary Care Commissioning Committee 21 March 2018 Urgent planned PCCC decisions for reporting New Mill Street Surgery The committee was informed that in February 2018 the PCCC voting members at the Primary Care Programme Board agreed to issue New Mill Street Surgery with a remedial breach notice. 32. Primary Care Commissioning Committee 21 March 2018 Urgent planned PCCC decisions for reporting Dulwich Health Centre The committee was informed that in February 2018 the PCCC voting members at the Primary Care Programme Board agreed the proposed contract model. 33. Primary Care Commissioning Committee 21 March 2018 Southwark CCG Prescribing Improvement Scheme 18/19 The committee approved the scheme for implementation in Southwark CCG from April 2018, subject to agreement by the medicines management committee. Chair: Dr Jonty Heaversedge 11 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

40 5. Committee items for the Governing Body to discuss The Governing Body should note and discuss the below items. These are items where assurance has been received at a prime committee, but where the Governing Body may wish to seek additional assurance or discuss pertinent issues relating to the business of the CCG. No. Committee name Meeting date Agenda item Recommendation for discussion / to note Associated Documents 1. Integrated Governance & Performance Committee 26 April 2018 CCG IAF Assurance Report (M1) The committee recommended to the Governing Body for review and approval ENC E (i) 2. Integrated Governance & Performance Committee 26 April 2018 CCG Finance Report (M12) The committee recommended to the Governing Body for review and approval ENC E (ii) 3. Integrated Governance & Performance Committee 26 April 2018 CCG Risk Report & Board Assurance Framework (M1) The committee recommended to the Governing Body for review and approval ENC E (iii a-b) Chair: Dr Jonty Heaversedge 12 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

41 NHS Southwark Clinical Commissioning Group ENGAGEMENT AND PATIENT EXPERIENCE COMMITTEE (EPEC) 1. Introduction Terms of Reference 1.1. The Engagement and Patient Experience Committee [the Committee ] is established in accordance with the CCG s constitution. These terms of reference set out the remit, membership, responsibilities and reporting arrangements of the Committee and shall have effect as if incorporated into the CCG s constitution The Engagement and Patient Experience Committee reports to the Southwark CCG Governing Body. EPEC is established to monitor and provide assurance to the Governing Body that the CCG engages patients in decision making processes, ensuring statutory duties and best practice are met. The statutory duties are those set out in the National Health Service Act 2006 (as amended) sections 13Q, 14Z2 and 242 and Patient and public participation in commissioning health and care: statutory guidance for CCGs and NHS England (NHS England, April 2017) 1.3. All members of staff and members of the CCG are directed to co-operate with any requests made by the Engagement and Patient Experience Committee. 2. Committee Membership 2.1 The membership of the Committee is below: a. CCG Lay Member (with responsibility for patient and public engagement) b. Southwark CCG Clinical Lead (Engagement Lead) with a nominated clinical lead deputy c. Managing Director, Southwark CCG d. Head of Membership, Engagement and Equalities, Southwark CCG e. Membership and Engagement Manager, Southwark CCG f. Four Southwark residents / patients g. Healthwatch representative h. Representative from the Forum for Equality and Humans Rights in Southwark (FEHRS) 2.2 The Committee is chaired by the Lay Member with the engagement portfolio. 2.3 The Committee will meet six times a year. 3. Duties 3.1 To assume responsibility for monitoring, advising and providing assurance on patient engagement ensuring statutory duties are met and building on local good practice. 3.2 To develop and drive forward the CCG s Approach to Engagement, Engagement Toolkit and annual workplan ensuring appropriate on-going patient and public engagement. Chair: Dr Jonty Heaversedge Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

42 3.3 To receive regular reports on engagement activity ensuring that engagement happens in a timely manner in order to influence decision-making. 3.4 To contribute to and reflect upon consultation and engagement outcomes 4. Remit and Responsibilities 4.1. The Committee will receive verbal reports from Locality Patient Participation Groups, Healthwatch, FEHRS and any voluntary and community group members on key health and wellbeing issues. 4.2 The group will receive reports on the engagement activity carried out by the Commissioning Development Groups and other programme boards/groups where engagement activity has been carried out. 4.3 The Committee will receive regular reports on patient experience, highlighting key issues and actions taken. 5. Accountability and relationship with the CCG Governing Body 5.1 The Committee will operate with delegated responsibility for decision making from the CCG Governing Body as set out in paragraph 1.2. above. The Engagement and Patient Experience Committee will additionally act to undertake an advisory function where decisions must be taken by the CCG Governing Body. 6. Reporting arrangements 6.1 The committee will report on its activities to the CCG Governing Body via bi-monthly reports. 6.2 The minutes of the Committee meetings shall be formally recorded and submitted to the CCG Governing Body. Minutes and papers of the Committee are publically available on the CCG website. 6.3 Recommendations and decisions arising from the work of the Committee will be reported to the CCG Governing Body as required. 7. Conduct of the Committee 7.1. The Committee will operate within Southwark CCG Governing Body local policies where these relate to the discharge of its functions The Committee will operate in accordance with Department of Health guidance and national policy requirements The Committee will abide by the Southwark CCG standards of conduct. Compliance will be overseen by the Chair of the Committee. Chair: Dr Jonty Heaversedge Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

43 7.4. Committee members will be required to declare any interests they may have in accordance with the Southwark CCG s Conflict of Interest Policy The Committee agrees to enact its responsibilities as set out in these Terms of Reference in accordance with the Nolan Principles for Standards in Public Life (attached as appendix 1) 8. Quorum rules 8.1. To be quorate, membership shall be one CCG member of staff, one clinical lead, two local people and one other organisation (either Healthwatch or FEHRS) 8.2. The Committee will be supported by the Head of Membership, Engagement and Equalities. 9. Committee Support 9.1. The committee will be supported by the Engagement and Membership Manager who will ensure that the minutes of the committee are approved and published on the website within one week after the meeting. 10. Monitoring adherence to the ToR The Chair of the Committee will be responsible for ensuring the Committee abides by the terms of reference. 11. Review 11.1 The Terms of Reference will be reviewed at least annually or following any relevant changes in CCG s governance structure. April 2018 Chair: Dr Jonty Heaversedge Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

44 Appendix One: NOLAN PRINCIPLES OF PUBLIC LIFE 1. SELFLESSNESS Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family, or their friends. 2. INTEGRITY Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties. 3. OBJECTIVITY In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit. 4. ACCOUNTABILITY Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. 5. OPENNESS Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. 6. HONESTY Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. 7. LEADERSHIP Holders of public office should promote and support these principles by leadership and example. These principles apply to all aspects of public life. The Committee on Standards in Public Life has set them out here for the benefit of all who serve the public in any way. Chair: Dr Jonty Heaversedge Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

45 INTEGRATED GOVERNANCE & PERFORMANCE COMMITTEE 1. Introduction TERMS OF REFERENCE 1.1 The Integrated Governance and Performance Committee [the Committee ] is established in accordance with the CCG s constitution. These terms of reference set out the remit, membership, responsibilities and reporting arrangements of the Committee and shall have effect as if incorporated into the CCG s constitution. 1.2 The Integrated Governance and Performance Committee is established to provide oversight of the activities of the CCG and of providers, particularly in respect of the following areas: a. Finance b. QIPP c. Performance d. Governance and Risk Management e. Quality f. Safety 1.3 The Integrated Governance and Performance Committee is additionally responsible for assuring the effective functioning of the following areas for both the activities of the CCG and of its main contracted providers. a. Safeguarding adults and children b. Information Governance c. Equality Delivery System d. Emergency Planning and Business Continuity 1.4. The Committee will be enabled to maintain effective control in these areas in its operation and through the operation of its sub-committees All members of staff and members of the CCG are directed to co-operate with any requests made by the Integrated Governance and Performance Committee. 2. Committee Membership 2.1 All clinical leads and lay members are invited to attend the Integrated Governance and Performance Committee meetings. 2.2 The membership of the Committee is as below: All clinical lead members of the Governing Body, All lay members and 1

46 All executive members including the Accountable Officer, as required Head of Governance and Assurance The Committee will be supported by appropriate members of the Public Health, CCG management team as required. 2.3 The Committee will meet monthly. 2.4 Members will be expected to attend all meetings. Executive director committee members will be required to nominate a deputy if they are unable to attend. 2.5 The Committee may ask responsible officers from its providers to attend on a regular/ ad hoc basis to provide assurance or reports. 3. Duties Integrated Governance 3.1. The over-arching duty of the Committee is to act to oversee governance in a way that is truly integrated: where all aspects of commissioning and provider activities are scrutinised using an approach that considers finance, quality, safety and performance together To give assurance to the Governing Body that actions and plans put in place are appropriate, adequate and followed through as planned To act as an advisory forum to enable the CCG Governing Body to manage the performance, QIPP delivery, safety and quality of all its providers To prepare for inclusion in the CCG s constitution, the CCG s overarching Scheme of Reservation and Delegation, which sets out those decisions of the CCG reserved to the membership and those delegated to the - o Governing Body o committees and sub-committees of the CCG, o o Governing Body members or employees an individual who is member of the CCG but not the Governing Body or a specified person. 3.5 Approve governance arrangements and supporting policies, including those to minimise risk related to the CCG s responsibilities and remit to secure continuous improvement in quality and outcomes for the resident population. 3.6 Recommend proposals for action on litigation against or on behalf of the CCG to the Governing Body. 2

47 3.7 To oversee the procedures for identifying, investigating and learning from serious incidents and for safeguarding children and vulnerable adults. 3.8 Receive regular reports on the activities of the following groups or subcommittees: a. Quality and Safety sub-committee b. Safeguarding Executive c. Information Governance Steering Group (IGSG) d. Medicines Management Committee e. Lambeth and Southwark ICT Steering Group f. Dulwich Programme Board 3.9 To receive the Board Assurance Framework and CCG risk reports on a regular basis for scrutiny of mitigation and to review their adequacy. The Committee will assure the Governing Body and the Audit Committee on adequacy of risk management arrangements for the CCG To consider changes to the CCG Constitution and governance structure and recommend them to the CCG Governing Body before final sign off by the Council of Members To receive assurance on the CCG s compliance with information governance requirements via IG Steering Group reports 3.12 To receive and provide formal comment on the following: a. Equality Delivery System (EDS-2) via the Quality and Safety Subcommittee b. Emergency Planning and Business Continuity Plans c. Annual Governance Statement and Annual Report 3.13 Assure the Governing Body that there are robust procedures in place to enable the CCG to deliver: a. Effective management of finances and financial performance against contracts, b. Assurance of safety and quality of local services, c. Assurance that national performance targets are being met, d. Recovery plans when finances, quality or performance is off track, e. Effective discharge of duties in regard to safeguarding; equality delivery system and information governance Assure itself that the Quality and Safety Subcommittee is working effectively to support the Integrated Governance and Performance Committee The Committee will act to recommend changes to the CCG Constitution and governance structure to the Council of Members via the CCG Governing Body. 3

48 Finance and Performance: 3.16 Receive regular performance and delivery progress reports on Finance & QIPP Performance. The Committee will act to provide oversight of the extent to which projected benefits are being achieved and will assure themselves that the application of any proposed action or recovery plans are sufficient to address identified variance Receive appraisals of the current and forecast year-end financial position and position against the QIPP Plan from Finance Director. This will include plans for mitigating or remedial actions where variance is identified. The Committee should report this to the Governing Body To ensure that any issues relating to financial probity or emergent financial risks are brought to the attention of the CCG Governing Body and CCG Audit Committee The Committee will operate with delegated responsibility to take decisions in relation to the following areas. a. Agree CCG action plans to address areas of sub-optimal performance, financial variance or projected QIPP shortfall. b. Receive and approve tender ratification reports between the values of 250,000 and 1,000,000. c. Receive and make recommendations to the Governing Body on tender ratifications reports for values over 1,000, Act with delegated authority from the Governing Body to take decisions on its behalf in relation to specific programmes as directed. Provider Assurance (Finance, Performance, Quality and Safety) 3.18 To review providers performance against key quality and safety measures and gain assurance that the exceptions are being managed in an adequate way by the appropriate organisation To review the key quality issues identified by clinical leads within each provider and assure that action is taken. Escalate any concerns or issues to the CCG Governing Body if required To assure the Governing Body that there are robust procedures in place with providers for the effective management of clinical incidents, for managing infection control, for safeguarding children, young people and vulnerable adults and for the safe and effective prescribing and management of medicines. 4

49 3.21 To review the providers position against key performance metrics and undertake enhanced scrutiny and remedial action planning for any consistently low performing areas To monitor the financial position of major providers, using exception based reporting to provide scrutiny for any consistently low performing areas. 4. Accountability and relationship with the CCG Governing Body 4.1 The Committee will operate with some delegated responsibility for decision making from the CCG Governing Body. The Integrated Governance and Performance Committee will additionally act to undertake an advisory function where decisions must be taken by the CCG Governing Body. 5. Reporting arrangements 5.1. The committee will report on its activities to the CCG Governing Body via a monthly report The minutes of the Committee meetings shall be formally recorded and submitted to the CCG Governing Body. Minutes will be made publically available on the CCG website Recommendations and decisions arising from the work of the Committee will be reported to the CCG Governing Body as required The Committee will receive minutes from all its sub-committees for the period. 6. Conduct of the Committee 6.1. The Committee will operate within CCG local policies where these relate to the discharge of its functions The Committee will operate in accordance with NHS England guidance and national policy requirements The Committee will abide by the CCG standards of conduct. Compliance will be overseen by the Chair of the Committee Committee members will be required to declare any interests they may have in accordance with the CCG Conflict of Interest Policy The Committee agrees to enact its responsibilities as set out in these Terms of Reference in accordance with the Nolan Principles for Standards in Public Life. 7. Quorum rules 5

50 The quorum of the Committee is six members with appropriate representation from clinical leads and any two CCG directors. 8. Committee support 8.1. The committee will be supported by the Assurance Manager who will ensure that the minutes of the committee are approved within one week after the meeting. 9. Monitoring adherence to the Terms of Reference 9.1. The Chair of the Committee will be responsible for ensuring the Committee abides by the Terms of Reference. 10. Review The Terms of Reference will be reviewed at least annually or following any relevant changes in CCG s governance structure. Reviewed: March

51 Southwark CCG Governing Body 10 May 2018 Recommendation from Integrated Governance and Performance Committee: CHC AQP Care Homes Contract The 26 April IGP recommended the re-signing of the contract for the CHC AQP collaborative framework to the Governing Body. The CCG is a member of the CHC AQP collaborative framework agreement between 29 London CCGs and 162 care homes with nursing in London and surrounding areas for the provision of non-specialist nursing home care for people receiving CHC. In the CCG commissioned 105 placements using this framework at a total value of 4.2M. The framework benefits the CCG by: Ensuring that the CCG pays a rate for nursing care homes that reflects the cost of care for an efficient provider Providing a systematic approach to quality and the collection of patient and family feedback through the publication of quality dashboards Supporting patient and family choice of care home. The contract and specification have been reviewed in partnership with the care home sector and a re-procurement exercise has been carried out. Care homes that newly applied to be members of the framework submitted competitive tenders that were evaluated on a quality basis; existing members underwent a light-touch evaluation. The CCG will need to re-sign the contract to continue to experience the benefits that membership of this framework provides. Due to the value of anticipated expenditure in 2018/19 the Governing Body is asked to note and formally approve the re-singing of the AQP Framework. Responsible Director: Kate Moriarty-Baker, Director of Quality and Chief Nurse Chair: Dr Jonty Heaversedge 1 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

52 Southwark CCG Assurance Report April 2018

53 2 Summary and Background Summary: This report provides the latest performance data for the following: Constitutional standards (as well as activity and other requirements included in the planning 2017/ /19 template) Improvement and Assessment Framework Quality Premium Metrics agreed by IGP as requiring additional focus The January 2017 Governing Body agreed an approach to providing regular deep dives into key performance indicators. The agreed focus area for April 2018 is A&E. The format of the assurance report has been updated to support this focus while retaining all metrics across constitution standards, the IAF, Quality Premium and additional metrics agreed as requiring additional assurance. The IAF was refreshed in November Updates for the 2017/18 IAF include the removal of 12 metrics, revision of some existing metrics and the addition of 5 new metrics. The full list of metrics is available in the technical annex: This report has been updated in line with these changes. Background: In addition to the main NHS constitution standards, the following data are included: The Improvement and Assessment Framework includes indicators across four domains (Better Health, Better Care, Sustainability, Leadership) and six clinical priorities (Mental Health, Dementia, Learning Disability, Cancer, Diabetes, Maternity). Separate assessments for each of the clinical areas have now been made by NHS England, with clear targets for individual measures. The Quality Premium incentive scheme is intended to reward CCGs for improvements in the quality of the services they commission; for associated improvements in health outcomes; and for reducing health inequalities within their population. Local indicators were agreed by IGP. The 2017/18 targets and baselines are included. Supplementary metrics are those indicators which have been identified previously by IGP as requiring additional scrutiny at the committee.

54 3 Approach and Contents Approach This report is structured to provide: A deep dive focus area A dashboard view of the main provider and CCG constitution standards position vs agreed plans and national standards. Narrative highlighting trends, issues, actions and forecast position for each constitution standard. Current performance against the IAF measures and Quality Premium indicators. This includes a baseline and the current performance. Trends relative to the baseline have been included to indicate relative improvement. RAG ratings for the IAF are based on criteria described in the IAF guidance or, where not available, relative to Southwark s position nationally. RAG ratings for Quality Premium Indicators are an assessment of how likely targets will be achieved with additional actions between now and the end of the year. Areas of focus previously identified as priorities at IG&P are also included for review. Contents Page 1 A&E Focus Pack 4 2 Constitutional standards 8 3 Appendix 1: Supplementary Metrics 25 4 Appendix 2: Full IAF and assigned leads 34 5 Appendix 3: 2017/18 QP targets and baseline 40

55 Focus Pack: A&E

56 A&E focus pack Denmark Hill A&E 4 hour performance target continues to track below the planned trajectory for the Trust. Attendances: ED average daily attendances have increased by 5% from January to March 2018 compared to the same months in 2017 Average Daily ED (Type 1 & 3 Attendances By Month) Source: KCH Data / Transformation Nous 5

57 A&E focus pack Majors/Resus UCC The average daily increase in attendances is primarily related to Majors and Resus resulting in a 14% increase over the same months in 2017 In contrast, the UCC average daily attendances have dropped by 8% compared to the same months in 2017 Performance Majors and Resus performance has steadily decreased since August 2017 UCC performance has been 90% or below since October % 92% 92% 92% 93% 94% 90% 90% 89% 86% 83% 81% 58% 55% 54% 64% 64% 60% 52% 51% 51% 49% 45% 42% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Source: KCH Data / Transformation Nous UCC Majors/Resus 6

58 A&E focus pack In January, a Denmark Hill UCC working group was established to identify issues impacting performance. The group has identified a number of issues affecting the entire department. In particular: Streaming of patients Large numbers of walking majors (light) patients are streamed into the UCC who have a broader scope of acuity and complexity Speciality patients are seen in the UCC due to a lack of a speciality assessment area Patients streamed to Majors might be moved to UCC due to high wait times Most breaches are occurring in Majors and Resus Wait times build up in the evening hours resulting in large amounts of breaches recorded at the start of the next day Most breaches are for patients that are not admitted Workforce ED doctors working in the UCC are being reassigned to clinical areas where there is a higher degree of risk (Majors and Resus) during out of hours GP shift fill rates above 89%, but concerns remain across all staff groups (e.g. high numbers of ENP vacancies) Leadership Increased focus on avoiding 12 hour breaches rather than ensuring the delivery of the 4 hour performance target Management staff changes over the last year (new permanent General Manager started last week) No KCH Clinical Lead for the UCC Clinical Director for ED has recently stepped down and a recruitment process is underway Support to King s Besides EPCS, SCCG set up The Corner Surgery redirection scheme to help with out-of-area patients with primary care needs over the winter. This scheme will continue for 2018/19. SCCG/ICDT participate in the KCH UCC working group to assist in driving improvements in the department SCCG/Surge Hub are holding weekend reassurance telephone calls with Denmark Hill every Thursday and Friday SCCG/ICDT attend the weekly KCH Emergency Pathway Board SCCG management team attend daily (M-F) 8am meetings at Denmark Hill to discuss performance and issues from the previous day 7

59 Constitution Standards Page 9 10: Acute Constitutional actuals against trajectory Page 11 12: A&E Page 13 14: Elective Access Page 15: Diagnostics Page 16 17: Cancer Page 18: LAS Page 19: IAPT Page 20: Dementia Page 21: Early Intervention to Psychosis Page 22: Mental Health CYP Page 23: Learning Disabilities: Inpatient Projections Page 24: Other Commitments: E-referrals, Personal Health Budgets, Wheelchair Waits

60 Acute constitution standards: latest position against plan KCH Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 A & E RTT Cancer 62 days Diagnostics Actual Nat target - 95 Plan Diff Actual Nat target - 92 Plan Diff Actual Nat target - 85 Plan Diff Actual Nat target - 1 Plan Diff Note latest month may not be based on published data. GSTT Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-18 Dec-18 Jan-18 Feb-18 A & E RTT Cancer 62 days Diagnostics Actual Nat target - 95 Plan Diff Actual Nat target - 92 Plan Diff Actual Nat target - 85 Plan Diff Actual Nat target - 1 Plan Diff Note latest month may not be based on published data. 9

61 10 Southwark CCG constitution standards: latest position against plan Southwark CCG RTT & diagnostics Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-17 Feb-18 RTT Diagnostics Nat target - 92 Nat target - 1 Actual Plan Diff Actual Plan Diff Southwark CCG cancer Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-17 Feb-18 2 week wait 2 week breast symptomatic 31 day 1 st treatment (diagnosis to treatment) 31 day subsequent surgery 31 day subsequent drugs 31 day subsequent radiotherapy 62 day 1st treatment (from GP urgent referral) 62 day 1st treatment (from screening) 62 day 1st treatment (from consultant upgrade) Nat target - 93 Nat target - 93 Nat target - 96% Nat target - 94% Nat target - 98% Nat target - 94% Nat target - 85% Nat target - 90% No national target Actual Plan Diff Actual Plan Diff Actual Plan Diff Actual Plan Diff Actual Plan Diff Actual Plan Diff Actual Plan Diff Actual Plan Diff Actual Plan Diff

62 Accident and emergency A&E waits all types (target 95%) - % of patients who spent 4 hours or less in A&E before treatment or admission Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar GSTT KCH Denmark Hill A&E waits type 1 (target 95%) - % of patients who spent 4 hours or less in A&E before treatment or admission April May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar GSTT KCH Latest data reflects continued local pressure on the 4 hour target into 2017/18, in line with national pressures. Recovery plans had been agreed with both local acute providers and are subject to constant review and discussion at the Lambeth & Southwark A&E Delivery Board. KCH continues to face challenges due to staffing issues across site and low discharges. 11

63 Accident and emergency Performance against the 4 hour standard at both GSTT and KCH remains below the national 95% target. KCH: Performance for KCH continues to track below the planned trajectory for the Trust. A&E performance for March was 71.2% for all types. Poor performance on the Denmark Hill site is contributed to flow issues throughout the hospital, high numbers of unfilled clinical shifts (doctors and nurses) and low numbers of discharges. The UCC Working Group has moved into an implementation phase and has started to make changes within the UCC to improve performance. Due to this work, in mid-march the UCC started to achieve over 90% performance against the 4 hour target. The Trust also held another Multi Agency Discharge Event (MADE) the week prior to the Easter bank holiday to help create capacity over the weekend. The event was successful in discharging 93 patients on the day of the event and setting up 37 patients to be discharged the following day by 10am. Besides weekly telephone conferences with KCH for weekend planning, senior management from the CCG are also attending daily 8:00am meetings at Denmark Hill to help escalate any issues quickly. The KCH Emergency Pathway Board continues to meet weekly with regular attendance by the CCG, ICDT, Transformation Nous and NHS Improvement to help facilitate improvements on site. GSTT: Performance for GSTT slipped against the planned trajectory for the Trust, achieving 85.1% for March for all types which is a decrease on February performance of 87.4%. Bed pressures remain high at St Thomas and work is being done on updating and re-launching the Trust-wide full capacity protocol with clinical MDT support. The new Majors re-build section of the Emergency Department has fully opened with the CDU building works to be completed in May With the new opening of the area, the team is currently trialling a new Rapid Assessment Team (RAT) model for quick assessment in the ED. The Trust is also piloting additional SELDOC GP shifts overnight in the UCC to help protect UCC performance overnight. The Trust held a One Team engagement week in March to support the front door and improve speciality response times to ED referrals. The Clinical and Operational Management team for the Acute Assessment Unit also continue work on the Care Redesign Programme to review and create new acute ambulatory pathways. 12

64 Referral-to-treatment: 18 weeks Incomplete (target 92%): The % waiting to start treatment who have been waiting less than 18 weeks Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Southwark CCG KCH (Trust wide) GSTT (Trust wide) Overall RTT performance for Southwark CCG did not meet the trajectory of 86.9% for February The compliant specialities were Dermatology, General Medicine, Geriatric medicine, Thoracic medicine and Rheumatology. Guy s and St Thomas : performance for Southwark CCG at GSTT in February 2018 was 88.0%; this was a decline in performance from 88.4% in January The specialities that were non-compliant were: Cardiology, ENT, Gastroenterology, General Medicine, General Surgery, Gynaecology, Plastic Surgery and Trauma and Orthopaedics (T&O). Demand and capacity plans for each service have also been revised to focus on RTT recovery. A revised recovery trajectory for RTT was submitted to NHSI in November 2017, and the Trust submitted a more detailed plan to NHSI on 22nd December This plan was revised following feedback. The Trust will be involving local directorates in reviewing the local plans so that the Trust can be assured that the plans devised will deliver the expected outcomes. A new Red2Green (R2G) report has been rolled out to all services and is being used at weekly Patient Tracking List (PTL) meetings as part of long waiter management. The R2G report is designed to track those patients whose pathways are at 40 weeks or over. Newly established planning and performance meetings for each directorate are now in place at the Trust. These meetings will be fed back to the Chief Operating Officer for oversight. King s College Hospital: performance for Southwark CCG at KCH in February 2018 was 80.5%. The compliant specialities were General Medicine, Gynaecology, Geriatric Medicine, Thoracic Medicine and Rheumatology. This is an improvement from 79.5% in January 2018 and the overall performance for SCCG at KCH has improved since April The key driver for performance was a reduction of elective activity to cope with increase in pressures on non-elective pathways. The Trust has implemented a new RTT governance structure with an RTT Delivery Group meeting weekly with each of the DH and PRUH teams. An RTT Recovery Lead has also joined the Trust in Q4 (2017/18) for a period of 9 months to focus on demand and capacity alignment, and long-wait PTL review with each of the key services. 13

65 Referral-to-treatment: 18 weeks The number of patients waiting over 52 weeks for Southwark CCG in February 2018 was 45; this was a decline compare to January However, despite the recent increase, there has been an overall downward trend of patients waiting more than 52 weeks for elective care since April Of these 45 breaches, forty three occurred at KCH (13 in General Surgery, 1 in Gynaecology, 1 in General Medicine, 13 in Trauma and Orthopaedics (T&O), 4 in Ophthalmology, 1 in Urology and 10 in Other. The remaining two breaches for Southwark CCG, occurred at GSTT (1 in Other) and Imperial College (1 in Trauma and Orthopaedics (T&O). Both Trusts are working with Southwark, Lambeth and Bromley CCGs participating in Referral Management groups focussing on 5 key specialties areas. (Neurology, ENT, Gynaecology, Dermatology, Ophthalmology). There are now 2 groups looking at Advice and Guidance and Paediatrics. The Gynaecology group has closed with ongoing work being picked up in the advice and guidance work stream. 14

66 Diagnostics Diagnostic target: A maximum of 1% of patients should wait 6 weeks or more for a diagnostic test Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Southwark CCG KCH GSTT The 1% diagnostic waits standard was met by Southwark CCG in January. The diagnostic modalities that were non-compliant were CT, Audiology Assessments, Endoscopies, Sleep Studies and Urodynamics. KCH: Performance for Southwark CCG at KCH in February 2018 was not achieved at 1.03%. The non-compliant modalities were MRI, CT, Urodynamics and Endoscopies (Colonoscopy, Cystoscopy and Gastroscopy). Key drivers for performance included increased demand for diagnostic testing, reduced endoscopy capacity and ageing equipment which results in poor capability and downtime of machines. The Trust has secured additional MRI and CT capacity at the DH site for March and April 2018 through mobile scanners. The Trust was also allocated external funding to access additional endoscopy at CUH, which commenced from February GSTT: Performance for Southwark CCG at GSTT in February 2018 was achieved, reaching 0.8%. This was a significant improvement from 3.7% in January The non-compliant modalities were CT, Sleep Studies, Colonoscopy and Gastroscopy. The Trust has implemented a range of actions to resolve the challenges and has successfully reduced the backlog for Endoscopy and Paediatric MRI. The Trust continues to outsource to The Alliance (Independent Sector provider for medical diagnostic imaging) for Non-Obstetric Ultrasound and have established additional sessions to increase capacity. For Paediatric sleep studies, demand has exceeded capacity, although a recovery plan is being developed, it is anticipated that recovery will not occur until Q4 (2018/19). All non-compliant services are aiming for compliance by March 2018, with the exception of bravo endoscopies and paediatric MRIs. 15

67 Cancer waits 2 weeks GP referral (target 93%): % patients seen within 2 weeks of an urgent GP referral for suspected cancer 31 days treatment (target 96%): % patients receiving first definitive treatment within 31 days of a cancer diagnosis 62 days treatment (target 85%): % patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer SCCG Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 2 weeks days days King s: 62 day GSTT: 62 day Southwark CCG did not meet their trajectory of 87.5% for Cancer 62 Day performance in February 2018, reaching 64.3%. This was a significant drop in performance compared to 82.8% in January The high performance in January 2018, was in part due to less than expected breaches in January. These delayed breaches are reflected in the February data, and to some extend will be reflected in the March performance figures. These breaches relate to patients who delayed their diagnostic/treatment around the Christmas and New Year period, and were therefore treated later. The dip in February was therefore expected and was flagged to the commissioners earlier in the year. There were fifteen breaches in February Of the 15 breaches, 1 was due to Delay in Workup, 1 was due to Patient Unfit, 1 was due to Other Medical Condition Prioritised, 3 were due to Admin Issue, 2 were due to Intertrust with no Information and 7 were due to Patient Choice. Southwark CCG met the national 2WW standard and trajectory of 93.0% in February This was an increase in performance compared to 94.7% in January

68 Cancer waits South East London (SEL) acute providers submitted revised Cancer Recovery Plans together with revised trajectories, which were approved by regulators in November The Return to Trajectory plans outline how the Trusts will return to recovery by March As part of the SEL cancer delivery plan, additional funding was provided to support performance improvement. These include additional diagnostic capacity, implementation of Straight to Test (STT), Training radiographers in reporting and Multidisciplinary Team (MDT) Co-ordinators to track patients on the pathways. A new Standard Operating Procedure (SOP) for Inter Trust Transfers (ITT) was implemented across South East London Trusts on 11 December It is expected that this will improve performance of ITT. The SEL system has received additional funding to support performance recovery during 2017/18. This included funding for a range of initiatives as part of the early Diagnostic Transformation funding including: KCH were allocated funding for additional Endoscopy capacity to support the Upper and Lower GI pathways, and funding to support the implementation of straight to test for the Lower Gastrointestinal (LGI) pathway. From November 2017, KCH have been utilising the mobile CT and MRI scanners on the Lewisham and Greenwich Trust sites in order to further improve diagnostic access for patients on a cancer pathway. KCH commenced outsourcing to Croydon University Hospital for additional endoscopy capacity in February 2018 In March 2018, The SEL Accountable Cancer Network (ACN) and SEL Cancer Alliance submitted a bid for Cancer Transformation funding to support on-going work to: Improve tumour group pathways for Lower Gastrointestinal (GI), Colorectal, Lung and prostate Optimise the secondary care diagnostic pathway including diagnostic capacity, workforce and strategy Optimise administrative processes and management of cancer pathways including, cancer data teams, tracking and established a shared approach across SEL to manage shared pathway patients Support rapid improvement in treatment within 24 days, with a focus on optimising radiotherapy pathways. 17

69 London Ambulance Service performance LAS releases STP level data for the Ambulance Response Programme (ARP) to provide more information to CCGs. In 2018/19 the embargo will be lifted and CCG level data will be released against the targets. In February, LAS struggled to meet the ARP targets for Category 1, 2 and 3 for South East London. While targets were missed in February, the performance is improving against the 90% Centile Category 1 target as well as the Category 4 target. LAS acknowledges that improvements still need to be made. In particular, LAS is working on addressing the triage function for certain calls to make sure patients are placed in the correct Category. LAS is currently experiencing higher Category 2 calls and lower Category 3 calls then LAS previously predicted in their modelling. South East London Performance: Category National Standard December 2017 (South East London) January 2018 (South East London) February 2018 (South East London) Category 1 Category 2 7 minutes (mean) 00:07:28 00:07:14 00:07:14 15 minutes (90% Centile) 00:12:08 00:12:08 00:11:33 18 minutes (mean) 00:21:56 00:19:17 00:19:55 40 minutes (90% Centile) 00:45:37 00:40:15 00:40:43 Category minutes 02:28:53 02:04:47 02:18:08 Category minutes 02:33:41 02:00:31 02:06:48 18

70 Improving Access to Psychological Therapies (IAPT) Month Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Monthly 1 st contacts to equal 15% trajectory Number of first contacts* Recovery rate (target 50%) Local data Published Recovery Rate Waiting Time: 6 weeks (Target: 75%) Waiting Time: 18 weeks (Target: 95%) % 47% 42% 42% 41% 46% 44% 42% 37% 35% 42% 46% 49% 50% 46% 41% 41% 37% 42% 39% 41% 33% 35% tbc tbc tbc 72% 69% 72% 77% 76% 81% 86% 82% tbc tbc tbc tbc 99% 97% 99% 98% 99% 99% 100% 99% tbc tbc tbc tbc March 2018 performance for Access at 4.8% against 4.2% target and Recovery at 49% against 50% target Weekly IAPT performance monitoring meeting in place with SLaM / CCG colleagues to review compliance with trajectory and any actions required to calibrate performance SLaM IAPT Team and CCG working in partnership to deliver IAPT improvement actions recommended by the NHSI Intensive Support Team (supported by the SEL NHSE Delivery and Transformation Team) The CCG has invested an additional 100k into the SLaM IAPT service following the collaborative SLaM / CCG / NHSI / NHSE service review These additional monies were invested to increase service capacity in Q4 of 2017/18 and to improve performance against access and recovery targets (achieved) and sustain this performance throughout As a follow up on resources, the CCG is working in partnership with SLaM in Q1 of 2018/19 to put in place a resource plan for any additional staffing requirements to ensure continued compliance with access and recovery targets (this is aligned to Trust submitted projections via SEL STP workforce modelling on staffing levels required to meet trajectory) Any additional resourcing requirements will be presented to the next meeting of IG&P following review 19

71 Dementia Diagnosis Rate January 2018 estimated prevalence = 1,530 (65+) Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Trajectory diagnoses Actual number diagnosed ,168 1,156 1,156 1,154 1,149 1,162 1,155 1,151 1,147 1,140 1,145 1,142 Trajectory - % diagnosed Actual % diagnosed Data extracted from HSCIC monthly dementia registers publication. Green = above target; Amber = <1% below target; Red = >1% below target. Reported Performance Position In February 2018, there were 1,142 patients (65+) on dementia practice registers which means the CCG is exceeding the national two thirds diagnosis target and is performing at a rate of 74.6% with a gap of an additional 389 people who could benefit from diagnosis. 20

72 Early intervention to psychosis services Referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICE-recommended care package 2017/18 Target: 50% 2018/19 Target: 55% Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended package care package in the reporting period within 2 weeks of referral. Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended care package Actual % 69% 85% 81% Target % 50% 50% 50% 50% 55% 55% 55% 55% 21

73 Mental Health: Children and Young People Improve Access Rate to CYPMH Percentage of new young people receiving treatment from NHS funded community services - 17/18: 7.3%; 18/19: 9.1% Percentage of CYP with a diagnosable MH condition receiving treatment from NHS funded community services 17/18: 30%; 18/19: 32% Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 New CYP receiving treatment from NHS community services Total CYP receiving treatment from NHS community services Plan Actual - - Plan Actual *450 Updated using published data that has flowed to MHSDS (Mental Health Services Data Set) from the provider. We previously used referrals accepted to show number receiving treatment, however NHS Digital has now clarified the CYP MH Access Indicator. Data issues in Q2 account for the fall in activity. *Q3 is a forecast from NHS Digital based on two months of data. Data is missing from teams that are jointly or solely commissioned with/by social care. The provider (SLAM) therefore is working with Southwark Council on improving reconciliation between MOSAIC and EPJS information systems currently used for teams jointly commissioned. Work to include Council only commissioned services needed. CYP eating disorders Waiting Times for Routine Referrals to CYP Eating Disorder Services - Within 4 Weeks: 100% Waiting Times for Urgent Referrals to CYP Eating Disorder Services - Within 1 Week: 100% Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Routine Referrals to CYP Eating Disorder Services Urgent Referrals to CYP Eating Disorder Services % in 4 weeks 80.8% 87.5% 91.2% % in 1 weeks 50.0% 100% 66% The service experienced a short term reduction in capacity during Q3 due to national training programme. Note: The data above shows a rolling 12 month position 22

74 Learning Disabilities: Inpatient projections Target: Reach inpatient rate within the range inpatients per million population for NHS England commissioned services and inpatients per million for CCG commissioned services by March The trajectories are on a Transforming Care Partnership (TCP) basis. The reduction in inpatient numbers is a proxy measure for a reduction in the number of inpatient beds, and the transformational change to deliver more services in the community rather than through inpatient services. Actual performance is reported as integers of 5. Q1 Q2 Q3 Q4 The number of people from the TCP who have a learning disability and/or autistic spectrum disorder that are in inpatient care for mental and/or behavioural healthcare needs, and whose bed is commissioned by a CCG. This will include all adults in inpatient wards that are not classified as low-, medium- or high-secure. Plan Actual Rate per Million GP Registered Population (CCG commissioned) based on GP Registered Population of Transforming Care Partnership (18+ only) of 1,486,759 Plan Actual The number of people from the TCP who have a learning disability and/or autistic spectrum disorder that are in inpatient care for mental and/or behavioural healthcare needs, and whose bed is commissioned by NHS England. This will include all adults in inpatient wards that are classified as low- medium- or high-secure, and all children and young people in Tier 4 CAMHS services. Rate per Million GP Registered Population (CCG commissioned) based on GP Registered Population of Transforming Care Partnership (18+ only) of 1,486,759 Plan Actual Plan Actual

75 Other commitments E-referral coverage: target 100% by October 2019 % of patients referred to 1st Outpatient Services (including two-weekwaits), via e-rs Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual 26.4% 28.7% 29.9% 30.6% 32.5% 41.5% 45.4% 47.1% 49.9% 54.1% 56.3%* 61.4%* *based on estimated denominator subject to change Personal Health Budgets: target rate of PHBs per 100,000 registered population by Q4 18/19. This is equivalent to 179 PHBs. Q1 Q2 Q3 Q4 Personal health budgets in place at the beginning of quarter New personal health budgets that began during the quarter Total number of PHB in the quarter (new plus those in place at the start of the quarter) Plan Actual Plan Actual Plan Actual Children Waiting more than 18 Weeks for a Wheelchair: target 100% less than 18 weeks by Q4 18/19 Q1 Q2 Q3 Q4 Percentage of children whose episode of care was closed within the reporting period where equipment was delivered in 18 weeks or less of being referred to the service Children whose episode of care was closed within the reporting period where equipment was NOT delivered in 18 weeks or less of being referred to the service Plan 33.3% 53.3% 73.3% 93.3% Actual 66.7% 81.8% 85.7% Actual

