AGENDA Lead Action required Appendices

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1 Meeting in Public of the Enfield Clinical Commissioning Group Governing Body 11 May pm to 5pm Millfield House Silver Street Edmonton N18 1PJ AGENDA Lead Action required Appendices 1. Welcome and Apologies 1.1 Chair s Welcome & Chair s Report Chair To note Appendix A 1.2 Apologies for Absence Chair To note Oral 2. Declarations of Interest 2.1 To confirm the entries in the Register of Declarations remain accurate 2.2 To declare any interest relating to items on the agenda All To review Register to be circulated as part of the attendance sheet. All To declare Oral 3. Questions from the Public Chair To note NB: The Chair will provide a written answer to those questions relating to items on the agenda and which have been received in advance and invite questions of clarification on the answers given. There will be a further opportunity to ask questions relating to agenda items at the conclusion of the meeting. 4 Overview Reports 4.1 Chief Officer s Report Chief Officer To note Appendix B 5. Quality and Safety 5.1 Quality and Safety Exception Report 6. Performance, Finance and Contracts 6.1 Integrated Performance & Quality Report for April 2016 Governing Body Nurse Member/ Director of Quality and Integrated Governance. Director of Operations 6.2 Finance Committee Report Chair of Finance Committee. 6.3 (a) 2016/2017 Financial Plan Chief Finance including CCG Financial Officer Recovery Plan; and (b) Month /16 Financial Performance. To note To discuss To note To discuss Appendix C Appendix D Appendix E Appendix F Appendix Fi 1

2 7. Strategy and Partnerships 7.1 NHS 111 and Out of Hours Procurement Director of Strategy and Partnerships To note Appendix G 8. Governance 8.1 Audit Committee Report Chair of Audit Committee 8.2 Governing Body Assurance Director of Quality Framework and Corporate Risk and Integrated Register Governance 8.3 Changes to the CCG Constitution 9. Patient and Public Engagement 9.1 Patient and Public Engagement Committee Report 10. Minutes, Action Log Director of Quality and Integrated Governance Lay Governing Body member and Director of Quality and Integrated Governance To approve To review To approve To note Appendix H Appendix I Appendix J Appendix K 10.1 To approve as a correct record the Part 1 Minutes of the meeting held on 9 March Chair To approve Appendix L 10.2 Action Log no actions Chair To note 11. Items for Information 11.1 Health and Wellbeing Board draft minutes 11 February NCL Primary Care Joint Committee Minutes 19 January 2016 Chair To note Appendix M Chair To note Appendix N 12. Public Open Space on agenda items 13. Date and Place of Public Meetings all at 2.30pm 13 July September November January March 2017 (all to be agreed) Chair Oral 2

3 MEETING: NHS Enfield Clinical Commissioning Group Governing Body DATE 11 May 2016 TITLE: Chair s Report LEAD GOVERNING Chair of the Enfield CCG Governing Body BODY MEMBER: AUTHOR & POSITION: David Triggs, Board Secretary, on behalf of Chair CONTACT DETAILS: Summary: Agenda Item: 1.1 Appendix A This report updates the Governing Body on those matters that fall under the remit of the Chair of NHS Enfield Clinical Commissioning Group and that are not covered elsewhere on the agenda. Recommended action: The Governing Body is asked to note the update. Strategic Objective(s) supported by this paper: This paper supports all objectives in particular operating collaboratively with the clinical leadership of the CCG Audit Trail: None Patient & Public Involvement (PPI): None Equality Impact Assessment: Equality impact assessments are undertaken in relation to substantial commissioning changes and will be available where necessary in relation to individual work programmes Risks: All risks identified are recorded on the NHS Enfield CCG risk register and board assurance framework, or available as part of individual work programmes Resource Implications: Where relevant they are detailed, or available as part of individual work programmes Next Steps: An updated report will be provided at each governing body meeting 3

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5 NHS Enfield Clinical Commissioning Group Chair s Report 1. Changes to Membership of the Governing Body I would like to welcome back Dr Ujjal Sarkar following his period away from the CCG Governing Body. Dr Sarker will be covering Contract Management at the provider trusts and Safeguarding Adults. I would like to thank Dr Puvitha Thambinayagam for her support in covering for Dr Sarkar during his absence. 2. GP Member Engagement Event 4 May 2016 The Enfield CCG GP member practices engagement event took place on Wednesday 4 May The meeting is being held the same day that these papers are being published. The main items on the agenda are as outlined below and I will give a verbal update at the Governing Body meeting. Mental health transformation Financial recovery plan Repeat prescribing GP federation / network development Level 3 primary care co-commissioning Chair s Report 11 May

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7 Agenda Item: 4.1 Appendix: B MEETING: NHS Enfield Clinical Commissioning Group Governing Body DATE: 11 May 2016 TITLE: Report of the Chief Officer LEAD GOVERNING BODY Chief Officer MEMBER: AUTHOR & POSITION: David Triggs, Board Secretary, on behalf of Chief Officer CONTACT DETAILS: EXECUTIVE SUMMARY The report of the Chief Officer provides the Governing Body with an update on significant developments within our local health and care system, across the commissioning portfolio and relevant NHSE (London) and national issues. The report provides an update on the following: 1. Future of Primary Care Commissioning 2. System wide Transformation Sustainability and Transformation Plan 3. GP See and Direct Pilot 4. Paediatric Assessment Unit on Chase Farm Hospital site 5. Enfield Urgent Care Review 6. Care Quality Commission visits 7. CCG 360 degree stakeholder survey 8. Governing Body Non-voting Membership 9. Contracts update 10. Executive Committee 11. Procurement Committee RECOMMENDATIONS The Governing Body is asked to note the contents of the report. 7

8 REPORT OF THE CHIEF OFFICER 11 MAY Future of Primary Care Commissioning The North Central London CCGs began primary care co-commissioning with NHS England in October 2015, and formed a Primary Care Joint Committee to oversee this new area. In April 2016 the Committee held a workshop to discuss how the Committee was progressing and to explore the possibility of moving to delegated commissioning arrangements for primary care from April This would mean CCGs take on formally delegated primary care commissioning responsibilities from NHSE, rather than taking joint responsibility with NHSE. The Committee agreed that further consideration be given to requesting to move to delegated commissioning in north central London. The Committee felt there were potential benefits that needed further exploration, as well as recognition that this is a national direction of travel. Benefits may include more local decision making and flexibility in commissioning primary care which would support the implementation of our primary care strategy. The Chairs and Chief Officers of NCL CCGs agreed to support further work on this. A programme of work will now commence to consider an application to move to delegated commissioning (application to be submitted in October 2016). This will include a programme of engagement with GP practice members and other partners. There will also be an assessment of the risks, as well as an options appraisal of the governance models. If a proposal is approved by CCG Governing Bodies and NHSE, due diligence work will be required between October 2016 and the go live date of 1 st April System wide Transformation Sustainability and Transformation Plan (STP) NHS Shared Planning Guidance 2016/ /21 outlines a new approach to ensure health and care services are planned by place rather than around individual institutions. As in previous years, NHS organisations are required to produce individual Operational Plans for 2016/17. In addition, every health and care system will work together to produce a multi-year Sustainability and Transformation Plan (STP), showing how local services will evolve and become sustainable over the next five years ultimately delivering the Five Year Forward View. To do this, local health and care systems will come together into STP footprints. The health and care systems within these geographic footprints will work together to narrow the gaps in the quality of care, their population s health and wellbeing, and in NHS finances. Local health and social care organisations have agreed to work across the North Central London (NCL) STP geographic footprint to develop an agreed STP. Work is underway to develop an overarching high level plan for submission at the end of June 2016, with fully developed and agreed plans to be submitted in November This plan will support access to transformation funding. 3 GP See and Direct Pilot Service North Middlesex University Hospital NHS Trust The GP See and Direct Pilot which commenced on 17 th February 2016 for a 13 weeks period was evaluated for effectiveness using March data. The pilot was agreed by Enfield CCG, Haringey CCG and North Middlesex University Hospital NHS Trust to respond to the pressures in the A&E Department by reducing the flow of patients. Large numbers of patients are attending the A&E department for issues which are better treated outside of the hospital setting. Early evaluation has demonstrated that the model is effectively redirecting patients away from the Emergency 8

9 Department and as a result, the pilot will be extended for a further 13 weeks period. It is anticipated that a clinically and financially sustainable model will be identified and considered as a viable long term solution. Additionally, this pilot is providing education to patients (and their carers) and may help patients make improved choices about where and how to access healthcare. 4 Paediatric Assessment Unit on Chase Farm Hospital site The Chase Farm Paediatric Assessment Unit (CF PAU) was opened in November 2013, as part of the implementation of the BEH Clinical Strategy. It is co-located with the Urgent Care Centre. 94% of children attending the Urgent Care Centre are managed within the UCC, with very few children referred into the PAU. A review of the Unit was agreed prior to Commissioning Intentions being published in September Within the review group there was consensus that the PAU in its current form is not viable and further work has been done to explore an alternative. An option was agreed where the Urgent Care Centre continues to see and treat children with urgent care needs along with GP access to consultant advice via a hotline. This is supplemented by access to an urgent outpatient appointment at Chase Farm Hospital within two weeks. The hotline will be available between and (tbc) from Monday to Friday, with access by and agreement to phone back at other times. Transfer arrangements for children attending the UCC who need to be seen in an alternative setting will be unchanged. The proposed model is supported by the CCC s Clinical Reference Group. The proposal was presented to Health Scrutiny on 9 th March 2016 and a follow up meeting held with the Chair of the Scrutiny Panel on the 30 th March It was agreed that a case review would be carried out to provide further assurance about the proposed model prior to going out to public consultation for 90 days. The case review was carried out on the 28 th April 2016 and consultation documents are currently being finalised. 5 Enfield Urgent Care Review Enfield CCG commenced a review of urgent care services in February 2016 in order to make sure that we are meeting the needs of our local population. Over the last few years, demand for NHS services has been rising across the country, particularly for services with faster access like urgent or emergency care. We want to find out more about how local people access urgent care services and their experience of them. We will use this information to guide our future commissioning decisions on local urgent care services. During this review we asked people how they decided what services to access and what their experience was. This survey has now concluded and ran from 19 th February to 3 rd April The review findings will be considered by the Governing Body and will be published on Enfield CCG s website. 6 Care Quality Commission (CQC) visits to local providers The outcome of the CQC inspection visit on 30 November 2015 to Barnet, Enfield and Haringey Mental Health NHS Trust was published on 26 March It was identified as Requiring Improvement. A Quality Summit, led by the CQC, took place on 27 April 2016 to feedback findings and discuss recommendations. The Trust then developed an action plan and sought commissioner comments before submitting the final plan to the CQC. The final action plan was signed off by the 9

10 Trust and sent to the CQC on 3 rd May. Progress with the action plan and the necessary assurances, will be reported monthly to the Joint Quality and Performance (JQP) meeting. The outcome of the CQC inspection visit on 8 December 2015 to Whittington Health is still awaited, as is the inspection at the Royal Free London FT undertaken in February. 7 CCG 360 Stakeholder Survey - update NHS England (NHSE) has a statutory responsibility to conduct an annual performance review of each CCG, assessing against the 5 components of the new CCG Assurance framework 2015/16. As part of this process, NHSE commissioned Ipsos MORI to undertake a CCG 360 degree Stakeholder Survey on behalf of all Clinical Commissioning Groups. The survey was carried out from 1 March 2016 to 4 th April The overall response rate across all CCGs in England for 2016 was 59%. Individual response rates for the 5 CCGs in north central London are below. CCG Name Barnet CCG Camden CCG Enfield CCG Haringey CCG Islington CCG Overall response rate GP member practices Health and Wellbeing boards Local Health Watch/ other patient groups Other patient groups NHS providers Other CCGs Upper tier / unitary local authorities Wider stakeholders 53% 51% 50% 100% 67% 67% 75% 40% 47% 52% 42% 50% 100% 75% 63% 50% 80% - 59% 57% 50% 100% 60% 67% 75% 67% 40% 61% 53% 50% 100% 100% 33% 75% 100% 100% 44% 50% 0% 50% 0% 45% 50% 0% 36% Enfield CCG s overall response rates in previous years were: 68% in the GP practices response rates for last year was 63%. 60% in 2014 The report was sent to all CCGs on 29 th April 2016 and will be uploaded onto Enfield CCG s website. This report will be reviewed and an improvement action plan will be developed. This plan will be shared with the Governing Body, staff and stakeholders. 8 Governing Body Non-voting Membership At its meeting in private on 13 April 2016, the Governing Body approved the motion to add the role of Director of Recovery as a non-voting member of the Governing Body. This was in order to enhance the CCG s ability to deliver its financial recovery plan. The post of Recovery Director is a mandated post within the CCG management structure whilst the CCG is under legal directions from NHSE. At the current time, the Governing Body comprises 15 voting members including the Chief Officer and Chief Finance Officer. Other directors attend meetings of the Governing Body in a non-voting capacity. 10

11 9 Contracts Update The following contracts have been agreed; North Middlesex, Moorfields, Guys and St Thomas, King s and Royal Brompton. Both the Royal Free and UCLH contracts are close to agreement with an overall contract value agreed with the lead commissioner and the Provider. BEHMHT remains in discussion with NHS England and NHS Improvement. 10 Executive Committee The CCG Executive Committee has met on 24 February 2016, 30 March and 27 April. The following reports were considered: Monthly Integrated Performance and Quality Report Board Assurance Framework and Corporate Risk Register 16/17 Planning Guidance Operating Plan Sustainability and Transformation Plan 2016/17 Contract Negotiations summary Primary Care updates Locality Commissioning Update Changes to the CCG Constitution Freedom of Information Guidance Review of the following policies: ASH Data Management Policy ECCG Fire Safety Policy Whistleblowing Policy review ECCG Fire Safety Policy HR Policies for approval 11 Procurement Committee The Procurement Committee has met on 2 March and 6 April and is due to meet on 4 May 2016 (the day these papers are due to be published). At the March and April meetings the following matters were discussed: Contract Register Register of Procurement Decisions Healthcare Networks in Enfield NHS 111 & Out of Hours Procurement Future Commissioning Models Procurement Strategy for re-procurement of Community Gynaecology, Ophthalmology and Urology Services Work Plan 11