76 Supplementary metrics Page 26: Mental Health CPA 7 day follow up on discharge Page 27: Serious Incidents and Never Events Page 28: MRSA and C Difficile Page 29-30: Friends and Family Test Page 31-32: Better care Fund Targets Page 33: CHC Discharge to Assess

77 Mental health: Patients on CPA followed up within 7 days of discharge from psychiatric inpatient care 2015/16 target 95% Number of patients on CPA who were followed up within 7 days after discharge from psychiatric inpatient care Total number of patients on CPA discharged from psychiatric inpatient care Proportion of patients on CPA who were followed up within 7 days after discharge from psychiatric inpatient care (Southwark) London benchmark 15/16 Q % 96.9% 15/16 Q % 97.4% 15/16 Q % 97.8% 15/16 Q % 97.1% 16/17 Q % 97.0% 16/17 Q % 97.0% 16/17 Q % 96.7% 16/17 Q % 97.0% 17/18 Q % 96.7% 17/18 Q % 97.4% 17/18 Q % 94.7% 26

78 Serious Incidents & Never Events requiring investigation Provider Serious Incidents (SIs) KCH All SIs at Denmark Hill Serious Incidents (notified) 2017/18 (Southwark patients in brackets) Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar 5(2) 16(5) 9 (2) 6 (1) 9 (2) 2(1) 11(4) 14(4) 18 (3) 11 (2) 4 (1) 9 (2) KCH All SIs at PRUH GSTT Acute & Community All SIs 4 7(1) 14(3) 7 10 (3) 8 (2) 4 8(3) 11 (2) 9 (1) 8 (2) 9 (1) SLaM All SIs 10(2) 11(2) 12(4) 14 (1) 4 7(3) 16(2) 6(3) 6 (2) 0 10 (2) 13 (4) LAS All SIs 7 7 (1) (1) TBC Other - Southwark patients only The data represents when serious incidents (SIs) were reported to commissioners, not when they actually occurred. London Ambulance Service (LAS) monthly SI figures will be provided during 2018/19. Due to reporting timeframes, these are sometimes in arrears of two months. The reports do not always refer to the borough of the patient affected. KCH reported 9 SIs at Denmark Hill in March 2018, 2 of which involved a Southwark resident. The Southwark CCG Quality Team actively manage the assurance process to ensure robustness of investigations, action plans and implementation of lessons learnt. 4 SIs were notified at the PRUH. SIs logged at the PRUH are reviewed and assured by NHS Bromley CCG. GSTT reported 9 SIs in March, 1 of which involved a Southwark resident. Southwark CCG support the lead commissioner, Lambeth CCG, in management of SIs at GSTT. SLaM reported 13 incidents in March, 4 involving a Southwark resident. All incidents are assessed case by case on level of significant harm outcome and significance for learning. 27

79 Healthcare Acquired Infections MRSA / c.difficile MRSA MRSA April May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar SCCG MRSA target is zero for the year. This has not been met for the current year. The 1 case in February was assigned to Guy s and St Thomas NHS Foundation Trust C Difficile C Diff April May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar SCCG C Diff target is 45 for The CCG will not achieve this target for 2017/ cases of C difficile have been identified YTD. This is above the trajectory of 41 to the end of month 11. Of the seven cases in February, 2 were assigned to acute (1 KCH and 1 GSTT) and 5 assigned to non-acute (4 KCH and 1 GSTT) 28

80 Friends & Family Test response rates and recommendation A&E patient response rate Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Den. Hill 5% 6% 5% 4% 2% 3% 4% 5% 5% 10% 10% 14% GSTT 14% 18% 19% 26% 25% 25% 23% 18% 23% 20% 22% 21% Inpatients - patient response rate Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Den. Hill 21% 19% 22% 21% 22% 16% 20% 17% 18% 22% 19% 20% GSTT 19% 19% 18% 21% 23% 22% 21% 20% 20% 19% 22% 21% A&E - % recommending care Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Den. Hill 85% 77% 70% 77% 82% 86% 80% 86% 76% 77% 81% 80% 79% GSTT 87% 84% 84% 81% 84% 81% 83% 85% 84% 84% 86% 87% 84% Inpatients - % recommending care Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Den. Hill 92% 93% 93% 92% 95% 93% 95% 95% 95% 93% 93% 94% 94% GSTT 96% 96% 97% 97% 96% 96% 96% 95% 95% 95% 95% 96% 95% In February the London average A&E recommendation was 82% (with an average response rate of 18%). King s had a lower response rate and participants recommending care. GST was higher for both The London average inpatient recommendation was 94% (on an average response rate of 21%). Both trusts were in line with this. 29

81 2016/ /17 Friends & Family Test staff The Work question asks how likely staff would be to recommend the NHS service they work in to friends and family as a place to work. The Care question asks how likely staff are to recommend the NHS services they work in to friends and family who need similar treatment or care. Recommended to work at Q2 2016/17 Q3 2016/17 Q4 2016/17 Q1 2017/18 Q2 2017/18 KCH 48% Staff FFT not 41% 58% 57% GSTT 75% conducted in Q3 78% 2017/18 77% 77% SLaM 63% because the NHS Staff Survey takes 64% 65% 66% London 63% place 64% 64% 63% Recommended to get care at Q2 2016/17 Q3 2016/17 Q4 2016/17 Q1 2017/18 Q2 2017/18 KCH 82% 67% 84% 82% Staff FFT not GSTT 94% conducted in Q3 93% 2017/18 93% 93% SLaM 72% because the NHS Staff Survey takes 75% 74% 76% London 78% place 77% 79% 80% Note: Response rate staff Q2: Kings: 18%, GST: 10%, SLaM: 23%, London average 11% 30

82 Better Care Fund indicators Delayed transfers of care Delayed transfers of care from hospital (delayed bed days, Southwark residents) Days delayed Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Target Actual Reducing delayed transfers of care is the key objective for the current BCF. The targets for 2017/18 were mandated and have been achieved every month in the year to date. Southwark has been amongst the best performers on the target. February data shows a continued reduction in rates since the peak in December and the second lowest number in the year to date, confirming that the discharge system is coping well with winter pressures. It should be noted that within the above total there are individual targets for delays attributable to Social Care, NHS and joint delays. Social care remains well within target levels as it has during the year to date, with only 31 delays against the target of 183 in February. NHS delays of 243 days were over target by 48 days, and there were no jointly attributable delays. As with January, a notable feature of the February data is that a majority of the delays were at GSTT with 144. Of these a very high proportion related to patient choice (101 days). Management of patient choice is a key theme in the high impact change model being implemented in the trusts. There were relatively few delays at KCH (53 days) and at SLAM (27 days). Care home admissions Permanent admissions of older people (aged 65+) to residential/nursing care homes Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Target Admissions With 113 admissions in the tear to date the target has been hit exactly with good performance over the last 4 winter months being crucial. It had been flagged as a risk earlier in the year that this target could be exceeded due to pressures to discharge from hospital, hence it is a success that this has been managed at target levels. 31

83 Better Care Fund indicators Non-elective admissions (CCG) Non-elective admissions Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Jan Plan YTD Actual YTD Variance % variance year to date 1.2% 0.1% 0.9% -4.5% -1.6% 4.5%* 4.2* 3.0* 3.3* 2.3% 4.6% 1.5% 1.6% The BCF is monitored against overall CCG Operating Plan trajectories for non-elective admissions agreed with NHSE. *Since May there has been a national data rebasing exercise to both plan and actuals taking into account changes for national activity recording changes as well as changes in responsible commissioner rules between CCG and NHS England. This resulted in a step increase against plan from June, and this is a common feature across all CCGs. Overall on these national figures Southwark is 1.6% over target following these adjustments. Note: The local view of non-elective activity data as shown in the M10 Integrated Report in the agenda pack is that non-elective admissions are 0.7% over target. This discrepancy arises from the national adjustment. Reablement (% still at home 91 days after receiving reablement / rehabilitation on discharge from hospital) Final year performance in 2016/17 showed an unexpected drop to 83.3% from previous performance at 91%. This has improved to 87% in the year to date, although marginally below the target of 88%. Performance for Q3 was 90%. They key performance target relates to those discharged in Q3 and still at home 91 days later in Q4. 32

84 Quality Premium: 2017/18 CHC D2A CCG CHC Discharge to Assess Trajectory Month Q1 2017/18 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Percentage of CHC decision support tool assessments (taken from total number of Non-Fast Track assessments) to take place in the acute hospital setting 60% 55% 45% 35% 25% 20% 15% <15% CCG Achievement Against Trajectory 60% 53% 43% 35% 0% 0% 5% 10% The CCG is working in partnership with Lambeth CCG as well as Social Care, community health services and acute partners to transfer CHC assessment activity from acute settings to the community. The programme is overseen by the CHC D2A Board which reports to the A&E Delivery Board. The CCG has achieved it s target of <15% of assessments in acute hospitals for March 2018 and also, due to the rapid progress that the CCG made between December and March, the CCG also met the CCG Quality Indicator target for Q4 as a whole. The CCG will be working with partners to review the pathway at the next CHC D2A Board. 33

85 Quality Premium and Improvement and Assessment Framework Page 35: Better Health Page 36-38: Better Care Page 39: Sustainability and Leadership Page 40-41: Quality Premium

86 35 Better Health Indicator name Frequency of reporting Baseline Time period Current performance Trend Lead Meetings providing additional oversight 102a. Child Obesity: Percentage of children aged classified as overweight or obese Annual 43.2% % CG Council Healthy Weight Steering Group Children and Young People CDG Health and Wellbeing Board 103a. Diabetes: Patients who have achieved all NICE recommended targets Annual 2016/ % CG 103b. Diabetes: People with diabetes diagnosed less than a year who attend structured education course Annual 2016/17 (2015 cohort) 7.0% CG 104a. Falls: injuries from falls in people aged 65 and over (Emergency admissions per 100,000 population) Annual 2,444 Q1 2017/18 2,338 CG Adults commissioning development group 105b. Personalisation and choice: Personal Health budgets per 100,000 Quarterly 6.0 Q3 2017/ KMB Adults commissioning development group 106a. Inequality in unplanned hospitalisation for chronic ACS conditions and urgent care sensitive conditions Quarterly 1,980 Q1 2017/18 2,481 CG/ICDT Adults commissioning development group 107a. Anti-microbial resistance: appropriate prescribing of antibiotics in primary care Quarterly Jan KMB Meds management committee 107b. Anti-microbial resistance: appropriate prescribing of broad spectrum antibiotics in primary care Quarterly 10.9 Jan KMB Meds management committee 108a. The proportion of carers with a long term condition who feel supported to manage their condition Annual Not available Not available KMB

87 36 Better Care (1 of 3) Indicator name Frequency of reporting Baseline Time period Current performance Trend Lead Meetings providing additional oversight 121a High quality care - Acute Quarterly Q2 2017/ KMB Quality and safety sub-committee 121b High quality care Primary care Quarterly Q2 2017/ KMB Quality and safety sub-committee/ Primary Care Commissioning Committee 121c High quality care Social Care Quarterly Q2 2017/ KMB Adult safeguarding board Cancer 122a Cancers diagnosed at early stages Annual CG Cancer Locality Group 122b 62 days waits Quarterly 83.3 Feb CG Cancer Locality Group Cancer 62 Day Review Group 122c One year survival rates for all cancers Annual CG Cancer Locality Group 122d Cancer patient experience Annual CG Cancer Locality Group Mental Health 123a IAPT recovery rate Monthly 38% Mar % CG IAPT Monthly Contract meetings 123b Improving Access to Psychological Therapies access 3.9% Q4 2017/18 4.1% CG IAPT Monthly Contract meetings 123c Early access to psychosis treatment standard Monthly 28.6% Q3 2017/18 81% CG 123d 123e 123f Children and young people with a diagnosable mental health condition receiving treatment from NHS funded community services Proportion of crisis resolution and home treatment (CRHT) services able to meet selected core functions The number of bed days for inappropriate Out of area placements (OAPs) in mental health services for adults in non-specialist acute inpatient care. Quarterly Not available Q4 2016/17 Not available CG Quarterly Not available Q4 2016/17 Not available CG Quarterly Not available Q4 2016/17 Not available CG CCG Monthly Contract monitoring meeting 4 borough commissioner s group meeting CYP Transformation board CYP Commissioning Development Group A&E Delivery Board/ Working Group CCG Monthly Contract meetings with SLAM CCG Monthly Contract monitoring meeting with SLAM Joint CCG/LA Panel meetings

88 37 Better Care (2 of 3) Indicator name Frequency of reporting Baseline Time period Current performance Trend Lead Meetings providing additional oversight Learning Disability 124a Learning Disability: reliance on specialist inpatient care for people with a learning disability/autism Quarterly 49 per million Q3 2017/18 61 per million KMB Transforming Care steering group 124b 124c Learning Disability: proportion of people with a learning disability receiving an annual health check Completeness of the GP learning disability register Annual 31% 2016/17 48% KMB Not available 2016/17 3.1% KMB Maternity 125a Neonatal mortality and still births (per 1,000 births) Annual CG CQRG 125b Women s experience of maternity services 3 yearly 81.1 Not available CG CQRG 125c Choices in maternity services Annual 69.5 Not available CG 125d Smoking: maternal smoking at delivery Quarterly 2.9% Q3 2017/18 3.7% CG Dementia 126a Estimated diagnosis rate for people with dementia Monthly 76.3% Feb % CG Adult Commissioning Development Group 126b Dementia care planning and post-diagnostic support Annual 76.3% 2016/ % CG 4 Boroughs Redesign Group / Adult Commissioning Development Group

89 Better Care (3 of 3) Indicator name Frequency of reporting Baseline Time period Current performance Trend Lead Meetings providing additional oversight Urgent and emergency care 127b Emergency admissions for urgent care sensitive conditions per 100,000 registered patients Quarterly 2834 Q1 2017/ CG A&E Delivery Board/ Strategic Contract Meeting 127c Percentage of patients admitted, transferred or discharged from A&E within 4 hours Monthly 83.5% Mar % CG A&E Delivery Board/ Health and Wellbeing Board 127e Delayed transfers of care attributable to the NHS per 100,000 population Quarterly 4.4 Nov CG Health and Social Care Partnership Board A&E Delivery Board Health and Wellbeing Board 127f Population use of hospital beds following emergency admission (total length of episodes per 1000 population) Quarterly Q1 2017/ CG Strategic Partnership A&E Delivery Board Emergency Care Board Contract Monitoring Board 105c. Percentage of deaths with three or more emergency admissions in last three months of life Not available Not available Primary medical services 128b Patient experience of GP services 6 monthly 78.6% % CG Primary Care Commissioning Committee 128c 128d Primary care access - percentage of registered population offered full extended access Primary care workforce (GP/PN WTE per 1,000 patients) Bi Annual % CG Primary Care Commissioning Committee TBC 0.81 Mar KMB Primary Care Commissioning Committee 129a Elective access: patients waiting 18 weeks or less from referral to hospital treatment Monthly 84.7% Feb CG Planned Care Programme Board Performance Oversight Groups 130a 7 day services: achievement of clinical standards in the delivery of 7 day services Not available Not available CG SEL A&E delivery Board and Oversight Group 131a Percentage of NHS Continuing Healthcare full assessments taking place in an acute hospital setting 59.6% Q4 2017/18 5% KMB NHS Continuing Care discharge to assess board 132a Evidence that sepsis awareness raising amongst healthcare professionals has been prioritised by the CCG Not available Not available KMB 38

90 Sustainability Indicator name Planned frequency of reporting Baseline Time period Current performance Trend Lead Meetings providing additional oversight 141b. In-year financial performance Quarterly Q2 2017/18 MH IGP/Audit Committee 144a. Personalisation and choice: utilisation of the NHS e-referral service to enable choice at first routine appointment Leadership Monthly 27.8% Mar % MH Planned care programme board South East London Local digital road map Indicator name Baseline Time period Current performance Trend Lead Meetings providing additional oversight 162a. Probity and corporate governance Fully Compliant Q2 17/18 Fully Compliant MH 163a. Workforce engagement - Staff engagement index /5 KMB 163b. Workforce engagement - Progress against workforce race equality standard MK 164a. Effectiveness of working relationships in the local system / CG 165a. Quality of CCG leadership Q1 17/18 AB 166a. Compliance with statutory guidance on patient and public participation in commissioning health and care MK 39

91 Quality Premium: 2017/18 (1 of 2) Quality Premium target Target Baseline Current Performance Proportion of QP Cancers diagnosed at early stage 2016 plus 4% 46.7% (2014) 52.4% (2015) 17% Overall experience of making a GP appointment (GP survey) Improve 3% point on July 17 data 66.5% (Jan 2017) (London 68%) 69% (July 2017) 17% NHS Continuing Healthcare: NHS CHC eligibility decision is made by the CCG within 28 days from receipt of the Checklist (or other notification) >80% 100% 78% (Q4) 8.5% NHS Continuing Healthcare: NHS CHC assessments take place in an acute hospital setting. <15% 78% 5% (Q4) 8.5% Mental Health: Improve inequitable rates of access to Children & Young People s Mental Health Services 32% (1,984) 15.3% (950) (16/17 estimate from NHSE) 450 (vs 496 trajectory) (Q3 estimate) 17% Atrial Fibrillation Reported Prevalence: Increase register size 2,372 2,262 (QOF 2015/16) 2,560 (31/03/2018) 15% 40

92 Quality Premium: 2017/18 (2 of 2) Quality Premium target Target Baseline Proportion of QP Q1 2017/18 Q2 2017/18 Q3 2017/18 Notes Reducing gram negative blood stream infections (BSI) across the whole health economy: reduction in all E coli BSI reported at CCG level based (Jan Dec 2016) The CCG achieved the target set and 146 cases were reported in local residents during the period April to March 2018 Reducing gram negative blood stream infections (BSI) across the whole health economy: Collection and reporting of a core primary care data set for all E coli BSI in Q / % N/A N/A N/A N/A N/A Delay in recruiting surveillance nurse - plans to go live with data collection to commence April 2018 Reduction of inappropriate antibiotic prescribing for UTI in primary care: reduction in the Trimethoprim:Nitrofurantoin prescribing ratio based on CCG baseline data Reduction of inappropriate antibiotic prescribing for UTI in primary care: reduction in the number of trimethoprim items prescribed to patients aged 70 years or greater (April 2016-March 2017) 2084 (April 2016-March 2017) 7.65% for Q1 (Forecast 17/18 full year: 1920) 351 for Q2 (Forecast 17/18 full year: 1662) 329 for Q3 (Forecast 17/18 full year: 1547) 100% of practices are achieving this indicator at Q3. Sustained decrease with this indicator Projected value based on Q1, Q2 & Q3 data. 68% of practices are achieving this indicator at Q3. On-going monitoring of prescribing and education planned Sustained reduction of inappropriate prescribing in primary care: items per STAR-PU must be equal to or below England 2013/14 mean performance value (2016/17) 1.7% 0.17 for Q1 (Forecast 17/18 full year: 0.68) 0.16 for Q2 (Forecast 17/18 full year: 0.64) 0.18 for Q3 (Forecast 17/18 full year: 0.68) CCG is currently meeting this indicator. Note: MOT arranging educational sessions with the 5 highest % broad spectrum prescribing practices at quarter 2 17/18 41

93 CCG Finance Report 2017/18 Month 12 (Period to end of March 2018) Integrated Governance & Performance Committee 26 th April 2018

94 Financial Performance Duties Duty YTD Target YTD Performance RAG Annual Target Annual Performance RAG Achieve planned surplus (Expenditure not to exceed income) Capital resource does not exceed the allowance Revenue resource does not exceed the allowance Capital Resource use on specified matters does not exceed the allowance Revenue resource use on specified matters does not exceed the allowance Revenue administration resource use does not exceed the allowance 9,743k 11,074k 9,743k 11,074k 69k 50k 69k 50k 476,928k 465,854k 476,928k 465,854k N/A N/A N/A N/A N/A N/A N/A N/A 6,500k 6,457k 6,500k 6,457k Notes: 1. The above duties correspond to those reported in Note 18 of the 2016/17 Annual accounts, and represent the statutory duties of NHS Southwark Clinical Commissioning Group ( the CCG ). The forecast planned surplus reduced as a result of the national treatment of No Cheaper Stock Obtainable (NCSOs) or drugs in short supply costs covered later in this report. The surplus increased again at year end, to over 11m, due to the release of the 0.5% reserve held all year on NHSE planning instructions and also the return of Category M drugs rebate which was released nationally in Month 12. A summary of the surplus components can be found on page 3 2. The CCG is to receive a capital allocation of 69k for IT in March 2018, and as a result is also bound by the additional financial duty relating to the capital resource. 3. To support the delivery of the above, an in-year QIPP programme of 12,393k has been established, and is being delivered in full. QIPP monitoring information is included later in this report. Note: a red negative sign indicates budget overspend 2

95 Summary of Surplus plan movements Surplus Component Value Planned Surplus for 2017/18 9,743,000 No cheaper supply obtainable (NCSO) drugs: surplus reduction Non-Recurrent reserves release: national required treatment Category M drugs rebate: national required treatment Overall underspend in other programme areas ( 1,276,842) 2,017, , ,256 Underspend in running costs 43,014 Total Surplus Achieved 11,073,720 Note: a red negative sign indicates budget overspend 3

96 Summary of Position The CCG was underspent at the end of Month 12 by 11,074k. This is a substantial increase compared to month 11 and the increase is caused mainly by the following: 2,017k NR reserve release as per national guidance 292k Category M drugs rebate release as per national guidance 299k underspend on other Prog and Running costs budgets (incl release of CCG reserves). The CCG released 1,554k of reserves over and above the 2,017k NR reserve release to offset adverse variances on on Acute, Client Groups, Delegated Primary Care Commissioning, and Prescribing, which are partially offset against favourable variances against Primary Health Care Services and Transformation. The CCG has approved payments of 1.75m in year with regard to the implementation of the Trust Special Administrator Agreement relating to Lewisham and Greenwich Trust, for the 2017/18 financial year (the last year of such support). This has been included in the forecast figures in the Acute financial position later on page 8 of this report. Data available for this report: 11 months Acute data is available for the current year for the two major contracts. 10 months of GP Prescribing data is now available for the current year. Continuing Care information is available for 12 months. Southwark CCG Running Costs are treated as a separate allocation so are shown as separate in the summary. Cross subsidisation of Running Costs by underspend on Programme Budgets is not permitted. Note: a red negative sign indicates budget overspend 3

97 CCG Programme Budget Summary 2017/18 - Month 12 Programme Budget Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Acute 222,363-1,385-1,385 Client Groups 78, Community & Primary Care Health Services 52,639 1,038 1,038 Delegated Primary Care 43,860-1,304-1,304 Transformation 1, Prescribing 31, Better Care Fund (excluding schemes totalling 5.4m reported elsewhere: total BCF 21.05m) 15, Corporate Costs 11, Earmarked Budgets & Reserves 1,554 1,554 1, % Non-recurrent reserve (uncommitted) 2,017 2,017 2,017 Planned Surplus 9,743 9,743 9,743 Total 470,428 11,031 11,031 Reserves not yet utilised in above position N/A Reserves not yet utilised in above position (Mth 11 for comparison) 3,116 Drawdown of prior yr surpluses in 2017/ Note: a red negative sign indicates budget overspend 5

98 CCG Running Costs Summary 2017/18 Month 12 Running Costs Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Running costs 6, Month 11 (for comparison) 6, Notes: 1. The running costs allocation is separate from the Programme budget and should be monitored separately. 2. The running costs budget has increased slightly in 2017/18 ( 39k). There was a further increase in Month 3 due to: 3k allocation for Market Rents adjustment 1k allocation for HSCN funding 3. In line with national requirements, the running cost allocation per head of population has reduced from 25 in 2013/14, to in 2017/18. Although the budget has increased slightly in 2017/18, there is a reduction in budget per head of population in 2017/18, due to an increase in the Southwark population size. Note: a red negative sign indicates budget overspend 6

99 Acute Financial Position 2017/18 Acute Contract Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) King's College Hospital NHS Foundation Trust Guy's and St Thomas NHS Foundation Trust (excluding Community contract) 86, , Lewisham and Greenwich NHS Trust 4, University College London Hospital 2, London Ambulance 12, Other contracts and non-contracted activity 18, Total Acute 222,363-1,385-1,385 Month 11 (for comparison) 222, ,044 Note: a red negative sign indicates budget overspend 7

100 Notes on Acute Budgets The year to date position is based on Month 11 information adjusted where appropriate for areas where reporting doesn t yet reflect contractual arrangement or doesn t yet include agreed challenges. The Month 11 position is then pro-rated up to Month 12. The position at Month 12 shows an adverse variance of 1,385k. Within this, there are adverse variances (based on SLAM data) relating to the Lewisham & Greenwich NHS Trust, University College London Hospital NHS Foundation Trust, St George s Healthcare NHS Foundation Trust, The Royal Marsden NHS Foundation Trust, Croydon Health Services NHS Trust, Moorfield s Eye Hospital NHSFT and BMI Healthcare, as well as other, smaller contracts. These adverse variances are partially offset by underspends against non contracted activity budgets and release of Acute earmarked reserves. King s College Hospital NHS Foundation Trust the position shows performance in line with plan. There is an underlying underspend position of 675k. The reported position is driven by adverse variances on elective (- 624k), outpatient follow up (- 523k), outpatient procedure (- 213k), critical care (- 214k), and drugs and devices (- 659k). The overspends are partially offset by significant underspends on the following PODs: emergency ( 198k), non-elective ( 339k), outpatient 1st ( 364k) and unbundled diagnostics ( 156k). 8

101 Notes on Acute Budgets Guy s & St Thomas NHS Foundation Trust the ytd position shows an underspend of 47k. There is an underlying underspend position of 546k, driven by underspends on the following PODs: maternity pathway ( 565k), Community ( 490k), A&E ( 150k) and other ( 998k this includes the release of Identification Rule benefits). These underspends are partially offset by overspends on Outpatient follow up (- 702k) Critical Care (- 330k), emergency (- 946k) and drugs and devices (- 298k) as well as other smaller variances. 9

102 Client Group Financial Position 2017/18 Programme Budget Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Mental Health Contracts (excl. IAPT) 58, IAPT 3, Learning Disabilities 1, Continuing Healthcare Assessment & Support Older Adults 3, Palliative care 2, Children Services 2, Young Persons with Disability (YPD) 5, Other Client Groups Total Client Groups 78, Month 11 (for comparison) 77, Note: a red negative sign indicates budget overspend 10

103 Notes on Client Groups Budgets QIPP savings of 1,333k have been applied to the South London and Maudsley NHS Foundation Trust (SLaM) contract and the CCG and the Trust are working closely to ensure effective delivery of the savings. There is a further 850k of QIPP savings allocated to other Client Groups budgets and as at Month 11, the full QIPP target of 2,183k has been met. As at Month 12, there is an adverse variance on Client Groups of 787k, which is mainly due to: Learning Disabilities: 78k adverse due to higher than planned activity Palliative care 376k this high cost relates to significant additional demand above planned levels. YPD: 231k adverse There were 5 additional service users earlier in the year, which increased prior months costs and continues to be a pressure on current budget albeit at a lower level. Residential placement costs are reviewed and monitored closely by both the Commissioning and Finance teams throughout the year in light of the shared costs with Southwark Council for this type of activity. 11

104 Community & Primary Care Health Services Programme Budget Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Community Contract 33, Extended Primary Care Services 1, Population Health management 1, GP Forward View and Primary Care Investments 9, Primary Care Transformation ETTF allocations - LCR and Interoperability 1, Other Primary Health Services 5, Total 52,639 1,038 1,038 Month 11 (for comparison) 52, Note: a red negative sign indicates budget overspend 12

105 Notes on Community & Primary Care Health Services GSTT Community Contract and GP Forward View are currently performing in line with plan in year. Extended Primary Care Services shows a favourable variance of 360k due to a benefit of the same amount relating to the prior financial year. This favourable variance is being used to partially offset the adverse variance reported on Delegated Primary Care budgets that is a result of the shortfall in allocation. Additionally, the CCG also received additional income in Month 12, which offset spend that was already being reported. In addition to this, there were underspends on Minor Ailments, Interpreting, Spirometry and 111. Estates and Technology Transformation Fund allocations were received in Month 7 for Interoperability and the Local Care Record. NHSE have directed where this allocation is to be reported and as a result, a new line has been added into these budgets for these items. Additional funds of 1M were received in Month 10 for Digitisation of Patient Records in some practices. Note: a red negative sign indicates budget overspend 13

106 Transformation 2017/18 Programme Budget Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) GP Federations Business Plans Population Health Fellows Staffing Costs Total 1, Month 11 (for comparison) 1, Transformation budgets underspent by 406k caused by vacancies in the staffing structure and lower than planned expenditure on the GP Federations Business Plans. 475k of Transformation budget was affected by an NHSE coding requirement in Month 4. As a result of the coding requirement, this element of the Transformation budget now sits within the Community and Primary Care Health Services budgets reported on the previous pages. Note: a red negative sign indicates budget overspend 14

107 Prescribing Financial Position 2017/18 Programme Budget Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) North Southwark 16, South Southwark 14, Prescribing Incentive Scheme Drugs held centrally Personally Administered Drugs NCSO drugs adjustment -1,276-1,233-1,233 Admin and Other Prescribing Total 31, Month 11 (for comparison) 31, Note: a red negative sign indicates budget overspend 15

108 Notes on Prescribing Budgets Ten months of data for GP Prescribing is available as at Month 12. As at Month 12, both North and South Southwark prescribing budgets had un underspend, with a combined value of 253k. This is an improvement compared to the month 11 position, and is based on the information provided by the NHS Business Services Authority. Additionally in Month 12, CCGs received guidance with regard to the Category M drugs rebate treatment. Prior to Month 12, the rebate had been held by NHSE. In Month 12, it was returned to CCGs. The value of the rebate for Southwark CCG was 291k. Within the reported prescribing position there is a significant national cost pressure in terms of No Cheaper Stock Obtainable (NCSOs) or drugs in short supply in 2017/18. For Southwark this is 1.3m. There has been national agreement that CCGs will achieve their target surplus less the effect of NCSO drugs. Partially offsetting this adverse movement is the release of 548k prescribing budget that was not allocated as a result of the requirements of the CEP process earlier in the year. 16

109 Better Care Fund 2017/18 (1 of 2) The Better Care Fund (BCF) is a pooled budget between the CCG and Southwark Council and is hosted by the Council. The CCG s contribution to the BCF in 2017/18 is 21,050k. This funds a number of schemes, some of which are led by Southwark Council, and some are led by the CCG. Under the pooled budget arrangement, there is no requirement to physically transfer cash to the host for the pooled budget to exist. On that basis, the CCG only transfers the proportion of its contribution needed to fund the Council led schemes. On that basis, the reporting of the BCF is split into two segments: the amount paid to the Council, and the CCG led schemes which are reported as part of the relevant directorate. The CCG led schemes have also been included as part of the BCF section of this report to provide transparency with regard to how the full CCG BCF contribution is spent. Programme Budget Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Better Care Fund: CCG Contribution to Southwark Council led Schemes 15, Total 15, Month 11 (for comparison) 15, The BCF plan was agreed and submitted in line with national timetables in Month 5. It has been assessed by NHS England and has been fully approved following the regional assurance process. Note: a red negative sign indicates budget overspend 17

110 Better Care Fund 2017/18 (2 of 2) BCF schemes reported as part of other expenditure areas Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Community GSTT schemes: Admission Avoidance, Hospital at home, Enhanced Rapid Response Primary Health Services schemes: Self management, Enhanced primary care access 3, , Medicines Management Total 5, Month 11 (for comparison) 5, Total CCG contribution to BCF Annual Budget ( 000s) Variance to Month 12 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Total CCG Contribution to BCF 21, Note: a red negative sign indicates budget overspend 18

111 Corporate Costs 2017/18 Programme Budget Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) GP IT Development Costs for Dulwich Health Centre and Other Projects Estates Costs 2, Medicines Optimisation Digitalisation 1, Healthy London Partnership 2, Other Corporate 2, Total 11, Month 11 (for comparison) 10, These costs are not counted against the CCG Running Costs allocation. The increase in budget in Month 12 is due to an allocation for Dulwich development costs Our Healthier South East London programme is reported in Other Corporate. The CCG contributes 647k to OHSEL funding. Note: a red negative sign indicates budget overspend 19

112 Primary Care Co-commissioning 2017/18 As of the 1 April 2015, the CCG entered into Level 2 co-commissioning of primary care with NHS England. There were 3 levels available to CCGs with regard to co-commissioning: Level 1: Greater involvement in primary care decision-making Level 2: Joint Commissioning enables decisions Level 3: Delegated Commissioning enables decisions. The CCG has moved to Level 3 for the 2017/18 financial year. Level 3 is an opportunity for CCGs to take on full responsibility for the commissioning of general practice services. Note: a red negative sign indicates budget overspend 20

113 Primary Care Co-commissioning 2017/18 Primary Care Services Medical Services Description Annual Budget YTD Budget YTD Actual Expenditure YTD Variance 2016/17 Outturn 000's 000's 000's 000's 000's Additional and Essential Services 34,661 34,661 34, ,935 QIPP Savings Enhanced Services ,745 Quality and Outcomes Framework (QOF) 2,900 2,900 3, ,796 Premises Payment 5,011 5,011 5, ,844 Seniority Other Administered Funds (Maternity etc) Personally Administered Drugs Prior Year write back Other Total 43,860 43,860 45,164-1,304 42,341 Month 11 (for comparison) 43,208 39,606 40, The primary care medical budget calculated for this CCG leaves a net deficit position of 1,190k against the 17/18 allocation of 43,208k. The CCG weighted practice list size has increased from April 2017 to February 2018 resulting in an increased cost. Also reflected in the ytd position is the impact of a number of practice closures and is therefore offset by closed practice budgets as well as the population reserve budget which was based on the ONS predicted annual growth of 1.3%. The reported position is an overspend of 1,304k reflecting the release into the position of the net deficit and cost pressures from caretaking arrangements. Caretaking cost pressures are partially offset by underspends against the budgets set for a closed practice. Note: a red negative sign indicates budget overspend 21

114 Earmarked Budgets and Reserves 2017/18 (1 of 2) Programme Budget Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) General Contingency (0.5%) Non-Recurrent Expenditure (0.5%) 2,017 2,017 2,017 Drawdown of Historic Surplus Paramedic Rebanding Additional Funding non-recurrent OHSEL STP Infrastructure Reserve Winter Resilience TSA Reserve Local Activity/ Risk Reserve Total 3,571 3,571 3,571 Month 11 (for comparison) 4,873 1,143 1,757 Reserves not yet utilised in above position N/A Note: a red negative sign indicates budget overspend 22

115 Earmarked Budgets and Reserves 2017/18 (2 of 2) Programme Budget Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Planned Surplus 9,743 9,743 9,743 Month 11 (for comparison) 9,743 8,931 9,743 The Planned Surplus increased in Month 3, due to an adjustment to the Surplus/Deficit Carry Forward. As at Month 2, this was included at the planned surplus as at Month 11 of the 2016/17 financial year. In Month 3, the allocation was adjusted to reflect the actual surplus achieved in 2016/17, so the allocation increased by 150k from 10,063k to 10,213k. The Planned Surplus from the start of the year takes into account the following elements: 10,213k Surplus carried forward - 700k Drawdown of historical surplus 230k Planned in year surplus 9,743k net surplus target after the above. Note: a red negative sign indicates budget overspend 23

116 Running Costs 2017/18 (Separate Allocation) Budgets Annual Budget ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000) Staff Costs 3, CSU Recharge 1, Office Accommodation Other 1, Total 6, Month 11 (for comparison) 6, This is the separate allocation of per head of population for running costs. Staff costs are overspent due to posts recharged to other organisations ( 320k), and the Partnership Commissioning Team Recharge ( 212k) recharges due based on the agreement with the Council. The offsetting income for these items is shown in the Other category. In addition there is a one-off payment in lieu of notice from earlier in the year. The Other costs include Audit Fees. Note: a red negative sign indicates budget overspend 24

117 Capital 2017/18 (Separate Allocation) Capital Projects Annual Budget ( 000s) Actual Spend to Month 12 ( 000s) Variance to Month 12 ( 000s) End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000) CCG Capital funding Funding for Adastra infrastructure Total Month 11 (for comparison) N/A N/A N/A N/A As at Month 12, the CCG received 50k for Southwark capital schemes and 19k for a separate scheme relating to Adastra infrastructure. With regard to the 19k allocation, it was not possible to spend this allocation in the 2017/18 financial year. The CCG also has an allocation of 529k for GPIT equipment, that is reflected in NHSE s accounts. Note: a red negative sign indicates budget overspend 25

118 QIPP Monitoring SOUTHWARK CCG QIPP Annual Plan Year to Date Forecast QIPP Target (Post-RAG-Rating) ( 000s) YTD Plan ( 000s) YTD Actual ( 000s) YTD Variance ( 000s) Acute 6,355 6,355 6,355 0 Mental Health 2,183 2,183 2,183 0 Primary Care Prescribing Community Services 1,000 1,000 1,000 0 Continuing Health Care 1,000 1,000 1,000 0 Corporate Southwark CCG QIPP Target 2017/18 12,393 12,393 12,393 0 YTD RAG Outturn ( 000s) Variance ( 000s) Ytd Shortfall from plan: 0.0% Forecast shortfall from plan: 0.0% Total QIPP savings plans of 12,393k are in place for 2017/18. The CCG delivered the QIPP programme in full in 2017/18. The majority of the Acute and Mental Health QIPP plans were contractually agreed with the relevant providers and on that basis, there was a reduced risk to the CCG of underachieving the QIPP plans for 2017/18. Note: a red negative sign indicates budget overspend 26

119 Cash Position 2017/18 The Maximum Cash Drawdown (after payments made on behalf of NHS Southwark CCG by NHS Business Services Authority PPA & HOT) is 433,207k. The actual and forecast drawdown of cash is shown in the table below. Cash drawdown Monthly Drawdown 000s Cumulative Drawdown 000s Proportion of Annual Cash Resource Limit KPI % of cash balance as drawdown 000s Month end cash Bank Balance 000s ACTUAL Apr-17 36,100 36, % May-17 36,500 72, % Jun-17 37, , % Jul-17 36, , % Aug-17 33, , % Sep-17 33, , % Oct-17 34, , % Nov-17 32, , % Dec-17 41, , % Jan-18 37, , % Feb-18 33, , % Mar-18 39, , % Annual Total 431,400 Achievement The cash KPI was again achieved in Month 12, showing continued successful management of the cash position to achieve the target cash balance. 27

120 Better Payments Practice Code (BPPC) 2017/18 Feb-18 Mar-18 NHS NON-NHS TOTAL NHS NON-NHS TOTAL NUMBERS FOR THE MONTH Total number of invoices paid in the month , ,295 Number of invoices paid within target , ,268 Numbers percentage for the month 99.22% 98.52% 98.68% 97.48% 98.06% 97.92% VALUES FOR THE MONTH ( 000s) Total value of invoices paid in the month 25,663 7,252 32,915 29,416 15,272 44,688 Value of invoices paid within target 25,661 7,196 32,857 29,358 14,894 44,252 Value percentage for the month 99.99% 99.22% 99.82% 99.80% 97.53% 99.02% CUMULATIVE NUMBERS TO THE MONTH Total number of invoices paid YTD 2,804 9,348 12,152 3,122 10,325 13,447 Number of invoices paid within target 2,765 8,999 11,764 3,075 9,957 13,032 Numbers percentage cumulative 98.61% 96.27% 96.81% 98.49% 96.44% 96.91% CUMULATIVE VALUES TO THE MONTH ( 000s) Total value of invoices paid YTD 310, , , , , ,524 Value of invoices paid within target 309, , , , , ,160 Value percentage cumulative 99.74% 98.66% 99.45% 99.74% 98.66% 99.45% 95% <95% Under the Better Payments Practice Code (BPPC), CCGs are expected to pay 95% of all creditors within 30 days of the receipt of invoices. This is measured both in terms of the total value of invoices and the number of invoices by count. The CCG continues to show high performance against target, and as a result, all cumulative and in month targets are green rated. 28

121 Aged Debtors (Receivables) 2017/18 Customer Account Group Current Debt 1-30 amount AR Ageing amount AR Ageing amount AR Ageing amount AR Ageing amount AR Ageing 181+ amount Total AR due amount NHS 1,820, , , ,034 2,385,157 Non-NHS 3,598,525 1,429,096 1, ,679 5,190,058 Total 5,418, ,806, , , , ,575, The value of the non-nhs 181+ debt remains at 160k relates to Southwark Council. The NHS debt 181+ includes 100k King s College Hospital NHSFT contribution to the STP programme. The 5.03m current and non-nhs Debt relates mainly to the Section 75 Public Health agreement with Southwark Council. No issues are expected with the payment of these invoices. The 1.8m NHS current debt relates to: 571k from SE London CCGs- mainly relating to contributions to hosted services such as the Our Healthier South East London programme. 1,007k NHSE. This includes an invoice for 753k which relates to funding that was given out as an allocation by NHSE and as a result, the CCG has cancelled this invoice in April

122 Financial sanctions imposed by the CCG As part of the NHS standard contract, the CCG is required to report quarterly on financial fines and penalties imposed on providers for failure to achieve national standards. The sanctions are routinely calculated and form part of regular monitoring of contracts, recognising the national requirements against each indicator. The standards are split into 2 main categories: Operational Standards: include requirements for 18 weeks referral to treatment, A&E waiting times, Cancer standards, mixed sex accommodation, cancelled operations. National Quality Standards: include requirements for MRSA, C-Diff, over 52 week waiters, Ambulance handovers, duty of candour, required data, trolley waits in A&E. Please note: the full list of standards is not included in the financial sanctions tables. Only those standards that have incurred financial sanctions are reported. The December 2015 document Delivering the Forward View: NHS Planning Guidance 2016/ /21 states on page 12: Providers who are eligible for sustainability and transformation funding in 2016/17 will not face a double jeopardy scenario whereby they incur penalties as well as losing access to funding; a single penalty will be imposed. On that basis there are not expected to additional financial sanctions imposed by the CCG. 30

123 Revenue Resource Limit (1 of 3) Admin ( 000s) Programme ( 000s) Total ( 000s) Initial CCG Programme Allocation 2017/18 444, ,410 Running Costs Allowance 2017/18 6,496 6,496 Brought forward surplus from 2016/17 less drawdown 9,513 9, /18 Opening Allocations 6, , ,119 In year Allocations: Liaison and Diversion/CYP Co-commissioning non-rec (Month 3) London Transformation Fund Allocation non-rec (Month 3) 2,000 2,000 Reception and clerical training non-rec (Month 3) Diabetes Treatment and Diabetes Treatment and Care Transformation Fund non-rec (Month 3, 6, 9 and 11) 1,107 1,107 NHS WiFi non-rec (Month 3) Market rents adjustment non-rec (Month 3) Paramedic Rebanding Additional Funding non-rec (Mth 3) TB allocations Qtr 1 non-rec (Month 3) Health & Social Care Network (HSCN) non-rec (Month 3) Acute hosp urgent & emerg liaison MH serv - non-rec (Month 3,4,7&10) Infrastructure funding for STPs non-rec (Month 3) GP Forward view for SEL CCGs (Month 4) 7,363 7,363 HLP and London levies contribution (Month 5 & 7) GPFV Implementation and Resilience funding (Month 5) ETTF - Local Care Record and Interoperability (Month 7) 1,542 1,542 GP Extended Hours - London Pilot Programme (Month 8) Total Confirmed Allocation cont d 6, , ,897 31

124 Revenue Resource Limit (2 of 3) Admin ( 000s) Programme ( 000s) Total ( 000s) Allocation as per previous page 6, , ,897 In year Allocations: Charge Exempt Overseas Visitor (CEOV) Adjustment (Month 8) Online consultations (Month 9) Funding of Super partnership (Month 9) GP Wifi rounding correction to M3 allocation (Month 9) -1-1 SEL Wide Tech Bid Digitisation of Patient Records (Month 10) Rightcare: Strengthen programme delivery by focusing intensively on one programme level of care (Month 10) HLP 2017/18 (Month 11) 2,437 2,437 Practice Digitalisation Allocations to SEL CCGs (Month 11) Collaborative Funding to SEL CCGs (Month 11) Overseas Visitors Adjustments (Month 11) SEL Risk Share (Month 11) -2,000-2,000 Primary Care Winter Costs (Month 11 & 12) Elective Care Demand Management (Month 11) SEL Demand Management funding for Visual DX (Month 11) ETTF Digitalisation of patient records (Month 11) Additional Resilience Funding distribution (Month 11 & 12) London Online consultations additional funding (Month 11) SEL STP UEC Programme Funding (Month 11) Total Confirmed Allocation 6, , ,480 32

125 Revenue Resource Limit (3 of 3) Admin ( 000s) Programme ( 000s) Total ( 000s) Allocation as per previous page 6, , ,480 In year Allocations: International Recruitment SE London Primary Care balances ECDS early adopters bonus , , ,928 33

126 Revenue Resource Limit (2 of 2) There have been a number of changes to the Start Allocation in Month 12: SEL Schemes for which Southwark CCG received funding ( 181k outgoing to other SEL CCGs International Recruitment ( 28k incoming) SE London Primary Care Balances ( 400k incoming) ECDS early adopters bonus ( 20k incoming) Adjustments are not reflected in the table on the previous pages until such time as they have been agreed and confirmed through the NHSE standard process. 34

127 Recommendations 1. To note the budgets and position for the Programme Budgets and the Running Costs as at end of the 2017/2018 financial year. 2. To note that, subject to Audit, all financial targets have been achieved for Malcolm Hines Chief Finance Officer NHS Southwark CCG 19 April

128 Risk Highlight Report Integrated Governance and Performance Committee April 2018

129 Summary of Risks in April 2018 Summary of Risks on the Board Assurance Framework Extreme risks High risks Moderate risks Low risks TOTAL Summary of Risks on the Directorate Risk Registers Extreme risks High risks Moderate risks Low risks TOTAL Note: This summary is based on residual risk scores 2

130 Extreme Risks on BAF.. (1) There are currently 13 extreme risks on the BAF as follows: No. Ref Directorate Risk Title Initial Risk Score Residual (current) risk score Highlights of Controls (See Full BAF Enc Bii for more information) 1. IC-06 Integrated Commissioning Risk that providers do not deliver contractually agreed trajectories for Referral to Treatment specifically delivery of recovery plan to meet Referral to Treatment waiting time targets by March x4=20 5x4=20 Further workstreams have been agreed and will commence in May. These are Paediatric ENT, Paediatric MSK, Cardiology, MSK, gastroenterology and long term conditions (commenced in March). Ophthalmology SPoR contract was awarded on 7 November 2017 and went live in March Dermatology SPoR contract was awarded on 23 December 2017 and went live on 3 April IC-07 Integrated Commissioning Risk that providers do not deliver contractually agreed trajectories for A&E NHS constitutional standards, specifically delivery of recovery plan to meet A&E 4 hour waiting time targets by March x4=20 5x4=20 Trajectories for delivery of NHS constitution standards agreed with providers in 2017/18. In addition to System Oversight Group monitoring, Southwark CO attends NHSI's monthly escalation meetings with Lambeth CCG and Bromley CCG Chief Officers and NHSE for assurance on recovery plan. CCG management attending daily meetings at KCH from 8-9am. Options appraisal document around the UCC presented to KCH Emergency Pathway Board with the recommendation to keep a integrated ED/UCC. UCC weekly working group meeting has turned into an implementation group to drive changes within the UCC. The ICDT is providing support to this project. Chaired by NHS Improvement Rachel Williams. 3

131 Extreme Risks on BAF.. (2) No. Ref Directorate Risk Title Initial Risk Score Residual (current) risk score Highlights of Controls (See Full BAF Enc Bii for more information) 3. IC-34 Integrated Commissioning Risk that providers do not deliver 62 day target for urgent cancer referrals. 4x5=20 4x5=20 Governance arrangements in place. SEL wide Cancer Recovery Plan, Cancer Diagnostic Fund, Transformation Fund in place. SEL wide cancer recovery plan - a pack outlining the next steps, priorities and approach for 2018/19 has been created. There is a particular focus on improving shared pathway performance. The pack includes draft trajectories for internal and shared performance - these trajectories still need to be signed off by NHSE/I. 4. IC-35 Integrated Commissioning Risk that adverse CQC inspection outcomes for general practices in Southwark will negatively impact on quality of care provided to the registered populations. 4x5=20 4x4=16 CCG, with input for GP federations, have endorsed 6 prioritised practices for resilience funding using London set criteria. CCG currently working with these practices to agree their resilience plans and funding which will be paid against a signed MoU, Risk for the GP service provision in the Bermondsey area due to specific practice issues. CCG is supporting both practice improvements and monitoring closely, the CCG has completed an options appraisal for future service provision. 4

132 Extreme Risks on BAF.. (3) No. Ref Directorate Risk Title Initial Risk Score Residual (current) risk score Highlights of Controls (See Full BAF Enc Bii for more information) 5. IC-45 Integrated Commissioning Risk to the sustainability of GP practices across north and south Southwark due to workforce, workload, financial pressures and infrastructure, impacting on quality outcomes for Southwark primary care patients. 4x5=20 4x4=16 The CCG supports practices through a range of actions on Workforce, care design, practice infrastructure and workload. CCG working with federations to develop different work force models including practice based pharmacists, and to develop training practices, nurse mentors and placements for pre reg. nurses. Roll out of GP Forward View (GPFV) resilience funding. Focus on ensuring the resilience funding plan is delivered. Practices investing in service provision and estates (as per contract requirements) Final contract offer signed by all PMS and GMS practices signed up to premium specification, APMS negotiation in progress. 6. IC-31 Integrated Commissioning Risk that the provider does not deliver achievement of IAPT 50% recovery rate in year as well as by end March This will impact on CCG IAF outcome and reputational impact as a result of CCG failing to meet NHS constitutional targets. 4x4=16 4x4=16 IAPT Performance targets monitoring: SLaM has been taking action to improve the recovery rate, and this has now increased to 49% for March Following national IST review recommendations, SLaM are reviewing complex psychological treatment pathways. The review will include a focus on IPTT waiting lists and their impact upon achievement of IAPT recovery rate and other targets. The service review will report through CCG governance structures and return to the CSC for further discussion about the potential impact of changes to the local IAPT model - RB - Q

133 Extreme Risks on BAF.. (4) No. Ref Directorate Risk Title Initial Risk Score Residual (current) risk score Highlights of Controls (See Full BAF Enc Bii for more information) 7. IC-22 Integrated Commissioning Risk that public health grant reductions will continue to reduce provider funding which will impact on the delivery of public health prevention for adults and children e.g. stop smoking, sexual health, health checks, health visiting and school nursing. 4x4=16 4x4=16 Population health management: GP federations have requested 10% management fee for population health management contract which may affect delivery of number of health checks if Southwark Council accepts and continues to commission these services through the population health management contract. This has been requested for the substance misuse and sexual health contracts. Council Commissioners have not confirmed their acceptance to date and the CCG has chased these responses. 8. FM-06 Finance and Business Our Healthier South East London programme delivery - Risk that the programme does not deliver intended benefits in terms of system transformation 5x4=20 5x4=20 SEL Strategy Programme governance structure in place. Governance structure includes: Clinical Advisory Group, Community-based Care (CbC) Working Group, Capital Finance and Estates Group. Community based Care workshops are also on-going. Engagement with patients and clinicians is on-going. Sustainability and Transformation Plan: Version 2 STP plan submitted to NHSE on 21 October. Provider Collaborative Productivity workstream underway to support delivery of efficiency savings across SEL. Programme delivery plans are in place to achieve our 2017/18 commissioning intentions and these have been built into our signed contracts. 6

134 Extreme Risks on BAF.. (5) No. Ref Directorate Risk Title Initial Risk Score Residual (current) risk score Highlights of Controls (See Full BAF Enc Bii for more information) SEL Strategy Programme governance structure in place. Governance structure includes: Clinical Advisory Group, Community-based Care (CbC) Working Group, Capital Finance and Estates Group. Community based Care workshops are also on-going. Engagement with patients and clinicians is on-going. 9. FB-34 Finance and Business OHSEL Programme: Risk that current planning and strategic approach does not deliver a sustainable financial position in the context of lower levels of growth in the period to 2020/21 5x4=20 5x4=20 Sustainability and Transformation Plan: Version 2 STP plan submitted to NHSE on 21 October. Provider Collaborative Productivity workstream underway to support delivery of efficiency savings across SEL. Programme delivery plans are in place to achieve our 2017/18 commissioning intentions and these have been built into our signed contracts. Capped Expenditure Process (CEP): All organisations in SEL are in discussion about how to reduce the risks inherent in their plans and ensure that overall we deliver the control totals for SEL. M8 financial position further worsened for Bexley CCG ( 7m) affecting the SEL-wide control total. Risk that other SEL CCGs may not be in a position to contribute to the recovery of the SEL control total. Regular discussions with all CFOs, ICDT, SEL AO to agree mitigations and maximise delivery of control total. Proposal being discussed with SEL AO. 7

135 Extreme Risks on BAF.. (6) No Ref Directorate Risk Title Previous score Current score Highlights of Controls (See Full BAF Enc Bii for more information) CCG and Council partners working through options to deliver a new Southwark approach to placements for 2018/19. Key to this will be budget control and managing demand, capacity, step down and recovery with the provider offer from SLaM and Supported Housing services. 10 IC-25 Integrated Commissioning Significant financial and operational risks to Southwark mental health placements delivery in 2018/19 if robust governance arrangements are not developed in partnership with the Council. 4x5=20 4x5=20 Key focus of the newly agreed Joint Mental Health and Wellbeing Strategy is to delivery a new supported housing model in Southwark to support discharge and move on which will help deliver the Southwark recovery model. CCG and Council partners will undertake a joint review of services commencing in summer Governance arrangements for Placements Panel reviewed and financial risks associated with this identified. Gap: Council not agreed CCG outcomes offer to close 2017/18 on an overspend known to all parties on a month by month basis against agreed / actual placement activity. Under negotiation. 11 QN-11 Quality and Nursing Risk of not meeting the Transforming Care performance target is a reputational risk to the CCG 3x4=12 4x4=16 TCP control totals now in place and the subject of weekly monitoring. The TCP is 1 patient above trajectory and risks to delivery remain high. The TCP has RAG rated all patients on the basis of their likely discharge within the lifetime of the programme. 38 patients are likely to remain in hospital across the TCP, principally in secure settings, giving little room for variance against plan. MG on-going 8

136 Extreme Risks on BAF.. (7) No Ref Directorate Risk Title Previous score Current score Highlights of Controls (See Full BAF Enc Bii for more information) 12. FB-35 NEW Finance and Business Failure to deliver financial targets and financial sustainability compounded by increasing pressure on QIPP delivery and financial challenges facing acute providers 4x5=20 3x5=20 Robust monitoring and oversight of CCG financial position: Monthly reporting to IG&P Committee, Governing Body (bimonthly) and to SMT. CCG financial plan approved by CoM and GB. Budget Framework in place. Risk share arrangements in place in SEL STP and across London. Acute contracts: GST and KCH contracts signed which limit risks to the CCG. Ongoing work at STP level including all SEL commissioners, NHS provider organisations and Councils to ensure ongoing sustainability of the health and social care systems in south east London as reported above. 13. FB-36 NEW Finance and Business CSU Performance: Risk that North East London Commissioning Support Unit (NEL CSU) does not deliver high quality support to Southwark CCG GP practices impacting on ability to discharge business processes and access referral pathways 4x4=16 4x4=16 Formal SLA monitoring process in place which take place on a monthly basis. CSU reporting on fortnightly basis on progress on actions, this is also being monitored by the Lambeth and Southwark IT and Informatics Steering Group. Southwark CCG reps regularly meet with CSU around CCG and GPIT on assurance and this work is being led on our behalf by Jo Steranka. Issues have been escalated in writing to the CSU by Finance Director - April 2018; Investigation into outstanding issues is being undertaken by JS - April 2018; Discussions have been held with clinical leads NB and LD regarding feedback to localities on 26 April (See page 12 and full BAF for more details) 9

137 New risks on the BAF for this month (1) There are 2 new BAF risks logged for this month No. Ref Directorate Risk Title Previous score Current score Background and Controls 1. FB-35 NEW Finance and Business Failure to deliver financial targets and financial sustainability compounded by increasing pressure on QIPP delivery and financial challenges facing acute providers 4x5=20 3x5=15 Robust monitoring and oversight of CCG financial position: Monthly reporting to IG&P Committee, Governing Body (bi-monthly) and to SMT. CCG financial plan approved by CoM and GB. Budget Framework in place. Risk share arrangements in place in SEL STP and across London. Acute contracts: GST and KCH contracts signed which limit risks to the CCG. Ongoing work at STP level including all SEL commissioners, NHS provider organisations and Councils to ensure ongoing sustainability of the health and social care systems in south east London as reported above. Primary Care budgets: 1.43m shortfall in funding in 2018/19 is planned to be mitigated by using Primary Care Non-Recurrent reserve and Contingency budget, remaining through planning process by allocating a contribution to these budgets from non-delegated primary care commissioning funding. 10

138 New risks on the BAF for this month (2) No. Ref Directorate Risk Title Previous score Current score Background and Controls Formal SLA monitoring process in place which take place on a monthly basis. 2. FB-36 NEW Finance and Business CSU Performance: Risk that North East London Commissioning Support Unit (NEL CSU) does not deliver high quality support to Southwark CCG GP practices impacting on ability to discharge business processes and access referral pathways 4x4=16 4x4=16 Southwark CCG reps regularly meet with CSU around CCG and GPIT on assurance and this work is being led on our behalf by Jo Steranka. CSU reporting on fortnightly basis on progress on actions, this is also being monitored by the Lambeth and Southwark IT and Informatics Steering Group. Service desk performance has significantly improved and CSU is now meeting its KPIs. CSU has reviewed it engineer support and is putting in place new processes to resolve historical problems. Issues have been escalated in writing to the CSU by Finance Director - April 2018; Investigation into outstanding issues is being undertaken by JS - April 2018; Discussions have been held with clinical leads NB and LD regarding feedback to localities on 26 April 11

139 Risks closed on the BAF for this month (1) 4 BAF risks were closed No. Ref Directorate Risk Title Previous month score Current score Reason for Closure Trajectory achieved in 2017/ QN- 28 Quality and Nursing Failure to achieve NHS Continuing Healthcare Discharge to Assess Trajectory within the urgent and emergency care improvement plan 1x4=4 1x4=4 D2A trajectory has been exceeded. Further work will be required to establish the implications for future commissioning. Review process is underway with the D2A board. Spending on D2A provision was higher than projected due to greater volumes and longer time spent on pathway due to GSTT community assessment delays. A risk relating to over-activity in D2A has been added to the Quality and Safety DRR 2. FB-01 Finance and Business Failure to deliver financial targets and financial sustainability compounded by increasing pressure from acute providers financial challenges and 1% nonrecurrent reserve frozen nationally 1x5=5 1x5=5 Accounts for 17/18 due to be closed with financial targets delivered 12

140 Risks closed on the BAF for this month (2) No. Ref Directorate Risk Title Previous month score Current score Reason for Closure 3. FB-04 Finance and Business CSU Performance: Risk that North East London Commissioning Support Unit (NEL CSU) does not deliver high quality support to Southwark CCG impacting on discharge of CCG functions. 3x4=12 1x4=4 Issues impacting on support to CCG have been addressed. Risk has now been superseded to focus on impact on GP practices only 4. IC-53 Integrated Commissioning Risk that the GP Practice funding transferred to the CCG under delegated commissioning will curtail the CCG's ability to commission sustainable GP practice services and the premium focus to improve access, prevention and continuity of care 1x4=4 1x4=4 CCG has reset budgets for 18/19 and these are fully funded 13

141 BAF risks: de-escalation The following risk was de-escalated on the BAF: No Ref Directorate Risk Title Previous month s Risk Score Current risk score Reason for De-escalation 1. IC-50 Integrated Commissioning Risk that national timelines for e-referral System implementation are not met due to technical and implementation issues with the system. This would result in a loss of CQUIN payments for our acute providers and loss of payment for any activity not booked through e-rs from October x4=12 2x4=8 Utilisation has increased from around 22% in December 2016 to over 60% in March A credible plan of ensuring 100% utilisation by October 2018 in place. BAF risks: escalation There were no escalated BAF risks this month 14

142 Highlights of risks on Directorate Risk Registers (1) The following changes were made to directorate risk registers No Risk ID Directorate Risk Title Previous risk score Current risk score Background and Controls 1 QN-26 Quality and Nursing Failure to achieve a 10% reduction in reported E coli bacteraemia cases for patients registered with a Southwark GP. 3x3=9 2x3=6 CLOSED RISK Target for 10% reduction has been achieved. Expectation that this may reopen when plans for 18/19 are reviewed) NEW RISK Reviewing D2A pathway as part of the D2A board. 2. QN-29 Quality and Nursing Risks due to Cost pressures relating to the D2A pathway 4x4=16 4x4=16 Financial monitoring systems have been strengthened to ensure that the CCG has more timely data on D2A costs. Pressure flagged as part of 18/19 QIPP planning, but spend may be in excess of this. Uncertainties related to expected activity for 18/19 will need continued monitoring of spend and activity. 3. IG-11 Finance and Business IG and ICT Security Risk Associated with moving some part of CCG IT infrastructure to cloud platform 3x5=15 1x3=3 CLOSED RISK Guidance provided by NHS Digital stating that personal confidential data can be moved into public Cloud environments. 15

143 Highlights of risks on Directorate Risk Registers (2) The following changes were made to directorate risk registers No Risk ID Directorate Risk Title Previous risk score Current risk score Background and Controls RISK ESCALATED: 4. TP-15 Transformation Inability to recruit and retain full complement of embedded staff within GP Federations and Local Care Networks may risk ability to deliver FYFV/OHSEL STP objectives 3x3=9 4x3=12 Discussions taking place with Federations and LCNs in relation to embedded staffing model for 2018/19. Contract extensions have been made for 8b LCN Programme posts through to Mar 19. Secondment of HS to LCN Director of Delivery post extended beyond Mar 18. Transformation Team consultation underway with staff responses to consultation received. Management response due 12/04. Interim resource secured for LCN Business Support (shared with Lambeth LCNs). Improving Health have now fully recruited to B7 Neighbourhood Development & Delivery Manager posts. Risk escalated due to continuing vacancies and uncertainty over staff consultation and resourcing for 2018/19 5. TP-11 Transformation Public and Patient Engagement structures do not sufficiently inform commissioning decisions and services are established/ developed that are not in line with patient needs/views 1x2=3 1x2=2 CLOSED RISK The CCG has been assured as Green Star in this area by NHSE and nominated for national prizes for engagement, so it is proposed that this risk is closed. 16

144 Highlights of risks on Directorate Risk Registers (3) The following changes were made to directorate risk registers No Risk ID Directorate Risk Title Previous risk score Current risk score Background and Controls RISK DE-ESCALATED: Risk de-escalated due to arrangement of workshop with Caldicott Guardians, LCN reps and IG leads re next phase of DSA to progress next phase of DSA Controls: Data Sharing Agreement for direct care purposes has been signed off by Federations and Foundation Trusts. Pseudonymised data relating to care coordination cohort is shared on a 6 monthly basis. 6. TP-14 Transformation IG arrangements for the LCN care coordination programme are not fit for purpose resulting in an inability to meet/measure programme objectives 3x4=12 2x3=6 Adult Social Care currently reviewing appropriate internal governance process for Data Sharing Agreement, which will enable data sharing for direct care purposes to expand to Adult Social Care. Longer-term population health analytics approach included within STP Digital Roadmap and LCR work programme, with support from STP CIO and KHP Informatics Group 2018/19 Care Coordination CQUIN for Foundation Trusts includes workshop with Caldicott Guardians, IG leads and LCN reps to review data sharing requirements for secondary use of data (e.g. understanding total treatment burden for cohort, evaluation purposes). Workshop to include good practice from elsewhere (e.g. North West London). 17

145 Highlights of risks on Directorate Risk Registers (4) The following changes were made to directorate risk registers No Risk ID Directorate Risk Title Previous risk score Current risk score Background and Controls NEW RISK Joint review of service agreed and in progress MOU between Council and SLaM being developed 7. IC-47 Integrated Commissioning Risk that Council will be unable to find CAMHS services after June 2018 as services are not budgeted for thus impacting on services to this vulnerable population group. 3x4=12 3x4=12 CAMHS workstream placed under Joint Mental Health and Wellbeing Strategy Mental Health and Wellbeing Strategy signed off by Health and Wellbeing Board, Cabinet and CCG Governing Body Gap: Risks to development of an innovative new model within the context of possible budget reduction from Council Actions: CAMHS Review being undertaken by CAMHS Review Steering Group, with end date of June 2018 Put an MOU in place to secure for Q1 - BB - June

146 BAF Heat Map April

147 Recommendations The IGP is requested to note and approve the contents of the report specifically: 1. Note changes in the BAF risks, updates provided by the teams, and receive assurance on the proactive management of strategic risks; 2. Note the highlights on directorate risk registers; 3. Note the current extreme risks for the CCG and the BAF risk profile depicted in the Heat Map; 4. Approve the report and recommend it to the Governing Body. 20

148 TP-08 18/04/2018 QN-28 12/04/2018 QN-15 12/04/2018 QN-11 12/04/2018 Risk ID Date reviewed CCG CORPORATE OBJECTIVES Quality and Safety 1. Act to comprehensively assure and improve the quality and safety of all commissioned services. NHS Southwark Clinical Commissioning Group Board Assurance Framework April Work towards the delivery of NHS Constitution standards for the residents of Southwark, taking remedial action with providers where there is variance from agreed standards or recovery trajectories. System Transformation 3. Support the on-going development and delivery of the South East London Sustainability and Transformation Plan. 4. Implement year three of the CCG s Five Year Forward View to establish a population based approach to commissioning. This includes the further development of GP federations and Local Care Networks and the CCG Involvement 5. Ensure patients and local people are involved in decisions related to the design, and commissioning of local services. Local people should be empowered in relation to their health and care. 6. Ensure the effective involvement of member practices and other partners in commissioning decisions. Sustainable Delivery and Governance 7. Maintain effective governance within the organisation and across partnerships. Act to secure the financial stability of the local health economy, deliver Value for Money (VfM) and all other statutory responsibilities. 8. Have in place an organisation and workforce capable of delivering the CCG s objectives. Strategic Objective alignment Risk Title & Description (Cause & Effect) Director Responsible Risk Owner Monitoring Committee/ Group Initial Risk Score (Likelihood x Impact) Residual Risk Risk Controls Assurance Score (Likelihood x Gaps in mitigation/ assurance Impact) SMART Actions with name of Risk Actionee & deadline for completion of action Target Risk Score (Likelihood x Impact) Direction of Travel Quality and Safety Risk of not meeting the Transforming Care performance target is a reputational risk to the CCG Kate Moriarty- Baker Mathew Griffiths Quality & Safety Sub Committee Governance arrangements: Southwark Transforming Care Steering Group is chaired by the Director of Quality and Chief Nurse. The group reports to IGP and provides updates to SEL TCP operational group which in turn reported to the SEL Strategic Group. Care and Treatment Reviews (CTRs) and Care, Education and Treatment Reviews (CETRs): CCG proactive in ensuring pre-admission CTRs for clients at risk of admission and post-admission CTRs, as well as CETRs for children and young people, take place within timescales. CCG has robust processes in place to review the care management and discharge planning for all clients fitting the Transforming Care criteria. All clients have care plans and a programme of further review. Additional clinical resource in place to support CTRs and discharge planning. Additional resources funded through Winter Pressures with capacity in place. TCP currently not achieving trajectory. Recovery plan submitted to NHSE with discharge control totals set for the STP. 2 additional case managers have been recruited to support the recovery plan Joint CCG-Local Authority review of registers for LD clients with MH and/or autism in assessment and treatment in order to identify those at risk of crisis in the community and to track for inpatient discharges, including CAMHS ongoing Transforming Care is reviewed on a monthly basis at IG&P meetings. TCP programme-level monitoring. Governing Body presentation on Transforming Care Programme in September Monthly reporting on SEL TCP to SEL Executive Potential pressure on CCG trajectories through NHSE specialised commissioning patients being stepped down to CCG beds. Concerns around local authority approach to Ordinary Residence disputes escalated to NHSE National Programme Director for TCP - awaiting update on way forward TCP and SEL resources are being used to recruit x2 case managers to support the management and appropriate discharges from asessment and treatment plus additonal PMO support. TCP control totals now in place and the subject of weekly monitoring. The TCP is 1 patient above trajectory and risks to delivery remain high. The TCP has RAG rated all patients on the basis of their likely discharge within the lifetime of the programme. 38 patients are likely to remain in hospital across the TCP, principally in secure settings, giving little room for variance against plan. MG - ongoing Quality and Safety Risk that failure to achieve performance targets at main providers will negatively impact on the quality of services Kate Moriarty- Baker Jacquie Foster Quality & Safety Sub Committee Governance: Quality and Safety Sub-Committee (QSC) meetings well-attended by GB clinical leads and lay members. Each quarter focusses on system-wide learning, quality assurance and quality improvement. Sub-Committee receives monthly feedback from the Clinical Quality Review Groups (CQRG). Minutes of QSC and CQRG feedback summaries are sent to the IGP committee. Regular updates are provided to the Governing Body on quality issues related to achievement of constitutional standards. Executives from local trusts attend Governing Body to assure on pertinent quality issues. Monthly quality report to IGP and quality updates to Governing Body. Assurance provided to Governing Body on learning from Serious Incidents. Evidence of assurance of safety in ED requested by the CCG Quality Team, this has included x2 audits in ED of quality and safety impact on patients of non-achievement of constitutional standards, IPC and 28-day re-booking audits have been reviewed at CQRG. Robust quality monitoring systems and processes: CQRG meetings are a key mechanism by which the CCG gains assurance on quality of service - CCG Quality and Safety team attends all main provider CQRG meetings, serious incident and other relevant meetings. CQC Action plans for KCH, SLaM, LAS and GSTT tracked by the CCG for assurance at each CQRG. Southwark CCG attends the South London Quality Surveillance Group (QSG) meetings, chaired by NHS England, where local, regional and national quality priorities and risks are discussed. All serious incidents, Quality Alerts and Never Events are reviewed and monitored by the CCG Quality team. Local programme of clinical site visits to Southwark providers continued in Visit to SLaM Home Treatment Team took place May 17 - the team was assured. Feedback from visits to providers conducted by local CCGs fed into CQRGs. Learning from Quality and Safety Subcommittee is being disseminated to practices by CES at PLTs. CCG-led review of SLaM CQRG completed. Second 4 Borough workshop held in January CQC: quarterly meetings have been set up between the CQC lead for each local provider and Southwark CCG to exchange intelligence and build early warning systems. Safeguarding Executive Committee minutes CQRG minutes for KCH, GSTT, LAS and SLaM. Copies of new SAR Policy Serious Incident Committees and Quality and Governance Committee minutes IGP minutes Quality and Safety sub- Committee minutes GB minutes SLaM CQRG Chair is vacant resulting in less robust meeting Monthly monitoring of quality and safety via CQRGs with KCH, GSTT, SLaM, LAS and at IGP - ongoing Spec for CQRG Chair agreed - post to be filled D2A board overseeing development of local service. Lambeth and Southwark joint plans assured by NHS England. Transfer protocol and patient and family communications agreed at D2A board. Soft launch of D2A on 11 September Monthly L&S CHC D2A Data Collection Weekly team monitoring of performance initiated to address concerns early - MG ongoing Quality and Nursing Failure to achieve NHS Continuing Healthcare Discharge to Assess Trajectory within the urgent and emergency care improvement plan Kate Moriarty- Baker Mathew Griffiths IG&P Additional resources funded through Winter Pressures with capacity in place. Arrangements in place for care home provision. Consultant and Nursing Champions identified at GSTT and KCH. Assessment approval process in place to ensure that DSTs and HNAs not completed in acutes. On behalf of SEL CCGs Southwark Director of Quality and Chief Nurse had an assurance call with NHSE regarding CHC D2A across the patch, NHSE indicated on the call that they were assured of good systems and processes for this programme in place. CCG performance for December, January and February has exceeded trajectory with 0%, 0% and 5% respectively Monthly L&S CHC D2A Board Monthly reporting to the L&S A&E Delivery Board. Delivery of the Urgent and emergency care improvement plan is overseen by OHSEL/STP Due to current success of the programme, potential pressure around nursing home bed capacity Director of Quality and Chief Nurse is reporting on D2A at GB meetings on a monthly basis, including in public - KMB - ongoing D2A trajectory has been exceeded. Further work will be required to establish the implications for future commissioning. Review process is underway with the D2A board. Spending on D2A provision was higher than projected due to greater volumes and longer time spent on pathway due to GSTT community assessment delays. A risk relating to overactivity in D2A has been added to the Quality and Safety DRR - MG/ KMB Closed - Trajectory achieved in 2017/18 Implementation of outcomes-based contracts forms part of the FYFV strategy and implementation plan. Commissioning Development group quarterly reports to CSC System Transformation Failure to implement Multispeciality Community Providers type of contracting arrangements will Ross Graves make it harder to provide joined-up care that is preventative, high quality and efficient Caroline Gilmartin/ ICDT Commissioning Strategy Committee Joint approach to segmentation agreed with Southwark Council, which will underpin joint commissioning arrangements and the development of a shared outcomes framework. Commissioning Development Groups are informing the development of commissioning intentions for 2018/19, including prioritisation of population segments. Prioritisaion paper to be considered by Joint Commissioning Strategy Committee in early May Joint Commissioner + Provider LCN workshop took place in February 2018 to confirm scope of services and ambition for LCNs. Southwark Community Based Care Programme to be established in Q1 18/19, with Ross Graves and Kris Domini as Joint SROs. Small task & finish group established to set-up Programme, including development of a Programme Inititation Document (PID) which will ensure alignment with interdependent commissioning development (e.g. population segmentation). STP Community Based Care Exec Joint Commisioning Strategy Committee FYFV Into Action Implementation Plan Southwark CBC/LCN Programme Board to be established GST Charity resources yet to be secured Plans to return to CSC - RGr - May Discussions taking place with GST Charity to support LCN development in the context of population based commissioning and delivery. Southwark CBC/LCN Programme Board (to be established) 1

149 FB-01 11/04/2018 TP-16 18/04/2018 TP-15 18/04/2018 TP-12 18/04/2018 TP-02 18/04/2018 Risk ID Date reviewed Strategic Objective alignment Risk Title & Description (Cause & Effect) Director Responsible Risk Owner Monitoring Committee/ Group Initial Risk Score (Likelihood x Impact) Residual Risk Risk Controls Assurance Score (Likelihood x Gaps in mitigation/ assurance Impact) SMART Actions with name of Risk Actionee & deadline for completion of action Target Risk Score (Likelihood x Impact) Direction of Travel System Transformation Risk that operational and financial instability of local GP Federation impacts on service delivery of EPCS and other neighbourhood/population based initiatives. Ross Graves Caroline Gilmartin/ Jean Young Local Care Network Provider Group CCG/Federation dialogue on future sustainability through joint Board to Boards focused on identification of other income streams, including future contracting arrangements and partnership opportunities. Open book accounting for Extended Primary Care Service and non-recurrent CCG transformation investment. CCG has secured additional GP Access Investment (under GP Forward View) to support continued investment in Extended Primary Care Service, and Population Health Management contract has been extended for an additional two years through to the end of 2019/20. Partnership discussions progressing postively between federations and other local providers facilitated to enable more sustainable/ affordable corporate support/ infrastructure. Joint Contract and Service Development meetings for Extended Primary Care Service and Population Health Management Contracts Open book accounting process Quarterly board to board meetings between CCG and Federations CCG operating plan/business planning process CCG non-recurrent funding availability for 18/19 Federation investment not yet finalised through business planning process. Question as to whether the LCN Provider Group has plans to meet in 2018/18 Joint Federation/CCG B2B - Q RG System Transformation Risk of slow progress in the delivery of the CCG's Five Year Forward View strategy and operational plan due to staff unable to make a connection between their roles and the overarching priorities set out in the operational plan. Ross Graves Ross Graves Senior Management Team Leadership team setting out plan for internal communications with internal and external stakeholders, with a particular focus on directors and their teams Forward View Into Action (FVIA) programme established and overseen by SMT. SMT updates FVIA programme monitored by SMT - on going - RGr Council of Members: Regular meetings discuss CCG business incl. operating plan and budgetary framework, CCG constitution changes, CCG's forward plan and commissioning intentions. Attendance at meetings achieving quorum requirements. New chair and deputy chair in place from September 2017 with an objective to engage all member poractices in the CCG's activities. Involvement CCG does not manage to engage fully and sufficiently with a small cohort of GP member practices, thus impacting on fulfilment of CCG's constitutional requirements. Ross Graves Rosemary Watts Commissioning Strategy Committee Stakeholder Survey 2018: 89% (34/38) practices responded. 85% (29) rate the effectiveness of their working relationship with the CCG as very or fairly good. 9% (3) of member respondents rated their working relationship as fairly or very poor. The results will be discussed at the May locality meetings and the June CSC. Locality meetings: 10 times a year. Enable practices to raise their issues and take part in key discussions relating to CCG business. Discussions with clinical leads and directors in January and February 2018 about format and agendas of meetings. New terms of reference to be drafted for discussion at April locality meetings Membership Support Scheme with payments on a quarterly basis with payments for criteria to encourage participation in CCG affairs such as logging on to Members and Staff Zone, attendance at locality meetings and submission of at least 1 quality alert in the quarter. Locality meeting minutes and locality reports to CSC Council of Members minutes 360 stakeholder survey results 2017 Report Reports on take up of Membership Support Scheme None identified Continued engagement with practices - RW - ongoing New locality terms of reference - April RW 360 stakeholder survey report - April RW GP Bulletin and Members and Staff Zone: Bulletin well received and published weekly with a range of information for practices e.g. care pathways, medicines optimisation, workforce development, etc. GP bulletin Engagement agenda within the Quality Directorate: PLTs, Practice Nurse Forum, GP Forum for salaried GPs. Involvement Risk that CCG does not fully comply with its duties under equalities legislation leaving commissioning and procurement decisions at risk of challenge. Ross Graves Rosemary Watts Equality Leadership Group reporting to CSC and / or IG&P Governance: Governance refreshed and bi-monthly Equality Leadership Group (ELG) established with refreshed membership and chair. Lay member for Patient and Public Involvement includes Equalities; Clinical Lead for Engagement, Equalities and Early Action identified. Governing Body training completed 7 September. Equality training for staff took place on 17 July Compliance: The PSED report for 2017 was published 31 January EDS2 areas for goals 1 and 2 for have been identified: Talking Therapies in Southwark, EPCS and Continuing Health Care and a workshop took place in November 2017 as part of the external assurance process. Actions plans are currently being developed by commissionning leads. Review of GB and committee papers is taking place on 12 April 2018 for goal 4 and includes survey of GB members. Review undertaken by two lay members and one external person. WRES analysis and analysis of staff survey results from an equality perspective is currently being undertaken as part of goal 3 and a staff workshop to explore issues and solutions is being planned for May Public Sector Equality Duty report for 2017 (published January 2018) Equality Leadership Group minutes Evidence templates development and assurance Working on completing EDS2 Goals 3&4 deliverables - RW - Sept Monitoring: Equality work programme has been developed and is a standing agenda item on the ELG. Sustainable Delivery and Governance Failure to deliver financial targets and financial sustainability compounded by increasing pressure from acute providers financial challenges and 1% non-recurrent reserve frozen nationally Malcolm Hines Julian Westcott Integrated Governance and Performance Committee Robust monitoring and oversight of CCG financial position: Monthly reporting to IG&P Committee, Governing Body (bi-monthly) and to SMT. CCG financial plan approved by CoM and GB. CCG has in place strong internal systems to regularly monitor progress, including monthly reports to IG&P Committee, in depth reviews of finance at the CCG Governing Body and regular updates to SMT. CCG Audit committee reviews the completeness and accuracy of information provided to the GB and is responsible for systems of financial reporting to the Governing Body, including those of budgetary control. Annual systematic internal audit review of financial management takes place as well as regular external monitoring through the NHSE quarterly assurance process. There is an annual financial reporting process which the CCG adheres to and this includes scrutiny sign off of annual accounts by external auditors. Budget Framework in place. Risk share arrangements: Partnership working is well-established with monthly CFO meetings in both SEL and across London to address generic financial pressures and opportunities. Acute contracts: GST and KCH contracts signed which limit risks to the CCG. Ongoing work at STP level including all SEL commissioners, NHS provider organisations and Councils to ensure ongoing sustainability of the health and social care systems in south east London as reported above. NHSE has indicated 1% reserve to remain frozen. Primary Care budgets: Southwark has a 1.406m (after using 432k from 1% NR reserve) shortfall to be met from overall budget. Agreed to use 216k Primary Care Contingency budget to further mitigate this shortfall. This would leave the shortfall at 1,190k. There is ongoing work to identify recurrent solutions to this issue. CCG is mitigating primary care gap by the use of reserves. IGP and GB minutes for assurance CoM assurance - CoM minutes NHS England Assurance CCG Financial Plan and Budgetary Framework Monthly finance reports to IG&P Committee and Governing Body May IGP received updates on financial risks Increasing financial pressures within Council as a result of reduced funding may be adversely affect CCG due to the effect of actions taken within the Council. CCG finance team monitoring issue of financial pressures within Council affecting the CCG - MH - ongoing CCG in the process of agreeing final mental health figures - JW/MH - March Closed: Accounts for 17/18 due to be closed with financial targets delivered There will be a national adjustment for NCSO drugs costs which will reduce the CCG surplus by approx. 1.3m. the CCG still expects to achieve a net surplus at year end. This is an agreed adjustment with NHSE. 2