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13 Agenda Item: 5.1 Appendix C MEETING: NHS Enfield Clinical Commissioning Group Governing Body DATE: 11 May 2016 TITLE: Quality and Safety Exception Report LEAD GOVERNING Angela Dempsey, Governing Body Nurse Member BODY MEMBER: Aimee Fairbairns, Director of Quality & Integrated Governance AUTHOR & POSITION: Bridget Pratt, Assistant Director of Quality, Governance and Risk Sharon Ibrahim, Interim Clinical Governance Lead Quality & Governance Team CONTACT DETAILS: SUMMARY: This report provides a summary of the key exceptions and quality issues discussed by the Quality and Safety Committee at the meeting held in March 2016; the Quality and Risk Sub Group in April 2016; and with Providers at the March and April CQRG meetings. It updates the Governing Body on Enfield CCG s work to improve quality and covers key quality and safety areas within the CCGs Quality Strategy and Implementation Plan. Summary of key exceptions outlined in the report: CQC report & Quality Summit for Barnet, Enfield and Haringey Mental Health NHS Trust; Never events at Royal Free London NHS Foundation Trust; 62 day cancer breaches at Royal Free London NHS Foundation Trust; Emergency Department performance at North Middlesex University Hospital NHS Trust. CCG Quality Governance Update (Level 2 Information Governance Toolkit Compliance) SUPPORTING PAPERS: There are no supporting papers report informed by the work of the Quality and Safety Committee and the Clinical Quality Review Groups (CQRG) RECOMMENDED ACTION: The Governing Body is asked to. Note the exceptions reported Note that all quality and safety issues are being monitored at the monthly Clinical Quality Review Groups and the Contract Management meetings; and Raise and discuss any issues that require further clarification by the Quality and Safety Committee. Note Enfield CCG 2015/2016 Information Governance Toolkit Submission at level 2 13

14 approved at the March Quality & Safety Committee Plans supported by this paper: This paper supports the Enfield Clinical Commissioning Group s (CCG) strategic plan to achieve a robust governance framework and to ensure there is continuous service quality improvement with service providers. Patient & Public Involvement (PPI): Enfield Clinical Commissioning Group wishes to involve patients and the public at all levels within the CCG and will be working with its Patients and Public Engagement Committee to determine the most effective way to achieve this. Equality Impact Assessment: Not required. Risks: Capacity, development, and duplication are all risks to quality and safety and are reflected in the CCG s corporate risk register. Resource Implications: None at this stage. Audit Trail: Enfield CCG Quality and Risk sub-group meeting 20 April 2016 Enfield CCG Quality and Safety Committee meeting 16 March 2016 Minutes of the Royal Free London Hospital CQRG Minutes of the North Middlesex University Hospital CQRG Minutes of Barnet, Enfield & Haringey Mental Health Trust CQRG 14

15 Quality and Safety Exception Report 1. Barnet, Enfield and Haringey Mental Health Trust (BEH-MHT) 1.1 Quality and safety exceptions CQC Report and Quality Summit: The CQC report for BEH has now been published and the Trust received an overall score of Requires Improvement. One service, Forensic inpatient/secure wards, was awarded a rating of Outstanding ; Five of the eleven services inspected were each awarded a rating of Good (community services and in-patient wards for older adults with mental health problems); The remaining five services (acute wards for adults and psychiatric intensive care, child and adolescent mental wards, adult community mental health services, mental health crisis and specialist community mental health services for children and young people) were each awarded a rating of Requires Improvement. The Trust acknowledged that the overall result underpin local findings already subject to Trust improvement work. Enfield CCG held a planning meeting to review the should and must do s and areas of specific focus for commissioners. The Trust has also identified the must/should do actions that can/are being addressed by the organisation directly; in addition there are some actions that have wider implications and need commissioner/system wide support to complete and this is being discussed with commissioners. A Quality Summit, led by the CQC, took place on 27 April 2016 to feedback findings and discuss recommendations following the publication of the report, in order for the Trust to draft action plans and seek commissioner comments before submitting the final plan to the CQC. At the Quality Summit, the CQC noted that the BEH forensic service is the 1 st one in the region to be awarded outstanding; they were struck by the morale of staff throughout the organisation being higher than any other in the region and that the motivated/caring attitude of staff permeated through every service. It was noted that older people s mental health services had made great progress since the last visit. For Community services, the CQC noted that the Trust was providing a good standard of care, no areas of concern other than the health visitor numbers. The Trust presented an overview of its draft action plan. The final action plan will be signed off by the Trust and is due to be sent to the CQC 3 rd May. Progress with the action plan and the necessary assurances, will be reported monthly to the Joint Quality and Performance (JQP) meeting. Through the JQP the CCG will also facilitate system wide support on relevant areas such as risks and mitigation. Clinically effective care The Rapid Assessment Interface and Discharge (RAID) service provided by BEHMHT within North Middlesex University (NMUH) and Barnet Hospitals emergency departments (ED) has been challenged in meeting the one hour response time for emergency department referrals. Additional staff have been employed to manage the crisis lounge overnight but this has not had a sustained effect. The Trust has been requested to provide detail on the persistent cause of breaches. The Barnet site service met the standard for the first time in December The CSU is to provide information on ED breaches to establish if any there is a 15

16 relationship between RAID response times and either 4 or 12 hour breaches. Further analysis of activity and capacity is being undertaken to inform how best to model the service for 2016/17. Patient safety Patient experience The Trust is currently not submitting completed SI reports within the 60 day standard. Some reports are expected to breach this timeframe due to the complexity of the investigation but this does not apply to all late submissions. The monthly Joint Performance and Quality Review Meeting is now receiving a monthly tracker from the Trust to maintain better oversight of reporting compliance. In light of the Southern Health NHS Trust Review, the Trust undertook a review of processes in relation to investigating death. No immediate concerns were noted during the review, but a Trust wide Serious Incident Group to oversee all SI reports and action plans was recommended by the reviewers; the proposal has been accepted. During February 2016 the FFT response rate at BEHMHT rose slightly to 6.6%. Three services in February did not return data. BEH MHT has appointed a patient experience manager who is now in post and addressing FFT response rates and supporting services to improve patient experience. Patient Experience Information is reviewed within in each service as part of each Borough s quarterly Deep Dive Meetings. Managers have been requested to check FFT responses weekly and respond via You said, we did posters to keep services informed of progress with feedback. Patient and Carer Experience Survey response rates remain high across the Trust. Deep dive meetings are held within the Boroughs to identify areas for additional work and agree actions. 2. North Middlesex University Hospital Trust (NMUH) 2.1 Quality and safety exceptions Clinically effective care. Patient safety NMUH did not meet the 95% 4 hour wait standard in January reporting performance of 67.2%. In-year activity remains down on 2014/15 levels. The Trust has been unable to meet the standard since Q2 2015/16. An action plan has been produced to support improvement in the Emergency Department performance and care. The TDA and NHSE have organised a weekly teleconference with the Trust to support delivery of the action plan and to receive updates on ED performance. From February 2016, the Trust also report an A&E quality and performance dashboard to CQRG as part of the A&E recovery action plan. The North West Utilisation Management Unit (NWUMU) walk the pathway report has been shared with stakeholders; findings will be incorporated into the ED action plan over the coming weeks. Quarter three saw an improvement in the Trust s compliance with incident reporting standards once an SI had been 16

17 Patient experience identified, however there were some long delays between some incidents occurring and being identified as an SI. The Trust has also made improvements to its compliance with submitting completed investigation reports during quarters two and three. At the end of quarter three only one report was overdue for submission. After exceeding 62 day diagnostic standard trajectory in December and January, NMUH failed the standard with 78.9% in February. This has been attributed to an increased number of late incoming inter-trust transfers. The Trust commenced Clinical Harm Reviews for patients with >62 day waits. Reviews were conducted on patients for whom a cancer has been diagnosed and have received first treatment. Of the 8 cases reviewed to date, 5 reviews (colorectal, lung and urology) are complete and no harm identified. The findings of the Harm Reviews were presented to the Trust Cancer Board in March The FFT results for ED demonstrate a continued fall in the satisfaction rate of service users with only 66% of patients in January 2016 reporting that they would recommend the service. This places the Trust the lowest of the 20 London ED providers. At the February 2016 CQRG the Trust acknowledged that the FFT results for ED had deteriorated further in January. It was noted that feedback received via the patient interviews in ED suggested that patients feel that they are being cared for and listened to, but acknowledged that updating patients on what was due to happen next for them required improvement. It was also reported that noise is an issue for some patients; the Trust reported that this can be addressed but not eliminated due to the volume of attendees, particularly at night. Monitoring will continue via the CQRG 3 Royal Free London Foundation Trust (RFL) 3.1 Quality and safety exceptions The CQC commenced a comprehensive inspection on 2 February 2016 visiting the three main hospital sites and the Enfield Civic Centre. The CQC inspectors returned for three further unannounced visits subsequent to the main inspection. The CQC full report is expected in May Clinically effective care The Trust reported non-compliance with 18 and 52 week incomplete standards and the 6 week diagnostic standard for January All patients that have waited 52+ weeks are being actively managed via weekly Waiting List Action Group meetings and Root Cause Analyses reviews are being conducted. The Trust expects to return to RTT compliance by the end of September 2016, with specialist service RTT compliant by the end of December All cases with long waiting times are being escalated to Divisional or Chief Operating officers and being offered outsourced services where appropriate. 17

18 Patient safety Patient experience At the time of writing the Trust has reported 10 Never Events for 2015/16 with a recurring theme of retained foreign objects. A Trust wide deep-dive review has been undertaken and will report to May CQRG. Commissioners have also arranged to meet with the Trust following the April CQRG to focus specifically on Never Events. The Trust continues to undertake clinical harm reviews of all patients whose pathway has breached the 62 day standard. The 62 day assurance sub group has advised that, for the current cohort of breaches (from September 2015), the recall and completeness of RCA s is not sufficient to fully quality assure and that the trust RCA process and report outputs do not meet the level required by the September 2015 guidance on breach reporting. The Trust has been asked to inform April CQRG of actions being taken to assure commissioners that they are incorporating the September 2015 guidance into their operations. The Trust presented a patient experience report to the February 2016 CQRG. The report outlined the strategic approach to enhancing patient experience and responding to reports of poor experience. The Trust has launched a John s Campaign initiative (a campaign championing the right of elderly or frail adults to have their carers with them in hospital) including flexible visiting times across wards, safe guarding training for carers, free television for particularly anxious patients and vintage television programmes. 4. Other providers 4.1 London Ambulance Service The Trust have been in special measures since November 2015 following the Care Quality Commission (CQC) rating of inadequate. The inspection found that whilst the Trust were caring, improvements were needed on safety, effectiveness, responsiveness and leadership. Monthly CQRG meetings receive the Trust s report of progress against their Quality Improvement Plan, which was developed following the CQC rating and which has been agreed by commissioners and the TDA. The plan is formed of five work streams and corresponding actions that directly correlate to CQC recommendations of must-do and should-do. LAS performance is under weekly scrutiny from the TDA, NHSE and the lead commissioner Brent CCG. The TDA have confirmed good progress in recruiting to vacancies particularly in HART (Hazardous Area Response Team). There are also good systems in place for medicines system and storage but further work is still required. 5. CCG Quality Governance 5.1 Provider Quality Accounts The Quality & Safety Committee received an update on the 2015/2016 provider Quality Accounts process. NHS Provider Trusts have been required since April 2010 to publish a Quality Account outlining quality improvements made, challenges and their priorities for the prospective year. The aim of this is to drive improvement in NHS services by creating a mechanism for greater public accountability. 18

19 A 30 day consultation period with stakeholders for statements in response is required with final accounts including statements published on NHS Choices. The process involves informal comments on drafts accounts and review of updated drafts prior to sign off of final statement by the chair of the Quality and Safety Committee. The statements will also be reported for information to the Governing Body. The Quality & Safety Committee will receive the quality account statements as follows: Barnet, Enfield and Haringey Mental Health Trust Royal Free London Foundation Trust North Middlesex University Hospital NHS Trust Small providers As was done last year, given the date of the Quality & safety Committee and provider Quality Accounts completion timeline, the May Quality & Safety Committee will asked to delegate through chair s action any further review of provider drafts required and sign off for final statements prior to formal agreement through CQRG. The July Governing Body will then be provided the accounts and final statements for information. 5.2 Continuing Healthcare Report Q2 & Q3 The Quality & Safety Committee noted the Q2 and Q3 Continuing Healthcare Report. The report provides an overview and update to the Quality & Safety Committee on the Continuing Healthcare Service managed by Enfield Clinical Commissioning (Enfield CCG) in relation to activity, patient experience and patient safety as of March The key updates were: Audit and Monitoring Enfield Continuing Healthcare has recently had an internal audit. The outcome of this was an amber/green rating with 4 medium rated actions all of which have been actioned. NHSE Deep Dive In November 2015 ECCG Accountable Officer was notified of the intention to undertake a deep dive on Continuing Healthcare against the responsibilities set out in the standing rules and National Framework for NHS Continuing Healthcare and FNC Funded Nursing Care. Enfield Continuing Healthcare are part of the pilot programme for NHSE to contribute to the development of the CHC Assurance framework which was rolled out nationally in December Patient surveys CHC launched the patient survey In November It can be completed either on-line or in paper format. Details are sent to all patients with their eligibility decision letter both eligible and noneligible for Continuing Healthcare. In Q3 60 surveys were issued of which 2 were returned PHB (Personal Health Budgets Update) PHB s are offered to all eligible CHC individuals that live within a community setting only at this time. There are currently no issues with PHB s it is an evolving process Enfield CHC currently commission Mysupportbroker to undertake support planning. They audit all client account, attend quarterly meetings with CHC to report findings. Exceptions are raised outside of this meeting. The Committee commended the high quality report that showed good practice in the CHC service. 5.3 GP Tranformation Group The Quality & Safety Committee received an update on the GP Transformation Group. The CCG has a statutory responsibility for improving the quality of primary care. The General Practice Transformation Group is one of the main groups overseeing this function. The committee noted an update on the Quality and Outcomes Framework. In 2014/15, QOF performance has been the 19