150 FB /04/2018 FB-06 11/04/2018 FB-36 (NEW) 11/04/2018 FB-04 11/04/2018 FB-35 11/04/2018 Risk ID Date reviewed Strategic Objective alignment Risk Title & Description (Cause & Effect) Director Responsible Risk Owner Monitoring Committee/ Group Initial Risk Score (Likelihood x Impact) Residual Risk Risk Controls Assurance Score (Likelihood x Gaps in mitigation/ assurance Impact) SMART Actions with name of Risk Actionee & deadline for completion of action Target Risk Score (Likelihood x Impact) Direction of Travel Sustainable Delivery and Governance Failure to deliver financial targets and financial sustainability compounded by increasing pressure on QIPP delivery and financial challenges facing acute providers Malcolm Hines Julian Westcott Integrated Governance and Performance Committee Robust monitoring and oversight of CCG financial position: Monthly reporting to IG&P Committee, Governing Body (bi-monthly) and to SMT. CCG financial plan approved by CoM and GB. CCG has in place strong internal systems to regularly monitor progress, including monthly reports to IG&P Committee, in depth reviews of finance at the CCG Governing Body and regular updates to SMT. CCG Audit committee reviews the completeness and accuracy of information provided to the GB and is responsible for systems of financial reporting to the Governing Body, including those of budgetary control. Annual systematic internal audit review of financial management takes place as well as regular external monitoring through the NHSE quarterly assurance process. There is an annual financial reporting process which the CCG adheres to and this includes scrutiny sign off of annual accounts by external auditors. Budget Framework in place. Risk share arrangements: Partnership working is well-established with monthly CFO meetings in both SEL and across London to address generic financial pressures and opportunities. Acute contracts: GST and KCH contracts signed which limit risks to the CCG. Ongoing work at STP level including all SEL commissioners, NHS provider organisations and Councils to ensure ongoing sustainability of the health and social care systems in south east London as reported above. NHSE has indicated 1% reserve to remain frozen. IGP and GB minutes for assurance CoM assurance - CoM minutes NHS England Assurance CCG Financial Plan and Budgetary Framework Monthly finance reports to IG&P Committee and Governing Body Increasing financial pressures within Council as a result of reduced funding may be adversely affect CCG due to the effect of actions taken within the Council. CCG finance team monitoring issue of financial pressures within Council affecting the CCG - MH - ongoing CCG in the process of agreeing final mental health figures - JW/MH - ongoing New Primary Care budgets: Southwark has a 1.43m shortfall in funding in 2018/19. Planned to use Primary Care Non-Recurrent reserve and Contingency budget to part mitigate this shortfall. The remainder of the shortfall will be covered through the planning process by allocating a contribution to these budgets from non-delegated primary care commissioning funding March IGP 2018 received updates on financial risks Formal SLA monitoring process in place which take place on a monthly basis. Management Group monitoring of KPIs Risk reduced from 3X4 Sustainable Delivery and Governance CSU Performance: Risk that North East London Commissioning Support Unit (NEL CSU) does not deliver high quality support to Southwark CCG impacting on discharge of CCG functions. Malcolm Hines Julian Westcott Integrated Governance and Performance Committee Procurement of services: Completed contract extensions for all CSU provided services (except ICT) to 2018 and agreed new pricing from October 2016 to June London wide discussions ongoing re Business Intelligence Service. CSU are working to an improvement plan with milestones tracked via action tracker. CFO working with the CSU for service improvements. Lambeth and Southwark CCG reps regularly meet with CSU around CCG and GPIT on assurance and this work is being led on our behalf by Jo Steranka. CSU reporting on fortnightly basis on progress on actions, this is also being monitored by the Lambeth and Southwark IT and Informatics Sterring Group. CSU has agreed to a credit of 40K to reflect non-delivery in relation to GP facilitators (being verified with finance team). Service desk performance has significantly improved and CSU is now meeting its KPIs. CSU has reviewed it engineer support and is putting in place new processes to resolve historial problems. IG toolkit audit - significant assurance Quarterly FOI reports and KPIs are satisfactory. Bi-annual SAR reports on CSU being carried out, and results of these reported to Audit committee Continue monthly monitoring of KPIs and the SLA for services provided by the NELCSU, MH - ongoing Group set up for negotiating contract ending June MH - ongoing Close - issues impacting on support to CCG have been addressed. Risk has now been superceded to focus on impact on GP practices only Continue monthly monitoring of KPIs and the SLA for services provided by the NELCSU, MH - ongoing Sustainable Delivery and Governance CSU Performance: Risk that North East London Commissioning Support Unit (NEL CSU) does not deliver high quality support to Southwark CCG GP practices impacting on ability to discharge business processes and access referral pathways Malcolm Hines/ Caroline Gilmartin Jo Steranka/ Jean Young/ Omar Al- Ramadhani Integrated Governance and Performance Committee Formal SLA monitoring process in place which take place on a monthly basis. CSU are working to an improvement plan with milestones tracked via action tracker. Finance Director working with the CSU for service improvements. Southwark CCG reps regularly meet with CSU around CCG and GPIT on assurance and this work is being led on our behalf by Jo Steranka. CSU reporting on fortnightly basis on progress on actions, this is also being monitored by the Lambeth and Southwark IT and Informatics Sterring Group. Issues have been escalated in writing to the CSU by Finance Director, response expected April 2018 Investigation into outstanding issues is being undertaken by JS, Discussions have been held with GB clinical leads: NB and LD, regarding feedback to localities on 26 April Management Group monitoring of KPIs Issues related to GP practice IT systems support provided by NELCSU Group set up for negotiating contract ending June MH - ongoing Approach to improving lines of communication: Meetings are being arranged with Chair of Practice Managers Forum and other practice representatives - JS - April 2018 Feedback to north and south localities to be provided on 26 April by NB and LD - April New Regular attendance by SU at PM forum being re-introduced - MH - May 2018 STP governance new structure and team in place. Sustainable Delivery and Governance Our Healthier South East London (OHSEL) Strategy Programme:Risk that current planning and strategic approach is not sufficiently robust to manage pressures Andrew Bland Malcolm Hines Integrated Governance and Performance Committee Governing Body Sustainability and Transformation Plan: The CCG Five Year Strategy and SEL Five Year Sustainability and Transformation Plan (STP) published. CCG s two year Operating Plan submitted. Work on Sustainability Transformation Plan (STP) progressing well, governance structures revised. SE London CCGs and providers have ownership of STP to deliver transformation across boroughs. Contracts with KCH, GSTT and SLaM signed. The finance and activity impact of commissioning intentions at CCG and SEL level and has been built into provider contracts. CCG is risk assessing QIPP schemes for 2017/19 including phasing and impact and developing further options for consideration where deliverable. Lambeth and Southwark QIPP working group is meeting to agree acute related implementation plans. Implementation plans are being finalised. Provider Collaborative Productivity workstream underway to support delivery of efficiency savings across SEL. Programme delivery plans are in place to achieve our 2017/18 commissioning intentions and these have been built into our signed contracts. GB oversight of STP through Chief Officer's updates Finance and risk reporting to Governing Body at every meeting and IGP reports every month Series of deep dives on clinical, estates and digital programmes underway - MH Sustainable Delivery and Governance Our Healthier South East London (OHSEL) Strategy Programme:Risk that current planning and strategic approach does not deliver sustainable financial position in the context of lower levels of growth in the period to 2020/21 Andrew Bland Malcolm Hines Integrated Governance and Performance Committee Governing Body STP Governance: arrangements in place. Capped Expenditure Process (CEP): All organisations in SEL are in discussion about how to reduce the risks inherent in their plans and ensure that overall we deliver the control totals for SEL. CCGs are reviewing options for extending QIPP e.g. Treatment Access Policy (TAP), Continuing Health Care. SEL Collaborative QIPP Schemes have been agreed. SROs appointed, project plan in place with governance through the SEL DOC/ CFO groups. CCGs required to hold 0.5% NR fund to mitigate health strategies. CCGs have been required to deliver SEL wide control total which has been reflected in the Operating Plan. Financial Plans: All organisations have submitted draft plans on 8th March and further work is required by CCGs and Trusts to agree their 18/19 control totals. GB oversight of STP through Chief Officer's updates Finance and risk reporting to Governing Body at every meeting and IGP reports every month and Financial Framework approved by Council of members M8 financial position further worsened for Bexley CCG ( 7m) affecting the SEL-wide control total. Risk that other SEL CCGs may not be in a position to contribute to the recovery of the SEL control total Regular discussions with all CFOs, ICDT, SEL AO to agree mitigations and maximise delivery of control total. Proposal being discussed with SEL AO - MH

151 IC-31 12/04/2018 IC-30 12/04/2018 IC-13 12/04/2018 FB-07 11/04/2018 Risk ID Date reviewed Strategic Objective alignment Risk Title & Description (Cause & Effect) Director Responsible Risk Owner Monitoring Committee/ Group Initial Risk Score (Likelihood x Impact) Residual Risk Risk Controls Assurance Score (Likelihood x Gaps in mitigation/ assurance Impact) SMART Actions with name of Risk Actionee & deadline for completion of action Target Risk Score (Likelihood x Impact) Direction of Travel Governance structure in place and operating effectively. Dulwich Programme Board meeting monthly, regular updates provided to SMT, Integrated Governance and Performance Committee and CCG Governing Body. Programme Board has HealthWatch representation and patient reps from the CCG's Engagement and Patient Experience Committee. SMT and Dulwich Project Board monitoring. GB oversight through IGP System Transformation Failure to implement a new service model in the Dulwich area would delay implementation of CCG's SELwide OHSEL strategic plans and result in additional costs to the CCG such as double running costs and double moves, additional work at business case stage to manage this risk and costly management solutions. Malcolm Hines Rebecca Scott Integrated Governance and Performance Committee Progress on work plan is progressing as scheduled. Dulwich Hospital site identified as location for health centre 'hub'. Subsequently confirmed as a new build through the PID and Site Options Appraisal. Continued close working with CHP, NHSPS and LIFTCo partner on agreeing process and timetable. Financial Close now scheduled for 18 April Close working with NHS Property Services: Close monitoring of progress of the project. Maintaining close working relationships with NHS Property Services. On-going liaison with Project Appraisal Unit (PAU) to brief them on issues in advance of the submission of the business case. Procurement. DH decided that the development will be procured via a Land Retained Agreement through the LIFT programme. LSL LIFTCo appointed, CHP appointed architects project proposal sent to LIFTCo. Separate procurement process being developed to ensure full occupation of primary care space in new building Design work: Design of the building progressed following a series of workshops involving patients and clinicians. Business case: Stage 1 approved in March 17. Stage 2 Business case approved 20 March Overview and Scrutiny Committee oversight. Consultation Institute have assured consultation process and confirmed it follows best practice Business case now approved DH approval of procurement method Primary Care Commissioning Committee has signed off specification and process Business case approval now confirmed. Financial Close scheduled for 18 April 2018 with start on site soon after. Some outstanding legal issues to be agreed in advance of that. On going monitoring. Primary Care Procurement starts in April RS Effective governance: CCG works with Lambeth CCG (lead commissioners for GSTT community nursing provider) on performance monitoring through core contract and CQRG meetings. Quality Alert system in place to monitor quality issues. Sustainable Delivery and Governance High numbers of staff vacancies is a risk to sustaining good quality community nursing service impacting on the delivery of care to patients and ability to manage patients in the community reducing the impact on Trust admissions (Also on Lambeth BAF) Caroline Gilmartin Jean Young Integrated Governance and Performance Committee Service escalation process for the community nursing service has been distributed. Community nursing lead and team attended June Locality meeting with constructive outcome. Leads will attend these meetings quarterly. GSTT reported at February Contract Monitoring Board that the Dulwich and Peckham team still have the highest level of vacancies (33%), reduced from 43% in November, and the lowest in Walworth (15%) and Bermondsey (18%) across all the teams. The current overall Southwark and Lambeth vacancy rate is 24% in Jan In the same month the service had 1728 accepted new referals and 24,313 face to face patient contacts (highest rate in August at 1693 accepted new referrals and 25,888 face to face contacts). A total of 8 qualified staff are in the pipeline to join the service and recruitment is ongoing. Recent actions to improve recruitment & retention - Fully recruited on clinical posts at Bands 8a, 7, 4 and 3 - Trust transfer policy is facilitating easier staff transfer into community services - Promotion of the service at universities and job fares to promote the services for newly qualified staff - Continuing to support staff with opportunities such as mentorship and improving arrangements for clinical supervision - The next GSTT nursing conference theme will focus on releasing staff potential and career development within community services - Nurse managers and clinical leads carrying out joint visits with staff - Successful conversion of agency staff into substantive posts - Exploring service level team building training options - To improve retention, the service is providing coaching and mentoring to staff wishing to develop into more senior roles within the service. - Recruitment and retention newsletter in place, focusing on support and learning opportunities available CQRG and core contract meeting minutes including review of provider recruitment and retention plan monitored at least quarterly. Neighbourhood nursing (based on Buurzborg model) pilot in the Walworth area since August 2017 Provider Daily Surge reports monitored by CCG Impact on service improvement following recruitment Assurance that Carenotes and SPA working as per specification Utilisation of escalation process Regular short progress updates to be made to GP practices through the locality meetings JY on-going Monitor implementation of actions through the GST Contract meetings to improve service quality including recruitment - JY ongoing CCG in the process of finalising patient outcome measures with GSTT for the District Nursing service which will be overseen by a clinical quality working group during. Q1-4 17/18. The proposed list includes wound management healing times and diabetes outcomes - JY April 18 CCG to raise assurance issue through Contract Monitoring Board and CQRG meetings at least quarterly- JY/JF - On-going Sustainable Delivery and Governance Non-delivery of the Adult Mental Health (AMH) Transformation Model and Enhanced Staying Well Team will place at risk (1) the required independent living and primary care support infrastructure that is needed to reduce inpatient acute beds at SLaM (2018/19 QiPP); and (2) transfer of care support and processes that will enable primary care to deliver the Mental Health agenda. Caroline Gilmartin Rod Booth Commissioning Development Groups/ CSC Effective governance: AMH transformation plans approved by Governing Body. Primary Care Development Models being developed via the Serious Mental Illness Commissioning Development Group. A monthly service design and delivery group with providers, service users and clinicians to oversee service delivery and on-going service improvement to ensure timely service delivery and to identify and manage risks. Quality assurance: Impact Assessments have been carried out for various areas of the new model of Care. Mental Health Team working closely with the Director of Quality & Nursing and the 4 borough CQRG group to ensure that there is continuity of care and quality standards are maintained. Implementation: Some schemes fully implemented and schemes around improving community and crisis response such as enhanced Home Treatment (24 hour access) fully implemented since October New service model for primary care liaison and transfers agreed in consultation with GP lead for Mental Health. Following June 17 CSC meeting, proposal under consideration for LIT to support discharge to primary care with fully developed health only model. New delivery model signed off and SLaM staff consultation process has commenced. Robust contracting process: Progress of implementing the AMH Transformation model us review at the weekly 4 borough (L/S/L/C) meetings and at the monthly Southwark contract Meeting. Published AMH model Serious Mental Illness Commissioning Development Group minutes Adults and Children and Young Peoples' Commissioning Development Groups minutes Joint Mental Health and Wellbeing Strategy Delivery Plan Non-delivery of discharge facilitation function. (1) Enhanced Staying Well Team service specification agreed for roll out - 31st March RB (2) New model for medicinces management in place - 31st August RB (3) New supported housing model agreed for roll out - 31st March RB (4) SLaM Borough based model operational from 1st July RB Strategy - Joint Mental Health and Wellbeing Strategy agreed by CCG Governing Body and Council Cabinet in January This sets the strtegic framework across Southwark CCG and Council for delivery of the new service models. Sustainable Delivery and Governance Risk that the provider does not (1) deliver achievement of IAPT 50% recovery rate in year as well as by end March 2019; and (2) deliver the increased access target of 19% during 2018/19. This will impact on CCG IAF outcome and reputational impact as a result of CCG failing to achieve national constitutional target. Caroline Gilmartin Rod Booth Integrated Governance and Performance Committee IAPT Performance targets monitoring: At core SLAM contract monitoring meeting and monthly at IGP. Continued close monitoring of service performance because of concerns about required KPI's and targets not being met. This includes monitoring of IAPT data submissions to NHSE and regular meetings with the provider to discuss performance. SLaM has been taking action to improve the recovery rate, and this has now increased to 46% for February The CCG has agreed non-recurrent funding to recruit additional therapists and to support a new marketing campaign for the service to increase referrals Data Reporting: One of the agreed actions from the recent NHSI Intensive Support Team (IST) diagnostic review of the service was that there should be centralised data reporting from Business Intelligence at SLaM. Plans for this have now been finalised and from January 2018 data reporting methods have been aligned with NHS Digital, so there will be no discrepancy between national and local data reporting in future IST Review and Recovery Plan: The IST review identified a number of areas which need to be addressed to improve the service offer and ensure that required targets can be consistently achieved. A detailed action plan has now been completed which includes IST report recommendations, and this was discussed during a follow-up meeting with IST in February The action plan is considered during weekly teleconference calls and monthly contract monitoring meetings. The plan states that compliance with the 50% recovery target should be achieved by March Proposals to review the Southwark IAPT model have been agreed by CSC in relation to its ability to deliver the required recovery rate within the current structure - the Southwark IAPT service supports people with complex needs in Step 4 which is not offered in all IAPT services. SLaM are currently reviewing complex psychological treatment pathways and this review will consider the best way to deliver high intensity step 4 treatments. Performance reports to IGP and IGP minutes SLAM contract monitoring meeting minutes Paper to CSC regarding revised model March 2018 recovery rate is 49% Access rate currently meeting target Capacity in the model to deliver recovery and access Ability of current model to deliver recovery rate and other targets Following national IST review recommendations, SLaM are reviewing complex psychological treatment pathways. The review will include a focus on IPTT waiting lists and their impact upon achievement of IAPT recovery rate and other targets. The service review will report through CCG governance structures and return to the CSC for further discussion about the potential impact of changes to the local IAPT model - RB - Q Access: SLaM in process of devleoping a 4 borough business case on additional resources required to meet the new 19% access target 4

152 IC /04/2018 IC-34 12/04/2018 IC-07 12/04/2018 IC-06 12/04/2018 Risk ID Date reviewed Strategic Objective alignment Risk Title & Description (Cause & Effect) Director Responsible Risk Owner Monitoring Committee/ Group Initial Risk Score (Likelihood x Impact) Residual Risk Risk Controls Assurance Score (Likelihood x Gaps in mitigation/ assurance Impact) SMART Actions with name of Risk Actionee & deadline for completion of action Target Risk Score (Likelihood x Impact) Direction of Travel Recovery Plan monitoring: RTT recovery plans included in KCH and GSTT contracts for 2017/18 and monitored with KCH, NHSI and NHSE through the System Oversight Group fortnightly. ICDT members are attending internal trust-wide performance improvement meetings. Outcome of NHSI investigation into RTT needed to have a fully integrated recovery plan. NHSI supported RTT Improvement Director working at the trust 2 days/week. NHS Improvement enhanced performance management framework On-going requirement to validate >18 week waiters Sustainable Delivery and Governance Sustainable Delivery and Governance Risk that providers do not deliver contractually agreed trajectories for Referral to Treatment target, specifically delivery of recovery plan. Effect would be longer waiting times for patients, and reputational impact as a consequence of failing to meet NHS Constitutional Standards. Risk that providers do not deliver contractually agreed trajectories for A&E NHS constitutional standards, specifically delivery of recovery plan to meet A&E 4 hour waiting time targets. Effect would be longer waiting times for patients, possible clinical risk to patient safety and reputational impact as a consequence of failing to meet NHS Constitutional Standards Caroline Gilmartin/ Sarah Cottingham Caroline Gilmartin/ Sarah Cottingham Caroline Gilmartin/ ICDT Kerry Lipsitz and ICDT Integrated Governance and Performance Committee Integrated Governance and Performance Committee Outsourcing: GSTT commenced ENT outsourcing to Concordia in January 2017, and Orthopaedics is expected to begin outsourcing to BMI once contracts have been agreed. The ICDT is working with KCH to identify further opportunities to outsource activity. Insourcing: ICDT working with KCH to increase outpatient and day case capacity. Services currently being insourced are outpatient appointments and day cases for Ophthalmology, Dermatology, and General Surgery. Planned Care Workstream Visual DX, a decision support tool, is being rolled out across all practices following a successful pilot. Partipating GPs reported increased confidence in diagnosis, greater confidence in their ability to manage patients in primary care, and reduced referrals to secondary care. Southwark, Lambeth and Bromley CCGs rolled out Consultant Connect on 16th October, a telephone advice and guidance service that allows GPs to seek advice from a local specialty consultant in real time. Numerous communications have been circulated to GPs and practices publicising the service. Further workstreams have been agreed and will commence in May. These are Paediatric ENT, Paediatric MSK, Cardiology, MSK, gastroenterology and long term conditions (commenced in March). Ophthalmology SPoR contract was awarded on 7 November 2017 and went live in March Dermatology SPoR contract was awarded on 23 December 2017 and went live on 3 April Contractual agreements: Trajectories for delivery of NHS constitution standards agreed with providers in 2017/18 and supplied to NHSE and NHSI. Trajectories reflect distance from national target and set improvement expectations across the coming year, whilst also reflecting the delivery of estates and transformation programmes at both GSTT and KCH. Additional non-elective activity commissioned as part of the contracting round. System Resilience allocations authorised to support providers across the system to reduce pressure at ED with oversight by the A&E Delivery Board. A&E Recovery Plan: Both GSTT and KCH have extensive recovery plans which detail, by month, the improvements expected and detailed action plans to ensure delivery. These plans are scrutinised on a weekly basis through 'Here and Now' groups and Emergency Care Boards. Performance management: Comprehensive approach to performance management with partner organisations including NHSE and NHSI and through the System Oversight Group, acute contract monitoring and overseen by CCG IG&P Committee and Governing Body. Detailed reports, plans and briefings shared with Governing Body members and included in monthly performance reports. CO attends NHSI's monthly escalation meetings with Lambeth CCG and Bromley CCG Chief Officers and NHSE for assurance on recovery plan. Lambeth and Southwark and SE London Discharge to Assess and Trusted Assessor workstreams - new for 17/18 these workstreams aim to reduce the volume of patients having assessments for CHC, community or social care in hospital in order to maximise rehab potential and to reduce bed occupancy and delayed transfers of care at acute providers. Workstreams established with impact expected from October onwards. Winter Monies and Plans - Through Lambeth and Southwark A&E Delivery Board, winter monies have been allocated to all system partners to improve resilience for the winter period. Providers and commissioners agreed that monies would be top sliced to ensure there is adequate funding available to support Discharge to Assess and Trusted Assessors workstreams which aim to significantly reduce the number of patients waiting in hospital for assessments. Winter plans submitted to NHSE; escalation meetings on-going with NHSE/NHSI and Secretary of State to be held. New winter scheme: The Corner Surgery for KCH to redirect non-urgent primary care patients from November Options appraisal document around the UCC presented to KCH Emergency Pathway Board with the recommendation to keep a integrated ED/UCC. Contract monitoring meetings Monthly performance reports to IG&P and GB System Oversight Group minutes and actions Planned Care Programme Board which reviews progress on referral optimisation work ICDT attend provider internal performance meetings. NHS England enhanced performance management framework with weekly oversight CCG hold weekly Thursday and Friday call with KCH and Surge Hub for weekend planning and assurance. CCG managment attending daily meetings at KCH from 8-9am KCH & GSTT reporting on progress with Transformation programme and ECIP recommendations IGP and GB performance reports. KCH & GSTT CQRG and contract monitoring meetings. System Oversight Group minutes and actions A&E Delivery board minutes Recovery plans complex and multifactorial. Financial stability and sustainability of KCH Demand increases above population growth Insufficient capacity to implement plan Planned capacity is being diverted to cope with urgent and emergency care pressures. Estates plans for both GSTT and KCH are subject to slippage with negative impact. Workforce issues delay the opening of estates or cause operational difficulties Recovery plans for both GSTT and KCH are highly complex thus are subject to delay or revision Pressure from KCH and outside organisations might result in Southwark looking at contracting a seperate UCC which carries risks for the organisation and the block contract. Proposals for additional resource to support referral optimisation from NHSE have been approved to enable us to expand Consultant Connect and roll out Visual DX more widely. Implementation underway -April OA-R/DS Working with NHSE to explore further outsourcing opportunities - on-going- ICDT/DS Process improvement to improve flow and capacity through patient choice protocols and patient discharge - KMB, on-going Co-ordinating actions and supporting trusts to reduce DTOCs and delays in discharging patients who are medically fit - KMB - ongoing Work on-going with both Trusts to review recovery plans and examine options for further mitigations. - KL/AB/SC - on-going Work being undertaken on MH breaches by SLaM, KCH and CCG - ongoing Work on-going with The Hurley Group and KCH around filling gaps in GP rotas and issuing honorary contracts to improve shift cover - ongoing UCC weekly working group meeting has turned into an implementation group to drive changes within the UCC. The ICDT is providing support to this project. Chaired by NHS Improvement Rachel Williams NHSE/NHSI update on trust action plans Governance: Cancer 62 day SEL System Leadership Group meetings in place to address SEL wide issues - SRO is Lambeth Chief Officer. Governance structure in place across the three trusts to oversee shared breaches, pathway delays and delayed transfers. SEL Cancer Network, led by the Accountable Cancer Network - developing and implementing tumour level pathways across SEL. Implementation of the improvement plan with the oversight of the SEL Leadership Group - ICDT - on-going Sustainable Delivery and Governance Risk that providers do not deliver contractually agreed trajectories for 62 day target for urgent cancer referrals Caroline Gilmartin/ Sarah Cottingham Caroline Gilmartin/ ICDT Integrated Governance and Performance Committee SEL wide cancer recovery plan - a pack outlining the next steps, priorities and approach for 2018/19 has been created. There is a particular focus on improving shared pathway performance. The pack includes draft trajectories for internal and shared performance - these trajectories still need to be signed off by NHSE/I. GSTT and KCH have reviewed their access policy and escalation processes to ensure that patient choice delays are managed more tightly. GSTT has seen significant improvement in internal performance as a result of changes to tracking, escalation and the introduction of ers for all two week referrals, the latter having a particular impact in improving the early part of the cancer pathway. KCH are implementing ers for 2ww with mandatory ers referrals from 1 July. Cancer diagnostic fund - SEL made 4 successful bids around additional training and point of care testing - implementation and monitoring will be undertaken through the Accountable Cancer Network and the 62 days review group. Transformation fund - SEL transformation fund secured. 2 bids for additional diagnostic funding agreed. In January 2018, a third national funding bid was agreed to support the prostate pathway within SEL. In addition, SEL has agreed to locally fund additional diagnostic outsourcing with 1m in total being provided by the three SEL trusts and Lambeth and Southwark CCGs. Additonal outsourcing began for CT and MRI at LGT and KCH in late November/early December 2017.Endoscopy outsoucing (to increase capacity) commenced in Febraury Macmillan GP - Recruited to support the GP clinical lead in Southwark improve quality and efficiency of cancer care. Shared pathway review groups - Bilateral meetings were held between GSTT/ LGT and GSTT/KCH. The meeting reviewed the new agreed final shared pathways. Following review, a number of shared care actions were produced which are being taken forward through a weekly task and finish group. Assurance meetings with NHSE SEL System Leadership Group minutes for oversight role IGP reporting SEL wide Cancer Recovery Plan Primary care led Cancer Locality meetings - oversees quality and primary care actions Impact of unplanned admissions on planned cancer procedures. Avoidable breaches are occurring. Patients on inter trust pathways referred late. Patient choice delays Late referrals from outside SEL Diagnostic capacity - Long term Improve uptake of new 2 week wait referral forms and supporting information - national audit ongoing. Forms have been updated to include reference to e-rs - System Perf/ National team - on-going The System Performance team are communicating with GPs to ensure 2 week wait referrals made to GSTT are via e-rs only. We are communicating this to GPs through the planned care newsletter, GP bulletin and practice visits. We will also ensure comms are sent out to GPs notifying of them of when King's 2 week wait clinics will become e-rs only.- Mar System Performance team Diagnostic Capacity Review - The Accountable Cancer Network (ACN) is producing a SEL wide diagnostic review paper focusing on imaging and endoscopy. This paper will review demand and capacity and outline medium to long term options. Upon completion we will take forward the recommendations of the review- on-going - ICDT The outcome of the CQC inspection process has resulted in adverse outcomes for some Southwark practices. The current status is as follows: - 2 practices closed; 3 practices are under caretaking arrangements; 1 has had their rating improved and are no longer in special measures as a result of support from the CCG, NHSE, GP federation and GPFV-funded support; -6 practice remains in special measures, but has received support from the CCG, NHS England, GP federation and GPFVfunded support; all have received contractual action Sustainable Delivery and Governance Risk that adverse CQC inspection outcomes for general practices in Southwark will negatively impact on quality of care provided to the registered populations. Caroline Gilmartin Jean Young Primary Care Commissioning Committee practices are rated as requires improvement: - all of these practices have been followed up with support from the CCG teams and LMC, where requested;2 of these have received contractual action, 1 of these notifications are outstanding To recognise the additional workload of 2 recent list dispersals in the same area of North Southwark, the CCG has identified and provided additional funding for practices taking on a significant number of patients in a short period for the additional admin and clinical health check work. This is in addition to the funding practices receive for taking on new registered patients from the national contract formula allocation. Securing high quality GP service sites has also been a challenge as a result of practice changes where these have been owned by the contract holder and continues to be a high priority for the CCG in the short and long term. This is linked to the estates strategy. CCG, with input for GP federations, have endorsed 6 prioritised practices for resilience funding using London set criteria. The CCG continues to work with these practices and has agreed their resiliance plan and funding which will be paid against a signed Memoradum of Understanding between each practice and the CCG. Quality and Safety Committee minutes Primary Care Commissioning Committee minutes Quality improvement approach Contract management process Sustainability of improvements made after intensive support in 6 months and onwards Full report on specific risks in 1 caretaking practice awaited in partnership with NHS England. Practices appropriately funding premises improvement as per their contract and statatory responsibilities Primary Care Commissioning team reviews status of practices and improvement actions on a weekly basis - JY on-going Primary Care Commissioning Committee receive updates on progress against contractual actions and CQC status changes - bimonthly JY CCG to monitor GPFV resilience plan against agreed funding - JY monthly, Q4 and Q Risk for the GP service provision in the Bermondsey area due to specific practice issues. CCG is supporting both practice improvements and monitoring closely, the CCG has completed an options appraisal for future service provision. 5

153 IC-25 12/04/2018 IC-50 12/04/2018 IC-45 12/04/2018 IC /04/2018 Risk ID Date reviewed Strategic Objective alignment Risk Title & Description (Cause & Effect) Director Responsible Risk Owner Monitoring Committee/ Group Initial Risk Score (Likelihood x Impact) Residual Risk Risk Controls Assurance Score (Likelihood x Gaps in mitigation/ assurance Impact) SMART Actions with name of Risk Actionee & deadline for completion of action Target Risk Score (Likelihood x Impact) Direction of Travel LAS recruitment: Target staffing; however this is an on-going challenge due to turnover. Sustainable Delivery and Governance Risk that London Ambulance Service (LAS) does not achieve performance targets for response rates as limited data is being released around ARP to CCGs which allows for no oversight of responses to Southwark residents. Risk that LAS does not deliver improvements required based on CQC inspection outcomes. Caroline Gilmartin Kerry Lipsitz Integrated Governance and Performance Committee Centralised commissioning arrangements. Led by North West London Commissioning Alliance on behalf of London CCGs to enable a single commissioner voice. London-wide Strategic Commissioning Board in place chaired by the CO of Brent CCG. Joint approach with NHS England. London Chief Officers' meeting that Southwark CCG leads for SEL has agreed an STP approach to LAS commissioning. Emergency Pathway Board at KCH: attended by CCG representatives where hospital handovers are discussed. New working practices implemented & will be continually monitored to ensure performance improvement is maintained. Monitoring of action plans: LAS CQC action plan reviewed at each CQRG meeting; CCG representatives incl. Southwark attend these meetings to seek assurance. CQC reinspection on 30/6/17: Significant improvements made in the 5 inspected areas and the service moved up a rating to 'requires improvement' overall. Quality improvement: Quality Report reviewed at each CQRG. Southwark CCG participated in a Quality Working Group to design and negotiate LAS CQUINs and the 17/18 Quality Schedule, it is expected that this group will continue for 18/19. Focus is upon non-conveyance to incentivise hear and treat, see and treat rather than automatic transfers to hospital. Focus on demand management schemes at London level. Ambulance Response Programme (ARP) - From November 2017, the service will implement this pilot providing LAS extra time on a call to better understand the condition of a patient before dispatch. This will also modify performance targets that the LAS work to. Demand Management - SEL wide Demand Management Group formed to identify and implement opportunities to reduce demand on the LAS and implement: Hear and treat - LAS will be working to increase hear and treat activity by 2%. Technology - LAS will be improving access to technology, e.g. provision of tablets for LAS ground crews to help them identify potential alternative pathways. Alternative care pathways (ACPs) - The service is looking at increasing the use of ACPs across London. London Strategic Commissioning Board oversight. NHSE tripartite oversight Performance review at IGP CQRG minutes NW London commissioning team performance review processes SEL wide LAS demand management group Quality Working Group minutes London wide significant quality and financial pressures High staff turnover Alternative Care Pathways usage does not improve. Description of specific risks on King's handover times and demand management Ownership of demand management projects across SEL CCGs is not robust. Needs direct STP leadership to drive programme. SEL Demand Management group to implement demand management projects for 2018/19. CCGs will be focusing on alternative care pathways, frequency callers/attenders, communications to care homes and mental health pathways. on-going - SEL CCGs KCH developing improvement plans around improving ambulance handover times to improvement performance - ongoing CQC inspected LAS in February Overall, the CQC rated LAS as requires improvement compared to being rated as inadequate in CQC inspected LAS again in Feb/March Waiting for outcomes from the report. Meeting to be held with the ICDT team to start the transition of moving LAS contract responsibilities to that team. - KL Sustainable Delivery and Governance Risk to the sustainability of GP practices across north and south Southwark due to workforce, workload, financial pressures and infrastructure, impacting on quality outcomes for Southwark primary care patients. Caroline Gilmartin Jean Young Primary Care Commissioning Committee CCG monitors GP practice quality through Quality Assurance Framework incl. monitoring against SEL and similar boroughs in London (statistical neighbours). CCG supported federations submit provider resilience plan for practices to access funding and support to improve and sustain local General Practice as per the General Practice Forward View. The CCG support provided as below: Workforce: Investment and guidance, Enabling training practices to be set up; Supporting recruitment processes; Development of pre-reg nurse placements and mentoring; Supporting different ways of working i.e. primary care pharmacist. Workforce access, specifically nursing, is included in prim. care commissioning intentions. Supporting federations to develop nurse leadership to lead and retain workforce. Supporting the establishment of Local care networks (partnership working). Starting to develop a primary and community care service for wound management to maximise resources. Care redesign: Supporting practice mergers (e.g. Nexus); GP Federations established, infrastructure funding for at scale working, leadership development; Extended Primary Care Services commissioning and development; Estates and Technology Transformation Fund (ETTF) bids to test apps which support patients with self care and alternative access; Local Care Networks establishment and support, of which GP Federations are part. Practice Infrastructure: ETTF applications to fund estates development and premises improvement; Testing new consultation methods (telephone/e-consultation/skype); Funding virtual Community of Interest Network (CoIN) for practice mergers; practice Wi-Fi. Securing support for key worker homes to attract workers into the area. Workload: Supporting practices access transformation funds to increase investment in general practice and support sustainability & transformation; Developing locality resilience plans with GP federation including immediate and long term support; Local Care Record (LCR) implementation by CCG enables direct access to patient results and information within the GP practices. Primary Care Commissioning Committee oversight and minutes Local delivery of London Strategic/CBC Framework to delivery accessible, coordinated and proactive care in progress STP funding and delivery Potential access to support for practice mergers Impact of practices working at scale Practices investing in good quality workforce that is sustainable Practices investing in service provision and estates (as per contract requirements) CCG working with federations to develop different work force models including practice based pharmacists - MK - on-going CCG working with federations to develop training practices, nurse mentors and placements for pre reg nurse - KMB - on-going Roll out of GP Forward View (GPFV) resilience funding. Focus on ensuring the resilience funding plan is delivered JY on-going Negotiation of APMS contracts with premium specification - April JY Commissioning: CCG's GP practice commissioning incentives aim to simplify the primary care incentive and payment structure enabling practices' stronger focus on lower number of incentives in line with our published FYFV. This is focused on improved access, prevention and coordinated care. Completed successful negotiation of the PMS premium in May Final contract offer signed by all PMS and GMS practices signed up to premium specification, APMS negotiation in progress. Premium offer seeks to reduce unwarranted variation and incentivising continuous quality improvement through sustainable GP practices for the benefit of the local population. Governance - All SEL organisations have nominated executive director leads. Director of Integrated Commissioning is the lead director for implementation for Southwark. Lambeth, Southwark and Bromley e-rs Steering Group oversees achievement of the national CQUIN trajectories - membership includes senior managers from Lambeth, Southwark and Bromley CCGs and Guy's & St. Thomas' and King's College Hospital (Denmark Hill and PRUH). Planned Care Programme Board: Progress in implementing e-rs is reviewed at the LSB Planned Care Programme Board. Work through the e-rs Steering Sub Group to publish clinics on e-rs for specific specialties - DS/System Performance team - On-going Previous risk score: 3x4 Sustainable Delivery and Governance Risk that national timelines for e- Referral System implementation are not met due to technical and implementation issues with the system. This would result in a loss of CQUIN payments for our acute providers and loss of payment for any activity not booked through e- RS from October Caroline Gilmartin/ Sarah Cottingham Caroline Gilmartin/ ICDT Integrated Governance and Performance Committee Support for GP practices: GP communications: Monthly practice packs are sent out which detail e-rs utilisation and regular updates are provided in the fornightly planned care newsletter. Ad hoc communications are sent out to all practices advising on planned paper switch off for both GSTT and KCH. Assurance and training: GPs were asked to return an 'Are you ready' e-rs assessment questionnaire which highlighted practice training needs and issues. All practices were required to respond to a self certification form confirming that they were e-rs ready. A GP IT Faciitator is available to provide training to practices. Group training sessions for admin and clinical staff were delivered during the summer and individual training has been provided on request. For CSU IT support to GP practices and the specific impact that this would have on utilisation of e-referrals, please refer to Risk FB-36. GSTT - The trust has produced a phased plan for publishing services and is working across the system to quality assure all its published services. Tranche 1 specialties became e-rs only on 1 September and tranche 2 specialties became e-rs only on 1 December. 8 specialties became e-rs only on 1 February 2018 and the rest of the trust's specialties went e-rs only from 1 April. KCH - The trust has produced a phased paper switch-off plan. The CCG is supporting King's in their move to e-rs only for their first tranche of specialties and on 1 February 2018, 15 specialties became e-rs only at King's DH and a further 5 became e-rs only on 1 April. Lambeth, Southwark and Bromley e-rs Steering Group reviews performance Monthly performance reports to IG&P and GB LSB Planned Care Programme Board Known technical limitations of the e- RS system Current incompatibility of e-rs with DXS and trust PAS systems Engagement from specialties at trusts. Working with trust e-rs leads to get GP clinical sign-off on e-rs DoS - on-going - System Performance e-rs training sessions via e-rs facilitator and practice managers - on-going - System Performance Supporting GSTT and King's to move to e-rs only. Support includes issuing regular communication to update GPs, communicating changes to other CCGs in and out of SEL and helping to contact practices to resolve referral issues - October 2018 (national deadline for paper switch off) - System Performance Utilisation has increased from around 22% in December 2016 to over 60% in March A credible plan of ensuring 100% utilisation by October 2018 in place. CCG Implementation - Implementation plan has been produced with Lambeth and includes detailed actions and timelines. Quality and Safety Significant financial and operational risks to Southwark mental health placements delivery in 2018/19 if robust governance arrangements are not developed in partnership with the Council (noting the Council has served notice on the current S75 partnership agreement for placements with no alternative arrangements proposed as at 15th March 2018). This will compromise our ability to generate quality patient outcomes for the population we serve as well as lack of opportunity for recovery and independent living. Caroline Gilmartin Rod Booth Adult CDG The CCG and Local Authority continue to co-chair all panels to ensure patients are following through the pathway correctly with regular reviews. A Placement Management Group has be developed with the CCG, SLaM & the Local Authority to: a) Develop a framework to provide strategic oversight of placement budget b) Develop KPIs and outcomes to monitor performance c) Review funding Panels to further strengthen governance d) Review CPA and Section 117 policy The CCG and Council have endorsed the development of an population segmentation contracting model through the SMI CDG to re-procure mental health accommodation based support services in Southwark. The placement panel process will be reviewed as part of this new model. CCG and Council partners working through options to deliver a new Southwark approach to placements for 2018/19. Key to this will be budget control and managing demand, capacity, step down and recovery with the provider offer from SLaM and Supported Housing services. Key focus of the newly agreed Joint Mental Health and Wellbeing Strategy is to delivery a new supported housing model in Southwark to support discharge and move on which will help deliver the Southwark recovery model. CCG and Council partners will undertake a joint review of services commencing in summer Governance arrangements for Placements Panel reviewed and financial risks associated with this identified. Quality concerns letter. A briefing on actions and Outcomes from the task & finish group will be reported back to Directors. Southwark Council external reviews of mental health and social care placements CCG has instructed solicitors for legal advice Need to review processes for the management of complex MH clients Financial controls not strong - budget overspent Council wish CCG to use Resource Allocation System (RAS). CCG do not consider tool fit for purpose. CCG and LA need to develop a process for agreeing joint funding where this is appropriate Council not agreed CCG outcomes offer to close 2017/18 on an overspend known to all parties on a month by month basis agaisnt agreed / actual placement activity - under negotiation. Analysis of residential placement data to ensure accuracy so that costs can be identified and apportioned correctly. Development of population segmentaiton contracting model for mental health accommodation based support services. CCG are reviewing and strengthening the processes in place for the management of complex MH clients Provider has been alerted to quality concerns in forensic team management, waiting for response. Meeting with LA to finalise splits and propose 17/18 allocation but agreement not yet achieved. PCT to lead work with CCG and LA to create revised s75 / pooled budget model for

154 IC /04/2018 IC-22 12/04/2018 Risk ID Date reviewed Strategic Objective alignment Risk Title & Description (Cause & Effect) Director Responsible Risk Owner Monitoring Committee/ Group Initial Risk Score (Likelihood x Impact) Residual Risk Risk Controls Assurance Score (Likelihood x Gaps in mitigation/ assurance Impact) SMART Actions with name of Risk Actionee & deadline for completion of action Target Risk Score (Likelihood x Impact) Direction of Travel Quality and Safety Risk that public health grant reductions will continue to reduce provider funding which will impact on the delivery of public health prevention for adults and children e.g. stop smoking, sexual health, health checks, health visiting and school nursing. Caroline Gilmartin Jean Young Children and Young People's Commissioning Development Group Section 75 agreement: CCG commissions mental health services, children's services (health visiting, school nursing and early years nutrition) health checks, sexual health and smoking cessation services on behalf of the Council under a Section 75 agreement. The Health & Social Care Partnership Board oversees the S75 meeting bi monthly. This Group receives a quarterly Section 75 report on activity and finance. CCG has commissioned health check services in partnership with Southwark Council from GP Federations through a population health management contract which will be delivered by both GP federations on a population basis. This contract is until 31 March CCG reviewed the quality standards with focus on the population health management contract to ensure focus fit for population needs. s.75 specification for services signed 17/18. Integrated Child Pathway: CCG and LA have prioritised development of a integrated child pathway school (-12 months to 19 years) in their commissioning intentions with a focus on school readiness as a outcome, prevention and early intervention. Progress of Integrated Child Pathway Development through the CYP CDG to joint CSC quarterly. Stop Smoking Service: CCG has agreed a new pathway utilising remaining resources for a targeted stop smoking service working on behalf of the Council with GST, SLAM and community pharmacies. CCG ring fenced the prescribing budget for pharmacy based supply of stop smoking therapy products. Concern decommissioning of stop smoking services from GP services will reduce number of people quitting smoking and/or GP practices not working with patients to stop smoking particularly those with LTC. Council reduction of health checks budget and decommissioning of stop smoking services has resulted in a smaller population health management contract value for 2017/18 and thereby relatively reducing income into GP practices and GP federations since the procurement of this contract. Population health management: GP federations have requested 10% management fee for population health management contract which may affect delivery of number of health checks if Southwark Council accepts and continues to commission these services through the population health management contract. This has been requested for the sexual health contracts. Council Commissioners have now confirmed their position (4th April) and the CCG is in the process of responding to this proposal. Substance misuse service to continue in same format with a 1819 review Minutes of Health and Social Care partnership Group meetings Meetings of population health contract performance and monitoring Meetings of 0-19 commissioning intention working group CYP CDG workplan Public health grant reductions being made year on year reducing funding to deliver targets Council responsible for commissioning of public health services which CCG can only influence Current proposals do not include an accurate understanding on actual and possible cost reduction as well as impact on residents and NHS spend. Agreed programme between LA and GSTT for funding CCG will monitor outcomes of the Population Health Management Contract on a monthly basis - JY 17/18 CCG has agreed to work with the federations to reduce inequalities of patients accessing LARC services - on-going CCG to respond to Council's proposal re S and population health management contract management fee JY April Sustainable Delivery and Governance Risk that the GP Practice funding transferred to the CCG under delegated commissioning will curtail the CCG's ability to commission sustainable GP practice services and the premium focus to improve access, prevention and continuity of care Caroline Gilmartin/ Malcolm Hines Jean Young Primary Care Commissioning Committee CCG undertook full delegated commissioning of GP practice services from 1 April The CCG has now received full budgets which are in the process of being verified. NHSE has indicated the CCG will have a GP practice delegated commissioning budget with a deficit of 1.83m - now reduced to 1.406m. GP practice budgets verified by the CCG finance team. CCG has calculated final PMS Premium at per weighted patient. CCG agreed a Local Incentive Scheme to enable the delivery of the new PMS premium specification in Q3 due to delays to the PMS contract start date to 1st Jan 18 from 1 Oct 17 as a result of Londonwide LMC assurance process. PMS contract received full assurance and has been sent to all PMS practices which have all signed up to contract and premium. CCG negotiating APMS equalisation with all APMS contracts. All caretaking arrangements will be finished by 1 October Delegation document issued by NHS England NHSE have confirmed budget which is less than expenditure Unclear what the deficit relates to and how CCG will manage stabilising practices with this deficit. CCG finance and primary care team working on planning to minimise the deficit between allocated and actual budget for dicussion at the Primary Care Commissioning Committee - Q4 JY/JW Funding gap being mitigated from reserves - MH - Q4 CCG negotiating APMS contracts JY Apr/May Close - CCG has reset budgets for 18/19 and these are fully funded CCG has reset budgets for 18/19 and these are fully funded. 7

155 Southwark CCG Committee Report ITEM FOR DISCUSSION CCG Committee Governing Body Month May Year 2018 Item title: Enclosure number: Healthy People in Healthy Places Annual Public Health Report of the Director of Health & Wellbeing 2017 C Any know conflict of interest No The item is being presented to the committee for (select only one): Discussion Assurance Report Author Responsible Director Chair: Dr Jonty Heaversedge 1 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

156 Name Dr Benjamin Dallyn Name Prof Kevin Fenton Job title Senior House Officer in Public Health Medicine Job title Director of Health and Wellbeing Directorate N/A Directorate N/A wark.gov.uk hwark.gov.uk 1. Purpose of the paper (why does the committee need to discuss / receive assurance?) The attached document is the independent report of the Director of Health and Wellbeing (incorporating the role of the Director of Public Health), published on 13 March 2018, covering the period January to December The Health and Social Care Act 2012 places a statutory requirement for Local Authority Directors of Public Health to report on the health of the local population, and for Local Authorities to subsequently publish that report. The report is provided in three parts: Part A provides a thematic review of the importance of place in shaping health and addressing inequalities; Part B takes the form of a statistical bulletin that reviews the current state, recent achievements and next steps for childhood obesity, sexual health, mental health, long-term conditions and air quality; Part C is a compilation of additional resource including a specially developed video that showcases the history of public health in Southwark and explains how public health will engage in shaping regeneration for healthier and happier lives in the years ahead (see Appendix 2). Additional slide resources and infographics will be added to the website in due course. These papers are provided to the Governing Body as an item updating NHS Southwark CCG on public health in Southwark. 2. Describe the issue being presented to the committee for discussion or assurance Chair: Dr Jonty Heaversedge 2 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

157 The report makes five recommendations to be taken forward in 2018/19: 1. Leadership: Develop and enhance cross-council governance, partnership and communication opportunities on social regeneration efforts to raise awareness, facilitate collaboration, and encourage more systematic evaluation of the opportunities and impact of urban renewal to improve health and wellbeing, reduce inequalities and improve life chances. 2. Strategy: Ensure local health and wellbeing plans are in place for all major regeneration efforts taking place across the borough and that these are developed through wide engagement with local communities and stakeholders. 3. Evidence-based policy: Further accelerate the use of local health, social and other relevant data into local planning decisions to ensure that a more comprehensive understanding of the wellbeing needs and potential health and inequalities impacts are considered. 4. Monitoring and Evaluation: Develop a standard set of key indicators for social regeneration, working collaboratively with a wide range of partners including local communities, to guide the evaluation of all urban renewal projects in the borough. 5. Partnership: Develop and maintain robust governance, communication and other opportunities to support community participation and to engage key stakeholders on the Council s progress on social regeneration and identify opportunities for collaboration. We provide updates within the Statistical Bulletin on demography in Southwark, highlighting the borough s diversity; that the population will grow 20% over the course of the next decade and that important inequalities remain. Childhood obesity remains a particular challenge for public health in Southwark and in the last year we ve undertaken a wide range of work on the back of our obesity strategy: we ve worked closely with planners and received a number of accreditations and awards. While we report some of the highest rates of sexually transmitted infections (STI) in the country, the trajectories on both new STI diagnoses and HIV are improving. Poor mental health afflicts many of our residents and our rates of suicide are among the highest in London. In 2017 we developed strategies for mental health and for suicide and 2018 will see the implementation of our plans. We are working closely with our NHS partners to better understand and meet the need arising from long term conditions. Air quality has been another area of work where the council has undertaken analysis and built air quality into policy through its New Southwark Plan. We have worked with schools and other partners in an effort to mitigate the risks that air quality present. Within the statistical bulletin we have identified a number of key areas for work in 2018/19 among which are commitments to: 1. Collaborate with Guy s and St Thomas Charity, local faith groups and other council departments to deliver sustainable, community-driven interventions around obesity and multiple long term conditions. 2. Develop a new sexual and reproductive health strategy in partnership with Lambeth and Lewisham. 3. Work with NHS Southwark Clinical Commissioning Group and partners across the council to more closely integrate physical and mental health in Southwark in connection with the Southwark Bridges to Health and Wellbeing model. Chair: Dr Jonty Heaversedge 3 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

158 4. Pilot a digital NHS Health Check and improve uptake and health outcomes. 5. Promote School Travel Plans and increase the number of local schools attaining Transport for London s STARs Silver or Gold accreditation each year. 3. What stakeholder engagement has taken place? The report is an independent report on the state of public health in Southwark. The report was presented at Southwark s Health and Wellbeing Board on Monday 26 March Supporting information / documents Please append any relevant documents including detailed reports; options appraisals; background documents; national guidance etc. Appendix # Name of document i Healthy People in Healthy Places Annual Public Health Report of the Director of Health & Wellbeing 2017 ii Healthy People Healthy Places - video iii Healthy People in Healthy Places Annual Public Health Report of the Director of Health and Wellbeing 2017 Accompanying slides Date paper completed Friday, 27 April 2018 Chair: Dr Jonty Heaversedge 4 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

159 Healthy People in Healthy Places Annual Public Health Report of the Director of Health & Wellbeing 2017 Tap here to go to contents >>> Please cite as: Annual Public Health Report of the Director of Health and Wellbeing 2017, London Borough of Southwark. Published 14 March 2018

160 Foreword from the Director of Health & Wellbeing Each year, Directors of Public Health in local authorities across England fulfil a statutory requirement to write an annual report on the health of their population. The Annual Public Health Report (APHR) is a vehicle for informing local people about the health of their community, as well as providing necessary information for decision makers in local health services and authorities on health gaps and priorities that need to be addressed. It is often an extremely powerful tool both to engage with local communities and fellow professionals in public health, health and social care. Since starting as Southwark's Director of Health and Wellbeing in April 2017 I have had the privilege of working across the Council and alongside a range of healthcare, community, business, academic and other partners to help ensure that the health and wellbeing of current and future generations of Southwark's residents are at the centre of everything we do. Our public health team have identified five overarching priorities in support of the Council's Fairer Future for All promises: social regeneration; providing effective and high quality care for all; improving health outcomes; making health everyone's business; and investing in our staff. Today, our work is underpinned by three core values: tackling inequalities; promoting effective partnerships, and using data and evidence to inform practice and policies. With this renewed strategic focus and streamlined approach to our population health priorities, the past year has seen a strengthening of our visibility and relationships across the Council. We now have innovative and robust partnerships with colleagues in Education, Planning, Social Care, Regeneration, Culture, Leisure, the Environment and Communities. We have strengthened our work with the Southwark CCG, local health providers, and the wider primary care family. And we are increasingly working alongside local businesses and communities to tackle a range of issues including mental ill health, food poverty, and social regeneration. These partnerships form the cornerstone of our health in all policies approach and address to the fundamental truth that health is much more than healthcare, but a state of complete physical, mental, social and spiritual wellbeing. This year's APHR provides an opportunity to reflect on our collective progress in improving health and tackling inequalities in Southwark over the past year. The report's theme, "Healthy People in Healthy Places", reflects Southwark's commitment to place individual and community wellbeing at the heart of its efforts to revitalise communities. From major regeneration projects currently planned or underway across the borough, to efforts to create healthier high streets, place matters. We now have unparalleled opportunities to be global exemplars in leveraging regeneration efforts to fundamentally change our borough's health profile, including improving increasing healthy life expectancy and reducing the wellbeing gap, for new and existing communities. Our Healthy People in Healthy Places report is in three parts. In Part A we provide a thematic review of the importance of place in shaping health and addressing inequalities. We identify a few key recommendations to our system partners to help accelerate our progress on place shaping for health in the year ahead. In Part B, we provide a statistical bulletin which builds upon the comprehensive review of our community health profile covered in our APHR This section focuses on a few areas where we have made good progress in the past year, but where further action in required. Part C includes links to key resources on health and wellbeing in the borough including our new APHR video, PowerPoint slides, with links to other data and intelligence tools and resources. We will be adding new infographics to this resource pack in the coming months. In summary, this year s report sets out where we will focus our efforts over the next year, from prioritising place shaping for health and wellbeing and relentlessly striving to address the borough s key health priorities, to improving the ways in which we communicate, engage and work with partners and local communities, and providing useful and innovative tools to inform decision making. In all of this, we will be engaging further with stakeholders including and beyond the traditional realms of healthcare, ensuring the most effective use of our resources, tailoring our support to where we can have the greatest impact, and pushing for even greater influence where it matters most. Professor Kevin Fenton MD PhD FFPH Director of Health and Wellbeing incorporating the role of Director of Public Health March 2018 Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 2 of 34

161 Acknowledgments Contributors Jin Lim, Richard Pinder, Rosie Dalton-Lucas, Chris Williamson, Kiran Attridge, Sadie Regmi, Sophie Baird, Talia Bashari, Nora Cooke O'Dowd, Clizia Deidda, Sabrina Kwaa and Carolyn Sharpe.

162 Contents Foreword from Professor Kevin Fenton 3 Part A: The Report Healthy people in healthy places 5 Tap on a chapter to jump pages... Part B: Statistical Bulletin 12 Demographics 14 Childhood obesity 19 Sexual health 21 Mental health 23 Long term conditions 25 Air quality 27 Part C: Media and Resources 32 Tap here to go to contents Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 4 of 34

163 Healthy People in Healthy Places Annual Public Health Report of the Director of Health & Wellbeing 2017 Part A. The role of place in shaping health and wellbeing in Southwark

164 Place and health "...the places in which we are born, live, work and age influence our health and wellbeing..." Introduction From the air we breathe to the streets we walk, the places in which we are born, live, work and age influence our health and wellbeing by enabling or hindering healthy lifestyles. The fabric of our neighbourhoods can bear heavily on what we eat, how active we are, how we interact with others, and what activities we take part in. How these places and spaces are designed, maintained and evolve is therefore vital to the health and wellbeing of the people and communities within them. Healthy places are those which enable: Connection with others Healthy affordable homes Active living and travel Affordable quality food Safe, attractive public spaces for play and recreation Contact with nature in everyday life Access to quality services and amenities. Shaping place for health is an active process. Local authorities are strategic leaders in placeshaping, able to respond to residents' ambitions and aspirations and work with partners to deliver relevant services. Indeed, it is an exciting time for shaping place to health given local authorities focus on economic development and economic purpose for local communities; new statutory arrangements; new local strategic partnerships that can influence place; new institutional arrangements and ways of working. Today, Southwark s annual residents survey provides evidence of residents' requirements and aspirations. Our rolling programme of Joint Strategic Needs Assessments provide evidence of local needs across a range of functions and support the Council and our partners to deliver its place-shaping role effectively. Place-shaping is a highly important concept for those involved both in revitalising existing, and building new communities to understand. In some areas of the borough, the volume of new housing compared to the number of existing homes, where they exist, will be large. And their development will affect the character of a place and therefore this is a process that needs to be managed. In other areas, even limited development can be used to influence health, whether through changing the high-street, increasing opportunities for health promoting retailers and spaces, or improving the built environment. To support this, Southwark have been one of ten local authorities exploring an improved understanding and relationship with developers through the Town and Country Planning Association s Developer and Wellbeing programme. This is an important step in working towards a shared vision for health through place shaping that can account for local health needs, meet the viability test and also satisfy healthy planning policy requirement. Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 6 of 34

165 Place and health Shaping place for health: the role of regeneration Urban regeneration describes a process of redevelopment and renewal in cities, and is one of many options available for shaping place to improve health and wellbeing by influencing the built and social environment within a locality. Regeneration improves geographical areas with complex challenges by transforming housing, streets, transport and green spaces. Regeneration is too often only considered in terms of the built environment and the physical conditions in which we live. In Southwark, our approach to regeneration is also about ensuring access to quality services and amenities and supporting the creation of jobs. Regeneration has a fundamental role in improving the health, wellbeing and life chances of communities. Southwark is delivering some of Europe s most exciting and complex regeneration schemes which are helping to shape neighbourhoods at Elephant and Castle, Aylesbury, Canada Water and the London Bridge Quarter. In the ten years prior to 2015, Southwark fell from being the 10th most deprived local authority in the UK to the 41st. This has had a visible impact on people in Southwark with more adults in employment, more young people in education, employment or training, and fewer children living in deprivation. Of all the wider determinants of health and causes of health inequalities, deprivation is perhaps the most influential, meaning this economic growth will have a positive impact on the health of local people. "Regeneration has a fundamental role in improving the health, wellbeing and life chances of communities." Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 7 of 34

166 Place and health The health of Southwark's population Southwark is a densely populated and diverse inner London borough situated on the south bank of the River Thames, with Lambeth to the west and Lewisham to the east. Home to some 313,000 people, Southwark is a patchwork of communities: from leafy Dulwich, to bustling Peckham and Camberwell, and the rapidly changing Rotherhithe peninsula. There have been a number of significant improvements in health outcomes in Southwark in recent years [1]: Life expectancy in the borough continues to increase. Latest figures show that boys born today can expect to live to 79.1 years; just over five years longer than a boy born in Southwark in Girls born today can expect to live almost four years longer than their counterparts born in 2001, with a life expectancy today of 83.8 years. Life expectancy is still lower than the London average by 1.3 years for men and 0.4 years for women, however the gaps have been narrowing over time and have decreased by one-third for men and by half for women since Infant mortality is often used as a measure of the overall health and wellbeing of the population, reflecting a wide range of factors that influence health, such as economic development and living conditions as well as maternal health and wellbeing. Since 2001 the infant mortality rate in Southwark has fallen by 62% and is now below the national average. There have also been significant reductions in the rate of premature mortality in the borough, with the levels of cardiovascular mortality falling by more than half since 2001, and cancer falling by a fifth. Levels of teenage pregnancy in Southwark are at their lowest levels since monitoring began, numbers have fallen by over 200 per year compared to 1998, a much sharper reduction than seen in London as a whole. While there have been improvements in many areas, challenges remain, particularly in relation to sexual health, childhood obesity and mental health. Southwark has high levels of sexual health need due to its young, mobile and diverse population. Nationally, Southwark has the second highest rate of new STIs (excluding chlamydia). In 2016, 8,117 new sexually transmitted infections (STIs) were diagnosed in residents. The borough also has the second highest prevalence of HIV in England, with 2,557 residents diagnosed with the condition. Healthy weight continues to be a complex challenge faced by many people in our communities. The prevalence of being overweight or obese among eleven year olds in Southwark is among the highest in London, and above the national average. Severe mental illness (SMI) affects about 0.9% of people nationally, although Southwark demonstrates a higher burden: about 1.2% of the population (close to 4,000 people) are recorded by their GP as having a psychotic disorder schizophrenia, bipolar affective disorder and schizoaffective disorder. While nearly two-thirds of the general population of children in the borough are achieving high GCSE attainment, just half of children with free school meal status and only 18% of children in care achieve the same level. Homelessness has increased since 2010/11 with more families living in temporary accommodation, and violent crime rates have not reduced. We also know that there is a strong association between social economic deprivation and experience of poorer health. Unemployment or poor quality of employment, low income, low levels of education attainment and poor housing are all factors that impact on lifetime health outcomes. Between the most and least deprived in the borough, there is a 5½-year life expectancy difference among women and a 9½-year difference among men. While for women this inequality has not changed over the last three years, it has increased by two years in men. There is also a strong social dimension to health behaviours such as smoking, unhealthy weight, physical activity and uptake of screening and preventive interventions. "Since 2001 the infant mortality rate in Southwark has fallen by 62%..." Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 8 of 34

167 Place and health Making regeneration work for everyone Improving wellbeing and population health in Southwark will require action on many fronts. There is an opportunity to leverage urban renewal taking place across the borough to be a key driver of change in improving economic opportunities and productivity, health, wellbeing, sustainability and cohesion for local communities. Place shaping through regeneration will be critical to help tackle the wider social determinants of health. The evidence suggests that this may be achieved by ensuring that communities and health and wellbeing are at the centre of our regeneration process and that there is a whole council approach that drives regeneration so that changes in the physical environment contribute to the delivery of positive outcomes across the system: from affordable housing, to new schools and health and community facilities to improved health and wellbeing. Southwark has embarked upon a whole council approach on maximising the opportunities from urban renewal, and the 2017 Southwark Conversation was the council s largest event consultation with local residents about their aspirations, expectations and recommendations for changes in the borough. In Southwark, we are integrating health and wellbeing into planning. This approach is evident in how the New Southwark Plan (NSP), currently out to consultation, captures the many ways that the physical environment can affect health. The NSP is more than just about land use: through high quality spatial planning, we want to ensure that place shaping for health works for everyone. The NSP will support economic growth and provide affordable housing. Health and wellbeing is embedded throughout the NSP. Strategic policies within the NSP aim to encourage healthy lives by tackling the causes of ill-health and inequalities in Southwark, such as employment, active travel, poor air quality, protection and improvements to green space and are underpinned by management policies on training and apprenticeships, hot food takeaways, betting shops, pay day loans and active design, all of which will have a positive impact on health and wellbeing locally. We are also developing evidence informed strategic health and wellbeing plans in urban renewal areas, ensuring that all opportunities to improve health are realised. In Southwark, we have made use of the practical toolkits and checklists provided by the Town and Country Planning Association [2], the Healthy Urban Development Unit [3] as well as learning from the Healthy New Towns programme [4], to inform how we work across the Council and with developers. Key among these are the development of locality specific health and wellbeing plans; promoting active travel; ensuring viable requirements for play areas, open spaces, leisure and access to food growing and healthy food choices; mitigating the impacts of pollution and noise; responding to local health needs and developing relevant performance indicators/targets for healthrelated policies. In our major regeneration areas, such as Canada Water, Bermondsey and Old Kent Road, we are working on health plans, charters and outcome frameworks to ensure that regeneration impacts positively on health and wellbeing. Together with NHS Southwark Clinical Commissioning Group (CCG) and NHS partners, our Five Year Forward View outlines an ambition to create a much stronger emphasis on prevention and early action as well as deeper integration across health and social care, and wider council services [5]. Our ambition is informing not just service developments but how and where some of them will be made real through regeneration, innovative co-location and investment in community infrastructure. Working with local communities We have an opportunity to work towards achieving the best possible outcomes from redevelopment and renewal taking place across the borough. Evidence suggests that this means local communities must be engaged from the earliest point to be involved in the co-identification of needs and co-design of solutions and to bridge communities to local resources. Engaging and empowering local communities can improve community health and wellbeing, promote equity and increase people s control over their health and lives, which are key to addressing health inequalities. "Place shaping through regeneration will be critical to help tackle the wider social determinants of health." Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 9 of 34

168 Place and health Next steps The recent consultation (the Southwark Conversation) provides a rich source of information to help us further shape our borough so that the environment in which we live supports healthier lives. We will be working closely across the Council and with our NHS, voluntary and community sector partners and businesses to draw out implications for how we create healthier urban environments. We will want to continue listening to communities and ensuring that there is strong community engagement and participation in developing local regeneration plans. A priority for us will be the development of sound health plans for our major regeneration areas. We know that deprivation, poorer life chances and poor health are all inextricably connected. Our health plans will test and question our assumptions so that we help ourselves and partners to think creatively outside the box to address some of our complex heath concerns such as childhood obesity. While we will aim to create healthier places where the healthier choice is the easier choice we will also be looking at opportunities for integration, co-location and bringing services closer to communities. This will help us to drive improvement and equity in population health, both within and outside services. Supporting the CCG in the future development of community hubs will provide one opportunity to explore a more integrated upstream prevention model that could see housing and benefits advice provided alongside sign posting to health improvement services, improved models for brief advice and broader mental wellbeing services. Finally, we are developing high level indicators which will enable us to assess inequalities in health across the borough and to measure not just how regeneration impacts on people in local areas but to demonstrate that the benefits extend to people in other parts of the borough too. Recommendations In summary, given Southwark s commitment to shaping place for health and wellbeing and reducing health inequalities through regeneration, there are five key recommendations to accelerate progress and demonstrate the impact of this important strategic imperative: 1. Leadership: Develop and enhance cross-council governance, partnership and communication opportunities on social regeneration efforts to raise awareness, facilitate collaboration, and encourage more systematic evaluation of the opportunities and impact of urban renewal to improve health and wellbeing, reduce inequalities and improve life chances. 2. Strategy: Ensure local health and wellbeing plans are in place for all major regeneration efforts taking place across the borough and that these are developed through wide engagement with local communities and stakeholders. 3. Evidence-based policy: Further accelerate the use of local health, social and other relevant data into local planning decisions to ensure that a more comprehensive understanding of the wellbeing needs and potential health and inequalities impacts are considered. 4. Monitoring and Evaluation: Develop a standard set of key indicators for social regeneration, working collaboratively with a wide partners including local communities, to guide the evaluation of all urban renewal projects in the borough. 5. Partnership: Develop and maintain robust governance, communication and other opportunities to support community participation and to engage key stakeholders on the Council s progress on social regeneration and identify opportunities for collaboration. Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 10 of 34

169 Place and health References 1. Southwark health profiles jsna 2. TCPA Developers and Wellbeing Project tcpa.org.uk/developers-wellbeing 3. HUDU Health Impact Assessment guidance 4. delivering-healthy-urban-development/healthimpact-assessment 5. NHS England Healthy New Towns england.nhs.uk/ourwork/innovation/healthy-newtowns/ 6. Southwark CCG & Southwark Council, Five year forward view uk/documents/s72968/presentation%20five%20 Year%20Forward%20View.pdf 7. TCPA Practical Guides - Guide 8: Creating health promoting environments tcpa-practical-guides-guide-8-health 8. Sport England: Active design org/facilities-planning/active-design/ 9. Design Council: Active design org.uk/resources/guide/active-design-designingplaces-healthy-lives 10. TCPA Practical Guides - Guide 8: Creating health promoting environments PHE Spatial planning for health government/publications/spatial-planning-for-healthevidence-review 12. TfL Healthy Streets Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 11 of 34

170 Healthy People in Healthy Places Annual Public Health Report of the Director of Health & Wellbeing 2017 Part B. Statistical Bulletin 2017: A summary of Southwark's progress against key health priorities

171 Statistical Bulletin OVERVIEW The Statistical Bulletin to this year s Report focuses on a smaller number of key health and wellbeing priorities in the borough that affect our residents across the life course. It builds upon the more detailed review of public health priorities undertaken in the Annual Public Health Report By focusing on fewer areas, we aim to provide a more thorough review of each topic, including analysis of demographic, epidemiological and geographical inequalities within the borough. We also reflect on some of the key accomplishments in these areas over the past year and highlight priority action for the year ahead. This year's Statistical Bulletin consists of the following sections: 1. Changing demographics in Southwark 2. Childhood obesity 3. Sexual health 4. Mental health 5. Long-term conditions and co-morbidities 6. Air quality The selected public health priorities represent particular challenges in health and wellbeing across the life-course in Southwark. In some areas we are making steady progress and in others the improvements are slow and modest. In all areas, our commitment to partnership working, building upon the available evidence, and adopting multilevel approaches to improving health and tackling inequalities are paramount. These approaches have already yielded benefits in other areas in Southwark, including scaling up the NHS Health Check programme, promoting physical activity through our free swim and gym programme, introducing healthy and free school meals, transforming our local sexual health services, delivering new strategic approaches to suicide prevention and mental health and wellbeing, and strengthening our collaboration with planning and regeneration colleagues to ensure regeneration works for all and has the wellbeing of communities as a key outcome. Looking ahead, key to our success will be working with our partners to do a few things well, efficiently and at scale. The priorities highlighted in this report reflect areas where there are existing and potential opportunities to achieve prevention at scale and truly improve population health outcomes. Key to this will be strengthening our health in all policies approach in our collaboration with the council, with our NHS partners, business, education, academic, community and other sectors to realise our shared ambitions for success. Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 13 of 34

172 Statistical Bulletin DEMOGRAPHY Southwark is a densely populated and diverse inner London borough situated on the south bank of the River Thames, with Lambeth to the west and Lewisham to the east. Home to some 313,000 people, Southwark is a patchwork of communities: from leafy Dulwich in the south, to bustling Peckham and Camberwell, and the rapidly changing Rotherhithe peninsula. Towards the north, Borough and Bankside are thriving with high levels of private investment and development. Yet there remain areas affected by high levels of deprivation, where health outcomes fall short of what any resident should expect. 1.1 Population trends and projections The population of Southwark has been growing since the late 1980s, surpassing 300,000 inhabitants in This trend is set to continue across almost all areas of the borough in the next decade. In particular, redevelopments around Old Kent Road, South Bermondsey and Elephant and Castle, will lead to significant population increases in these communities. Population projections from the GLA for all London boroughs estimate 10% growth in Southwark, which is comparable to 10% growth in greater London and across other boroughs in south east London between 2016 and 2026, as seen in Figure 2. However, the projections used locally for service planning suggest the increase could be as high as 20%. Figure 1. Population projections in Southwark, Source: GLA 2017, 2015 Southwark Borough Preferred Option Projections Figure 2. Proportionate increase in population across South East London boroughs, Source: GLA 2017, 2016-based population projections & borough preferred option 1.2 Age The average age in Southwark is 32.9 years; almost seven years younger than the national average and two years younger than the London average. The young average age of the borough, stems not from a large number of children, but from a large number of young working age residents. Over 40% of the Southwark population consists of those aged 20 to 39, compared to 34% in the rest of London. Looking at the older age ranges, only 8% of the population of Southwark is aged over 65 compared to 12% in London and 18% in England. The ethnic diversity of the borough varies markedly across age groups and the population under 20 is much more diverse than other age groups, with a similar proportion of young people from white and black ethnic backgrounds. Figure 3. Population of Southwark in 10-year age bands, by ethnicity, 2016 Source: GLA 2017, Round trend-based ethnic group projections, 2016 Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 14 of 34

173 Statistical Bulletin 1.3. Diversity Southwark is a diverse borough with people from a wide range of ethnicities and backgrounds. Over 120 languages are spoken here, and 11% of households have no members who speak English as a first language. According to the 2011 census, 39% of Southwark residents were born outside the UK, showing not only the ethnic diversity of the borough, but also the cultural diversity. Just over half (54%) of Southwark s population is of white ethnicity, a quarter (25%) black and a third of Asian (11%) or other (10%) ethnicities (Figure 5). This differs from the rest of London where a considerably smaller proportion identify as black (13%) and a considerably larger proportion identify as Asian (21%). Figure 4. Age and sex distribution of the population in in Southwark, London and England, 2016 Source: ONS 2017, Mid-year 2016 resident population estimates Figure 5. Population of Southwark, by ethnicity, 2016 Source: GLA 2017, Round trend-based ethnic group projections, 2016 Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 15 of 34

174 Statistical Bulletin 1.4. Sexual orientation Research from the Office for National Statistics suggests that Southwark has one of the largest gay and lesbian populations in the country, where 5% (12,000 people) of the population of Southwark identify as being gay or lesbian, compared to only 2% of the entire London population and 1% in England. Estimates of those identifying as either bisexual, transgender are not considered reliable enough for practical use. Table 1. Age and sex distribution of the population in in Southwark, London and England, 2016 Source: ONS, Subnational sexual identity estimates, UK: 2003 to 2015 Adults aged 16 or older Southwark London Heterosexual 215, % 90.2% 93.6% Gay or lesbian 12, % 1.9% 1.1% Bisexual 2, % 0.7% 0.6% Other 2, % 0.3% 0.3% Don t know / refuse 13, % 6.9% 4.5% England 1.5. Deprivation The Indices of Deprivation 2015 is used to measure levels of relative deprivation between communities in England. Southwark is the 40th most deprived of 326 local authorities in England and ninth most deprived out of 32 local authorities in London There is significant variation in deprivation across the borough, with around 119,000 (38%) Southwark residents living in communities ranked in the 20% most deprived areas nationally. By contrast, only around 6,700 (2%) of residents live in communities considered the least deprived nationally. Around 15,000 children (28%) in Southwark aged under 16 live in low income families The most deprived areas are situated in Peckham through to Elephant and Castle in the north-west. However, there are pockets of deprivation across the borough. Parts of the river front and Dulwich are the least deprived parts of the borough. Deprivation has an important impact on health, as more deprived areas have lower life expectancy and higher prevalence of many behavioural risk factors than less deprived areas. These health inequalities are underpinned by inequalities in the broad social and economic circumstances which influence health. Figure 6. Indices of deprivation 2015 Source: Department of Communities and Local Government, English Indices of Deprivation 2015 Crown copyright and database rights 2018, Ordnance Survey (0) Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 16 of 34

175 Statistical Bulletin 1.6. Life expectancy Life expectancy at birth has been increasing steadily over time. This is true across London and England, but the improvement has been more pronounced in Southwark. In , life expectancy at birth for men was 79.1 years and 83.8 years for women in Southwark. Between and , the average number of years that a new-born baby would expect to live, based on contemporary mortality rates, increased by four years for women and five years for men. However, life expectancy in Southwark is still below the London average and ranks 26 out of the 32 boroughs in London for both men and women. Figure 7. Trends in life expectancy for men, to Source: ONS 2017, Life expectancy at birth by local areas, UK, to Figure 8. Trends in life expectancy for women, to Source: ONS 2017, Life expectancy at birth by local areas, UK, to Table 2. Absolute and relative increase in life expectancy in Southwark and London, to Source: ONS 2017, Life expectancy at birth by local areas, UK, to Life expectancy at birth MEN Change over time Southwark yrs London yrs Gap % WOMEN Southwark yrs London yrs Gap % In , life expectancy for men in Southwark was 1.3 years below the London average and 0.4 years for women. It s worth noting however, that these gaps have been narrowing over time and have decreased by one-third for men and by half for women since Whilst there has been a significant increase in life expectancy in Southwark over time, this improvement has not been the same across all our communities. The Slope Index of Inequality tells us how much life expectancy at birth varies between our most and least deprived neighbourhoods. The range in years of life expectancy from the most to least deprived areas in Southwark was 5.5 years for women in and 9.5 years for men. This discrepancy has been increasing over time for men, but has stayed roughly the same for women. Figure 9. Slope index of inequality in Southwark, to Source: PHE 2017, Public Health Outcomes Framework Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 17 of 34