20 most successful since the CCG was established in April 2013 and demonstrates significant improvement. However while there have been significant gains, the range in performance of our exemplar practices against our outliers will continue to make at scale improvements challenging. As the CCG has a statutory duty to improve the quality of primary care, performance should be used to identify support to those practices that clearly have not been able to deliver the level of quality outcomes the CCG aspires to every patient receiving. The Primary Care Team has developed a search and reporting tool to enable the CCG to retrieve live QOF data from general practice. This solution will enable the CCG to track progress and performance of QOF per practice and identify opportunities to support practices to deliver enhanced clinical outcomes for patients on a routine and timely basis rather than during the last quarter of each financial year. The CCG is currently consulting with Enfield LMC regarding the piloting of this tool in two GP Practices. GP Outcomes Dashboard The GP Outcomes Dashboard was developed in 2014 and currently incorporates indicators for hospital activity, medicines management, patient experience, estates and NHS England GP Outcome Standard triggers. The dashboard is shared and discussed with practices on a locality basis as a means of supporting them to review their own performance against their geographical peers and in order to drive up performance by generating healthy competition between practices. Performance is also used to identify support to those practices that have not been able to deliver the level of quality the CCG aspires to every patient receiving and target these for joint visits with NHS England. 5.4 Quality & Safety Risk Register The Committee reviewed the Quality & Safety Risk Register. The Committee noted that NMUH remain the highest quality risk and the LAS risk remains a composite quality risk on the CCG assurance framework. One risk was recommended for closure related to Murrayfields Nursing Home the risk was inadequate ratio and lack of leadership. The provider is no longer under provider concerns. This was approved by the Committee /2016 IG Toolkit Submission & Data flow mapping report The Committee received the CCG Information Governance Toolkit pre-submission & Assessment report for and the Information Asset and Personal Confidential Data Flow Mapping (DFM) Report. Enfield CCG achieved level 2 (75%) a 6% increase from last year s score of 69%. The DFM report provides an update on the latest review of security standards and controls that are in place and required for the maintenance of Information asset and flow of Personal Identifiable Data (PID) in Enfield Clinical. The DFM report provides assurance that patient identifiable information in is being used safely within the CCG. The Committee approved the IG pre-submission assessment report. 5.6 Enfield Referral Service Quality & Performance Report The Committee received the ERS Quality & Performance Report. The Committee noted that the service had undergone several changes and reviews but remains central to the Enfield CCG (Clinical Commissioning Group) and is seen as a key area for supporting quality, delivering choice, driving performance and as an early warning system. 20

21 A dashboard has been developed to capture all the information required to monitor the number of referrals in ERS and the workflow including the community clinics. This is included in the report provided by the Head of Performance and Informatics which is taken to the Executive and Governing Body every eight weeks. The Outpatient Referral Improvement Programme (ORIP) group is supporting ERS in procuring a new IT (Information Technology) system which will improve safety, quality, governance, process and most importantly, the patient experience. The contract has been awarded to Docman. 5.7 CCG Quality Strategy and Continuing Health Care Policy The April Quality & Risk Sub Group reviewed the CCG Quality Strategy as it was due for an annual refresh. The policy now incorporates the Clinical Audit Research & Innovation policy as a separate policy is not required for commissioning organisations. An implementation plan will be developed for approval by the Quality & Safety Committee. The Committee also reviewed the CHC Policy due for routine review. The amendments are intended to: provide greater clarity around patient choice where continuing healthcare can be provided and what CHC will provide provide clarity in relation to individuals capacityto make a decision, and the role of professionals and family/carers provide clarity of the arrangements for End of Life care and palliative care more clarity on care home placement carity on care at home clarity on how respite will be addressed and funded clarity on equipment provide clarity around CHC provision of Personal Health Budgets and the pathway and the responsibility of the individual The Committee recommended the Quality Strategy and CHC policy to the Quality & Safety Committee for approval. 5.8 ECCG Primary Care Safeguarding children and Adults at Risk Symposium The Quality & Risk Sub Group received a summary on the recent primary care safeguarding adult and children's symposium which was well attended and excellently evaluated. The delegates were a mixture of reception staff, practice managers, practice nurses and GPs across Enfield. The symposium included presentations on a number of key topics pertinent to child and adult safeguarding such as Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), Female Genital Mutilation (FGM). Serious Case Reviews. Domestic Violence and the Identification, Referral to Improve Safety and Building responses to peer-on-peer abuse: The work of the MsUnderstood Partnership. The Quality & Risk Sub Group gave special thanks to the safeguarding team on the excellent engaging event that took place which covered a broad spectrum 5.9 Complaints & Patient Enquiries Report (Q4) The Quality & Risk Sub Group received the quarter 4 complaints report which report provides an account of the complaints received in Q4 2015/16 by NEL CSU on behalf of Enfield CCG and provides an analysis of patient-related enquiries directly received by the CCG Risk and Governance Team. Patient related enquiries include areas such as IFR, FOI, concern, signposting and general enquiries. There were a total of 123 cases (patient related contact) recorded across 2 areas (Complaints and Enquiries) in the period Q4 2015/16 which are broken down thus: 21

22 Area Total Complaints 6 Enquiries 117 Grand Total 123 Enfield CCG received six complaints about its commissioning function/decisions in Q4 2015/16 compared to only one complaint received in Q3 2015/16. There were three complaints in Q4 2015/16, which accounted for 50.00% of all complaints received, related to the decision to withdraw prescribing of gluten-free foods; this appears to be a recent decision as these are the first instances of this type of complaint emerging from the patient community. Six complaints were received in Q4 2015/16, up from only one in Q3 2015/16. Complaints ranged from: o CHC (x1) o Gluten-Free Prescribing (x3) and o Delay in processing referral (ERS) (x1) o Rejected for funding as PoLCE (ERS) (x1) There were 117 CCG enquiries in total that were reported in the period Q4 2015/16. General Enquiries accounted for the most cases (40 cases, 34.19%) followed by Signposting to Provider (29 cases, 24.77%) and Signposting to NHSE (27 cases, 23.08%). Gluten-free prescribing accounted for 50.00% of all complaints received (3 cases), followed by ERS (two cases) and CHC (one case). End of report. 22

23 Agenda Item: 6.1 Appendix: D MEETING: NHS Enfield Clinical Commissioning Group Governing Body DATE 11 May 2016 TITLE: April Integrated Performance Report LEAD GOVERNING BODY Jane Pike, Director of Operations MEMBER: AUTHOR & POSITION: ECCG Performance Team CONTACT DETAILS: Summary: The purpose of this report is to provide an update on the CCG s quality and operational performance against national and local standards, and remedial actions where standards have not been achieved. The contents of the report are based on the latest available data and are informed by the NHS Constitution, The Five Year Forward View, CCG Assurance Framework and other local priorities. The executive summary of the Integrated Performance & Quality Report gives an overview of key issues and progress update for the month. Recommended action: The Governing Body is asked to note the contents of the report. Objective(s) / Plans supported by this paper: NHS North Central London commissioning Strategy and Operating Plan Audit Trail: IPR report is provided to each Executive Committee and Governing Body Patient & Public Involvement (PPI): Reported at meetings of the public Governing body Equality Impact Assessment: Equality impact assessments are undertaken in relation to substantial commissioning changes and will be available where necessary in relation to individual work programmes Risks: All risks identified are recorded on the NHS Enfield CCG risk register and board assurance framework, or available as part of individual work programmes Resource Implications: Where relevant these are detailed or available as part of individual work programme Next Steps: An updated report will be provided at each governing body meeting. 23

24 24

25 Integrated Performance & Quality Report April 2016 Draft Template Version; Governing Body 25

26 Table of Contents Executive Summary 2 Patient Experience 16 Quality Premium 5 Serious Incidents Weeks RTT 5 Other Measures 21 6 Weeks Diagnostic Waits 6 Appendix 1 CCG Scorecard 22 A&E Performance 7 Appendix 3 NMUH Scorecard 23 Cancer Waits 9 Appendix 4 RFL Scorecard 24 Readmissions 10 Appendix 5 & 6 BMI Scorecards 25 London Ambulance Service (LAS) 11 Appendix 7 London MRSA Rates 26 IAPT 12 Appendix 8 London C Diff Rates 27 EIP & Dementia 13 Appendix 9 NEL/INWL NHS 111 Quality Dashboard 28 Healthcare Acquired Infections (HCAI) 14 Appendix 10 NHS 111 Performance 30 Summary-Level Hospital Mortality Indicator (SHMI) Enfield CCG

27 1. The aim of this report is to provide an update on the key NHS performance and quality measures relating to Enfield CCG and provide assurance on actions being taken to improve and maintain care standards. Executive Summary 6. Remedial Action Plans to address cancer standard breaches, including the 62 day standard, are being actively monitored with providers, with support from NHSE. Weekly Patient Tracker Lists (PTL) shows a reduction in total number of patients on waiting list. 2. Based on information available for month 11 of 2015/16, the CCG is forecasting a Quality Premium achievement of 130k due to risks associated with A&E 4-hour wait breaches for mental health patients, avoidable emergency admissions targets, RTT performance, Delayed Transfers, LAS response times and overall A&E 4- hour performance. The CCG has now submitted its choices of local indicators for the 2016/17 Quality Premium and is awaiting feedback from NHSE. 3. ECCG s 18 Weeks RTT performance was 91.3% in February, a rise of 0.6% from January. Performance trajectories for the CCG and RFL are being closely monitored. 4. Performance against the 6 weeks diagnostic standard remains below standard but on an improvement trajectory in February. Providers are utilising additional capacity to clear the backlog and recover performance. 7. ECCG successfully recovered its IAPT access performance and exceeded the national target with a year-end position of 15.4%. The CCG is also meeting the new IAPT RTT standards and liaising with provider to confirm definitions for the new psychosis standard. Reported dementia diagnosis rate is also in line with the national ambition of 66.7%. 8. C. Diff performance for February was below trajectory, with 5 cases against the target of 8. However, on a year to date basis, the CCG has exceeded its trajectory by 17 cases. There are no CCG-assigned MRSA case year to date. 9. Issues relating to FFT response rates are being addressed via the monthly CQRG with providers. Other quality measures (Serious Incidents, PLACE Surveys and mixed sex accommodation) are included in this report. 5. The A&E 4-hour standard was not achieved at RFL or NMUH in February. Lack of clinical leadership at NMUH, and increased attendances and bed flow issues at RFL are cited as the main contributory factors. 27 Enfield CCG

28 Quality Premium Update The 130k estimated achievement for 2015/16 based on assessment of latest data. Payments are also subject to the following quality and financial gateways: Quality: No cases of serious quality failures at a local provider where CCG is not considered to have made appropriate, proportionate response with its partners to resolve failures: CCG is currently compliant. Finance: Operate in a manner consistent with Managing Public Money; does not incur unplanned deficit in 2015/16, or require unplanned support to avoid unplanned deficit; and does not incur a qualified audit report in respect of 2015/16: CCG is currently compliant. National Local Reducing Potential Years of Life Lost (PYLL) through causes considered amenable to healthcare over time Reducing avoidable emergency admissions (composite measure) Reducing NHS-responsible DToCs rates Reducing mental health-related A&E 4hr wait breaches Reducing the number of antibiotics prescribed in primary care Reducing the proportion of broad spectrum antibiotics prescribed in primary care Secondary care providers validation of their total antibiotic prescription data Target 1.2% Reduction per year No change over 4 years; or rate of < 1k per 100k pop. (ISR) Less than 2014/15 Rate (days per 100k pop.) Same breach rate compares to all patients; OR less than 5% YTD Performance Available Sep 2016 (2.5% fall in 2014) Composite increased 32.2% (yr to 15/16 Q3 v. 12/13) 1605 (14/15) v (M /16) Apr-Feb data show higher % of breaches (c. 20% at NMUH, SUS data proxy) Maximum Available Likely Achievement Reporting Frequency 162, ,423 Annual 243,634 0 Quarterly 243,634 0 Monthly 487,268 0 Monthly Reduction from to (Feb) 81,211 81,211 Monthly Reduction from 12.5% to 11.3% 11.01% (Feb) 48,727 48,727 Monthly Compliance at RFL and NMUH NMUH compliant RFL compliant 32,485 32,485 Monthly Emergency admissions from care homes 6% Reduction 6.8% reduction (Oct YTD) 162, ,423 Quarterly Dementia Diagnosis Rates 66.7% 67.5% (Mar) 162, ,423 Monthly Sub total (achievement) Measures 1,624, , Week RTT - Incomplete Pathway A&E waits (CCG mapped from HES provider data) Cancer waits - 14 days (Urgent GP referral for Suspected Cancer) Cat A red 1 ambulance calls (LAS performance) Sub total (penalties) Net Total Constitutional Measures Target YTD Performance Potential Adjustment Likely Penalty Reporting Frequency 92% 90.5% -30% - 194,907 Monthly 95% 86.3% -30% - 194,907 Monthly 93% 94.2% -20% 0 Monthly 75% 68.5% -20% - 129,938 Monthly - 519, ,938 Enfield CCG