176 Statistical Bulletin 1.7. Healthy life expectancy Whilst our local residents are living longer, the length of the time spent living in good health is also an important factor. Healthy life expectancy is often considered a measure of whether we are adding life to years, as well as years to life. In , there was a 17.9 year gap between life expectancy and healthy life. National intelligence indicates that not everyone can expect the same number of years spent living in good health. The gap in healthy life expectancy between the most and least deprived areas of the country stands at 19 years for both males and females. Figure 10. Gap in life expectancy in Southwark, by sex Source: ONS 2017, Health state life expectancy at birth and at age 65 by local areas, UK Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 18 of 34

177 Statistical Bulletin CHILDHOOD OBESITY 2.1. Why is this important? Healthy weight (BMI above 2 nd centile but less than the 85 th centile) continues to be a complex challenge faced by many people in our communities. Excess weight (BMI greater than or equal to the 85 th centile) in childhood typically persists into adulthood and is associated with increased risk of a range of health consequences such as diabetes, hypertension and exacerbation of asthma, childhood obesity also puts children at risk of psychological problems. The National Child Measurement Programme (NCMP) measures the height and weight of children in Reception (aged four to five years) and Year 6 (aged years) in state maintained primary schools across England What is the picture like in Southwark? Obesity among children in Southwark is consistently above London and national levels. In , Southwark had the third highest level of Figure 11. Percentage of children who are overweight or obese in Reception and Year 6, in Southwark, London and England, Source: National Child Measurement Programme excess weight (overweight and obese) out of the 32 London Boroughs for children in Reception (26%) and fourth highest for children in Year 6 (43%). Trends indicate that there has been little change in the prevalence of excess weight since measuring began in 2007, mirroring the national and regional picture. Southwark s Healthy Weight Strategy Everybodys Business aims to reduce obesity by to 11% among children in Reception and 25% among Year 6 children. Excess weight and obesity in Reception is significantly higher than the Southwark average in the areas immediately south of the Old Kent Road, from Peckham through to Walworth and Elephant and Castle in the north west. By Year 6 there is little significant difference across the borough, indicating a whole population approach is required by this age. NCMP results show that excess weight and obesity among children are strongly associated with socio-economic status. The association grows stronger between Reception and Year 6, by which time children in the most deprived areas are 1.7 times more likely to be overweight or obese than children in the least deprived areas nationally. National results also show that excess weight and obesity is highest among children from Black or Black British ethnic groups for both Reception (29%) and Year 6 (46%) cohorts. Excess weight and obesity is lowest among children from Chinese ethnic background among both Reception (16%) and Year 6 (34%) cohorts. By Year 6 all ethnic groups, except Chinese, have a significantly higher level of excess weight or obesity than children who have a White ethnic background. Figure 12a. Prevalence of excess weight among Reception Year children, to Source: National Child Measurement Programme Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 19 of 34

178 Statistical Bulletin Key achievements in 2017 In 2017 we enhanced our commitment to early years by progressing to Stage 1 Baby Friendly accreditation, commissioning the Breastfeeding Welcome Scheme, and becoming a Healthy Early Years pilot borough. These initiatives will further develop in In 2017 we linked public health and planning policy teams to ensure resident and community health is a key consideration of all Council planning decisions. In 2017 we were formally recognised by the GLA and Sustain for our work addressing food poverty across the borough. We are currently developing a Food Poverty Action Plan to deliver targeted work using a strategic, coordinated approach with community partners. Key areas of work in In 2018 we will work to improve the confidence and competence of health and non-health professionals to effectively communicate healthy weight messages through a newly commissioned online training service. 2. In 2018 we will increase levels of physical activity by developing tailored support to schools with the highest levels of excess weight and by piloting a unique Clinical Advice Pad prescribing physical activity to residents. 3. In 2018 we will collaborate with Guy's and St Thomas Charity, local faith groups and other Council departments to develop sustainable, community-driven interventions around obesity and multiple long term conditions to extend the reach of healthy weight services across the borough. Figure 12b. Prevalence of excess weight among Year 6 children, to Source: National Child Measurement Programme Crown copyright and database rights 2018, Ordnance Survey (0) Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 20 of 34

179 Statistical Bulletin SEXUAL HEALTH 3.1. Why is this important? Poor sexual and reproductive health and ongoing transmission rates of HIV have major impacts on population mortality, morbidity and wider wellbeing, and result in significant costs for health service and local authority budgets. Promoting and improving sexual health involves initiatives aimed not only at individual behaviour, but also a wide range of social and environmental interventions. Young people between 15 and 24 years of age experience high rates of new Sexually Transmitted Infections (STIs) nationally. Teenagers may also be at increased risk of re-infection because they lack the skills and confidence to negotiate safer sex What is the picture like in Southwark? There were 8,117 new STI diagnoses in Southwark in With a rate of 2,628 new STI diagnoses per 100,000 population in 2016, Southwark has almost double the rate of STI diagnoses in London, and is the second highest of any borough in England, behind neighbouring Lambeth. Just over one-third of new STI diagnoses were made up of those aged 15 to 24. Young people are also more likely to become re-infected with STIs, contributing to infection persistence. In Southwark, an estimated 14% of year old women and 13% of year old men presenting with a new STI from 2012 to 2016 became re-infected within 12 months. Chlamydia was the most common STI in Southwark in 2016, with three times as many new diagnoses (1,155 per 100,000) than in London (571 per 100,000), followed by Gonorrhoea (498 per 100,000) and genital warts (226 per 100,000). 56% of all new STIs diagnoses were in men who have sex with men. Figure 13 shows the count of new diagnoses in 2016 for the most common STIs. The highest rates of new STIs are concentrated in the north-western part of the borough, while the south of the borough had far fewer cases of new STIs in 2016 (See map on next page). The overwhelming majority (84%) of all new STI diagnoses in Southwark occurred in the two most deprived quintiles. Half of the new STIs diagnosed in Southwark in 2016 were people who identified as white, one quarter in people who identified as black or black British; this roughly reflects the proportions of the different ethnic groups across the whole population of Southwark. It is worth noting that our infection rates are higher than the national average among all ethnic groups, with particularly large differences among white and mixed groups Figure 13. New STI diagnosis per 100,000 in Southwark, Source: PHE 2017, Sexual and Reproductive Health Profiles Figure 14. New diagnoses of most common STIs in Southwark, 2016 Source: PHE 2017, Sexual and Reproductive Health Profiles Figure 15. Rates per 100,000 population of new STIs by ethnic group in Southwark and England, 2016 Source: PHE 2017, Southwark Local authority HIV, sexual and reproductive health epidemiology report (LASER): 2016 Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 21 of 34

180 Statistical Bulletin Figure 16. Incidence of new sexually transmitted infections across Southwark in 2015 Source: PHE 2017, GUMCAD & CTAD systems Crown copyright and database rights 2018, Ordnance Survey (0) Levels of HIV in Southwark are particularly high, with the borough having the second highest prevalence in England, behind neighbouring Lambeth. There are currently 2,557 people living in the borough who have been diagnosed with HIV. Over half (58%) of all diagnosed HIV cases in Southwark were acquired through sex between men, and 37% through sex between a man and a woman. In 2016, more than 100 people in Southwark were newly diagnosed with HIV, with diagnosis rates significantly higher than the London average. The rate of new HIV diagnosis was 44 per 100,000 in Southwark in 2016, compared to 28 in London. While this is a big discrepancy, the gap has narrowed significantly over time as new diagnoses in Southwark have more than halved since Late diagnosis is the most important predictor of HIV-related morbidity and short-term mortality and this has also improved in Southwark over time. However, still over one-third (37%) of adults newly diagnosed with HIV were diagnosed late in Southwark between 2014 and Figure 17. New HIV diagnosis rate per 100,000 in Southwark and London, 2016 Source: PHE 2017, Sexual and Reproductive Health Profiles Key achievements in 2017 Between 2015 and 2016 (latest available data), new diagnoses of STIs declined by 9% and new diagnoses of HIV declined by 40%, while rates of testing continued to increase. In 2017, we agreed integrated sexual health contracts with our two local hospital trusts, maintaining high quality services while reducing contract costs by 9.3m over the next 4.5 years. In 2017, an innovative integrated young peoples wellbeing service was commissioned to better meet the multiple needs of young people, including sexual health, drugs and alcohol, and mental wellbeing. We are currently working with the service provider (Brook and cgl Southwark ) to embed the new service. Key areas of work for In 2018, we will develop a new sexual and reproductive health strategy in partnership with Lambeth and Lewisham councils, which will include annual action plans. 2. Following a pilot, we will explore options for access to oral contraception online, in order to reduce GP appointments and additional demand on specialist GUM clinics. 3. We will develop and implement, in partnership with Lambeth Council, a new model for the delivery of pharmacy sexual health services for our residents, with the aim of improving access to contraceptive options and reducing repeat use of emergency contraception. Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 22 of 34

181 Statistical Bulletin MENTAL HEALTH 4.1. Why is this important? As stated in the Joint Mental Health and Wellbeing Strategy, good mental health and a sense of wellbeing are central to living a purposeful, healthy and enjoyable life, because there is no health without mental health. Yet, for too many people, the reality is that they are living with poor mental health and its wide-ranging and long-lasting consequences for themselves, their family, friends and community. Mental ill health is driven by a wide range of other factors and can themselves cause problems such as unemployment, homelessness and substance misuse. It is estimated one in every four people will experience a mental health issue in any given year. It is estimated that 1 in every 8 spent in England on long term conditions is linked to poor mental health (King s Fund, 2012) What is the picture like in Southwark? It is estimated that almost 47,600 adults in Southwark experience a common mental disorder (CMD), which comprises different types of depression and anxiety, and this is expected to rise to approximately 52,000 individuals over the next decade as our population grows. All types of CMD are more prevalent in women than among men: one in five women report experiencing CMD, compared to one in eight men. The gender gap is particularly pronounced among those aged 16-24, where more than three times the number of women have a common mental disorder than men. Severe mental illness refers to psychotic conditions such as schizophrenia and bipolar affective disorder, which affects 1.2% of Southwark residents (4,000 people), compared to 1.1% in London. The prevalence of SMI increases with age among both men and women, peaking among those in their fifties. In contrast to the estimated prevalence of common mental disorders, the number of men diagnosed with SMI in Southwark in greater than women across each age group up to 70. Figure 18. People with an experience of common mental disorders in the past week, by gender and sex in Southwark Source: NHS Digital, Adult Psychiatric Morbidity Survey, 2014 Figure 19. People registered with GP as having SMI in Southwark by age and sex, 2016 Source: SMI Register, Southwark General Practice; EMIS Web Extract, December 2017 Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 23 of 34

182 Statistical Bulletin With approximately 13 people taking their life every day in England, suicide and self-harm are a major public health and social concern. The national suicide rate has been increasing year on year since and it is now the leading cause of death among men below the age of 50. For each of the last three years, between 14 and 32 Southwark residents have taken their own lives. While local figures fluctuate each year due to the small number of cases, there has been a general increasing trend in the number of suicides in Southwark since , reflecting the national picture. However, this change is not statistically significant. The overwhelming majority of suicides in Southwark occur among men, mirroring the national picture. Consistently since , almost four out of five local suicides were among men. Southwark is one of five London boroughs to report higher suicide rates than the national average in 2013/15. Whilst suicide is more common among men, women are much more likely to report having selfharmed. In 2015/16, there were 286 emergency hospital admissions for intentional self-harm in Southwark, 62% of these were women. Young people are also more likely to self-harm. The admission rate for young people is comparable to the overall rate for London (210 per 100,000), but significantly lower than the national average (431 per 100,000). Although the trend in London has stayed stable over time, Southwark has mirrored the national picture of a steady increase over the last five years. Figure 20. Directly age-standardised rates of suicide per 100,000, to Source: ONS 2017, Suicides in England and Wales by local authority Figure 21. Directly age-standardised rates of hospital admission as a result of self-harm per 100,000 population aged Source: PHE, Hospital admissions as a result of self-harm, 2011/12 to 2015/16 Key achievements in 2017 Southwark s Public Health Team have established a new multi-stakeholder Suicide Prevention Steering Group and facilitated the co-production of a local Suicide Prevention Strategy and Action Plan Southwark Council and Southwark NHS Clinical Commissioning Group have worked in partnership to develop a Joint Mental Health and Wellbeing Strategy In order to improve care for patients in crisis in A&E, Southwark CCG and Southwark Council have been part of the implementation of a centralised Place of Safety on the Maudsley hospital site. Key areas of work for To support the commitment of the Council and Southwark CCG to prevent mental ill health and promote wellbeing, we will work with partners to complete a needs assessment focusing on mental health promotion and wellbeing. 2. We will work with Southwark CCG to ensure the integration of physical health and mental health in Southwark, including work on long term conditions and mental health linked to the delivery of the Southwark Bridges to Health and Wellbeing segmentation model. 3. We will create an improved pathway to promote recovery and step down from high support mental health accommodation placements and also review placements that are out of borough to ensure quality care is being delivered, and ensure that care is provided in Southwark where appropriate. Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 24 of 34

183 Statistical Bulletin LONG-TERM CONDITIONS 5.1 Why is this important? It is estimated that 15 million people in England have a long-term condition (LTC). People with an LTC are said to account for 50% of all GP appointments and around 7 out of every 10 of the total health and care spend is attributed to caring for people with LTCs (Department of Health, 2012). 5.2 What is the picture like in Southwark? Data from General Practices provide a register of recorded disease prevalence for a number of LTCs. Hypertension (11%), Depression (8%), and Diabetes (6%) are the most prevalent measured diagnoses in Southwark, mirroring the national picture. General Practice data represent only those people who have been diagnosed with the condition, not those who may be living with a long term condition that is yet to be identified. Table 4 provides an estimate of the expected prevalence of certain conditions, by comparison to the diagnosed prevalence in the Southwark population. It is estimated that just under half of hypertension cases are undiagnosed in Southwark, and as many as fourth-fifths of Coronary Heart Disease cases. Increasingly, patients have to manage more than one LTC at a time. In Southwark, approximately 1% of the registered population have three or more chronic conditions, equivalent to over 3,500 patients. The large majority of people with multiple long term conditions in Southwark are aged over 50 and more than half of people with multiple LTCs are aged 70 and over. Table 3. Long term conditions in Southwark by GP Federation Source: NHS Digital, Quality and Outcomes Framework, 2016/17 Group Condition IHL* QHS** Southwark London England Cases Prevalence Prevalence Prevalence Dementia 0.5% 0.3% 1, % 0.5% 0.8% Mental Depression (18+) 7.6% 7.4% 19, % 6.6% 9.1% health and neurological Epilepsy (18+) 0.6% 0.5% 1, % 0.6% 0.8% conditions Learning Disabilities 0.3% 0.3% 1, % 0.4% 0.5% Mental Health 1.3% 1.2% 4, % 1.1% 0.9% Atrial Fibrillation 0.8% 0.7% 2, % 1.1% 1.8% CHD 1.4% 1.4% 4, % 2.0% 3.2% Cardiovascular conditions Stroke & TIA 1.0% 0.8% 2, % 1.1% 1.7% Heart Failure 0.4% 0.5% 1, % 0.5% 0.8% Hypertension 11.1% 10.2% 34, % 11.1% 13.8% Respiratory COPD 1.1% 1.6% 4, % 1.1% 1.9% conditions Asthma 4.6% 4.2% 14, % 4.6% 5.9% Cancer 1.5% 1.4% 4, % 1.8% 2.6% Other Chronic Kidney Disease (18+) 1.9% 2.4% 5, % 2.4% 4.1% Diabetes (17+) 6.5% 5.8% 16, % 6.5% 6.7% * IHL - Improving Health Limited, the GP federation in the south of the borough ** QHS - Quay Health Solutions, the GP federation in the north of the borough Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 25 of 34

184 Statistical Bulletin The GP Patient Survey assesses the health related quality of life of respondents, including those who identified as having a long term condition. A score out of one (which represents perfect health), gives an indication of a person s physical, mental and social well-being. From those who responded to the GP Patient survey in 2017 in Southwark, the average score was 0.81, while people with a LTC scored an average of 0.73, and those with three or more conditions had a score of 0.47 on average. This suggests that those respondents with multiple LTCs had considerably lower well-being and impairments to some aspect of their daily life such as mobility, self-care or participating in usual activities. Poor mental health is a big issue for people with long-term conditions and it is estimated that 30% of people with a physical long term condition also have a mental health problem. However, evidence indicates that a significant proportion of these cases go undetected, meaning many people do not get the support they may need. Key achievements in 2017 Between 1 April 2014 and 31 December 2017, 31,686 Health Checks have been completed in Southwark. We provided support to commissioning workstreams and the clinical effectiveness programme with NHS Southwark CCG, including intelligence support and the delivery of Protected Learning Time (PLT) sessions for local GPs. We conducted a cardiovascular disease (CVD) risk factors needs assessment, with a focus on primary prevention, to drive better outcomes for CVD at a local level. Table 4. Expected versus diagnosed prevalence in Southwark Source: NHS Digital, Quality and Outcomes Framework, 2016/17; PHE, Disease and risk factor prevalence; PHE, prevalence estimates for local and regional populations Condition Expected prevalence Diagnosed prevalence Hypertension 19.4% 10.6% Depression 11.0% 7.5% Diabetes* 9.2% 6.1% Coronary Heart Disease* 7.2% 1.4% Chronic Kidney Disease* 3.3% 2.2% Stroke* 3.2% 0.9% COPD 1.5% 1.4% Atrial Fibrillation 1.5% 0.8% Peripheral Arterial Disease* 0.9% 0.4% * Diagnosed prevalence from 2016/17 is mapped against the most recent modelled prevalence in the population Key areas of work for We will develop and pilot a Digital NHS Health Check which is easy to access and simple to use to further increase uptake and improve health outcomes. 2. Further work is planned for 2018 to assess the CVD profile locally in terms of secondary prevention, and explore benefits of using prevalence and/ or budget modelling approaches while setting priorities for public health interventions in the future. 3. We will continue to support the Southwark CCG in their programme of work to improve outcomes for people with long term conditions. Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 26 of 34

185 Statistical Bulletin AIR QUALITY 6.1 Why is this important? Air pollution affects everyone and is one of the six Mayoral objectives for London. Exposure to poor air quality is associated with both ill-health and premature death and is estimated by the Institute for Health Metrics & Evaluation to be ranked as the 10th largest risk factor for mortality and ill-health in England. The health impacts of air pollution cost the UK more than 20bn every year. There is a strong body of evidence which shows that short-term exposure to high levels of air pollution has a range of adverse health effects. These range from exacerbation of respiratory conditions such as asthma and chronic respiratory disease, through to an increase in emergency admissions to hospital. Poor air quality disproportionately affects the health outcomes of the very young, the elderly and the ill and can contribute to local health inequalities. While short-term exposure to air pollution is known to adversely affect health, the relative risk associated with long-term exposure is much greater, contributing to the initiation, progression and exacerbation of disease. It is estimated that the average reduction in UK life expectancy associated with air pollution is six months. In London recent studies have calculated that poor air quality affects the health of approximately 9,500 people every year. The majority of pollutants within London are now at concentrations below national air quality standards, but levels of nitrogen dioxide (NO 2 ) and particulate matter (PM 10 ) continue to exceed these standards in some areas and locations, including parts of Southwark. These key pollutants have varying effects on health. NO 2 can irritate and damage lungs while particulate matter increases the risk of respiratory disease, lung damage, cancer and premature death. PM 2.5 is the pollutant most evidently linked to poorer health outcomes as particulate matter of this size is small enough to pass through lungs into the bloodstream. 6.2 What is the picture like in Southwark? Air pollution data show a decrease in total emissions for nitrogen oxides (NO x ) and particulate matter (PM) in Southwark. NO x is the largest pollutant in Southwark with around 1,200 tonnes emitted in 2013 alone, over a quarter less than in Around 110 tonnes of PM 10 were emitted in Southwark in 2013 a decrease of a fifth since Around 56 tonnes of PM 2.5 were emitted in 2013 a decrease of over a quarter since These reductions in air pollution have been achieved through legislative standards and improved technology, as well as London-wide and local initiatives. All emissions are predicted to continue decreasing until the year After that it is difficult to predict due to, as yet unplanned interventions and other actions both nationally and locally. Table 5. Tonnes per year of emissions of NO x and PM in Southwark, over time with projections to 2020 Source: GLA, London Atmospheric Emissions Inventory (LAEI) 2013 Year NO x PM 10 PM , , , Figure 22. Trend in proportion of deaths linked to PM 2.5 Source: PHE 2015, Fraction of all-cause adult mortality attributable to anthropogenic particulate air pollution (measured as fine particulate matter, PM 2.5 ) Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 27 of 34

186 Statistical Bulletin Figure 23. Average annual NO 2 concentrations in Southwark Source: GLA, London Atmospheric Emissions Inventory (LAEI) 2013 As well as impacting health conditions, longterm exposure to air pollution can increase the risk of premature mortality and PM2.5 is thought to have an effect equivalent to over 80 deaths per year in Southwark, comparable to the number of deaths caused by lung cancer. The effect of PM2.5 on mortality is higher in Southwark than in London or England, but rates are falling due to reductions in emission rates. While emissions are decreasing, concentrations of NO2 remain above the legal limit along major roads in Southwark, particularly in the north west of the borough (part of the Congestion Charge zone). This is a particular issue for those with long-term conditions and those living along main roads. As there is a social gradient associated with housing on busy main roads, this is likely to contribute to local health inequalities. Estimates show that 45% of people living in Southwark are regularly exposed to high NO2 levels. Southwark Council has recently developed a new Air Quality Strategy and Action Plan for , outlining cross-council action to address air pollution and has been included in the New Southwark Plan. Air quality is a Public Health priority in Southwark and action is being taken to encourage walking and cycling in the borough, increase public awareness of air quality and protect the health of vulnerable groups. Successes in the last year include extensive work with schools to support them in reducing children s exposure to air quality. This includes providing guidance, undertaking air quality audits, enforcing vehicle idling and nuisance parking regulations and applying to be part of the pilot scheme, School Streets. Public Health has also undertaken a health needs assessment on outdoor air quality to create a picture of the local health impacts of poor air quality. This outlines a number of recommendations for action to meet the identified needs in Southwark. Key achievements in 2017 In 2017 Southwark Council undertook a needs assessment on the health impacts of air quality and a new Air Quality Strategy and Action Plan for The New Southwark Plan (currently out to consultation) includes a development management policy on air quality. We have worked extensively with schools to identify and implement a variety of air quality measures to reduce children s exposure to air pollution. Key areas of work for We will be engaging NHS partners in Southwark identify opportunities to improve health outcomes for those most affected by air pollution. 2. We will continue to develop the air quality communications campaign and advocate for wider, regional action to address air quality. 3. We will promote School Travel Plans and increase the number of schools attaining TfL STARs Silver or Gold accreditation each year Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 28 of 34

187 Statistical Bulletin Table 6.Summary table of health indicators in Southwark, March 2018 Source: PHE 2017, Public Health Outcomes Framework Domain Indicator Period London ranking* Southwark London England Life expectancy at birth among males (years) Wider determinants Life expectancy at birth among females (years) Healthy life expectancy among males (years) Healthy life expectancy among females (years) Childhood obesity Sexual Health Excess weight - Reception (%) 2016/ Excess weight - Year 6 (%) 2016/ All new STI diagnosis (rate per 100,000) ,628 1, New HIV diagnosis (rate per 100,000 aged 15+) Diagnosed prevalence of serious mental illness (%) 2016/ Mental Health Long term conditions Air Quality Self-harm hospital admissions (per 100,000 population aged 10-24) Age standardised suicide (rate per 100,000 population) 2015/ Diagnosed prevalence of Hypertension (%) 2016/ Diagnosed prevalence of Depression (%) 2016/ Diagnosed prevalence of Diabetes (%) 2016/ Fraction of all-cause adult mortality attributable to particulate air pollution (%) * - out of 32, 1 being the highest Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 29 of 34

188 Data sources, references and further reading Department for Communities and Local Government, English Indices of Deprivation uk/government/statistics/english-indices-ofdeprivation-2015 Department of Health, Long Term Conditions Compendium of Information, government/publications/long-term-conditionscompendium-of-information-third-edition EMIS Web Extract, SMI Register, Southwark General Practice [Accessed December 2017] Greater London Authority: 2016-based population projections & borough preferred options; Southwark Borough Preferred Option Projection 2015; Round trend-based ethnic group projections, [Accessed 05/02/2018] Greater London Authority, London Atmospheric Emissions Inventory (LAEI) gov.uk/dataset/london-atmospheric-emissionsinventory-2013 King s Fund, Long Term Conditions and Mental Health: The Cost of Co-Morbidities, 2012 www. kingsfund.org.uk/sites/default/files/field/field_ publication_file/long-term-conditions-mental-healthcost-comorbidities-naylor-feb12.pdf NHS Digital, Adult Psychiatric Morbidity Survey, NHS Digital, National Child Measurement Programme- England, [Access 05/02/2018] nhs.uk/catalogue/pub30113 NHS Digital, Quality and Outcomes Framework, 2016/17 NHS Southwark Clinical Commissioning Group (CCG) & Southwark council, Joint Mental Health and Wellbeing Strategy southwark.gov.uk/housing-community-servicesdepartment-community-engagement-team/ improving-mental-wellbeing/supporting_documents/ DRAFT%20V0.6%20Southwark%20Mental%20 Health%20and%20Wellbeing%20Strategy% pdf Office for National Statistics 2017, Health state life expectancy at birth and at age 65 by local areas, UK healthandsocialcare/healthandlifeexpectancies/ datasets/healthstatelifeexpectancyallagesuk Office for National Statistics, Life expectancy at birth by local areas, UK, to [Accessed 05/02/2018] peoplepopulationandcommunity/healthandsocialcare/ healthandlifeexpectancies/datasets/ lifeexpectancyatbirthandatage65bylocalareasuk Office for National Statistics, Mid-year 2016 resident population estimates gov.uk/peoplepopulationandcommunity/ populationandmigration/populationestimates/ bulletins/annualmidyearpopulationestimates/latest Office for National Statistics, Subnational sexual identity estimates, UK: 2003 to 2015 [Accessed 05/02/2018] peoplepopulationandcommunity/culturalidentity/ sexuality/articles/subnationalsexualidentityestimates/ uk2013to2015 Office for National Statistics, Suicides in England and Wales by local authority, to [Accessed 05/02/2018] www. ons.gov.uk/peoplepopulationandcommunity/ birthsdeathsandmarriages/deaths/datasets/ suicidesbylocalauthority Public Health England, Atrial fibrillation prevalence estimates for local populations [Accessed 05/02/2018] Public Health England, CKD prevalence estimates for local and regional populations 2015 [Accessed 05/02/2018] ckd-prevalence-estimates-for-local-and-regionalpopulations Public Health England, Diabetes prevalence estimates for local populations [Accessed 05/02/2018] www. gov.uk/government/publications/diabetes-prevalenceestimates-for-local-populations Public Health England, Disease and risk factor prevalence [Accessed 05/02/2018] phe.org.uk/profile/prevalence/data#page/0/ gid/ /pat/46/par/e /ati/152/are/ G85138 Public Health England, Hypertension prevalence estimates for local populations 2016 [Accessed on 05/02/2018] hypertension-prevalence-estimates-for-localpopulations Public Health England, Public Health Outcomes Framework [Accessed on 05/02/2018] fingertips.phe.org.uk/profile/public-health-outcomesframework/data#page/0/gid/ /pat/6/par/ E /ati/101/are/E /iid/30101/ age/230/sex/4 Public Health England, Sexual and Reproductive Health Profiles Public Health England, Southwark Local authority HIV, sexual and reproductive health epidemiology report (LASER): 2016 Southwark Council, Air Quality and Action Plan, strategies-plans-letters-and-reports Southwark Health and Wellbeing Board, Everybody s Business Southwark Healthy Weight Strategy s63091/appendix%201%20healthy%20weight%20 Strategy%202016%20-% pdf Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 30 of 34

189 Healthy People in Healthy Places Annual Public Health Report of the Director of Health & Wellbeing 2017 Part C. Accompanying media and resources

190 Videos BITESIZE VIDEOS ON PUBLIC HEALTH IN SOUTHWARK HISTORY (00:54) Learn about Southwark's pioneers in health and wellbeing: from London's first female mayor Ada Salter to the Peckham Pioneer Centre HEALTHY PEOPLE IN HEALTHY PLACES (06:42) Find out about about the problems that we face for the health of those living, working and learning in Southwark. We'll introduce you to some of the innovative projects run by our voluntary and community sector partners and how we plan to shape regeneration to maximise health and wellbeing over the years ahead. TODAY'S CHALLENGES (00:50) Today we're faced with high rates of childhood obesity, poor sexual health, mental illness and substantial inequalities THE WAY FORWARD (01:06) We're building health into all our work: shaping places that enable people to make healthier choices and live more fulfilling lives SUBSCRIBE TO SOUTHWARK COUNCIL'S YOUTUBE CHANNEL Visit to learn more Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 32 of 34

191 Additional resources Over the course of the year we'll be releasing further resources including: Infographics Joint Strategic Needs Assessments (JSNA) Ward health summaries Additional video content You can already download last year's report along with a wide range of needs assessments and a Microsoft PowerPoint compatible form of this report (including graphics) on our JSNA website available at southwark.gov.uk/jsna If you are seeking public health expertise for your project or want to discuss a matter in greater detail, please contact the team via at publichealth@southwark.gov.uk Annual Public Health Report of the Director of Health & Wellbeing 2017 southwark.gov.uk Page 33 of 34

192 Healthy People in Healthy Places Annual Public Health Report of the Director of Health & Wellbeing 2017 Learn more at southwark.gov.uk/publichealth

193 Healthy People in Healthy Places Annual Public Health Report of the Director of Health and Wellbeing 2017 Accompanying slides People & Health Intelligence Section Southwark Public Health March 2018

194 GATEWAY INFORMATION Report title: Status: Prepared by: Contributors: Approved by: Suggested citation: Contact details: Annual Public Health Report of the Director of Health and Wellbeing 2017 (accompanying slides) Public Nora Cooke O Dowd Sophie Baird, Chris Williamson, Richard Pinder Kevin Fenton Date of publication: 13 March 2018 Healthy People in Healthy Places; Annual Public Health Report of the Director of Health and Wellbeing 2017 (accompanying slides). Southwark Council: London publichealth@southwark.gov.uk Slide 2

195 INTRODUCTION This slide deck provides in Microsoft PowerPoint format the content delivered in the Annual Public Health Report of the Director of Public Health 2017 the original report can be found at Slide 3

196 How places and spaces are designed, maintained and evolve is vital to health and wellbeing PLACE & HEALTH The places in which we are born, live, work and age influence our health and wellbeing These places can be shaped to enable healthy lifestyles, supporting healthy eating and physical activity and participation in the community and in local activities Place-shaping is a highly important concept for those involved in both revitalising existing, and building new communities New development can affect the character of a place and this is therefore a process that needs to be managed Local authorities are strategic leaders in place-shaping Place-shaping is an active process which responds to residents ambitions and aspirations Southwark is currently exploring an improved understanding and relationship with developers through the TCPA s* Developer & Wellbeing programme Local authorities can work with partners towards a shared vision for health through place-shaping that can account for local health needs Healthy places are those which enable: connection with others healthy affordable homes active living & travel affordable quality food safe, attractive public spaces for play & recreation contact with nature in everyday life access to quality services & amenities * Town and Country Planning Association Slide 4

197 Regeneration has a fundamental role in improving the health, wellbeing and life chances of communities THE ROLE OF REGENERATION Urban regeneration is one of many options available for shaping place to improve health and wellbeing by influencing the built and social environment Southwark is delivering some of Europe s most exciting and complex regeneration schemes which are helping to shape neighbourhoods Regeneration is too often only considered in terms of the built environment and the physical conditions in which we live In Southwark our approach to regeneration is also about ensuring access to quality services and amenities and supporting the creation of jobs Place-shaping through regeneration will be critical to help tackle the wider social determinants of health Improving wellbeing and population health in Southwark will require action on many fronts with a whole council approach that drives regeneration Evidence suggests that this may be achieved by ensuring that communities and health and wellbeing are at the centre of our regeneration process In Southwark we are integrating health and wellbeing into planning Strategic policies within the New Southwark Plan aim to encourage healthy lives by tackling the causes of ill-health and inequalities in Southwark In our major regeneration areas we are also working on evidence-informed heath plans, charters and outcome frameworks to ensure that regeneration impacts positively on health and wellbeing Slide 5

198 We have an opportunity to work towards achieving the best possible outcomes from redevelopment & renewal MAKING REGENERATION WORK FOR EVERYONE Engaging and empowering local communities can improve community health and wellbeing Evidence suggests that local communities must be engaged from the earliest point to be involved in co-identification of needs and co-design of solutions, and to bridge communities to local resources This also promotes equity and increases people s control over their health and lives, which are key to addressing health inequalities The Southwark Conversation provides a rich source of information to help us further shape our borough We will be working closely with partners across the borough to draw out implications for how we create healthier urban environments and will continue listening to communities We will aim to create healthier places where the healthier choice is the easier choice Part of this is looking at opportunities for integration, co-location and bringing services closer to communities and will help us to drive improvement and equity in population health both within and outside services We are developing high level indicators which will enable us to assess inequalities in health across the borough These will measure not just how regeneration impacts on people in local areas, but also the benefits that extend to people in other parts of the borough Slide 6

199 Southwark is shaping place for health and wellbeing and reducing health inequalities through regeneration SHAPING PLACE FOR HEALTH AND WELLBEING There are five key recommendations to accelerate progress and demonstrate the impact of this important strategic imperative: 1. Develop and enhance cross-council governance, partnership and communication opportunities on social regeneration efforts to raise awareness, facilitate collaboration, and encourage more systematic evaluation of the opportunities and impact of urban renewal to improve health and wellbeing, reduce inequalities and improve life chances. 2. Ensure local health and wellbeing plans are in place for all major regeneration efforts taking place across the borough and that these are developed through wide engagement with local communities and stakeholders. 3. Further accelerate the use of local health, social and other relevant data into local planning decisions to ensure that a more comprehensive understanding of the wellbeing needs and potential health and inequalities impacts are considered. 4. Develop a standard set of key indicators for social regeneration, working collaboratively with a wide range of partners including local communities, to guide the evaluation of all urban renewal projects in the borough. 5. Develop and maintain robust governance, communication and other opportunities to support community participation and engage key stakeholders on the Council s progress on social regeneration Slide 7

200 The population of Southwark is set to continue to grow, increasing by 20% to over 370,000 in 2026 POPULATION PROJECTIONS Home to some 313,000 people, Southwark is a patchwork of communities: from leafy Dulwich in the south, to bustling Peckham and Camberwell, and the rapidly changing Rotherhithe peninsula. Towards the north, Borough and Bankside are thriving with high levels of private investment and development. The population of Southwark has been growing since the late 1980s, surpassing 300,000 inhabitants in Growth is set to continue across almost all areas of the borough in the next decade. In particular, redevelopments around Old Kent Road, South Bermondsey and Elephant and Castle, will lead to significant population increases in these communities. Population projections in Southwark, , , ,100 Local population projections used suggest that the population could increase could by a further 20% between 2016 and 2026 Mid-year population estimates GLA 2015 based population projections References 1. GLA 2017, 2015 Southwark Borough Preferred Option Projection Slide 8

201 Southwark is a young borough, with a large proportion of young working age population MEDIAN AGE IN SOUTHWARK Southwark has a comparatively young population, with median age of 32.9 years, compared to 34.8 years in London and 39.8 years in England. Some 92% of Southwark s population are under the age of 65: a much higher proportion than the national average of 82%. The young average age of the borough, stems not from a large number of children, but from a large number of young working age residents. Over 40% of the Southwark population consists of those aged 20 to 39, compared to 34% in the rest of London. Over the coming decade our population is predicted to grow older: The largest absolute population increase is expected in those aged 35-44, by around 18,000 The largest relative increase is predicted for those aged (52%) Age and sex distribution of the population in Southwark, London and England, % 6% 4% 2% 0% 2% 4% 6% 8% Percentage of population London Southwark males Southwark females Reference 1. Greater London Authority 2016-based borough preferred population projections Slide 9

202 There is deprivation across the borough, with 38% in the highest quintile for deprivation nationally DEPRIVATION Deprivation has an important impact on health, as more deprived areas have higher prevalence of behavioural risk factors, underpinned by inequalities in the broad social and economic circumstances which influence health. Southwark is the 40th most deprived of 326 local authorities in England and ninth most deprived out of 32 local authorities in London There is significant variation in deprivation across the borough, with around 119,000 (38%) Southwark residents living in communities ranked in the 20% most deprived areas nationally. The most deprived areas are situated in Peckham through to Elephant and Castle in the north-west. However, there are pockets of deprivation across the borough. Parts of the river front and Dulwich are the least deprived parts of the borough. By contrast, only around 6,700 (2%) of residents live in communities considered the least deprived nationally. Around 15,000 children (28%) in Southwark aged under 16 live in low income families Reference 1. Greater London Authority 2016-based borough preferred population projections Slide 10

203 Southwark is both ethnically and culturally diverse, particularly among those under 20 DIVERSITY Southwark is a diverse borough with people from a wide range of ethnicities and backgrounds. Over 120 languages are spoken here, and 11% of households have no members who speak English as a first language. Just over half (54%) of Southwark s population is of white ethnicity, a quarter (25%) black and a third of Asian (11%) or other (10%) ethnicities. This differs from the rest of London where a considerably smaller proportion (13%) identify as black and a considerably larger proportion identify as Asian (21%). The ethnic diversity of the borough varies markedly across age groups and the population under 20 is much more diverse than other age groups, with a similar proportion of young people from white and black ethnic backgrounds. According to the 2011 census, 39% of Southwark residents were born outside the UK, showing not only the ethnic diversity of the borough, but also the cultural diversity. Population of Southwark in 10-year age bands, by ethnicity % 80% 60% 40% 20% 0% White Asian Black Mixed Other References 1. GLA 2016, Round trend-based ethnic group projections, 2015 Slide 11

204 Life expectancy at birth has increased in Southwark, by four years for women and five years for men LIFE EXPECTANCY Life expectancy at birth has been increasing steadily over time. This is true across London and England, but the improvement has been more pronounced in Southwark. In , life expectancy at birth for men was 79.1 years and 83.8 years for women in Southwark. Between and , the average number of years that a new-born baby would expect to live, based on contemporary mortality rates, increased by four years for women and five years for men. However, life expectancy in Southwark is still below the London average and ranks 26 out of the 32 boroughs in London for both men and women. Trends in life expectancy for men, to Trends in life expectancy for women, to London Southwark London Southwark Reference 1. ONS 2017, Life expectancy at birth by local areas, UK, to Slide 12

205 The gap in life expectancy between Southwark and London has been narrowing, but deprivation gap remains LIFE EXPECTANCY Whilst there has been a significant increase in life expectancy in Southwark over time, this improvement has not been the same across all our communities. The range in years of life expectancy from the most to least deprived areas in Southwark was 5.5 years for women in and 9.5 years for men. This discrepancy has been increasing over time for men, but has stayed roughly the same for women. In , life expectancy for men in Southwark was 1.3 years below the London average and 0.4 years for women. These gaps have been narrowing over time and have decreased by one-third for men and by half for women since Male Life expectancy at birth Change over time Southwark years London years Southwark/London gap % Slope index of inequality in Southwark, to Female Life expectancy at birth Change over time Southwark years London years Southwark/London gap % Reference 1. ONS 2017, Life expectancy at birth by local areas, UK, to Public Health Outcomes Framework, Slope index of inequality in life expectancy at birth 5.5 Slide Male Female