29 Quality Premium The Quality Premium guidance was published in March. Significant developments include the Constitutional Measures performance to be assessed in Quarter 4 only, CCGs to choose 3 local measures (worth 10% each) from a menu of 80, and new National Measures to include early diagnosis of cancer, electronic outpatient appointment booking and experience of making a GP appointment. The CCG has now notified its 3 choices to NHS England, and feedback is awaited. Quality Gateway No cases of serious quality failures at a local provider where CCG is not considered to have made appropriate, proportionate response with its partners to resolve failures. Payments will be discretionary and subject to CCG assurance process criteria in relation to quality failures where gateway is not achieved. Financial Gateway Operate in a manner consistent with Managing Public Money; does not incur unplanned deficit in 2016/17, or require unplanned support to avoid unplanned deficit; and does not incur a qualified audit report in respect of 2016/17. National Local 1 Enfield CCG Improvement in the proportion of cancers (specific cancer sites, morphologies and behaviour*) diagnosed at stages 1 and 2 in the 2016 calendar year compared to the 2015 calendar year. 2 Increase in the proportion of GP referrals made by e-referrals 3 Improvement in overall experience of making a GP appointment a) Reduction in number of antibiotics prescribed in primary care b) Reduction in number of co-amoxiclav, cephalosporins and quinolones as a proportion of the total number of selected antibiotics prescribed in primary care. Percentage of patients receiving first definitive treatment for cancer, following an urgent GP referral for suspected cancer, within 2 months of the referral. Diagnosis rate for people (>65yrs) with dementia, expressed as a percentage of the estimated prevalence. The proportion of the estimated number of people who have depression and/or anxiety disorders people, who receive psychological therapies. Sub total (achievement) 18 Week RTT - Incomplete Pathway A&E waits (CCG mapped from HES provider data) Cancer waits Day Standard (Urgent GP referral to 1st definitive treatment for Cat A red 1 ambulance calls (LAS performance) Sub total (penalties) Net Total Measures Constitutional Measures Target 4% point improvement OR At least 60% diagnosed at stage 1 & 2 80% by March 2017 & year-onyear increase OR 20% point increase between March 2016 and March % OR 3% point increase between July 2016 to July 2017 publications 4% reduction on 2013/14 OR England average (1.161) 10% OR 20% reduction on 2014/15 value Latest Data % Allocation Maximum * Available Risk Rating 45.1% (2013) 20% 319,291 TBC Awaiting update from HSCIC (Oct 15 c. 40%) Reporting Frequency Annual moving to quarterly from May 16 20% 319,291 TBC Monthly c. 68% (Jan 16) 20% 319,291 TBC Bi-annually 14% less than baseline, and (yr to Dec15) 11.3% (yr to Dec15), and 5.6% less than baseline Enfield is likely to require a 4% improvement. For Enfield, this will mean a 20% increase is required; equivalent to c. 50% increase on estimated current performance. For Enfield, this will mean a 3% increase is required. Current performance (Jan publication) is c. 68%. 5% 79,823 TBC Monthly Enfield is performing well on both targets. 5% 79,823 TBC Monthly Enfield is likely to require a fall to 10%. 85% in Q3 and Q4 70.2% (Q3) 10% 159,646 TBC Quarterly 66.7% by March % (Mar) 10% 159,646 TBC Monthly 15% in 2016/ % (15/16) 10% 159,646 TBC Monthly Target Latest Data Weighting 100% 1,596,455 Weight Value Risk Rating Reporting Frequency S&TF/ Op Plans for Q4 16/17 TBC 25% 399,114 Monthly S&TF/ Op Plans for Q4 16/17 TBC 25% 399,114 Monthly S&TF/ Op Plans for Q4 16/17 TBC 25% 399,114 Monthly S&TF/ Op Plans for Q4 16/17 TBC 25% 399,114 Monthly % 1,596,455 Monthly data also released, but is less complete than the quarterly. A new denominator is used in 2016/17, so headline performance is likely to fall in April.

30 Across all Trusts, Enfield s performance for the 18 Weeks Referral to Treatment standard was 91.3% for February, a rise of 0.6% from January. This was driven by an improving position at the Royal Free Trust and continued good performance at North Middlesex and UCLH. At a national level, the overall commissioner performance for England was 92.1%, although several Trusts are not reporting currently. 18 Weeks RTT CCG Name Treatment Function Total number of incomplete pathways Total within 18 weeks % within 18 weeks Average (median) waiting time (in weeks) NHS ENFIELD CCG Other 4,601 4, % 5.3 NHS ENFIELD CCG General Surgery 1,864 1, % 7.4 NHS ENFIELD CCG ENT 1,618 1, % 6.0 NHS ENFIELD CCG Trauma & Orthopaedics 1,395 1, % 7.2 NHS ENFIELD CCG Dermatology 1,267 1, % 6.5 NHS ENFIELD CCG Gastroenterology 1, % 8.9 NHS ENFIELD CCG Ophthalmology % 5.5 NHS ENFIELD CCG Urology % 6.5 NHS ENFIELD CCG Gynaecology % 5.1 NHS ENFIELD CCG Cardiology % 6.2 NHS ENFIELD CCG Neurology % 7.1 NHS ENFIELD CCG Thoracic Medicine % 7.2 NHS ENFIELD CCG Rheumatology % 5.6 NHS ENFIELD CCG General Medicine % 5.9 NHS ENFIELD CCG Plastic Surgery % 8.3 NHS ENFIELD CCG Neurosurgery % 7.3 NHS ENFIELD CCG Geriatric Medicine % 7.7 NHS ENFIELD CCG Cardiothoracic Surgery % - NHS ENFIELD CCG Total 16,941 15, % 6.2 RFL s specialty-level recovery trajectory delivers aggregate Trust compliance with the 92% standard during Q2 2016/17. When applied to Enfield CCG, it was estimated that the overall CCG performance would reach 92% in June The latest performance suggests this remains a reasonable and cautious estimate. In February, Royal Free London reported 88.8% of Enfield patients had been waiting less than 18 weeks from referral to treatment, an improvement of 0.6% from January. There were no patients waiting more than 52 weeks, as at 29 th February. Enfield s performance for each specialty (or treatment function ) is seen below. Gastroenterology continues to have the longest average waits. Enfield CCG 30 Barts Health has not reported RTT figures since August The Trust s performance may impact on Enfield CCG s trajectory, should reporting resume in summer as planned. A national RTT Monitoring Tool is published monthly by NHS England. This allows quick access to submitted RTT statistics and derived metrics, including clearance times. It also provides a statistical stress test for future Trust performance. NMUH is shown as very low risk of failing the 92% standard in the next 6 months. Gastroenterology, still at 88%, is the only specialty at the Trust not compliant with the 92% standard.

31 6 Week Diagnostic Waits Enfield CCG continues to track below the trajectory for recovering diagnostics performance, due mainly to endoscopic modalities breaches at RFL and NMUH. The breach rate for February was 3.5% against the in-month trajectory of 1%, although an improvement of 2.3% compared to January performance. The CCG recorded the second highest number of breaches in London in February; 258 patients waited longer than 6 weeks for their diagnostic, 66 of which waited greater than 13 weeks. However, this was a notable reduction from January s breaches (403 patients with a >6 week wait, 104 patients >13 week wait). Modalities experiencing the longest waits for Enfield patients are colonoscopy, flexi-sigmoidoscopy and gastroscopy a theme that is common across North Central and North East London CCGs. All other modalities, with the exception of sleep studies and audiology, recorded less than 1% of patients waited longer than 6 weeks for their diagnostic in February. RFL Trust performance improved to 1.2% in February (from 3.6% in January). Marked improvement was seen in the performance of the cystoscopy, flexisigmoidoscopy, gastroscopy and colonoscopy modalities. The Trust aims to be complaint with the diagnostic standard in March. This is supported by the significant additional capacity secured through insourcing and outsourcing. NMUH s performance improved to 7.4% in February (from 10.8% in January). Improvement was seen across a number of diagnostics however flexi-sigmoidoscopy, gastroscopy and colonoscopy modalities remain challenged. The Trust s revised trajectory of compliance in March has been accepted by commissioners and is supported by ongoing outsourcing to the private sector and use of the Trust s on-site mobile unit. All outsourced patients are clinically vetted by a consultant prior to being transferred off site. The Trust have confirmed that clinical responsibility for the patient remains with NMUH for the outsourced patients. The clinical harm review process will be replicated for this group of patients and harm status confirmed at the end of treatment. The situation is being monitored by commissioners through contact meetings and Remedial Action Plan review meetings. 31 Enfield CCG

32 NMUH did not meet the 95% 4 hour wait standard in January reporting performance of 67.2%. In-year activity remains down on 2014/15 levels. The Trust has been unable to meet the standard since Q2 2015/16. For the current quarter the standard has been achieved 75.81% of the time against a target of 95%. There were no 12 hour trolley waits reported for the Trust in February. NMUH A&E 4 Hour Waits Shortage of in-patient beds, resulting from low discharge rates, was the second highest contributory factor. These issues are being addressed via the board review and system wide analysis currently underway by the Programme Director of Emergency Care. An action plan has been produced to support improvement in the Emergency Department performance and care. The TDA and NHSE have organised a weekly teleconference with the Trust to support delivery of the action plan and to receive updates on ED performance. From February 2016, the Trust also report an A&E quality and performance dashboard to CQRG as part of the A&E recovery action plan. The North West Utilisation Management Unity (NWUMU) walk the pathway report has been shared with stakeholders; findings will be incorporated into the ED action plan over the coming weeks. The wait for first clinician review remains the biggest contributor to the Trusts poor performance. Consultant and middle-grade fill rates remain of concern and recruitment plans continue. A new Trust Medical Director is in post from mid-february 2016 and the current part time interim will remain in post to undertake work with the A&E team on culture and behaviour. The Trust have confirmed that an A&E Clinical Director has now been appointed, start date is to be confirmed. Enfield CCG 32 The GP See and Direct pilot remains operational, currently seeing an average of 60 patients per day. This equates to around 1 in 12 A&E patients that are redirected to a more suitable non-emergency service. An audit of reasons for attendance is being undertaken. Health Education England North Central and East London (HENCEL) has undertaken a two-day assurance visit focused on assessing medical and nursing trainee support, with the ED one of the key areas assessed. The Trust is awaiting the report at the time of writing.

33 RFL did not meet the A&E standard for the third consecutive month in February, reporting 88.1% of patients seen within 4 hours of arrival across all sites. For the current quarter the standard has been achieved 88% of the time against a target of 95%. There were no 12 hour trolley waits reported for the Trust in February. RFL A&E 4 Hour Waits Repatriations and DToCs are supported by daily Surge teleconference calls and Clinical Directors with operational managers offering on-site support. In addition, the February meeting of the SRG signed off an escalation and capacity framework to support early discharge. A weekly action group with system representation has been set up to review progress on delayed discharges, admission avoidance and unplanned admissions. A range of other initiatives are being implemented as part of winter pressures funding including: 7 day social working; 24hr psychiatric liaison; home from hospital service and complex discharge co-ordinator. The Trust is also considering the St Thomas s model which has GPs based in acute sites. An out-of-hours care home support for nursing homes with high ambulance conveyances has also been operational since late February Exception reports received from the Trust and feedback from the daily surge calls indicate that there are contributory factors across the whole system. There are difficulties at all the Trust s sites - volumes and complexity of patients, staff absences, bed management with variable numbers of DTOCs and, more recently, control of infection. 33 Enfield CCG

34 Provisional data for February indicates ECCG met 4 out of the 8 cancer wait standards. Standards Target 2014/15 38 of the 60 breaches on the 2-week-wait pathway were attributed to patient choice. The 2-week-wait breast pathway was breached by 12 patients, 5 of which were from capacity issues at UCLH due to sickness of two consultants in December and January. CCGs are seeking assurance from the Trust about their capacity and plans to recover performance. The remaining breaches were attributed to patient choice at RFL and NMUH. There were 12 breaches in the 62-day standard for February; 8 on the Urological pathway, 2 Lower GI, 1 Skin and 1 Breast. Breach reasons were inter-trust delays (6), complex pathway (3), patient choice (2) and workup delay(1). These are attributed to RFL (5), NMUH (4), UCLH (2.5) and East & North Herts (0.5). 2 patients on the 62-day pathway waited 100+ days from GP referral. Both were on the Urological pathway at UCLH, attributed to inter-trust transfer delays from RFL. Enfield CCG Q1 2015/16 Cancer Waiting Times Q2 2015/16 Q3 2015/16 January 2016 February Week Waits 93% 94.4% 94.8% 93.8% 95.4% 90.9% 92.7% 2 Week Waits (Breast) 93% 94.2% 96.6% 93.6% 95.3% 89.7% 92.3% 31 Day 1st Definitive Treatment 96% 98.9% 94.3% 96.4% 99.0% 96.5% 97.9% 31 Day Subsequent Treatment (surgery) 94% 97.6% 97.8% 100.0% 96.9% 95.0% 100.0% 31 Day Subsequent Treatment (chemo) 98% 99.7% 99.0% 100.0% 100.0% 100.0% 96.6% 31 Day Subsequent Treatment (radio) 94% 99.3% 98.8% 94.9% 100.0% 100.0% 100.0% 62 Day 1st Definitive Treatment (GP Referral) 85% 77.9% 65.9% 64.4% 70.2% 63.6% 76.0% 62 Day 1st Definitive Treatment (Screening) 90% 96.6% 92.6% 93.3% 96.4% 100.0% 40.0% 62 Day 1st Definitive Treatment (Upgrade) N/A 91.9% 91.7% 90.6% 92.0% 100.0% 93.3% 34 RFL Trust have revised their trajectory to compliance against the 62-day standard to April 2016 following NHSE IMAS modelling. For the current cohort of RFL 62 day breaches (from September 2015), NELCSU have advised that the completeness of RCAs is not sufficient to fully quality assure. Areas of concern are; Clinical harm assessments not yet completed; No evidence of review by MDT; No evidence of RCA methodology in reports; Shared breaches not jointly reviewed with other providers. Clinical Harm Reviews are conducted for those with a 62+ day wait; The Trust is making progress in completing its clinical harm reviews but a backlog exists. At the February 2016 CQRG the Trust reported that 184 Clinical Harm reviews have been completed; either low or no harm was identified in all cases. The Trust will report month on month progress with reviews and actions to forthcoming CQRGs After exceeding the trajectory in December and January, NMUH failed the standard with 78.9% in February. This has been attributed to an increased number of late incoming inter-trust transfers. NMUH commenced Clinical Harm Reviews for patients with >62 day waits. Reviews were conducted on patients for whom a cancer has been diagnosed and have received first treatment. Of the 8 cases reviewed to date, 5 reviews (colorectal, lung and urology) are complete and no harm identified. The findings of the Harm Reviews were presented to the Trust Cancer Board in March 2016.