206 There is a two decade gap between life expectancy and healthy life expectancy HEALTHY LIFE EXPECTANCY Whilst our residents are living longer, the length of the time spent living in good health is also an important factor. Healthy life expectancy is often considered a measure of whether we are adding life to years, as well as years to life. In , there was a 17.9 year gap between life expectancy and healthy life expectancy for men and a considerably larger 21.2 year gap for women. National intelligence indicates that not everyone can expect the same number of years spent living in good health. The gap in healthy life expectancy between the most and least deprived areas of the country stands at 19 years for both males and females. Gap in life expectancy in Southwark, by sex Male 17.9 year gap Life Expectancy Female Healthy Life Expectancy 21.2 year gap References 1. ONS 2017, Health state life expectancy at birth and at age 65 by local areas, UK Slide 14

207 Southwark has among the highest levels of excess weight in the borough CHILDHOOD OBESITY The National Child Measurement Programme measures the height and weight of children in Reception (aged 4-5 years) and Year 6 (aged years) in state maintained primary schools across England. Obesity among children in Southwark is consistently above London and national levels. In , Southwark had the third highest level of excess weight (overweight and obese) out of the 32 London Boroughs for children in Reception (26%) and fourth highest for children in Year 6 (43%). Excess weight and obesity in Reception is significantly higher than the Southwark average in the areas immediately south of the Old Kent Road, from Peckham, through to Walworth and Elephant and Castle in the North West. By Year 6 there is little significant difference across the borough, indicating a whole population approach is required by this age. Percentage of children who are overweight or obese in Reception and Year 6, % 22% 23% 43% 39% Reception Year 6 Southwark London England 34% References 1. National Child Measurement Programme- England, Slide 15

208 We will continue our work with partners across the borough to reduce the obesogenic environment CHILDHOOD OBESITY Key achievements in 2017 In 2017, we enhanced our commitment to early years by progressing to Stage 1 Baby Friendly accreditation, commissioning the Breastfeeding Welcome Scheme, and becoming a Healthy Early Years pilot borough. These initiatives will further develop in In 2017, we linked public health and planning policy teams to ensure resident and community health is a key consideration of all Council planning decisions. In 2017, we were formally recognised by the GLA and Sustain for our work addressing food poverty across the borough. We are currently developing a Food Poverty Action Plan to deliver targeted work using a strategic, coordinated approach with community partners. Key areas of work for In 2018, we will work to improve the confidence and competence of health and non-health professionals to effectively communicate healthy weight messages through a newly commissioned online training service. 2. In 2018, we will increase levels of physical activity by developing tailored support to schools with the highest levels of excess weight and by piloting a unique Clinical Advice Pad prescribing physical activity to residents. 3. In 2018, we will collaborate with Guys and St Thomas Charity, local faith groups and other Council departments to develop sustainable, community-driven interventions around obesity and multiple long term conditions to extend the reach of healthy weight services across the borough. Slide 16

209 Southwark has the second highest rate of new STI diagnosis in England SEXUAL HEALTH There were 8,117 new STI diagnoses in Southwark in With a rate of 2,628 new STI diagnoses per 100,000 population in 2016, Southwark has almost double the rate of STI diagnoses in London, and is the second highest of any borough in England, behind neighbouring Lambeth. The most common STIs in Southwark are chlamydia, gonorrhoea and genital warts 56% of all new STIs diagnoses were in men who have sex with men. Just over one-third of new STI diagnoses were made up of those aged 15 to 24. Young people are also more likely to become reinfected with STIs, contributing to infection persistence. In Southwark, an estimated 14% of year old women and 13% of year old men presenting with a new STI from 2012 to 2016 became re-infected within 12 months. The overwhelming majority (84%) of all new STI diagnoses in Southwark occurred in the two most deprived quintiles. New STI diagnosis per 100,000 in Southwark ,390 2,628 1,378 1, Southwark London England References 1. PHE 2017, Sexual and Reproductive Health Profiles 2. PHE 2017, Southwark Local authority HIV, sexual and reproductive health epidemiology report (LASER): 2016 Slide 17

210 Southwark has the second highest rate of HIV prevalence in England, but rate of new diagnosis is declining HIV Levels of HIV in Southwark are particularly high, with the borough having the second prevalence in England, behind neighbouring Lambeth. There are currently 2,557 people living in the borough who have been diagnosed with HIV. In 2016, more than 100 people in Southwark were newly diagnosed with HIV. While the rate in Southwark is significantly higher than London, the gap has narrowed significantly time as new diagnoses in Southwark have more than halved since Late diagnosis is the most important predictor of HIV-related morbidity and short-term mortality and this has also improved in Southwark over time. However, still over onethird (37%) of adults newly diagnosed with HIV were diagnosed late in Southwark between 2014 and New HIV diagnosis rate per 100,000 in Southwark Southwark London region References 1. PHE 2017, Sexual and Reproductive Health Profiles 2. PHE 2017, Southwark Local authority HIV, sexual and reproductive health epidemiology report (LASER): 2016 Slide 18

211 We are developing a strategy with Lambeth and Lewisham to reduce the burden of poor sexual health SEXUAL HEALTH Key achievements in 2017 Between 2015 and 2016 (latest available data), new diagnoses of STIs declined by 9% and new diagnoses of HIV declined by 40%, while rates of testing continued to increase. In 2017, we agreed integrated sexual health contracts with KCH and GSTT, maintaining high quality services while reducing contract costs by 9.3m over the next 4.5 years. In 2017, an innovative integrated young peoples wellbeing service was commissioned to better meet the multiple needs of young people, including sexual health, drugs and alcohol, and mental wellbeing. We are currently working with the service provider (Brook and CGL) to embed the new service. Key areas of work for In 2018, we will develop a new sexual and reproductive health strategy in partnership with Lambeth and Lewisham councils, which will include annual action plans. 2. Following a pilot, we will explore options for access to oral contraception online, in order to reduce GP appointments and additional demand on specialist GUM clinics. 3. We will develop and implement, in partnership with Lambeth Council, a new model for the delivery of pharmacy sexual health services for our residents, with the aim of improving access to contraceptive options and reducing repeat use of emergency contraception. Slide 19

212 A considerable number of people in the borough experience mental ill health MENTAL HEALTH Mental health and a sense of wellbeing are central to living a purposeful, healthy and enjoyable life, because there is no health without mental health Almost 50,000 adults in Southwark experience a Common Mental Disorder, which comprises different types of depression and anxiety, and this is expected to rise. All types of CMD are more prevalent in women than men: 1 in 5 women report experiencing CMD, compared to 1 in 8 men. The gender gap is particularly pronounced among those aged 16-24, where more than three times the number of women have a common mental disorder than men. Severe mental illness refers to psychotic conditions such as schizophrenia and bipolar affective disorder, which affects 1.2% of Southwark residents (4,000 people), compared to 1.1% in London. The prevalence of SMI increases with age among both men and women, peaking among those in their fifties. In contrast to the estimated prevalence of common mental disorders, the number of men diagnosed with SMI in Southwark in greater than women across each age group up to 70. References 1. NHS Digital, Adult Psychiatric Morbidity Survey, SMI Register, Southwark General Practice; EMIS Web Extract, December 2017 Slide 20

213 Suicide is more common among men and self-harm among women and young people SUICIDE & SELF-HARM Every suicide is a tragic event and has devastating impacts on families, friends and communities. In Southwark we know that many suicides are preventable. Southwark is one of five London boroughs to report higher suicide rates than the national average in 2013/15. For each of the last three years, between 14 and 32 Southwark residents have taken their own lives. Almost four out of five local suicides were among men. Whilst suicide is more common among men, women are much more likely to report having self-harmed. In 2015/16, there were 286 emergency hospital admissions for intentional self-harm in Southwark, 62% of these were women. Young people are also more likely to selfharm. The admission rate for young people is comparable to the overall rate for London, but significantly lower than the national average Directly-standardised rates of hospital admission as a result of self-harm per 100,000 population aged / / / / /16 Southwark London England References 1. ONS 2017, Suicides in England and Wales by local authority 2. PHE, Hospital admissions as a result of self-harm, 2011/12 to 2015/16 Slide 21

214 Continually working with stakeholders is key to promoting good mental health and reducing suicide MENTAL HEALTH Key achievements in 2017 Southwark s Public Health Team have established a new multi-stakeholder Suicide Prevention Steering Group and facilitated the co-production of a local Suicide Prevention Strategy and Action Plan Key areas of work for To support the commitment of the Council and Southwark CCG to prevent mental ill health and promote wellbeing, we will work with local partners to complete a needs assessment focusing on mental health promotion and wellbeing. Southwark Council and Southwark NHS Clinical Commissioning Group have worked in partnership to develop a Joint Mental Health and Wellbeing Strategy In order to improve care for patients in crisis in A&E, Southwark CCG and Southwark Council have been part of the implementation of a centralised Place of Safety on the South London and Maudsley hospital site. 2. We will work with Southwark CCG to ensure the integration of physical health and mental health in Southwark, including work on long term conditions and mental health linked to the delivery of the Southwark population segmentation model. 3. We will create an improved pathway to promote recovery and step down from high support mental health accommodation placements and also review placements that are out of borough to ensure quality care is being delivered, and ensure that care is provided in Southwark where appropriate. Slide 22

215 Prevalence of diagnosed long-term conditions in Southwark is similar or lower than London LONG TERM CONDITIONS Data from General Practices provide a register of recorded disease prevalence for a number of Long Term Conditions (LTCs). Hypertension (11%), Depression (8%), and Diabetes (6%) are the most prevalent measured diagnoses in Southwark, mirroring the national picture. Increasingly, patients have to manage more than one LTC at a time. Approximately 1% of the registered Southwark population have three or more chronic conditions (3,500 patients). More than half of people with multiple LTCs are aged 70 and over. Diagnosed disease prevalence in 2016/17 Condition Group Condition IHL QHS Southwark London Cases Prevalence Prevalence Dementia 0.5% 0.3% 1, % 0.5% Mental Health & Depression (18+) 7.6% 7.4% 19, % 6.6% Neurological Epilepsy (18+) 0.6% 0.5% 1, % 0.6% conditions Learning Disabilities (18+) 0.3% 0.3% 1, % 0.4% Mental Health 1.3% 1.2% 4, % 1.1% Atrial Fibrillation 0.8% 0.7% 2, % 1.1% CHD 1.4% 1.4% 4, % 2.0% Cardiovascular Stroke & TIA 1.0% 0.8% 2, % 1.1% conditions Heart Failure 0.4% 0.5% 1, % 0.5% Hypertension 11.1% 10.2% 34, % 11.1% Respiratory COPD 1.1% 1.6% 4, % 1.1% conditions Asthma 4.6% 4.2% 14, % 4.6% High dependency & other LTCs Cancer 1.5% 1.4% 4, % 1.8% Chronic Kidney Disease (18+) 1.9% 2.4% 5, % 2.4% Diabetes (17+) 6.5% 5.8% 16, % 6.5% References 1. NHS Digital Quality Outcomes Framework 2016/17 Slide 23

216 We aim to promote early detection of long term conditions and improve outcomes LONG TERM CONDITIONS Key achievements in 2017 Between 1 April 2014 and 31 December 2017, 31,686 Health Checks have been completed in Southwark. We provided support to the clinical effectiveness programme in Southwark CCG, including intelligence and the delivery of Protected Learning Time (PLT) sessions for local GPs. We conducted cardiovascular disease (CVD) risk factors needs assessment, with a focus on primary prevention, to drive better outcomes for CVD at a local level. Key areas of work for We will develop and pilot a Digital NHS Health Check which is easy to access and simple to use to further increase uptake and improve health outcomes. 2. Further work is planned for 2018 to assess the CVD profile locally in terms of secondary prevention, and explore benefits of using prevalence and/or budget modelling approaches while setting priorities for public health interventions in the future. 3. We will continue to support the Southwark CCG in their programme of work to improve outcomes for people with long term conditions. Slide 24

217 Air quality in Southwark is improving, but roughly 80 deaths annually are attributable to particulate matter AIR QUALITY Air pollution data show a decrease in total emissions for nitrogen oxides (NOx) and particulate matter (PM) in Southwark. NOx is the largest pollutant in Southwark with around 1,200 tonnes emitted in 2013 alone, over a quarter less than in Around 110 tonnes of PM10 were emitted in Southwark in 2013 a decrease of a fifth since Around 56 tonnes of PM 2.5 were emitted in 2013 a decrease of over a quarter since Exposure to poor air quality is associated with both ill-health and premature death. As well as impacting health conditions, long-term exposure to air pollution can increase the risk of premature mortality and PM 2.5 is thought to have an effect equivalent to over 80 deaths per year in Southwark Reference 1. Greater London Authority, London Atmospheric Emissions Inventory (LAEI) 2013 Slide 25

218 Tackling air quality involves engagement with schools and wider community partners AIR QUALITY Key achievements in 2017 In 2017 Southwark Council undertook a needs assessment on the health impacts of air quality and a new Air Quality Strategy and Action Plan for The New Southwark Plan (currently out to consultation) includes a development management policy on air quality. We have worked extensively with schools to identify and implement a variety of air quality measures to reduce children s exposure to air pollution. Key areas of work for We will be engaging NHS partners in Southwark identify opportunities to improve health outcomes for those most affected by air pollution. 2. We will continue to develop the air quality communications campaign and advocate for wider, regional action to address air quality. 3. We will promote School Travel Plans and increase the number of schools attaining TfL STARs Silver or Gold accreditation each year Slide 26

219 There are a range of indicators that give us an overview of the state of health in Southwark KEY INDICATORS Every suicide is a tragic event and has devastating impacts on families, friends and communities. In Southwark we know that many suicides are preventable. References 1. PHE 2017, Public Health Outcomes Framework Slide 27

220 Southwark Integrated Governance & Performance Committee 22 February 2018 Room 132, 160 Tooley Street MINUTES Present: Dr Noel Baxter (NB) Rod Booth (RB) Robert Davidson (RD) Joy Ellery (JE) Jacquie Foster (JF) Dr Emily Gibbs (EG) Dr Richard Gibbs (RGi) Caroline Gilmartin (CG) Ross Graves (RGr) Dr Jonty Heaversedge (JH) Malcolm Hines (MH) Dr Nancy Küchemann (NK) Kate Moriarty Baker (KMB) Andrew Nebel (AN) Robert Park (RP) Dr Yvonneke Roe (YR) Kieran Swann (KS) Jo Steranka (JS) Richard Whitfield (RW) Apologies: Andrew Bland (AB) Ami David (AD) Linda Drake (LD) Mark Kewley (MK) Dr Mike Khan (MKh) David Smith (DS) Clinical Lead, SCCG Head of mental Health and Wellbeing, SCCG Clinical Lead, SCCG Lay Member, SCCG Head of Quality, SCCG Clinical Lead, SCCG Lay Member, SCCG Director of Integrated Commissioning, SCCG Interim Managing Director, SCCG Chair, SCCG Chief Financial Officer and Deputy Chief Officer, SCCG Clinical Lead, SCCG Director of Quality and Chief Nurse, SCCG Lay Member, SCCG - Chair Lay Member, SCCG Clinical Lead, SCCG Head of Governance and Assurance, SCCG Head of Digital Transformation Assurance Manager, SCCG (minutes) Chief Officer, SCCG Registered Nurse Member, SCCG Clinical Lead, SCCG Director of Transformation Secondary Care Doctor Member, SCCG Associate Director Performance, ICDT 1 Welcome The Chair welcomed members to the meeting. 2 Introduction and Apologies Apologies were noted. Chair: Dr Jonty Heaversedge 1 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

221 Declaration of Interest 3 All members were asked to declare any change in conflicts of interest and raise any conflicts relating to items on the agenda. The declaration of interests register was circulated for signing, and changes noted here. Malcolm Hines stated that the register had been updated to reflect his new role as Director of Finance for Southwark, Bromley and Bexley. He noted he would formally start in April AN noted that this role may represent a potential conflict of interest in relation to the agenda item on the financial plan. Minutes of the Previous Meeting and Action Log The minutes of the January meeting were reviewed for accuracy and completeness. JF highlighted the following points of clarification. Under matters arising the business case relates to Dulwich. On page 8, the audit is of ED. 4 Action: RW to amend minutes to reflect points of clarification. Noting the above additions, the January minutes were agreed as a comprehensive and accurate record. Completed actions were reviewed. AN updated the committee that the Public Sector Equality Duty Annual had been reviewed, signed off and uploaded to the CCG website in line with the process agreed at the January committee. The web address of the document is included in the action log giving opportunity for further comments to be made by members. There were no other outstanding actions. Matters Arising 5 MH updated the committee on the status of the Dulwich business case saying it has been agreed by the London Capital Committee and will now go to Paul Baumann (NHS England CFO) before going to the national Investment Committee in mid March. It was flagged previously at IGP that Southwark is in the lower performing quartile for neonatal deaths and stillbirths. This is based on data from More recent provider level data appears to show some difference in the rates at the two main trusts for Southwark This will be taken forward with the trusts via CQRG. The committee noted these matters arising CCG Risk Report & Board Assurance Framework (M11) 6 KS introduced the CCG s risk report for the month of February 2018 presenting the highlights of updates to risks for the CCG. KS stated that the BAF and risk registers have been updated by all risk owners and then Chair: Dr Jonty Heaversedge 2 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

222 reviewed by the CCG directors in their monthly risk meeting with the Governance and Assurance Manager. KS stated that there were a total of 26 risks on the BAF, with ten red rated extreme risks. He outlined the following changes to the BAF in February: There were no new risks on the BAF and no risks were closed. FM 04 CSU performance & quality of service provision was reviewed by the responsible director and escalated, returning it back to the previous risk score following challenge at the January IG&P One risk was closed on the BAF: Risk that budget reductions in adult social care impact disproportionately on key hospital discharge, re-ablement and intermediate care services, adding additional pressures to acute bed capacity. KS stated that teams also reviewed their directorate risk registers (total of 24 risks), with changes are detailed in the report. He highlighted the escalation of risk IC-25: Significant financial risk to the CCG if robust governance arrangements for mental health placements are not developed in partnership with the Council. He stated that risk articulation and controls will be reviewed by the Head of Mental Health Commissioning and will be escalated to the BAF. RP suggested that MH reviews risk FM-06 and distinguishes any risks relating to the delivery of the STP programme, with those that may relate to the delivery of a SEL Capped Expenditure Process requirement for financial balance. MH said that he would review the structure of this risk together with Richard Gibbs and Robert Park Action: MH / RG / RP. CG agreed, stating the importance of clarifying what is a risk vs an issue which is already in place, as well as identifying specific risks regarding the worsening of the financial position. RP requested that that the OHSEL risk register be reviewed at IG&P more regularly. RG stated the importance of not conflating the OHSEL programme risks associated with delivering their transformational programme in comparison to the SEL and STP level risks referred to above. He stated that the OHSEL programme risks should also be reviewed Action: RW/KS to schedule OHSEL programme risk register review for IGP The committee noted the changes in the BAF risks, updates provided by the teams, and received assurance on the proactive management of strategic risks. The Committee noted the highlights on directorate risk registers. The committee noted the current extreme risks for the CCG and the BAF risk profile depicted in the Heat Map. The committee approved the report and recommend it to the Governing Body. Chair: Dr Jonty Heaversedge 3 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

223 CCG Finance Report (M10) MH presented the M10 finance report. He emphasised that the report shows the position at M10. These further changes will be included in the M11 report. MH summarised the M10 position as follows: The CCG was underspent at the end of Month 9 by 7,057k for the year to date (ytd). This is 1.1m below the planned surplus at this point in the year ( 8,119k). This is due to the nationally agreed treatment of the NCSO drugs The CCG has needed to utilise 1,165k of reserves to achieve this YTD position. There are adverse variances on Acute, Client Groups, Delegated Primary Care Commissioning, Prescribing and Corporate, which are partially offset against a favourable variance against Primary Health Care Services, Transformation and Earmarked Budgets and Reserves. The CCG is forecasting to make a surplus of 8,466k, which is the annual target surplus of 9,743k less 1,276k relating to the NCSO adjustment. The target surplus is equivalent to the brought forward surplus from 2016/17, which has been returned to the CCG in the form of a non-recurrent allocation (increased by 150k in Month 3, due to the return of the full achievement in 2016/17) of 10,213k in line with national process, less 700k planned drawdown of prior year historic surplus. The surplus has then been adjusted for a planned inyear increase of 230k. 7 SEL CCGs are in discussion with NHSE about system wide commitments, such as the implementation of the Trust Special Administrator Agreement relating to Lewisham and Greenwich Trust. It is certain that a payment will be made this year, the last year of such support, of up to 1.75m maximum. This has been included at the maximum value in the Acute figures in this report. There is currently 5,716k of reserves uncommitted in the likely forecast position as at Month 10. These reserves include the earmarked budgets itemised on page 3 which are ring-fenced for specific application and are therefore not available to commit. They will be applied as and when necessary for the purposes detailed. In the worst case projection, the CCG would need to utilise 3,432k of reserves to offset adverse positions against plan in various Directorates. This is the remainder of the 7,162k total reserves after deducting the 2,017k not available for CCGs to commit, the 163k Month 3 allocation yet to be dispersed to Directorates, the 593k Winter Resilience Reserve, the 257k OHSEL STP infrastructure reserve and the 700k drawdown of historic underspend. This scenario utilises all of the remaining available CCG reserves MH stated that for Month 11 reporting it should be noted that the flexibility provided by the NCSO adjustment of 1.3m, and the 700k drawdown reserve (the latter set aside by the CCG in the 2017/18 plan to manage SEL CCG risks), will be made available to all SE London CCGs under the terms of the SE London CCG Risk Sharing agreement. Where relevant, these funds (i.e. The Draw down element) will be repayable in the future, in line with the Risk Share arrangement. This treatment has been agreed with the CCG s external auditors and the Governing Body. Chair: Dr Jonty Heaversedge 4 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

224 MH stated that these financial adjustments will go through the month eleven ledger, and therefore would go to the Southwark Governing Body as part of the finance report in May RGi stated his view that the decisions taken under the Collaborative Framework had been technically challenging but had been reached in a corporate manner. RGi stated that the lay members agreed that the CCG should look in future at the process for enacting the provisions of the Framework in future. The committee noted the budgets and position for the Programme Budgets and the Running Costs as at end of January The committee noted the forecast position for the year for both Programme Budgets and the Running Costs, and specifically, the reduced surplus forecast for the 2017/18 financial year as a result of the nationally agreed treatment for NCSO drugs The committee noted the forecast for Delegated Primary Care which includes the forecast effect of the allocation shortfall to the CCG. The committee noted the risks and mitigations in addition to those mentioned above. CCG IAF Assurance Report (M11) AN introduced the report which gives IG&P an overview of current performance against constitution standards, the Improvement and Assessment Framework, Quality Premium and supplementary metrics agreed by IGP as requiring additional focus. Key areas across the constitution standards were highlighted. HA said that that activity trajectories were currently being modelled for completion of the operating plan for 2018/19. These would be presented to the committee at a later date. 8 KS said that the coversheet for the assurance report had been refreshed to show the RAG rating and direction of movement for each of the updated metrics across the IAF and quality premium (which are not picked up in the regular review of constitution standards). MH suggested that actions that are already being undertaken aligning with these metrics be incorporated into this summary. KS stated that there were not necessarily discreet programmes of work which aligned with each metric. RD highlighted the metric for improving access rates to CYPMH was currently rated red, as the target access was not being met. CG agreed that this requires focus. She said that this metric did not necessarily show the full picture of services being accessed by children. For example, services where action is taken for children but no diagnosis would be made (for example a number of voluntary services) would Chair: Dr Jonty Heaversedge 5 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

225 not be included in this metric. She emphasised the importance of decisions about where to focus funding, identifying in particular the need for greater funding in upstream services. She said that there had been discussions with CAMHS, CCG and council teams about identifying a local metric which appropriately measures the granularity of progress being made in Southwark. NK asked if any specific actions were put in place when this metric was selected by the CCG for the QP. CG stated that specific actions were not taken to improve the metric. She said that other areas had been prioritised, this included coming to funding agreement with the council and strengthening relationships RB provided a focussed review of mental health services and activities in Southwark. He highlighted the increase in IAPT recovery rate for the current month and the increased number of first contacts to 601 (above the national target for January). RB highlighted the performance framework, stating that the local approach to transforming mental health care will take place in line with the FYFV and within the context of the OHSEL STP. OHSEL s Mental Health Regional Milestone Tracker has 12 workstreams with linked targets which will be used to support delivery of the Joint Mental Health and Wellbeing Strategy He provided a summary of performance against these workstreams, highlighting the impact of winter pressures on out of area placements at SLaM and liaison psychiatry may be having on rates of sectioning. RB highlighted the recent GP Protected Learning Time event which took place on 15 February and focussed on better identification and treating anxiety and depression in primary care. RB provided an overview of the mental health and wellbeing commissioning team s approach. He stated that each team member is aligned to specific performance areas. There is also a target on service reviews. RB highlighted the ambition to go beyond the current 67% dementia diagnosis target to achieve 80%. He flagged the importance of the wellbeing hub in supporting this. RB said that the Southwark Early Intervention Team (STEP) has consistently met the waiting time element of the standard over the past 18 months. He highlighted the Increase in funding for the OASIS service, to support mental health prevention and early intervention for young people (aged 14-35). JH asked how the IAPT service had been evaluated, and reflected on some of the experiences he had heard from patients reflecting a less positive service. He emphasised the metrics such as recovery rate and recurrence. RB stated that there has been a focus on improving recovery rates. He highlighted that the time that recovery rates were being measured had been impacting on rates of recovery. CG said that the service has a much more complex cohort of patients than a standard IAPT Chair: Dr Jonty Heaversedge 6 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

226 service. She said that as the service moves further towards LTC patients and embedding mental health into physical health will impact on the metric going forward. RB stated that 5% of the IAPT contract value will be dependent on outcomes in 2018/19. JH asked if there were areas of mental health services locally which require greater forcus from the governing body or clinical leadership. RB identified placement panels as an issue due to the few options for different types of care when leaving NHS care. CG said that this is an element of a wider model of care issue. She said that the mental health strategy speaks to a shift towards spend in early intervention and prevention in Southwark. RB also highlighted the crisis pathway and the number of presentations via A&E. He said that KCH is an outlier across the country and in order to deal with 12 hour target spot purchases of out of area placements are often being made. NK said that there are huge social determinants of mental health. She highlighted that these are not factors that are measured in this committee. The committee reviewed the assurance report and were assured that issues identified are being fully addressed. CCG Quality Update KMB presented the quality update which provides a snapshot of current quality and safety issues, and outlines quality assurance and improvement activity. 9 She said that the CCG has completed its initial programme of 3 training sessions which were delivered by the GMC and offered to GPs and practice staff. Attendance was high and feedback positive. The CCG has commissioned two further sessions from the GMC and is seeking alternative routes to keep up momentum on the issue. There is a waiting list for places, however the GMC are not able to continue delivery beyond the two planned. A Duty of Candour Guardian for General Practice is one of the options being considered. KMB stated that the CCG has recently established a forum to provide development support for sessional GPs working in the borough. The forum will promote peer support, aid GP retention, and improve quality and safety. KMB highlighted the launch of the General Practice Nursing 10 Point Plan in 2017 with the aim being to recognise and develop the role of general practice nurses to transform care and help make the NHS fit for the future. The plan sets out work needed to deliver more convenient access to care, more personalised care in the community and a stronger focus on prevention and population health, and so driving better outcomes and experience for patients. Four Regional Delivery Boards have been established to deliver the plan; the Southwark CCG Director of Quality and Chief Nurse represents SEL STP on the London Delivery Board KMB stated there had been 33 serious incidents logged in January 2018 by NHS Southwark Chair: Dr Jonty Heaversedge 7 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

227 CCG s providers, 3 of which affected Southwark residents. This is slightly below the 2017/18 average of 37 per month and is likely to indicate a delay in notifications by providers (SLaM did not declare any SIs in January but 3 so far in February). There was a Never Event in January at KCH Denmark Hill, a fall from an inadequately restricted window, their second NE in the financial year. For more information see App 1. JF highlighted the Quality Alerts submitted this month: The CCG received 26 Quality Alerts in January, a slight reduction from 36 in December. KMB said that CCG achieved its target of 0% CHC D2A assessments completed in acute hospitals in January for the second consecutive month. Issues with the timeliness of assessments undertaken by in the community by GSTT are affecting the throughput of the pathway however which is impacting the availability of D2A beds in care homes. The CCG is carrying out an analysis of the effect of D2A to assess if more patients may be suitable for to go home rather than to a care home bed, and is carrying out a lessons learnt exercise with the D2A Board to review implementation of the pathway. AN invited questions and comments JE voiced her concerns regarding workforce, and reflected positively on the general practice nursing 10 point plan. In particular the support to varied career paths in nursing careers. The committee noted the current quality and safety issues, and outlined quality assurance and improvement activity as described in the quality update. Budgetary and Contracting Framework onwards MH presented the item, which set out the CCG s financial framework for He reviewed the outturn against plans: approach to budget and contract setting; the resources available to Southwark CCG through to ; the STP Planning Context and Control Totals; the CCG s current position in terms of financial plans, QIPP and reserves. MH highlighted the major risks for and beyond, and set out the governance processes in the CCG and across the STP relating to budget setting. 10 MH stated that the CCG has a statutory responsibility to set a budget before the 31 March. This paper enables the CCG Governing Body to do so, whilst contract discussions are continuing to a 31 March signing deadline, which is later than last year s deadline. MH highlighted that Southwark has received a further 3,280k in line with the Autumn Budget 2017, and this will be invested in many contracts and budgets, and is of great assistance in meeting these increased targets. This increases our growth uplift to 3.33%, and must show parity of esteem investment in mental health services of at least this percentage year on year. MH highlighted that expected outturn across SEL CCGs, agreed with NHS England, is that 5 CCGs will achieve target positions, and one CCG will be approx. 7M away from its target, which was a 1.4M planned surplus. To reach this position, local flexibilities will have been utilised non-recurrently. This is similar to the position in many STP areas across the country. MH stated that the target surplus for Southwark in will be circa 650k in year, increasing Chair: Dr Jonty Heaversedge 8 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

228 our cumulative position. It is certain that there will be no drawdown of past surplus, to create a further safety net for SEL. MH set out the budget envelopes, which are still being negotiated with the provider organisations, and the higher QIPP programme of circa 16.5m, that needs to be delivered to achieve balance. In addition the CCG has to achieve an in year surplus of 650k, as part of all SEL CCG s jointly meeting its joint control total for the year. RGi flagged the risk of the CCG achieving an in-year surplus of 650K in addition to maintaining the cumulative surplus of ] 7,900K and managing in-year cost pressures. MH agreed with this and explained the planned reserve position and approach to risk-mitigation. JH highlighted the importance of using Governing Body members in the process of budget setting. MH said that discussions are continuing regarding the collective STP commissioner target surplus of 3,250k, and at present the paper assumes that Southwark s share will be a target of 650k surplus next year. MH reported that this compares to a planned 230k surplus in in-year. MH stated that there could still be movement on this figure and that this would be made clearer and circulated to members of the Governing Body in due course. The committee approved the financial framework for , and recommended it to the Governing Body. The committee approved the target of a 650k in year surplus for , subject to further information being provided by Malcolm Hines clarifying the flexibility in this figure. The committee noted the work being done to achieve our financial position, The committee noted the actions being taken to agree future years QIPP, some disinvestment, and limited investment, to ensure the CCG achieve our commissioning and financial targets for the next few years. GP IT contract assurance JS presented an update to the Committee on delivery of the NEL CSU GP IT Improvement Plan. 11 She highlighted the background to NEL CSU providing this service, and the contract management approach which is in place. She stated that following contract award, it became increasingly clear that NEL CSU was not succeeding in driving up service delivery standards as promised during the procurement, and as expected by the CCG and Practices. During summer 2017, a series of meetings were held with NEL CSU Directors pressing for an Improvement Plan to resolve issues raised. NEL CSU delivered a Service Remediation Plan. Delivery of this plan is being monitored against agreed milestones. Chair: Dr Jonty Heaversedge 9 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

229 AN welcomed questions and comments from the committee CG said that she had just been at the north locality meeting where this was discussed. She said that improving communication was the most important feedback she received this is in terms of keeping the practices up to date on what actions are taking place and improvements being made. She said that a meeting should be organised with a small number of practice managers to properly understand the issues. MH agreed that this is a priority. Action MH/JS arrange meeting with key practice manager contacts to discuss the issues they are experiencing. NK said that practices were not necessarily aware of how to report issues and that the concerns would be different at different practices. She supported the approach of speaking to a small number of people to gain an in-depth understanding of all of the issues they are aware of. JS highlighted the importance of issues also being reported through the agreed mechanisms in line with the contractual arrangements in place. IG Toolkit Assurance Report 12 The committee reviewed the report which outlines the review, endorsement and direction for the current assurance position regarding Southwark CCG s Information Governance (IG) Toolkit requirements and IG activities from 1 st April 2017 to 17 th January Southwark CCG is currently taking appropriate steps to ensure compliance with information governance standards as required by the NHS Information Governance Toolkit. The CCG is progressing towards its target of achieving level 3 IG Toolkit Compliance. The committee approved the IG toolkit assurance report Digitisation of GP records phase 2 13 The committee reviewed the procurement report and phase 2 PID for the Digitalisation of Care Records Held in GP Practices. A framework is already established for this type of supply and it is managed by NHS Digital. The framework name is GP Systems of Choice. This is a framework specifically set up to supply IT systems and services to GP practices and associated organisations. The framework is divided into 3 lots and the project team have identified that a Digitalisation service is available under Lot 2 of this framework. The committee approved the award of the contract at a value of 621,961 plus VAT to to the preferred supplier. Chair: Dr Jonty Heaversedge 10 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

230 IGSG Terms of reference 14 The committee reviewed the updated IG Steering Group Terms of Reference. Review by IGP is required on an annual basis. This is a requirement for the IG Toolkit submission. The CCG is aiming to achieving 100% of toolkit requirements, Level 3, as was achieved last year. The committee agreed the IGSC Terms of Reference. Items for Information 15 The committee noted the following minutes: Minutes Quality and Safety Sub-Committee (Nov, Dec 2017; Jan 2018) Minutes - S&L IT & Informatics Group (Dec 2017) 16 Any Other Business None. 17 Date of next meeting pm, Thursday 22 March 2018 Chair: Dr Jonty Heaversedge 11 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

231 Southwark Integrated Governance & Performance Committee 22 March 2018 Room 132, 160 Tooley Street MINUTES Present: Dr Noel Baxter (NB) Dr Robert Davidson (RD) Jacquie Foster (JF) Dr Emily Gibbs (EG) Dr Richard Gibbs (RGi) Caroline Gilmartin (CG) Ross Graves (RGr) Dr Mike Khan (MKh) Dr Nancy Küchemann (NK) Kate Moriarty Baker (KMB) Andrew Nebel (AN) Adeola Olukosi (AO) Robert Park (RP) Dr Yvonneke Roe (YR) David Smith (DS) Kieran Swann (KS) Julian Westcott (JW) Richard Whitfield (RW) Apologies: Andrew Bland (AB) Ami David (AD) Linda Drake (LD) Mark Kewley (MKe) Joy Ellery (JE) Dr Jonty Heaversedge (JH) Malcolm Hines (MH) Clinical Lead, SCCG Clinical Lead, SCCG Head of Quality, SCCG Clinical Lead, SCCG Lay Member, SCCG Director of Integrated Commissioning, SCCG Interim Managing Director, SCCG Secondary Care Doctor Member, SCCG Clinical Lead, SCCG Director of Quality and Chief Nurse, SCCG Lay Member, SCCG - Chair Local Care Network Pharmacist, SCCG Lay Member, SCCG Clinical Lead, SCCG Associate Director Performance, ICDT Head of Governance and Assurance, SCCG Head of Finance, SCCG Assurance Manager, SCCG (minutes) Chief Officer, SCCG Registered Nurse Member, SCCG Clinical Lead, SCCG Director of Transformation Lay Member, SCCG Chair, SCCG Chief Financial Officer and Deputy Chief Officer, SCCG 1 Welcome The Chair welcomed members to the meeting. 2 Introduction and Apologies Apologies were noted. Chair: Dr Jonty Heaversedge 1 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

232 Declaration of Interest 3 All members were asked to declare any change in conflicts of interest and raise any conflicts relating to items on the agenda. No potential conflicts were identified. The declaration of interests register was circulated for signing, and changes noted here. Minutes of the Previous Meeting and Action Log The minutes of the February meeting were reviewed for accuracy and completeness. The following corrections from JF were noted: Page 5: Final paragraph amend not to no, and correct spelling of voluntary Page 8. Clarify that autumn 2017 budget refers to the Autumn Budget 2017 Noting the above corrections, the February minutes were agreed as a comprehensive and accurate record of the meeting. Action: RW amend February minutes in line with corrections The action log was reviewed. Closed actions were noted and the following updates provided: Bring Health Foundation CEA evaluation approach back to IGP: KMB updated that CES will set out an initial framework which would be brought to IGP. It would then be used to provide 3 monthly updates after then. The committee agreed to close the action and add to the agenda forward plan. 4 Quality and Safety sub-committee take ownership of review into night bed moves at KCH and consider whether additional standards are required: JF updated that committee that KCH have been asked for further information via the CSU. She said that the issue has been added to the CQRG log and an update will be provided at this meeting. It was agreed that an update to IGP would be provided in April. MH and JS to arrange meeting with key practice manager contacts to discuss the issues they are experiencing regarding GP IT: NK and NB updated IGP on the discussions held at the north Southwark Locality meeting in the day. They said that providing feedback to practices that the issue has been escalated is not sufficient to assure them that issues will be resolved. They stated that issues are seriously impacting on the day to day running of effective business processes, and will impact on the ability to access services which are only available via e-rs. They said that that there had been questions at the locality meeting regarding at what stage the provider of IT services would be considered to be in breach of contract. CG reflected that there was a lack of clarity regarding which of the issues can be addressed locally and which were beyond the scope of the CCG, and therefore alternatives be identified. RGr agreed that the lead for this action would be transferred to him to coordinate a response, and that the information provided in this meeting would be used to frame a discussion with the Lambeth Chief Officer (as work with the CSU is being led by Lambeth on Southwark s behalf). Action: RGr to coordinate response to address GP IT issues Chair: Dr Jonty Heaversedge 2 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

233 CCG Risk Report & Board Assurance Framework (M12) KS introduced the CCG s risk report for the month of March 2018 presenting the highlights of updates to risks for the CCG. The BAF and risk registers have been updated by all risk owners and then reviewed by the CCG directors in their monthly risk meeting with the Governance and Assurance Manager. He stated that there are currently 11 extreme BAF risks, these include two new risks: Our Healthier South East London Programme delivery of financial balance through Capped Expenditure Process and Significant financial and operational risks to Southwark mental health placements delivery in 2017/18. Two risks have been closed on the BAF: Failure to achieve full delivery of QIPP Programme in 2017/18 leads to risk delivery of the CCG financial plan and Risk that Council's decision to end funding for children and young people's services. One risk was escalated: QN-11 - Risk of not meeting the Transforming Care performance target is a reputational risk to the CCG. One risk was de-escalated: IC-53 Risk that GP Practice funding transferred to the CCG under delegated commissioning will curtail the CCG's ability to commission sustainable GP practice services and the premium focus to improve access, prevention and continuity of care The four new risks added to the directorate risk register were reviewed by the committee. 5 RGi asked for a further updated relating to FB-34 newly added to the BAF, relating to delivery of sustainable final position across SEL. He asked whether this risk remains for the upcoming year. JW stated that the risk is correctly highlighted on the BAF. He said that there would be a GB seminar in April which would allow for a more granular understanding of this. RGr stated that this would also include lessons learnt from processes this year. He said that there is a plan to assess all risks across the system at a SEL level. KMB provided further information about QM-11, relating to the Transforming Care Programme. She stated that the SEL TCP has been challenged and has a relatively high trajectory to achieve. In response to this, a recovery plan has been laid out. KMB will be leading this as deputy SRO for the programme. This will involve agreeing a discharge control total across SEL, to get from the current position of 94 people in assessment and treatment to 58 by September CG provided further background to IC-25: Significant financial and operational risks to Southwark mental health placements delivery in 2017/18. She stated that the Council were not accepting of a PPM outcomes offer to close 2017/18 on an overspend known to all parties on a month by month basis against agreed / actual placement activity. She highlighted that there has been assessment of the respective financial requirements of the Council and CCG in relation to people on section 117s. This, however, has not been accepted. She said that discussions were ongoing regarding statutory obligations. She said that the Council has also served notice on the current S75 partnership agreement for placements with no alternative arrangements proposed. Chair: Dr Jonty Heaversedge 3 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