35 An overarching indicator within the 2015/16 CCG Outcome Indicator Set is emergency readmission within 30 days of discharge from hospital. This is used as a proxy indicator for outcomes of care. The official 2015/16 statistics will be published quarterly by the HSCIC, using HES data. This was supposed to start in late-march 2016, but has not yet been delivered. Local in-year monitoring is possible using SUS hospital data. On an annual basis, for Enfield CCG, these rates are quite stable. As at December, the 2015/16 rate is 11.6%, compared to 12.0% for year 2014/15 and 11.7% for 2013/14. Emergency Readmissions Objective comparison between hospitals is difficult due to differences in local populations, case-mix, etc. BMI s activity is all elective, so this cohort is less likely to be readmitted as an emergency at another Trust. The Royal Free (Hampstead site) has a higher rate because of its specialist services e.g. renal dialysis for which many of the readmissions could be at a different local hospital, and not necessarily connected to their renal care. Emergency readmission rate by Trust (originating) NMUH BCF BMI RFL Other 2013/ % 11.6% 6.0% 23.4% 9.4% 2014/ % 12.1% 7.5% 22.6% 10.3% 2015/ % 11.7% 6.9% 26.2% 9.0% The latest available national data from the HSCIC website suggests Enfield CCG has the lowest rate of emergency readmissions within London. However, this is data for 2011/12. Subsequent years data should be published when the indicator has acquired the necessary assurance from the Indicator and Methodology Assurance Service. A breakdown by provider shows that there is minimal difference between the CCG s two main providers. NMUH has a rate of 11.3% for Enfield patients, while the Barnet & Chase Farm sites of Royal Free have a rate of 11.7%. 35 Enfield CCG

36 London Ambulance Service (LAS) London Ambulance Service (LAS) continues to perform below standard against one of the key national measures 75% of Cat A RED 1 (immediately lifethreatening) call response within 8 minutes. Pan-London, 64.7% of Cat A RED 1 calls were responded to within 8 minutes in February. Performance in Enfield fell further to 50% for Cat A Red 1 calls. Its noted that performance in this category is subject to significant fluctuations as the number of people involved is relatively small. Graph below shows Enfield CCG s CAT A Red 1 in-year activity and performance compared to 2014/15. The Trust have been in special measures since November 2015 following the Care Quality Commission (CQC) rating of inadequate. The inspection found that whilst the Trust were caring, improvements were needed on safety, effectiveness, responsiveness and leadership. Monthly LAS CQRG meetings receive the Trust s report of progress against their Quality Improvement Plan, which was developed following the CQC rating and which has been agreed by commissioners and the TDA. The plan is formed of five work streams and corresponding actions that directly correlate to CQC recommendations of must-do and should-do. LAS performance is under weekly scrutiny from the TDA, NHSE and the lead commissioner Brent CCG. The TDA have confirmed good progress in recruiting to vacancies particularly in HAART. There are also good systems in place for medicines system and storage but further work is still required. The Trust recognise that response times must be improved to help address patient experience. Hospital handover time are also recognised as an issue. 36 The underlying problems which have not yet been solved are mainly a result of lack of capacity. Contributing factors identified by LAS in causing the recent deterioration of performance are an increase in demand both for Category A and Category C and a reduction in capacity as a result of less overtime being carried out. Enfield CCG

37 IAPT - Access, Recovery Rates & RTT Enfield CCG achieved the national target for Improving Access to Psychological Therapies (IAPT) year-end performance was confirmed as 15.4%, exceeding the annual target of 15%. Performance in March remained high with 526 patients entering treatment. Recovery rate in March rose to 53.3%, above the 50% target. This resulted in Q4 performance of 51.1%, again above the 50% standard. IAPT Recovery Rates Monthly Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar % 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% Monthly Actual 44.0% 51.0% 50.6% 51.8% 56.8% 45.8% 46.6% 47.5% 47.8% 50.6% 49.3% 53.3% The CCG continues to work with the service provider to address data discrepancies between local figures and national HSCIC data. This has been attributed to poor NHS Number completeness. Provider is putting systems in place to undertake PDS batch tracing. The CCG is also compliant against the new IAPT referral to treatment standards, ahead of the mandated timeframe of April Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 There are ongoing discussions with service provider to ensure sustainability in 2016/17, building on the progress made in 2015/16. Key actions from the Recovery Plan will be taken forward and developed to maximise performance. 6 weeks RTT 18 weeks RTT National Standard Monthly Actual National Standard Monthly Actual 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 89.4% 89.4% 85.5% 85.3% 87.1% 82.0% 89.7% 84.8% 87.2% 83.4% 89.7% 93.02% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 97.0% 99.0% 97.8% 99.4% 98.6% 98.2% 98.4% 99.2% 97.3% 98.8% 99.4% 97.67% 37 Enfield CCG

38 Early Intervention in Psychosis & Dementia Diagnosis Early Intervention in Psychosis (EIP) In February, BEH MHT reported that 40% of patients referred to the Enfield EIP team received treatment within 2 weeks of the referral. This is a marked improvement from January performance (14%) but below the 50% standard coming into effect in April. February's breaches were discussed through internal Trust EIP monitoring groups with team managers. Plans are in place to prevent repeated DNAs and avoidable delays by Trust services. New fields have been added to RiO to provide clearer recording of clock start and stop dates. Dementia Diagnosis Dementia prevalence amongst ECCG s 65+ population is estimated to be 2803 in , according to the recent Cognitive Function and Ageing Study (CFAS II). In its Operational Plan, ECCG committed to increasing reported diagnosis rates from 59.7% at end-march 2015 to the national standard of 66.7% by end-march The March data shows this has been achieved, with a diagnosis rate of 67.5%. Commissioners have sought assurance from the Trust that the methodology for measuring this standard is consistent with national guidance. Central reporting commenced in January, with the Trusts submitting December data. The latest data is for February, and shows 67% of patients treated within 2 weeks. Therefore, there is a definitional issue between national and local reporting which needs to be clarified. The new standard covers all ages of patients experiencing first episode psychosis. Prior to November, the Trust s reporting was for ages years. The GP DES scheme and community services CQUIN scheme are expected to boost diagnosis rates for Enfield. GP practice visits will be used to encourage practices with low diagnosis rates to identify and refer suitable patients and to update their registers. Enfield CCG 38 Average time from referral to assessment increased to around 9.8 weeks in February, whilst time from assessment to diagnosis decreased to around 7 weeks. BEHMHT have advised that it will be August 2016 before the service can offer initial assessments within 6 weeks of referral. This will be reviewed at the upcoming focused on the delivery of the service delivery.

39 Healthcare Acquired Infections (HCAI) MRSA No cases of MRSA were assigned to the CCG in February One case assigned to the CCG in December (from Barts Health) is still under investigation and will be subject to arbitration to determine if the case should be assigned to third party. No Trust-assigned cases of MRSA were reported at NMUH or RFL in December. C. Difficile Five cases of C. Difficile were attributed to the CCG in January The YTD total is 83 against the YTD trajectory of 69. The annual target of no more than 76 cases at year-end has now been exceeded. The table above shows C. Diff infections and rates for NCL. Enfield CCG has the second largest number of cases YTD. In February, NMUH reported 6 cases of C. Diff taking the cumulative count to 32 cases. The Trust are level with their YTD trajectory for no more than 34 cases at year end. NMUH joint review of incidences occurring, which was due in Q4 2015/16, has yet to take place. RFL reported 6 cases in February bringing their YTD total to 62 cases, 1 case above YTD trajectory of no more than 66 cases at year end. The Trust updated November CQRG on the implementation of an improvement plan to address the rise in C. Diff cases. 39 In relation to all attributable infections RFL exceeded the NHS national contract trajectory for quarters 1 and 2, but was compliant for quarter 3, recording 14 infections against a trajectory of 17. The Trust was also compliant in January and February 16 recording 9 infections against a trajectory of 11. Enfield CCG

40 Summary Hospital-Level Mortality Index (SHMI) The Summary Hospital-level Mortality Indicator (SHMI) is an indicator on Trust-level mortality. SHMI is the ratio between the actual number of patients who die following hospitalisation at the Trust and the number that would be expected to die on the basis of average England figures, given the patients treated there. An index of less than 1 indicates observed mortality is below expected. The CQC issued a 4th mortality outlier alert for NMUH in relation to therapeutic surgery occurring between August 2014 and July The Trust has investigated the service and reported back to CQC; further comment from CQC is awaited. Meetings with the Trust Relationship manager in regard to mortality numbers are on-going and assurance is monitored via the Trust Board and the Trust s internal Mortality Review Group. NMUH crude mortality rate per 1,000 admissions inmonth saw a slight rise over the 15/16 winter period. NMUH report closely monitoring mortality and reporting to Board. A new protocol for reporting and reviewing patient deaths has been agreed. Next SHMI data will be published in June Enfield CCG 40 Graph from NMUH Trust Board Papers 31 March 2016

41 Royal Free London February 2016 Patient Experience Acute Trusts North Middlesex University Hospital February 2016 RFL Patient experience continues to be on the agenda and discussed through RFL Clinical Quality Review Group (CQRG) meetings held with the Trust and commissioners. RFL Trust Director of Nursing is exploring options for a dashboard that captures cancer patient experiences at different points through the system. RFL hospital site noted an increase in the volume of complaints received during January Complaint data is currently being analysed to confirm issues and trends. BCF site also recorded an increase in complaints during January which has initiated a step change at Trust level. The quarterly CLIPs report will be discussed at April CQRG. Enfield CCG Feb-16 Jan-16 Average YTD Response % Response % Response Rate % Recommend Rate Recommend Rate Recommend A&E FFT (BGH) 48% 77% 43% 76% 45% 84% Birth FFT (BGH) 23% 98% 38% 98% 16% 97% Inpatients FFT (BGH/CFH) 35% 88% 41% 88% 33% 89% Outpatients FFT (RFL Trust) 0.9% 93% 1.3% 93% 0.5% 88% 41 NMUH Response Rate Feb-16 % Recommend Response Rate Jan-16 % Recommend Response Rate Average YTD % Recommend A&E FFT 25% 46% 19% 52% 12% 73% Birth FFT 39% 90% 27% 96% 38% 90% Inpatients FFT 28% 95% 23% 96% 28% 94% Outpatients FFT 2.3% 67% 2.1% 79% 2.4% 71% Positive A&E FFT recommendations continued to fall In February and places the Trust the lowest of the 20 London ED providers. Response rate improved but remained below London average. A separate patient experience survey, focusing on patients experiencing long waits, was initiated in A&E and fed back to February CQRG. It was noted that feedback received via the patient interviews in the Emergency Department suggested that patients feel that they are being cared for and listened to, but acknowledged that updating patients on what was due to happen next for them required improvement. It was also reported that noise is an issue for some patients; this can be addressed but not eliminated due to the volume of attendees, particularly at night. Other key actions taken by the Trust to improve all FFT indicators include; Outpatient department patient experience group has been developed and a patient experience strategy has been agreed, learning from recurring complaint themes is in use by the clinical business units, and, the sharing of patient stories through the patient experience group to highlight areas of good practice and share learning.

42 Friends & Family Test (FFT) BEH Mental Health Trust During February 2016 the FFT response rate at BEHMHT rose slightly to 6.6%. Of those responding across all services, 79% would recommend; for Secondary Care community services 81% of respondents would recommend; forensic services 68% of respondents would recommend. Three services in February did not return data. CQC s visit report was published in March 2016 the Trust was awarded good in 10 of the services visited for the caring domain and outstanding for Forensic Services. However, the overall organisational score was requiring improvement. A quality summit will take place on 27 April BEH has started reporting on the MH safety thermometer to CQRG and a formal report covering Q1 will be considered at the May CQRG. BEHMHT FFT: Percentage recommended by Service Category Jan 15-Feb 16 Service Category Provided Total Responses % Recommended Specialist Services % Acute Services % CAMHS % Secondary Care Community Services % Secure & Forensic Services % Mental Health Other % 42 Enfield CCG

43 Serious Incidents (SI) - NMUH The Trust reported 11 serious incidents during February 6 were recorded as treatment delays; 2 diagnostic category; 2 alleged abuse. At the end of February 2016 there were 2 overdue SI submissions. 1 never event was reported in February this was a medication incident but not related to an Enfield resident. Two Never Events have now been reported so far in 2015/16. A meeting took place in early February 2016 to review SIs by theme. CQRG will receive and review the findings. 43 Enfield CCG

44 Serious Incidents (SI) - RFL RFL reported 8 serious incidents across the Trust in February There are currently 13 reports are overdue; the Trust anticipate closing these by end of April The Trust s thematic review identified SI themes of pressure ulcers; falls; inability to identify deteriorating patient; unsafe transfer of patients. The Trust has undertaken an in-depth review of never events, including looking to other Trusts for learning on best practice in surgical procedures. April CQRG has been extended to allow further scrutiny of never events. The Trust has introduced a patient safety programme. Priority actions are diabetes and safer surgery. CQRG has received a report on improvements made in diabetes care. Enfield CCG 44

45 Serious Incidents (SI) - BEHMHT BEHMHT reported 3 Serious Incidents in February 2016, all in Mental Health, and relating to 1 apparent self harm; 1 information governance breach; and 1 fall. No never events have been reported in 2015/ Enfield CCG

46 Mixed Sex Accommodation (MSA) Other Measures Enfield CCG incurred 2 instances of Mixed Sex Accommodation (MSA) breaches in February 2016 both at RFL (Barnet site). Year to date performance is 28 breaches against a zero threshold. All patients are informed of the breach, nursed in side rooms where possible and privacy and dignity maintained as much as possible with screens. No complaints relating to mixed sex accommodation have been received to date. MSA breaches at RFL are subject to a detailed exception report and remain on the agenda for Clinical Quality Review Group meetings through update reports on breaches incurred and as an indicator for patient experience. UCLH Trust also report that their breaches take place in the ITU and occur when patients are fit to be transferred but no bed is available. Each patient that experiences an MSA breach has a discussion with the senior nurse of the relevant unit to ensure services remain fully aware of the circumstances and lessons are learnt where possible. MSA breaches at RFL Trust are predominantly at the Barnet site and are confined to patients in the Intensive Care or Recovery Units. Breaches result from the non-availability of general and acute ward beds. The inability to find suitable beds for patients is reported to be due to system wide demand and capacity issues. The Trust report that the SRG is working to address these breaches. RFL Chief Operating Officer is leading on a programme of work to improve hospital flow throughout all Trust sites and is anticipated to46 reduce the number of breaches. Enfield CCG Daily site management meetings take place, in which capacity and demand is discussed together with the ITU discharges and staffing overall. Similar work on managing patient flow to reduce delayed transfers is underway. Further assurance continues to be sought through monthly CQRG meetings. No complaints have been received about mixed sex breaches to date.