234 NK reflected on the impact this has had on the ability to transform the way that services are commissioned. The committee noted the changes in the BAF risks, updates provided by the teams, and received assurance on the proactive management of strategic risks. The Committee noted the highlights on directorate risk registers. The committee noted the current extreme risks for the CCG and the BAF risk profile depicted in the Heat Map. The committee noted the STP strategic risks The committee approved the report and recommended it to the Governing Body. CCG Finance Report (M11) JW presented the M11 finance report. He summarised the CCG position and said that the actions highlighted at the previous IGP have now taken place and are documented in the M11Finance Report: The CCG has approved payments of 1.75m with regard to the implementation of the Trust Special Administrator Agreement relating to Lewisham and Greenwich Trust, for the 2017/18 financial year (the last year of such support). This has been included in the forecast figures in the Acute financial position The flexibility provided by the NCSO adjustment of 1.3m, and the 700k drawdown reserve (the latter set aside by the CCG in the 2017/18 plan to manage SEL CCG risks), were made available to all SE London CCGs under the terms of the SE London CCG Risk Sharing agreement. 7 JW stated that as at Month 11, no capital funding has been released to the CCG for Southwark capital schemes. The CCG is expecting a capital allocation of 50k for the 2017/18 financial year and this will be reported when it is released to the CCG. RGi highlighted the significant reduction in aged debtors in the M11 report due to Southwark Council (Section 75 agreement relating to the 2016/17 financial year) issues being resolved. The total value of these invoices was 1.66m. NK said that there appears to be more red in the reports during 2017/18 than in previous years and requested that the planned April workshop also involve a retrospective review of the current year. JW highlighted that the current forecast planned surplus is reduced as a result of the national treatment of No Cheaper Stock Obtainable (NCSOs) or drugs in short supply costs. The surplus will increase again at year end, to over 10m, due to the release of the 0.5% reserve held all year on NHSE planning instructions and thus annual target be met. Chair: Dr Jonty Heaversedge 4 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

235 The committee noted the budgets and position for the Programme Budgets and the Running Costs as at end of February The committee noted the forecast position for the year for both Programme Budgets and the Running Costs, and specifically, the reduced surplus forecast for the 2017/18 financial year as a result of the nationally agreed treatment for NCSO drugs and the drawdown of reserves in line with the south east London Risk Share agreement The committee noted the forecast for Delegated Primary Care which includes the forecast effect of the allocation shortfall to the CCG. The committee noted the risks and mitigations in addition to those mentioned above. CCG IAF Assurance Report (M12) AN introduced the report which gives IG&P an overview of current performance against constitution standards, the Improvement and Assessment Framework, Quality Premium and supplementary metrics agreed by IGP as requiring additional focus. CG presented the focus pack on primary care commissioning to the committee. She highlighted the development of federations, EPCS and PMS agreement which includes a further shift towards population based services. 8 CG focussed on CQC outcomes for practices in Southwark and whether the committee can take assurance regarding the quality of GP services available in Southwark CCG. She highlighted that 11 practices (of 38) have been found by CQC to either be inadequate or requires improvement. She cited the example of a large practice which has not improved on second inspection as being particularly concerning. CG said that this has resulted in a reactive approach at times from the CCG, including putting in place short-term caretaking contracts. CG described the move towards a quality improvement approach being taken with the practices. The committee discussed concerns about the high number of general practices with adverse CQC ratings and the need to find more enduring fixes to reduce and keep these numbers down. RGr reflected on the strategic work planned and the push towards community based care. He said that it was important not to shift focus away from improving quality. NK asked if there were themes across the inadequate and requires improvement CQC inspections. KMB stated that themes are collated and reviewed, and have been presented previously. She highlighted systems and processes, as well as management of medication, safeguarding and infection control. KMB highlighted leadership at point of delivery as a key issue and said that there is not currently the same scrutiny of primary care as secondary care. Chair: Dr Jonty Heaversedge 5 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

236 CG stated that there is also a contractual approach where contractual breaches are issues and followed up. RD reflected on whether there has been genuine buy-in from senior GPs to delivering at scale general practice. He raised concerns that quality issues may extend beyond just those practices receiving lower CQC outcomes. KMB stressed the importance of keeping the patient at the centre of all discussions regarding primary care. The committee emphasised the needs for different options and approaches to addressing these issues to be provided to governing body members if an assessment of the level of assurance in the CCG s approach and the quality of primary care is to be made. DS was asked to highlight any key issues from the wider assurance report. He provided an update regarding RTT, stating that a significant impact on referral levels is being seen. A recent year on year comparison has been made, and in overall terms referrals to secondary care were flat. There would have been a net reduction in referrals if the impact of the suspension of the community dermatology service and the emergency shifting of activity to GSTT is corrected for. To contextualise, recent years have seen growth of between 7-10% per year, so this is a significant improvement. The level of patients waiting over 18 weeks for treatment at GSTT and KCH has also fallen from 29,025 in April 2017 to 21,696 in January 2018 due to a combination of increased efficiency, reduced referrals and improved validation. As such, whilst the 18 week performance is still challenged, real improvements are being made, with the aim of resuming the 18 week standard by the end of 18/19. DS also said that he had attended the south Southwark locality meeting, where Ian Smith (the new KCH chief executive) had spoken candidly with member practices about the Trust s management of finances and processes in A&E. He relayed that these issues were internal to the trust rather than relating to out of hospital services. Andrew Nebel initiated a discussion about the prioritisation of CCG resources and whether this could be focussed to a greater extent into areas of provision most amenable to CCG influence. This was in the context of the above discussions about primary/out of hospital care improvements and poor CQC outcomes, the role of LCNs and the key elements of King s A&E performance being identified as internal to the trust and beyond the management scope of the CCG. It was agreed that the issue of prioritising where CCG resources could be best utilised to achieve improvement in services would be explored further by lay members and RGr. The committee reviewed the assurance report and were assured that issues identified are being fully addressed. 9 CCG Quality Update Chair: Dr Jonty Heaversedge 6 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

237 KMB presented the quality update which provides a snapshot of current quality and safety issues, and outlines quality assurance and improvement activity. She focussed on briefing the committee on Southwark Serious Case Reviews (SCRs), Multi-agency Reviews (MARs) and Serious Adult Reviews (SARs) which involved the CCG during These were undertaken by the SCR or the SAR Subgroups of the Southwark Safeguarding Boards. KMB set out a summary and learning from each of the five case, the recommendations for the health sector and progress made to date against these recommendations. RD provided an example where the de-escallation of a child to child in need threshold had resulted in less focus. He emphasised the importance of managing the transition between categories. KMB agreed and said that the board has been asked to undertake a piece of work reviewing these transitions. KMB updated the committee on recent CQC inspections. KCH received a rating of Requires Improvement when the CQC inspection report was published in January LAS will be reinspected in March 2018; they are presently rated Requires Improvement. This was an improvement from their rating in 2015 of Inadequate, though they are currently still in Special Measures as advised by NHS Improvement, due to a number of LAS Board changes over the past year. SLaM received a rating of Requires Improvement (Adult Community services) in Autumn 2017, a re-grading from Good. The CQRG dedicated the December 2017 meeting to reviewing the CQC action plan and made further requests and suggestions which are tracked each month. KMB stated that quarterly meetings with the local CQC hospital inspectors have been arranged. KMB provided an overview of the work led by Helen Williams, the Consultant Vascular Pharmacist who works with the CCG. KMB said that a total of 30 serious incidents were notified to the CCG by its providers in February, 5 of which affected Southwark residents. This is lower than the 2017/18 monthly average of 37 SIs reported though not of statistical significance. Although not within this reporting period, KMB said that it is important to alert the Committee that KCH have reported 4 Never Events so far in March 2018; 2x retained foreign objects (swabs), 1x misplaced naso-gastric tube, 1x connection to air instead of oxygen (new category of NE). This raises the number of NE reported by KCH in 2017/18 from 2 to 6. Full RCA investigations will be undertaken with CCG involvement and oversight. NB added that there was still clear evidence that safer surgery protocols are being used at KCH. He also added that the incident relating to connection to air rather than O2 had highlighted the use of O2 in hospital and provides opportunity to positively affect behaviour. JF provided an update on the use of quality alerts during the month. 38 QA were received in January which were split as follows: KCH = 12 GSTT = 18 SLaM = 1 QRAGs = 7 KMB provided an overview of recent areas of focus at QSC. This includes systems to safely share care across organisations and review of the QI project for Rheumatoid Arthritis, Chair: Dr Jonty Heaversedge 7 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

238 agreeing to establish baseline referral data as the first step towards tracking change KMB stated that the CCG continues to meet its trajectory for CHC D2A. NHSE has confirmed that the CCG is assured on this target. The committee noted the current quality and safety issues, and outlined quality assurance and improvement activity as described in the quality update. The committee noted the Southwark Serious Case Reviews (SCRs), Multi-agency Reviews (MARs) and Serious Adult Reviews (SARs) which involved the CCG during 2017, and were assured by the approach undertaken by the SCR or the SAR Subgroups of the Southwark Safeguarding Boards. Operating Plan 2018/19 KS presented the CCG s Operating Plan for , which is a refresh of the CCG s two year plan covering the period which was approved by the Council of Members in March The revised Operating Plan is written to respond to NHS England s refreshed national planning guidance issued on 2 February KS stated that the Operating Plan is based on the revised activity and performance trajectories submitted to NHS England on 1 March 2018 and again, with minor further revisions, on 8 March The performance and activity trajectories were reviewed and approved by the CCG s Governing Body on 8 March The Operating Plan should be read with reference to the CCG s Financial Framework, which was endorsed at the Integrated Governance & Performance Committee on 22 February 2018 and Governing Body on 8 March 2018 ahead of formal ratification by the CCG Council of Members on 28 March KS emphasised that the plan is not intended to be a comprehensive plan of all activities of the CCG for the coming year. Instead it is an assurance document which sets out how the CCG plans to improve the health and wellbeing of people living in our borough by meeting mandatory requirements set by NHS England, setting out our locally-defined response to national requests. It can be read as a declaration of the CCG s commitment to meet national requirements; and statement of the extent of our ambition for the improvement of certain performance and outcome indicators. KS said that the CCG s budget and performance trajectories will be finalised with trusts as part of the on-going negotiations on variations to agreed two year contracts. He reiterated that both the operating plan trajectories and budget framework are subject to revision as the process of concluding negotiation of contract variations with provider trusts is concluded. A final revised Operating Plan will be presented to the CCG s Integrated Governance & Performance Committee and Governing Body in April and May 2018 respectively. NK asked for further information about the mental health investment standard and how this relates to QIPP. JW said that the mental health investment standard is achieved when QIPP is taken into Chair: Dr Jonty Heaversedge 8 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

239 consideration. It is the net investment which meets this standard. He said that QIPP is focussed on specific areas providing savings for re-investment in areas to have a greater impact. The Integrated Governance & Performance Committee endorsed the draft Operating Plan 2018/19 ahead of its presentation to the Council of Members for approval on 28 March Risk Management Framework and Corporate Objectives for KS presented the Risk Management Framework which sets out the organisation s approach to risk management. This provides the committee opportunity for review and comment in line with good governance and the requirements of the Information Governance Toolkit. 11 KS said that there were no suggested changes to the Framework following the CCG s 2017/18 audit on its risk management approach, which recorded substantial assurance (i.e. the highest level of assurance). The Framework has been updated only to reflect the following changes, which were highlighted in red in the document: Changes to job titles and roles. KS said that the CCG s Corporate Objectives 2018/19 (which form the basis of the CCG s BAF) have been included for review and approval. The objectives remain the same as the financial year 2017/18 as the objectives were set to cover the two-year planning period, which the CCG is currently midway through. The committee reviewed and approved the Risk Management Framework and Corporate Objectives 2018/19. IG&P Committee Terms of Reference 2018/19 12 KS presented the updated Integrated Governance and Performance Committee Terms of Reference. He said that It is a requirement that terms of reference (ToRs) for all main committees of the Governing Body be reviewed at least annually to ensure their accuracy. This is an audit requirement and is referenced as part of CCG governance processes described in the CCG s Constitution. When agreed by the committee, the terms of reference will be submitted to the Governing Body for formal approval. RG provided the following feedback: he suggested that the wording of membership be revised to include all clinical leads, lay members and executive members. He said that quoracy be revised to 6 (with appropriate representation from clinical leads), and that executive requirements for quoracy be revised to any two directors, rather than specifying representation from at least one of the MD or CFO. The committee agreed the terms of reference, with the addition of revisions highlighted above, and recommended them to the Governing Body for approval. Chair: Dr Jonty Heaversedge 9 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

240 IG toolkit submission report 13 KS outlined the IG Toolkit Submission position of the CCG for the year and outline remaining actions taken to achieve this position. The IG Toolkit Assurance Statement requires review and approval from appropriate committee before the final IG Toolkit score can be submitted KS stated that the CCG s current IGT score is 95% (Satisfactory). However, it is expected that this will be 100% prior to submission on 31st March 2018.There are two standards remaining at level 2. These are 230 and 340 which will be increased to level 3 once the SIRO approves the completion of the reviewer section on the IG toolkit. The committee reviewed the assurance statement and approved the final IG Toolkit position. Items for Information The committee noted the following minutes: 15 Minutes Information Governance Steering Group (Jan 2018) Minutes Quality and Safety Sub-Committee (Feb 2018) Minutes Safeguarding Executive (Jan 2018) Minutes Medicines Management Committee (Jan 2018) Any Other Business 16 KS stated that the meeting had not been quorate due to neither the CFO or CO being in attendance. He said that all decisions would be circulated via to the CFO and chair of the committee for sign off via chairs action. Note: Approved by CFO on 5 April 2018 It was confirmed that the national level NHS Investment Committee approved the Dulwich stage 2 business case at their meeting on the 20 March. This is subject to the usual conditions being met in advance of financial close. These relate to the final versions of legal documents, final price and vfm, Agreements for Lease being signed by the future tenants and the discharge of the remaining pre-construction planning conditions. 17 Date of next meeting pm, Thursday 26 April 2018 Chair: Dr Jonty Heaversedge 10 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

241 COMMISSIONING STRATEGY COMMITTEE Minutes 1 March 2018 Present Jonty Heaversedge (JH) Ross Graves (RGr) Robert Davidson (RD) Noel Baxter (NB) Richard Pinder (RPi) Emily Gibbs (EG) Nancy Küchemann (NK) Caroline Gilmartin (CGi) Kieran Swann (KS) Yvonneke Roe (YR) Kate Moriarty-Baker (KMB) Andrew Nebel (AN) Andrew Bland (AB) Robert Park (RP) Present via teleconference Richard Gibbs (RG) Penny Ackland (PA) Michael Khan (MKh) Linda Drake (LD) Joy Ellery (JE) CCG Chair (meeting Chair) Managing Director CCG Clinical Lead CCG Clinical Lead Consultant in Public Health, Southwark Council CCG Clinical Lead CCG Clinical Lead Director of Integrated Commissioning Head of Governance and Assurance CCG Clinical Lead Director of Quality and Chief Nurse Lay Member Accountable Officer Lay Member Lay Member Chair of Southwark LMC Secondary Care Doctor Member CCG Practice Nurse Lead Lay Member Apologies Ami David (AD) Malcolm Hines (MH) CCG Secondary Care Nurse Member Chief Financial Officer In attendance Mike Wilson (MW) Carol-Ann Murray (CAM) Omar Al-Ramadhani (OAR) Lucy Butterworth (LB) Emily Newell (EN) Pembroke House Joint Commissioning Manager- Children and Young People System Performance Manager System Performance Manager LSL Sexual Health Commissioning Team Chair: Dr Jonty Heaversedge 1 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

242 1. Introductions, apologies and declarations of interest JH welcomed all members to the meeting. Apologies were noted. All members were asked to declare any change in their interests and raise any conflicts relating to items on the agenda. There were no changes raised. The register was circulated for signing. 2. Minutes of the last meeting The minutes of 4 January 2018 were reviewed and agreed as an accurate record. It was agreed that the EIA for Ann Moss Way would be circulated Action KS / CG. The action log was reviewed and all actions were noted to be completed. 3. Locality Reports: January & February 2018 South Southwark YR summarised the South Southwark locality group report and highlighted discussions related to the south east London treatment access policy and incorrect out-of-area charging for homeopathic treatments via NELCSU. YR also reported back on locality discussions on ophthalmology pathways; quality alerts; CCG QIPP; safety issues relating to community services; and a discussion on the role CCG clinical leads. The committee discussed the approach to engaging with member practices on proposals to change the term limits for CCG clinical leads. North Southwark NB fed back on the discussion relating to the clinical leads length of terms. He noted that the January meeting heard from practices on GP IT; prescribing; estates strategy; and safety for clinicians visiting patients in their homes. NK fed back to CG on the importance of enacting an effective communication plan with practices and practice managers. CG agreed that this would help differentiate the practice, CCG and national issues with IT. It was agreed that CG would work with Jo Steranka to ensure there was a standing item in the GP bulletin on IT. CG agreed to work with MH, NK and JS on a communications plan with practices and practice managers Action CG/MH to draft and share with CSC and locality meetings. Chair: Dr Jonty Heaversedge 2 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

243 4. Planned care referral optimisation review and next steps JH clarified that the item is about optimising the value or referrals rather than the matter being about referral management. OAR presented the three sections of the report. He started with Consultant Connect noting that the advice and guidance services offering seven specialities has been run by the CCG on a trial basis. He reported that to date 700 calls had been received by the service and 50% of these had resulted in no onward referral. OAR noted that NHS England has agreed some further funding for expanding the pilot into additional specialities. He recommended this programme is continued. LD raised a point related to diabetes single point of referral and asked whether that could be integrated with Consultant Connect. OAR said this and other services could be further explored in the next phase of the pilot. JH said it was essential that the service can demonstrate that the service does reduce outpatient appointments as the data provided does not do this. YR asked for more data on diagnostic episodes and longer-term outcomes. OAR reported the flat-lining activity levels in the targeted specialties. The committee discussed analysing the impact of Consultant Connect. NK queried the data on the use of advice and guidance on ERS and asked whether there was additional work that could be completed to analyse data on activity levels on this and the impact it has had. She also asked whether there was an option to include mental health specialities. OAR said that this would be explored further in the next phase of the pilot. RPi asked whether there were risks associated with escalating costs. RGr talked about mapping out the CCG s programme of work and in order to identify the impact on outcomes as a way of giving some additional insight into how the initiatives were working. OAR reported that NHS England would cover the cost of the extended trial and estimated the cost being a maximum of 60k per CCG. CG explained the mechanisms for committing local trusts to staff Consultant Connect through the CCG s block contract. The Committee discussed the risk that trusts will in future start to charge for the consultant time on a tariff basis. The Committee noted its support for Consultant Connect. OAR described Visual DX, which is a virtual diagnostic support tool. He reported this was trailed by Southwark and Lambeth practices, noting the positive feedback from GPs and patients and also stating the evidence for a number of referrals being saved as a result of GPs using the programme. He reported NHS England s commitment to fund a further 12 month trial of this system and explained the costs of licences, which were discussed further by the committee. RG asked whether there was any way of identifying the impact of schemes on patient outcomes. OAR reported some evidence of patients feeling more assured with their diagnosis and experience when the GP was using Visual DX. JH asked whether the data would pick up on poor outcomes (e.g. delayed diagnosis) as a result of this process. It was agreed that this data could be picked up as part of the extended trial. Chair: Dr Jonty Heaversedge 3 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

244 The committee discussed the recommendation on the Peer Review scheme. The funding of the incentives was discussed and CG fed back on her experience of the push back from general practice on the uptake of this scheme in Southwark. The committee discussed the need for some further analysis to help practices review the impact of the range of solutions in place and verify the data that is used for this purpose. PE noted that the Southwark LMC did support the work in place to optimise the value of referrals, though she raised some points of contention on behalf of the LMC against the particular approach taken to referral peer review. JH suggested that the CCG should set out its own evaluation criteria for reviewing the impact of the pilot programmes. He also highlighted the risk of GP de-skilling. The committee agreed to cease the Peer Review scheme and to continue the extended trials of Visual DX and Consultant Connect. 5. Care at Home CAM presented the proposal being taken through the Council s governance, which covers the commissioning of care packages for children and young people. She reported that the local authority was leading this commissioning and the CCG was being invited to input into the development of this framework. She described the procurement process being undertaken relating to these services. KMB reported her support and described the framework as supporting an integrated approach to commissioning care and services for these eligible individuals. She described how the framework functions and noted the structure of it in relation to the quality of services and their cost. RG asked whether this procurement supports a greater scope for the CCG and Council to work together to integrate care. CG and KMB said it represented an example of the two organisations working closely together. KMB said that the cohort involved was small in number and it was not a suitable cohort for a population-based approach to commissioning. The Committee approved the proposal and supported the recommendation included in the paper. 6. Evaluation of the HIV care transition services CG reminded committee members of the de-commissioning decision which related to specialist advice and advocacy and counselling / support services for people diagnosed with HIV. CG reminded the committee of the agreement that decommissioned services be replaced with time-limited contracts to support a period of transition and an evaluation of how mainstream advice, advocacy and support services were responding to the needs of people diagnosed with HIV. EN presented the report, which evaluated changed arrangements from specialist HIV to Chair: Dr Jonty Heaversedge 4 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

245 mainstream advice and support services. She explained the evaluation has included a look at the establishment of peer support groups; mystery shopping of mainstream advice services; service user feedback; and input form a multi-professional assurance group. She further reported the feedback received, noting that this had returned good results and these were detailed in full in the paper presented to the committee. EN noted that she will complete a full evaluation report and set out a list of associated recommendations once after April The Committee noted the initial positive findings of the evaluation of current services post de-commissioning of specialist HIV services. It was agreed that the full evaluation will be presented back to the Committee early in 2018/ Update on Walworth Town Hall RS and MW presented the early thinking on the Walworth Town Hall. RS noted that an opportunity was being explored as a potential option for locating a health hub for the community of Elephant & Castle. She noted MW is involved together with public health colleagues in looking at opportunities for a broader community hub use of the site. RS set out the current use of the premises, which is comprised of Walworth Town Hall and The Walworth Clinic. RS reported that the CCG has initiated an early review of potential opportunities for the site. MW explained that Southwark Council is currently soliciting interest for the premises, which they specify as being for an arts and cultural use. He described some work Pembroke House has completed to look at the utilisation of community spaces / places and how these might link to statutory services to benefit local communities. He described his conceptualisation of this model of provision to the committee and noted the opportunity presented by the Walworth Town Hall expressions of interest process. NB asked whether the site was too close to the CCG s planned Aylesbury hub. RS said that it presented an opportunity where there were not many sites with potential in the immediate area. CG endorsed the proposal and noted that this was strengthened by being led by a well established organisation in Pembroke House. RP asked about the potential sources of capital for the site. RS said that there would likely be section 106 capital available and that other partners involved in the development would need to identify other sources of investment. MW outlined some further capital opportunities from partners including Southwark Council, GSTT Charity and the Heritage Foundation. RGr asked about other potential bidders for the expression of interest. MW described the Council s approach to setting the criteria for the EoIs. AN asked about what CCG endorsement of this bid would mean. RS said that the CCG was not at this point being asked to commit to a specific proposal, but to offer it s support to take this proposal to the next phase of development subject to the Council s decision. Chair: Dr Jonty Heaversedge 5 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

246 The Committee registered its support for the expression of interest for the Walworth Town Hall site. 8. Healthy London Partnership AB presented the proposal on HLP, which related to its activities and resources for the financial year 2018/19. AB stated that the report represents a recommendation to CCGs to fund a revised HLP programme, which describe the things that are to be done on a once for London basis. AB reported that the paper was asking for a continued investment, but noted that this contribution had reduced by 45% and would now require a commitment of 275k for Southwark CCG for 2018/19. AB highlighted the work and activities that the HLP would undertake for this resource. AB noted that CCG Accountable Officers have worked with HLP to undertake a rigorous process to reduce costs, remove duplicated expenditure with STP areas and also create some resource for London-wide targeted activities that could be drawn-down by STPs for work at a sub-regional level. AB explained the HLP operating model and talked through how the HLP was brought together and managed. He also explained the governance arrangements for HLP programmes, noting the involvement of NHS England and CCG AOs and chairs in the London-wide programme areas. JH recommended the proposal and explained his involvement in HLP work. He outlined his view that there is a risk in asking STP leaders to take on additional SRO roles for HLP programmes. JH welcomed AB s approach to brokering this proposal together with the multiple stakeholders involved. AB confirmed that the reduced expenditure represented by this proposal was to be re-allocated to the most appropriate scale of the function at sub-regional level. Additional savings would be available to CCGs where it was agreed a function did not now need to be picked-up at another scale. NK asked about whether the proposals have been shared with London Councils. AB confirmed that they have and are represented as part of the HLP governance structure. It was agreed that the CCG should received further updates on the benefits being delivered as part of the HLP work. JH confirmed this has already been fed back to the HLP leadership team. The Committee approved the proposal and recommended it to the Governing Body to for formal endorsement as part of the Managing Director s Report. Chair: Dr Jonty Heaversedge 6 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

247 7. Any Other Business No further items were raised. 8. Date of next meeting: 1 March 2018, 2-5pm. Chair: Dr Jonty Heaversedge 7 Chief Officer: Andrew Bland The best possible health outcomes for Southwark people

248 NHS Southwark Clinical Commissioning Group (CCG) Primary Care Commissioning Committee Tuesday 23 January 2018, 1pm Cambridge House, 1 Addington Square, Camberwell, London SE5 0HF MINUTES Present: Robert Park (Chair) Lay Member, Southwark CCG (SCCG) RP Caroline Gilmartin Director of Integrated Commissioning, SCCG CG Ross Greaves Interim Managing Director, SCCG RG Richard Gibbs Lay Member, SCCG Conflict of Interest Guardian RG Jill Webb Head of Primary Care, South East London primary care JW team Dr Emily Gibbs (from Clinical Lead, Primary Care, SCCG EG part 8) Andrew Nebel Lay Member, SCCG AN Malcolm Hines Chief Finance Officer, SCCG MH Stephen Whittle Southwark Healthwatch SW Dr Penny Ackland Southwark Local Medical Committee PA Maisie Anderson Councillor Cabinet Member Public Health and Social MA Regeneration Jacquie Foster Head of Quality, SCCG JF Rachel Doherty (notes) Primary Care Commissioning Manager, SCCG RD Apologies: Dr Jonty Heaversedge Chair, SCGG JH Kate Moriarty-Baker Interim Director of Quality and Chief Nurse KMB Andrew Bland Chief Officer, SCCG AB Joy Ellery Lay Member, SCCG JE Jean Young Head of Primary Care Commissioning, SCCG JY Ami David Registered Nurse Member AD 1.0 Introduction Introductions and apologies were noted as above. It was noted that EG will be joining the Committee for part Declarations of Interest The group declared if there had been changes to their interests and if they had a conflict with an agenda item. All members confirmed no changes or conflicts. 2.0 Minutes from the last meeting PA requested the following change to the minutes prior to the meeting. The change was agreed as follows: PA raised concerns that the information (about capacity within local practices) appeared to rely on perceived reported capacity and may not reflect their true capacity. The method of Chair: Dr Jonty Heaversedge 1 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

249 gathering this information should ideally entail a diligent self-assessment audit that includes impact on workforce, premises, etc It was agreed to remove the sentence 'She also stated that these business practices did not deliver services as well as small practices'. PA confirmed this was not the case. JF noted that Falmouth Road Group Practice would be having their infection control in February 2018 and not It was noted that RG attended the meeting. The minutes were agreed with the above changes. 2.1 Actions from the last meeting The actions were discussed as follows: Date of Action Action Point Lead Status Meeting number To provide a written response to Healthwatch in relation to the patient query raised at the Committee regarding Forest Hill Group Practice. JY Complete. The response will be circulated with the minutes. Closed To provide costs of APMS caretaking arrangements to the Committee JF to send CQC themes and quality resource tool to Committee members To provide more information in the quality report regarding quality alert themes and if they had been upheld for the next Committee To issue a remedial breach notice to Sternhall Lane Surgery in line with the Committee s approval. MH JF JF JW Ongoing Complete 2017/2018 summary to be reported at the March 2018 Committee. JF gave a brief summary of themes. Completed. 3.0 Questions from the public Chair: Dr Jonty Heaversedge 2 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

250 CG noted that the CCG has received questions from Martin Dadswell regarding the extended primary care service prior to the meeting. It was explained that the CCG will respond to these in writing and make them available to the public via the minutes. Date of Action Action Point Lead Status Meeting number To answer Martin Dadswell questions regarding the extended primary care service. RD NEW 4.0 Finance Report MH presented the report which was circulated on the day of the Committee. It was confirmed that month 9 the CCG was showing an overspend of 884k against the primary care budgets for the year to date. It was noted that NHS England have confirm that the 1% headroom of 432k in the delegated primary care budgets can be utilised in year which had the effect of reducing the funding gap on delegated primary care from 1.84m to 1.41m. MH explained that in the next report the finance team will provide a more detailed breakdown of costs for the caretaking contracts. SW noted that the PMS overspend reflects significant in year list size growth and questioned if the increasing population would continue to cause costs pressures. MH confirmed that NHS England determined funding allocations and that there was clear variation across south-east London. AN questioned what provision was being made to meet the savings target. MH confirmed that the savings target was due to a shortfall in funding that transferred to the CCG when they became delegated commissioners and that it had not been applied to certain areas as the majority of primary care funding costs are fixed due to contract mechanisms. 5.0 Quality Report JF presented the report. It was noted that there had been four CQC inspection reports published since the last Committee. New Mill Street Surgery had been rated as inadequate and placed in special measures following an inspection in November. It was noted that the CQC was providing support to this practice in the implementation of their action plan in relation to areas such as infection control, safeguarding and quality. JF explained that there was a process in place in which quality alerts regarding general practice could be raised by another provider. It was noted that since April alerts had been raised and that the quality team supported practices with investigations and the learning to be shared across organisations. JF noted that the team will present details and analysis to the Committee at the March Committee. Chair: Dr Jonty Heaversedge 3 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

251 The CCG has held two training events for GPs on the Duty of Candour and were exploring options to hold more for practices. JF explained that the infection control general practice audit cycle commenced in January 2017 following the appointment of an infection control specialist. It was noted that between April 2017 and January practices had been audited, 4 of these being completed by the north-east London Commissioning Support Unit who are contracted to across south-east London. MA asked what timescale the CCG working was towards to have all practices rated as good by the CQC. CG explained that general practices are independent contractors and that practices are individually responsible for ensuring that they are delivering services which are in line with their contract and CQC regulations. CG explained that the CCG has been supporting practices before and after their inspections. CG explained that the CCG can use contract levers to support improvements as delegated commissioners. CG noted that the CCG is also supporting quality improvement in general practices through a number of work programmes including Clinical Effectiveness Southwark and incoming quality alerts. SW noted that the contract levers the CCG could use were at the end of the CQC inspection process and asked what the CCG s role was where it was expected that practices performance may decline. CG explained that it was the practice s responsibility to ensure that they made the required improvement following CQC inspections, however the CCG monitor action plans and that the Committee is sighted on this via the contract action log. It was also noted that the CCG provides support to practices in certain areas which includes but is not limited to medicines management, safeguarding, incident reporting and infection control. SW also asked what provision there was to support practices to communicate to patients following CQC inspection. It was explained that it was practice s responsibility to communicate with their patients. Practices should display their CQC rating and were encouraged by the CCG to discuss the CQC outcome with their patients and inform them of any actions plans in place to address any issues highlighted. RG asked if there was correlation between quality alerts received regarding practices and CQC inspection outcomes. JF confirmed there did not appear to be a correlation. 6.0 Contract Action Log JW noted that the paper is provided routinely to the Committee to track progress of action plans and remedial notices with practices. It was confirmed that there were currently 5 practices with open cases, it was explained that this included the two practices which were being considered today under the CQC requires improvement standard operating procedure (SOP). 7.0 CQC Potential Requires Improvement Contract Remedial and Breach Notices Chair: Dr Jonty Heaversedge 4 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

252 7.1 Park Medical Centre It was noted that the practice had been rated as requires improvement overall following a second CQC inspection. It was explained that following the first CQC inspection the practice was required to complete an action plan to confirm that all improvements had been made. JW noted that the areas highlighted in the CQC inspection were new issues, but that the rating had decreased as the practice was now inadequate in well-led. It was explained that the London SOP for practices rated as requires improvement outlined that a breach and remedial notice would be issued if the practice had been rated as inadequate in at least one domain. The Committee agreed with the recommendation that the practice was issued with a remedial breach notice in line with the London SOP. Date of Action Action Point Lead Status Meeting number To issue a remedial breach notice to Park Medical Centre JW NEW 7.2 Falmouth Road Group Practice It was noted that the practice had been rated a requires improvement overall following a CQC inspection. JW explained the previous provider had been rated as inadequate and placed in special measures by the CQC following each of their three inspections, which resulted in the CQC taking action to cancel the provider s registration. It was noted that AT Medics Ltd had been successful following a procurement process and had been delivering services at the practice from January It was explained that the current provider had made improvements noted by the CQC but there was still come areas which needed continued improvement which resulted in the requires improvement overall rating. JW explained that officers had reviewed the London SOP for practices rated as required improvement and noted that it had been determined it was not proportionate to issue a remedial breach notice to the contractor as they had inherited legacy issues not all of which could have been resolved since 9 months. The Committee agreed with the recommendation to ask the practice for an action plan to seek assurance that actions have been put in place to remedy the issues highlighted. It was noted that the practice will be revisited by the CQC 6 months from the publication of the report. Date of Action Action Point Lead Status Meeting number To issue an action plan to Falmouth Road Group Practice. JW NEW 8.0 Contract Management Framework Chair: Dr Jonty Heaversedge 5 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

253 RD noted that the CCG had developed the contract management framework to support quality improvement following on the CCG taking on the delegated responsibility for the commissioning of general practice core services and therefore has the contractual responsibility for the management of GP core contracts. It was explained that the framework is in line with NHS England Primary Medical Services Policies and that the CCG had engaged with the LMC. It was noted that changes have been made following this engagement, but where comments were not adopted feedback had been provided to the LMC. JF noted that the quality team were in the process of redrafting the quality improvement framework for general practice and that this may have some implications to the references within the contract management framework. JW noted that the framework was in parallel to the continuous improvement framework within the new PMS premium specification. RG highlighted the importance of applying the framework consistently. The Committee approved the framework would be agreed by RP as Chair following alignment to the quality improvement framework. 9.0 Urgent Planed PCCC decision for reporting APMS Contract Commissioning Intentions a) Falmouth Road b) Lister Primary Care Centre (The Hurley) and Dr Hossain, Lister Primary Care Centre (Caretaking Contract) RD noted that the PCCC had made a decision in part 2 of the October Committee to reprocure the above practices as their APMS contract was due to expire. It was explained that the CCG had to agree a single practice for the patients of the Hurley at the Lister and the practice previously run by Dr Hossain s, which was now being caretaken by the Hurley. RD explained that the decision was not made in public as the decision to re-procure has commercial implications and announcements regarding procurements needed to be made at the same time to avoid potential challenges. It was confirmed that the new contracts will be 5 year contract with a possibility to extend for a further 5 years. It was noted that all three practices will have their contracts extended to 30 September 2018 to align to the London procurement timescales and that the new contract will be in place on 1 October RD explained that patients will be written to in February and patient engagement events will be held. Patients will also be asked to complete a survey as part of the engagement process and their will also be patient representatives on the procurement panel Update on St Giles Surgery (Begley) and Camberwell Green practice merger Chair: Dr Jonty Heaversedge 6 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

254 CG explained that the Committee had considered a business case from one of the St Giles (Begley) and Camberwell Green Surgery to merge patient lists to become one practice. It was noted that the Committee had concerns regarding patient engagement and that the other practice within St Giles Surgery was not included. CG explained that after the Committee she had written to the practices to outline these concerns. The practices have responded to confirm that they will be holding a PPG on 24 January and that they will provide a summary of the outcomes of the meeting and further engagement plans with the Committee. They have also provided assurance that patients will be engaged with regarding any changes about how the practices will work together but that they have confirmed they are no longer restructuring their appointment system in the way outlined in their business case. CG noted that the CCG will look at creating a clear set of written principles against which the PCCC can review business cases for mergers to ensure that there was consistency of decision making for the approvals of mergers. CG noted that she would be writing again to the practices and will aim to meet with all three practices in the near future. It was confirmed that the business case will be considered again as soon as possible, by the Committee, preferably before the end of the financial year. Date of Action Action Point Lead Status Meeting number To create a principles document for mergers RD NEW 11.0 Southwark Healthwatch Report Appointment systems at Southwark GP practices: are they working? RD noted that Aarti Gandesha had previously provided the Committee with updates following Healthwatch s Enter and View visits of general practice. RD explained that the final report was being presented to the Committee which outlined a number of recommendations for practices, the CCG and GP federations. The CCG and GP federations had provided a joint response to the report which was also within the Committee papers. It was highlighted that the CCG and GP federations are already supporting practices implement a number of the recommendations through different work programmes. SW explained that Healthwatch visited all GP practice sites between May and August 2017, spoke to receptionists and 550 patients registered with Southwark. SW explained that the purpose was to gain a better understanding of GP appointment systems and to speak to patient about if they understood the appointment system at their practice. It was summarised that the visits found that people s experience of GP practice varied. Chair: Dr Jonty Heaversedge 7 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland

255 CG noted that the CCG and Healthwatch had held a joint public event to present to patients the findings and to summarise the work programmes that are being completed to support practices improve access. CG explained that through the PMS premium specification the CCG was working with GP federations and the LMC to support practices improve access in a structured way using a tool which would review practices demand and resources. MA explained that the Council had completed engagement with the population as part of the social regeneration project. It was noted in the health section access to GP appointments was a theme that was raised. MA said that she would share this with Healthwatch and the CCG. The CCG and Healthwatch held a joint event on 5 December which presented the finding of the report and outlined the work the CCG and GP federations is doing to support practices improve access for patients. This work is also summarised in the CCG and GP federation joint response to the report which is enclosed. AN questioned if the CCG was going to progress the recommendations that patients could chose to attend either of the two extended primary care access hubs. It was noted that at the moment technical reasons and information governance would not support cross referrals. However it was noted that this would be reviewed going forwarded Any other business None raised 13.0 Public Open Space Ruth Driscoll introduced herself at the new Director for Link Age Southwark and said it would be good to understand in more detail the CCG s commissioning intentions in more detail and to also understand how Link Age Southwark can work with other providers to support the population. CG welcomed a meeting with Ruth Driscoll to discuss the role of Link Age Southwark in more detail. It was explained that the CCG was supporting the development of Local Care Networks which included the voluntary sector so services could be commissioned locally focused on populations Close 3pm Chair: Dr Jonty Heaversedge 8 The best possible health outcomes for Southwark people Chief Officer: Andrew Bland