47 Appendix 1 - Enfield CCG Scorecard Enfield CCG 2015/16 Scorecard Q1 Q2 Q3 Q4 2015/16 Indicator Type Target/ Threshold 2014/15 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD RTT Incomplete Pathways (Excl. RFL) 92% 92.2% 95.4% 95.4% 95.2% 94.9% 94.8% 94.0% 93.3% 94.2% 94.6% 94.3% 94.8% 94.7% RTT Diagnostics RTT Trajectory to CCG compliance 90.5% 90.7% 91.0% 91.1% 91.3% 91.5% 91.3% RTT Incomplete Pathways (incl. RFL) 92% % 90.3% 90.7% 90.4% 89.8% 90.2% 90.0% 89.6% 89.8% 90.7% 91.3% 90.5% RTT 52+ week waiters (incl. RFL) Diagnostics - 6+ week waiters Trajectory 2.2% 2.1% 2.0% 1.9% 1.7% 1.5% 1.3% 1.1% 1.0% 1.0% 1.0% 1.0% 1.0% Diagnostics - 6+ week waiters 1% 1.5% 3.5% 4.2% 4.8% 3.9% 4.3% 3.4% 3.4% 4.4% 5.3% 5.8% 3.5% 4.2% A&E A&E 4 Hour Waits 95% 94.4% 95.0% 94.5% 95.3% 95.4% 93.3% 88.5% 87.8% 80.2% 75.9% 71.1% 72.0% 86.3% DTOCs (days) Delayed Transfers of Care - Acute Delayed Transfers of Care - Non-Acute Cancer - 2 week 2 week wait 93% 94.4% 94.8% 93.8% 95.4% 90.9% 92.7% 94.2% 2 week wait breast symptomatic 93% 93.9% 96.6% 93.6% 95.3% 89.7% 92.3% 94.5% 31 day 1st definitive treatment 96% 98.9% 94.3% 96.4% 99.0% 96.5% 97.9% 96.8% Cancer - 31 day 31 day 1st subsequent treatment - surg. 94% 97.5% 97.8% 100.0% 96.9% 95.0% 100.0% 98.1% 31 day 1st subsequent treatment - chemo 98% 99.7% 99.0% 100.0% 100.0% 100.0% 96.6% 99.5% 31 day 1st subsequent treatment - radio 94% 99.3% 98.8% 94.9% 100.0% 100.0% 100.0% 98.1% 62 day standard Trajectory 75.0% 80.6% 85.1% 85.7% 85.7% Cancer - 62 day 62 day standard 85% 78.8% 65.9% 64.4% 70.2% 63.6% 76.0% 67.8% 62 day standard - screening 90% 96.2% 92.6% 93.3% 96.4% 100.0% 40.0% 91.0% 62 day standard - upgrade No Target 92.1% 91.7% 90.6% 92.0% 100.0% 93.3% 92.3% Mixed Sex Mixed Sex Accommodation Breaches HCAI LAS (Enfield) LAS (London wide) MRSA Reported Cases (CCG Assigned) * * 1** 0 0 1** C.Difficile Trajectory (Annual) C.Difficile Reported Cases Cat A (RED1): Response within 8 Min 75% 66.7% 66.7% 65.0% 67.3% 63.5% 69.7% 70.0% 62.0% 75.0% 68.4% 50.0% 66.0% Cat A (RED2): Response within 8 Min 75% 60.8% 61.5% 62.4% 59.1% 58.8% 57.9% 62.3% 55.1% 58.0% 53.8% 45.9% 58.2% Cat A: Response within 19 Min 95% 94.1% 93.2% 93.8% 91.7% 91.5% 88.8% 91.8% 90.4% 90.4% 89.7% 86.7% 91.5% Cat A (RED1): Response within 8 Min 75% 67.2% 69.5% 67.1% 66.6% 67.1% 65.8% 62.2% 70.1% 67.8% 72.8% 66.8% 64.7% 68.5% Cat A (RED2): Response within 8 Min 75% 59.7% 64.7% 66.5% 65.2% 66.1% 65.0% 62.1% 64.8% 63.8% 65.9% 60.4% 56.3% 64.3% Cat A: Response within 19 Min 95% 92.0% 94.3% 94.6% 93.4% 93.7% 93.2% 92.2% 92.9% 92.8% 93.3% 91.7% 91.4% 93.6% CPA Follow-ups 95% 97.5% 99.4% 96.4% 100.0% 98.8% IAPT Access Trajectory 15% (Annual) 3.10% 3.75% 4.00% 4.15% 15.00% IAPT Access Trajectory - Revised Nov %(Annual) 1.30% 1.30% 1.40% 1.50% 1.50% 14.30% IAPT Access Actual 15% (Annual) 10.0% 3.19% 3.10% 1.30% 2.03% 1.30% 1.60% 1.40% 1.5% 15.40% IAPT Recovery Rates Trajectory 50% 50.0% 50.0% 50.0% 50.0% 50.0% Mental Health IAPT Recovery Rates Actual 50% 44% (Q4) 48.5% 51.1% 46.6% 47.5% 47.8% 51.13% - 6 Weeks IAPT Waiting Times 75% 89.4% 89.4% 85.5% 85.3% 87.1% 82.0% 89.7% 84.7% 87.2% 83.4% 89.7% 93.02% c. 87.2% 18 Weeks IAPT Waiting Times 95% 97.0% 99.0% 97.7% 99.4% 98.6% 98.2% 98.4% 99.2% 97.3% 98.8% 99.4% 97.67% c. 98.4% Dementia Diagnosis Rate Trajectory 60.8% 61.4% 61.9% 62.4% 63.0% 63.5% 64.0% 64.6% 65.1% 65.6% 66.2% 66.7% 66.7% Dementia Diagnosis Rate 67% 59.7% N/A N/A 68.6% 68.6% 67.3% 67.8% 67.6% 68.0% 67.6% 67.9% 67.2% 67.5% 67.5% Psychosis (EIP) - 2 Week Wait 50% 67% (Q4) 100% 70% 100% 63.0% 40.0% 63.0% 50.0% 65.0% 60.0% 14.0% 40.0% N/A NB: RFL resumed reporting RTT performance at BCF sites as of July 2015, backdated to May Data previous 47 to these months will exclude performance at RFL Trust. * MRSA cases in June and November 2015 were provisionally assigned to the CCG but were reassigned to 'Third Party' following arbitration ** denotes MRSA that has been CCG assigned but that is still under investigation. Enfield CCG

48 Appendix 3 - North Middlesex University Hosp. Scorecard North Middlesex 2015/16 Scorecard Q1 Q2 Q3 Q4 2015/16 Indicator Type Target/ Threshold 2014/15 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD RTT Diagnostics A&E RTT Incomplete Pathways 92% 92.9% 96.5% 97.2% 96.1% 96.1% 96.3% 95.8% 95.3% 95.7% 96.3% 96.7% 96.2% 96.3% RTT 52+ week waiters Diagnostics - 6+ week waiters Trajectory 8.9% 6.3% 3.1% 1.8% 0.6% - Diagnostics - 6+ week waiters 1% 0.6% 0.7% 1.0% 3.1% 1.7% 3.1% 3.4% 5.0% 7.6% 10.1% 10.8% 7.4% 4.9% A&E 4 Hour Waits 95% 93.6% 94.4% 93.9% 94.7% 95.0% 92.4% 86.7% 86.1% 77.3% 71.9% 66.4% 67.2% 84.3% A&E 12 Hour Waits A&E attendance to emergency admission 18.9% 19.2% 20.9% 20.6% 21.1% 21.0% 22.5% 20.6% 21.1% 21.8% 21.2% - DTOCs Delayed Transfers of Care (days) - Trust level Cancer - 2 week 2 week wait 93% 94.5% 93.2% 93.2% 96.4% 94.1% 94.4% 94.3% 2 week wait breast symptomatic 93% 94.3% 93.2% 91.4% 97.2% 93.4% 95.3% 94.0% 31 day 1st definitive treatment 96% 99.3% 97.3% 99.6% 100.0% 98.9% 100.0% 99.3% Cancer - 31 day 31 day 1st subsequent treatment - surg. 94% 100.0% 87.5% 100.0% 100.0% 100.0% % 31 day 1st subsequent treatment - chemo 98% 100.0% 98.2% 100.0% 100.0% 100.0% 100.0% 99.1% 31 day 1st subsequent treatment - radio 94% 99.6% 96.4% 96.8% 99.4% 100.0% 100.0% 98.1% 62 day standard 85% 90.1% 76.0% 81.3% 85.4% 86.2% 78.9% 81.8% Cancer - 62 day 62 day standard - screening 90% 100.0% 93.1% 95.0% 100.0% 100.0% 100.0% 90.1% 62 day standard - upgrade No Target 96.0% 88.8% 98.3% 94.8% 100.0% 100.0% 95.4% Mixed Sex Mixed Sex Accommodation Breaches Cancelled Ops for non-clinical reasons rebooked >28 days Cancelled Ops Urgent operation cancelled for the 2nd time HCAI Ambulance Handover MRSA Reported Cases (Trust assigned) C.Difficile Trajectory 34 (Annual, Trust 46 C.Difficile Reported Cases apportioned) Handover time over 30min of arrival Handover time over 60min of arrival % of Data recorded electronically 90% 90% 87% 86% 88% 88% 87% 85% 86% 85% 86.0% 85.0% 84.4% 86% VTE VTE Risk Assessed Admissions 95% 95.9% 96.4% 97.0% 96.6% 96.7% 48 Enfield CCG

49 Appendix 4 - Royal Free London Hosp. Scorecard Royal Free Hospital (inc BCF) 2015/16 Scorecard Q1 Q2 Q3 Q4 2015/16 Indicator Type Target/ Threshold 2014/15 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD RTT Trajectory to compliance 88.3% 88.8% 89.3% 89.6% 90.0% 90.4% - RTT Diagnostics A&E RTT Incomplete Pathways 92% 92.2% 92.3% 88.1% 88.3% 87.8% 87.7% 88.7% 89.5% 87.5% 86.7% 87.2% 88.5% 88.1% RTT 52+ week waiters Diagnostics - 6+ week waiters Trajectory 3.28% 1.64% 0.07% 1.0% 1.0% - Diagnostics - 6+ week waiters 1% 3.0% 6.4% 7.0% 7.6% 6.8% 7.3% 5.1% 3.9% 4.2% 3.4% 3.6% 1.2% 5.1% A&E 4 Hour Waits 95% 95.1% 96.7% 97.1% 97.5% 95.9% 96.2% 95.4% 95.5% 92.7% 92.1% 85.0% 88.1% 94.0% A&E 12 Hour Waits A&E attendance to emergency admission 19.2% 18.5% 18.6% 25.5% 26.0% 26.0% 27.2% 24.0% 24.6% 23.3% 16.9% - DTOCs Delayed Transfers of Care (days) - Trust level Cancer - 2 week 2 week wait 93% 95.6% 95.0% 94.7% 96.2% 92.0% 93.1% 94.8% 2 week wait breast symptomatic 93% 95.2% 98.7% 95.3% 96.4% 86.5% 88.2% 95.3% 31 day 1st definitive treatment 96% 98.8% 99.5% 98.9% 99.2% 96.0% 99.5% 98.9% Cancer - 31 day 31 day 1st subsequent treatment - surg. 94% 98.8% 98.2% 100.0% 100.0% 97.1% 100.0% 99.2% 31 day 1st subsequent treatment - chemo 98% 100.0% 100% 100.0% 100.0% 100.0% 100.0% 100% 31 day 1st subsequent treatment - radio 94% 99.7% 100% 100.0% 100.0% 98.0% 100.0% 99.6% 62 day standard 85% 79.1% 76.4% 69.5% 73.6% 68.3% 67.9% 72.2% Cancer - 62 day 62 day standard - screening 90% 91.7% 90.5% 94.8% 93.0% 85.7% 74.4% 90.1% 62 day standard - upgrade No Target 88.8% 97.3% 79.6% 84.9% 92.0% 89.7% 93.0% Mixed Sex Mixed Sex Accommodation Breaches Cancelled Ops for non-clinical reasons rebooked >28 days Cancelled Ops Urgent operation cancelled for the 2nd time HCAI Ambulance Handover MRSA Reported Cases (Trust assigned) C.Difficile Trajectory 66 (Annual, Trust 46 C.Difficile Reported Cases apportioned) Handover time over 30min of arrival Handover time over 60min of arrival % of Data recorded electronically 90% 92% 91% 90% 91% 91% 91% 91% 92% 90% 92% 89% 91% 91% VTE VTE Risk Assessed Admissions 95% 96.8% 97.0% 96.3% 97.1% 96.8% 49 Enfield CCG

50 Appendix 5 BMI The Cavell Hospital Dashboard Quality Dashboard Summary APPT CM YTD NT451 CCG Name: NHS ENFIELD CCG OP FALSE CCG: 07X DC Provider: North London IP Month: February 2016 FU Category Enfield CCG CCG /SITE Level Measure ID Measure Units Measure in Contract Targets Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Wait Times CCG E.B.1 RTT 18 wks Performance - Admitted % Y No Data Wait Times CCG BMI-01 RTT 18 wks Performance Denominator - Admitted Pathways N No Data Wait Times CCG BMI-02 RTT 18 wks Performance Numerator - Admitted Pathways N No Data Wait Times CCG E.B.2 RTT 18 wks Performance - Non Admitted % Y No Data Wait Times CCG BMI-03 RTT 18 wks Performance Denominator - Non Admitted Pathways N No Data Wait Times CCG BMI-04 RTT 18 wks Performance Numerator - Non Admitted Pathways N No Data Wait Times CCG E.B.3 RTT 18 wks Performance - Incomplete % Y No Data Wait Times CCG BMI-03 RTT 18 wks Performance Denominator - Incomplete Pathways N No Data Wait Times CCG BMI-04 RTT 18 wks Performance Numerator - Incomplete Pathways N No Data Wait Times CCG E.B.S.4 Zero Tolerance RTT Waits Over 52 Weeks Cases Y No Data Wait Times CCG BMI-05 Diagnostic > 6 Week Wait Cases Y No Data Clinical SITE E.A.S.4 Zero tolerance to MRSA Cases Y No Data Clinical CCG BMI-06 MSSA Cases Y No Data Clinical CCG E.A.S.5 C.Diff Cases Y No Data Clinical CCG BMI-07 Re-admissions within 30 Days Cases Y No Data Clinical CCG E.B.S.2 Number of Non-Clinical Cancellations on Day of Admission or After Cases Y No Data Clinical CCG BMI-08 No of Falls Cases Y No Data Clinical CCG BMI-09 Mortality Cases Y No Data Clinical CCG BMI-10 Total Incidents Cases N No Data Clinical CCG BMI-11 Total Serious Incidents Cases Y No Data Clinical CCG BMI-12 Total Never Events Cases Y No Data Clinical CCG BMI-13 Breaches of Duty of Candour Cases Y No Data Clinical CCG E.B.S.1 Sleeping Accommodation Breach Cases Y No Data Clinical CCG BMI-14 Publication of Formulary Published Y Y Y Y Y Y Y Y Y Y Y Y Y No Data Patient Interaction SITE BMI-15 F&F Inpatient - Participation % Y No Data Patient Interaction SITE BMI-16 F&F Inpatient - Recommend % Y No Data Patient Interaction SITE BMI-17 F&F Inpatient - Not Recommend % Y No Data Patient Interaction SITE BMI-21 F&F Outpatient - Participation % N No Data Patient Interaction SITE BMI-22 F&F Outpatient - Recommend % Y No Data Patient Interaction SITE BMI-23 F&F Outpatient - Not Recommend % Y No Data Clinical SITE BMI-24 VTE Assessment Compliance % Y No Data Patient Interaction SITE BMI-25 Proms Participation* % Y No Data Patient Interaction CCG BMI-26 Total Complaints Cases Y No Data Patient Interaction CCG BMI-27 Complaints acknowledged to in 48hrs of receipt as a % of Total Complaints % Y No Data Patient Interaction CCG BMI-28 Complaints - full response within 20 days as a % of Total Complaints % Y No Data Patient Interaction SITE BMI-29 Patient Survey Satisfaction % Y No Data Patient Interaction SITE BMI-30 Patient Survey Participation % Y No Data Data Quality CCG BMI-31 Percentage of SUS Change % N No Data Data Quality SITE BMI-32 CDS Data Quality Outpatient % Y No Data Data Quality SITE BMI-33 CDS Data Quality Inpatient % N No Data Data Quality SITE BMI-34 CDS Data Quality - NHS Number % Y No Data Data Quality SITE BMI-35 CDS Data Quality - Ethnicity Category % Y No Data Performance CCG BMI-36 Follow-Up to New Outpatient Ratio (Total) Ratio Y No Data Performance CCG BMI-37 Outpatient DNA Rate % Y No Data Performance CCG BMI-38 Follow-Up DNA Rate % Y No Data Performance CCG BMI-39 Provider Cancelled FU as % of total FU % Y No Data Performance CCG BMI-40 Provider Cancelled OP as % of total OP % Y No Data Performance CCG BMI-41 Referral to OutPatient Ratio (Total) Ratio Y No Data Performance CCG BMI-42 New Outpatient to Surgery Ratio (Total) Ratio Y No Data Performance CCG BMI-43 Planned Procedures Not Carried Out Instance 50 N No Data Performance SITE BMI-44 Sufficient Appointment Slot Issues % Y No Data

51 Appendix 6 BMI The Kings Oak Hospital Dashboard Quality Dashboard Summary APPT CM YTD NT421 CCG Name: NHS ENFIELD CCG OP FALSE CCG: 07X DC Provider: Kings Oak IP Month: February 2016 FU Category Enfield CCG CCG /SITE Level Measure ID Measure Units Measure in Contract Targets Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Wait Times CCG E.B.1 RTT 18 wks Performance - Admitted % Y No Data Wait Times CCG BMI-01 RTT 18 wks Performance Denominator - Admitted Pathways N No Data Wait Times CCG BMI-02 RTT 18 wks Performance Numerator - Admitted Pathways N No Data Wait Times CCG E.B.2 RTT 18 wks Performance - Non Admitted % Y No Data Wait Times CCG BMI-03 RTT 18 wks Performance Denominator - Non Admitted Pathways N No Data Wait Times CCG BMI-04 RTT 18 wks Performance Numerator - Non Admitted Pathways N No Data Wait Times CCG E.B.3 RTT 18 wks Performance - Incomplete % Y No Data Wait Times CCG BMI-03 RTT 18 wks Performance Denominator - Incomplete Pathways N No Data Wait Times CCG BMI-04 RTT 18 wks Performance Numerator - Incomplete Pathways N No Data Wait Times CCG E.B.S.4 Zero Tolerance RTT Waits Over 52 Weeks Cases Y No Data Wait Times CCG BMI-05 Diagnostic > 6 Week Wait Cases Y No Data Clinical SITE E.A.S.4 Zero tolerance to MRSA Cases Y No Data Clinical CCG BMI-06 MSSA Cases Y No Data Clinical CCG E.A.S.5 C.Diff Cases Y No Data Clinical CCG BMI-07 Re-admissions within 30 Days Cases Y No Data Clinical CCG E.B.S.2 Number of Non-Clinical Cancellations on Day of Admission or After Cases Y No Data Clinical CCG BMI-08 No of Falls Cases Y No Data Clinical CCG BMI-09 Mortality Cases Y No Data Clinical CCG BMI-10 Total Incidents Cases N No Data Clinical CCG BMI-11 Total Serious Incidents Cases Y No Data Clinical CCG BMI-12 Total Never Events Cases Y No Data Clinical CCG BMI-13 Breaches of Duty of Candour Cases Y No Data Clinical CCG E.B.S.1 Sleeping Accommodation Breach Cases Y No Data Clinical CCG BMI-14 Publication of Formulary Published Y Y Y Y Y Y Y Y Y Y Y Y Y No Data Patient Interaction SITE BMI-15 F&F Inpatient - Participation % Y No Data Patient Interaction SITE BMI-16 F&F Inpatient - Recommend % Y No Data Patient Interaction SITE BMI-17 F&F Inpatient - Not Recommend % Y No Data Patient Interaction SITE BMI-21 F&F Outpatient - Participation % N No Data Patient Interaction SITE BMI-22 F&F Outpatient - Recommend % Y No Data Patient Interaction SITE BMI-23 F&F Outpatient - Not Recommend % Y No Data Clinical SITE BMI-24 VTE Assessment Compliance % Y No Data Patient Interaction SITE BMI-25 Proms Participation* % Y No Data Patient Interaction CCG BMI-26 Total Complaints Cases Y No Data Patient Interaction CCG BMI-27 Complaints acknowledged to in 48hrs of receipt as a % of Total Complaints % Y No Data Patient Interaction CCG BMI-28 Complaints - full response within 20 days as a % of Total Complaints % Y No Data Patient Interaction SITE BMI-29 Patient Survey Satisfaction % Y No Data Patient Interaction SITE BMI-30 Patient Survey Participation % Y No Data Data Quality CCG BMI-31 Percentage of SUS Change % N No Data Data Quality SITE BMI-32 CDS Data Quality Outpatient % Y No Data Data Quality SITE BMI-33 CDS Data Quality Inpatient % N No Data Data Quality SITE BMI-34 CDS Data Quality - NHS Number % Y No Data Data Quality SITE BMI-35 CDS Data Quality - Ethnicity Category % Y No Data Performance CCG BMI-36 Follow-Up to New Outpatient Ratio (Total) Ratio Y No Data Performance CCG BMI-37 Outpatient DNA Rate % Y No Data Performance CCG BMI-38 Follow-Up DNA Rate % Y No Data Performance CCG BMI-39 Provider Cancelled FU as % of total FU % Y No Data Performance CCG BMI-40 Provider Cancelled OP as % of total OP % Y No Data Performance CCG BMI-41 Referral to OutPatient Ratio (Total) Ratio Y No Data Performance CCG BMI-42 New Outpatient to Surgery Ratio (Total) Ratio Y No Data Performance CCG BMI-43 Planned Procedures Not Carried Out Instance 51 N No Data Performance SITE BMI-44 Sufficient Appointment Slot Issues % Y No Data

52 Appendix 7 - MRSA Rates London Providers NB. Trajectories for are Zero for MRSA. This data has been extracted from un-validated weekly HCAI Data. This is only available to NHS and certain 52other eligible bodies for HCAI reporting and monitoring purposes. Please prevent inappropriate use by treating this information as restricted; refrain from passing information on to others who have not been given prior access; and use it only for the purposes for which it has been provided. Enfield CCG

53 Appendix 8 - C Difficile Rates London Providers YTD Position Note The 2015/16 weekly C.diff. numbers are aggregated at provider level but not attributed to the Trusts, therefore to avoid giving an inaccurate position we have omitted any comparison to plan and associated RAG rating. This data has been extracted from un-validated weekly HCAI Data. This is only available to NHS and certain other eligible bodies for HCAI reporting and monitoring purposes. Please prevent inappropriate use by 53 treating this information as restricted; refrain from passing information on to others who have not been given prior access; and use it only for the purposes for which it has been provided. Enfield CCG

54 Appendix 9 - NHS 111 Quality Dashboard The table below shows how LCW are performing against the quality and performance indicators by which they are measured. Where there is a figure but the background is greyed out this means that, whilst LCW report against them, these particular indicators do not form part of the reporting requirements. LCW continue to consistently meet their NQRs and KPIs. The two NQRs that are consistently red have never been achieved by any London 111 provider and will be reviewed when the next contract is set. This status has been impacted by the decision to re-triage Green Ambulance outcomes. Quality and Performance Indicators KPI Type Target Performance Band Qrt 1 Qrt 2 Qrt 3 Qrt 4 A B C Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 INWL NCL INWL NCL INWL NCL INWL NCL INWL INWL INWL NCL INWL NCL INWL NCL INWL NCL INWL NCL INWL NCL INWL NCL Engaged calls Performance <0.1% 0.1% 0.3% 0.5% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Abandoned calls Performance <5% <5% 6% 7% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Answer Time Performance 95% 95% 92% 90% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 0% 0% Call waiting time Performance 95% 95% 92% 90% 97% 97% 97% 97% 97% 97% 97% 96% 97% 96% 95% 95% 96% 95% 96% 96% 96% 96% 95% 94% 95% 94% 0% 0% Life threatening referrals Quality 100% 100% 100% <100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Meeting individuals needs Quality 100% 100% 98% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Safeguarding Quality 100% 100% 100% <100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Triage rate Quality TBA 93% 80% 86% 82% 88% 81% 94% 80% 100% 81% 87% 84% 82% 88% 86% 89% 85% 89% 89% 87% 85% 86% 0% 0% Transfer to 999 Performance TBA 9% 12% 8% 11% 9% 12% 11% 13% 12% 14% 11% 13% 11% 13% 11% 13% 11% 13% 9% 11% 9% 11% 0% 0% Attend Accident & Emergency Department Performance TBA 7% 9% 7% 9% 8% 10% 9% 10% 9% 10% 7% 10% 7% 10% 8% 10% 8% 9% 8% 9% 8% 10% 0% 0% Referred to Primary Care and other dispositions Performance TBA 51% 61% 50% 61% 48% 59% 54% 58% 56% 58% 48% 58% 45% 57% 49% 57% 51% 59% 52% 59% 53% 59% 0% 0% Warm Transfers Performance 98% 98% 96% 94% 54% 56% 62% 61% 67% 67% 62% 61% 67% 65% 64% 64% 65% 62% 56% 57% 63% 59% 53% 52% 49% 47% 0% 0% Time taken for call back Performance 100% 100% 100% 100% 46% 46% 57% 52% 52% 51% 46% 43% 49% 47% 51% 44% 41% 41% 44% 40% 45% 45% 47% 42% 42% 38% 0% 0% Notifications Quality 100% 100% 100% <100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Patient Education Quality 100% 100% 100% <100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 54 Enfield CCG

55 Appendix 10(a) - NHS 111 NCL Performance Referral rates and triage rates to 999 ambulance dispatch are monitored through Clinical Quality Review Groups both across NCL and regionally across London. Notes: 1. The lower monthly figures for Total Number of Calls Received, prior to March 2015, are due to a technical problem. 2. The indicator Percentage of. calls directed to 999 for Ambulance Dispatch" is now based on triaged calls rather than total calls received. 55 Enfield CCG

56 Appendix 10(b) - NHS 111 NEL Performance 56 Enfield CCG

57 Agenda Item: 6.2 Appendix: E MEETING: NHS Enfield Clinical Commissioning Group Governing Body DATE: 11 May 2016 TITLE: Finance Committee Report LEAD GOVERNING BODY Dr Alpesh Patel MEMBER: AUTHOR: Arati Das, Deputy Chief Financial Officer CONTACT DETAILS: SUMMARY: The purpose of this summary is to outline the key matters discussed by the Finance Committee at its meeting on 20th April The Committee noted that the CCG had successfully met its 2015/16 control deficit of 33.4m and delivered 12.8m of QIPP savings against a target of 12.5m. The Committee was updated on the 5 Year Recovery Plan (2015/ /21) and the revised control total that has been directed by NHS England. The Chair acknowledged the challenges ahead for the CCG and the difficult decisions that would be need to be made in order to address the additional 7.2m of savings over and above the 9.9m in the original plan. The Committee was alerted to additional identified risks going forward. (These are set out under Risks and Mitigations of the M12 Finance and Contracts report). Key highlights were: The potential non viability of the NCL Transformation Fund and risk share arrangements leaving the CCG with a cost pressure of 3.3m Inclusion of additional 7.2m of QIPP under the direction of NHS England. The Better Care Fund was discussed with a further decision to be taken in conjunction with London Borough of Enfield and the Health & Wellbeing Board on the affordability of schemes and sharing of funds given the CCG s revised financial position. SUPPORTING PAPERS: Finance & Contracts Report Month 12 RECOMMENDED ACTION: The Governing Body are asked to note the report and additional risks. 57

58 Objective(s) / Plans supported by this paper: To ensure a robust system of Financial Governance is in place. Patient & Public Involvement (PPI): N/A Equality Impact Analysis: N/A. Risks: The Governing will note the additional risks referred to in the paper. Resource Implications: There are no specific resource implications. Audit Trail: The Finance Committee is accountable to the Governing Body. Next Steps: None 58

59 Agenda Item: 6.3 (a) Appendix: F MEETING: NHS Enfield Clinical Commissioning Group Governing Body DATE: 11 May 2016 TITLE: Financial Recovery Plan Update LEAD GOVERNING BODY Rob Whiteford, Chief Financial Officer MEMBER: AUTHOR: Arati Das, Deputy Chief Financial Officer CONTACT DETAILS: SUMMARY: Our revised submission for 2016/17 is a 41.1m cumulative deficit ( 7.7m in year deficit) compared to the previous submission of 2nd March 2016 which had a planned deficit of 48.1 cumulative ( 14.9 in year). Further to instructions from NHSE London Region received on the 13th April, the plan now incorporates an additional 7.2m of savings which are not yet identified. These instructions were to: 1. Produce a Recovery Plan by the end of April 2016 which ensures the CCG is in recurrent financial balance by the end of 2016/ To make additional savings of 2% of the Resource Limit in 2016/17 3. To show a maximum cumulative deficit of 41.1m. Governing Body members had significant misgivings in approving this plan. However, as we are an organisation under direction we were obliged to submit our plan as directed by NHSE. The CCG and NHSE London Region understand that this element of the plan is at extremely high risk of non-delivery. The CCG will develop options to address the required additional savings. These will be discussed with NHSE to assess impact and consequence. SUPPORTING PAPERS: 1. Letter from NHSE (Appendix 1) 2. 1 st Response from Chief Finance Officer (Appendix 2) 3. 2 nd Response from Chief Finance Officer (Appendix 3) RECOMMENDED ACTION: The Governing Body is asked to note the additional risks in respect of the revised plan. Objective(s) / Plans supported by this paper: To ensure enhance oversight of the CCG Financial Recovery Plan and QIPP. Patient & Public Involvement (PPI): N/A Equality Impact Analysis: N/A. Risks: The Governing will note the additional risks referred to in the paper. Resource Implications: The time of the Recovery Director in attending Governing Body meetings. Audit Trail: None Next Steps: implementation of the decision if approved. 59

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61 Appendix 1 VIA ONLY London Regional Office Southside 105 Victoria Street London, SW1E 6QT Paul Jenkins Chief Officer, Enfield CCG 13 th April 2016 Dear Paul, 2016/17 Plan Submission 18 th April 2016 I am writing following the recent 2016/17 stocktake meetings to confirm the next steps and action that is required regarding the financial position of the CCG s Plan for 2016/17. In December 2015, the Board approved 5 year revenue allocations for the spending review period and these allocations show that the CCG will receive lower financial growth for the next three years compared to 2016/7 and the final year 2020/21. During the last two years, London CCGs have benefitted overall from growth uplifts and in 2016/17 no London CCG is now lower than 5% below capitation. It is essential as we enter the middle years of the spending Review that your CCG s finances are put on a sustainable basis. At the stocktake meeting we discussed the CCG s 2016/17 Plan following the 2 nd March 2016 submission. The 2 nd March 2016 Plan submission shows that the CCG is planning for a cumulative deficit of 48.3m in 2016/17. The plan as submitted cannot be assured and we discussed action is now necessary to put the CCG s finances on a sustainable basis. As a result, the following action is now required: The CCG should produce a Financial Recovery Plan that ensures that the financial position is in recurrent balance by the end of this financial year and this Recovery Plan should be submitted to your DCO by the end of April Additional savings of 2% of the resource limit are required in 2016/17 on the basis that the savings plan will be delivered in full in 2017/18. On this basis, the NHS England London Region is expecting the 18 th April 2016 Plan submission to show a planned deficit of 41.1m as a maximum. In light of the above, it will be necessary to establish monthly assurance meetings to oversee performance of the 2016/17 plan and delivery of the Financial Recovery Plan and we will be in contact shortly to set up these meetings. I appreciate that this is a challenging time but it is essential that the CCG puts its finances on a sustainable basis going forward. If you wish to discuss the above further please contact your DCO or myself. Yours sincerely 61

62 David Slegg Director of Finance NHS England, London Region Cc Anne Rainsberry Simon Weldon Ceri Jacob Rob Whiteford 62

63 Appendix 2 Holbrook House Cockfosters Road Barnet EN4 0DR David Slegg Director of Finance NHS England London Region Southside 105 Victoria Street London SW1E 6QT Tel: Fax: Web: 14 th April 2016 Dear David, 2016/17 Plan Submission 18th April 2016 Thank you for your letter of the 13 th April. The CCG understands the importance of improving its financial position, and recognises the challenges faced both locally and nationally. We are not in a position to improve on our existing 2016/17 plan by the 18 th April. The CCG has implemented in full the recommendations of the 2014/15 financial governance review, which followed a 13.3m unplanned overspend on a planned deficit of 5.6m. In 2015/16 we have delivered an improved in year deficit of 14.4m, down from 18.9m in 2014/15. The 2016/17 national requirement to set aside 1% of our Resource Limit as uncommitted has added 3.8m non recurrently to our deficit. In the absence of this our plan for 2016/17 would be an annual deficit of 11.1m. This represents a 7.8m improvement on our 18.9m deficit in 2014/15, during a period where many CCGs have struggled to maintain existing run rates. In this context it is essential to establish an achievable plan from the outset. Chair: Dr Mo Abedi Chief Officer: Paul Jenkins 63

64 We do recognise the imperative to improve our position. Led by our Recovery Director our QIPP programme has delivered to plan in 2015/16. Our Governing Body met in private on the 13 th April and approved a revised 5 year recovery plan. I am meeting with your team on the 19 th April prior to sharing this more widely. In addition the Governing Body considered an extended QIPP programme involving even more challenging decisions. The nature and lead time of these is such that financial benefit would be from 2017/18. We welcome the monthly financial assurance meetings which we are certain will help us improve our positon further. The CCG are fully committed to doing so. Yours sincerely, Via Rob Whiteford Chief Finance Officer CC: Anne Rainsberry Simon Weldon Ceri Jacob 64 Page 2 of 2

65 Appendix 3 Holbrook House Cockfosters Road Barnet EN4 0DR David Slegg Director of Finance NHS England London Region Southside 105 Victoria Street London SW1E 6QT Tel: Fax: Web: 18 th April 2016 Dear David, 2016/17 Plan Submission 18th April 2016 Following our telephone conversation of the 15 th April. I have consulted with our Chairman, the Chair of the Finance Committee and the Chair of the Audit Committee. The outcome is as follows: 1) The CCG will submit a plan for a 41.1m cumulative deficit. This means an in year deficit plan of 7.7m. 2) This is achieved by adding 7.2m of presently unidentified savings to the existing savings plan. 3) This represents an in year savings target of 17.1m, 4.75% of our total allocation. The Governing Body members above have significant misgivings in approving the revised plan. However as an organisation under direction we are obliged to submit our plan as directed by NHSE. The plan is extremely high risk with regard to the 7.2m unidentified savings. We will draw up options and discuss consequence with NHSE prior to implementation. The CCG are fully committed to improving our financial position as quickly as possible. Chair: Dr Mo Abedi Chief Officer: Paul Jenkins 65

66 Yours sincerely, Via Rob Whiteford Chief Finance Officer 66 Page 2 of 2

67 Agenda Item: 6.3 (b) Appendix: Fi MEETING: NHS Enfield Clinical Commissioning Group Governing Body DATE: 11 May 2016 TITLE: Finance & Contracts Report Month 12 LEAD GOVERNING BODY Robert Whiteford, Chief Financial Officer AUTHOR: Arati Das, Deputy Chief Financial Officer CONTACT DETAILS: SUMMARY: This report updates the Governing Body on our financial performance. SUPPORTING PAPERS: No supporting papers. RECOMMENDED ACTION: Members of the Governing Body are asked to : NOTE the report. Members are encouraged to seek clarity on any areas not immediately clear, particularly on the risks and opportunities described. Objective(s) / Plans supported by this paper: Measure performance against our financial targets. Forecast our financial position accurately. Patient & Public Involvement (PPI): N/A Equality Impact Analysis: N/A. Risks: The risks in this paper are recorded on the Enfield CCG Risk Register and Board Assurance Framework where appropriate. Specific risks are referenced in the text. Resource Implications: Specific resource implications are detailed in the paper. Audit Trail: Appropriate information from the finance report is included in reports to the Executive Committee, the Audit Committee and the Governing Body. Next Steps: The report will be presented to the Governing Body. 67

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69 Finance Report- Month Year to date and forecast Table 1 sets out our financial performance for the 2015/16 financial year Table 1: Summary Financial Position Year to Date Forecast Outturn Movement in FOT m m m m m m m m m YTD Budget YTD Actual YTD Variance Annual Plan FOT Actual (Latest) FOT Variance FOT as at Month 11 FOT as at Month12 Change Allocation (361.5) (361.5) 0.0 (361.5) (361.5) 0.0 (361.5) (361.5) (0.0) Primary Care (0.2) (0.2) Prescribing Acute Care Mental Health Learning Disabilities End of Life care (0.0) (0.0) (0.0) Community Services (0.1) Continuing Care Running Cost Allowance (0.0) (0.0) Other Programme Costs (1.3) (1.3) (0.6) Reserves (11.7) (11.7) (1.6) (Surplus)/Deficit (0.0) (0.0) (0.0) In year (Surplus)/Deficit (0.0) (0.0) The month 12 cummulative position is that the CCG has met the in year planned deficit of 14.4m Acute contracts have overspent against plan by 11.8m which is reflected in an adverse 0.8m compared to the forecast outturn as at M11. The 0.8m variance is composed of a number of factors including the BCF contract having an adverse movement of 2.5m which has been offset by full utilisation of reserves of 1.6m and a gain of 0.5m in the North Middlesex University Hospital (NMUH) year end settlement. Primary Care has come within plan by 0.2m. The M11 forecast took a more prudent view than what materialised in M12. 69

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71 Finance Report- Month 12 Mental Health reflects an adverse variance of 0.6m against plan due to uncertainties associated with late billing from London Borough of Enfield. Continuing Care has overspent by 0.4m compared to plan in reflection of uncertainty caused by instability of reporting from London Borough of Enfield. Other Programme costs are underspent by 1.3m compared to plan of which half was recognised in the M11 forecast. All held reserves have now had to be fully utilised to balance the agreed postion, particularly for Acute. 2. Run Rate Table 2 shows the expenditure run rate month on month for 2015/16. Table 2: Run Rate m m m m m m m m M1-8 M9 M10 M11 M12 Final Annual Outturn Plan Variance Primary Care (0.2) Prescribing Acute Care Mental Health Learning Disabilities End of Life care (0.0) Community Services Continuing Care Running Cost Allowance (0.0) Other Programme Costs (1.3) Reserves (0.4) (11.7) Total CCG Expenditure (0.0) The run rate is provided for information only. The CCG has achieved its' control total. 71

72 3. Contract agreements All contracts are now agreed with year end deals finalised for all lead providers with the exception of BCF. Table 3 sets out the progress made on 2016/17 contracts. Table 3: Contract status Trust/Providers North Middlesex University Hospital NHS Trust Barnet, Enfield and Haringey NHS Mental Health Trust Barnet, Enfield and Haringey NHS Mental Health Trust The Whittington Hospital NHS Trust BMI Health Care University College Hospital NHS Foundation Trust Royal Free and Barnet and Chase Farm NHS Foundation Not agreed Not agreed Not agreed Not agreed Not agreed Not agreed Not agreed Update Contracts were due to be signed on 31st March. Any contract that is not signed by 25th April will automatically go into formal dispute resolution. None of the main acute contracts have been agreed yet. Operational and Finance Plans have been submitted to NHSE. 4. Contracts Table 4 shows the financial performance of our acute contracts by provider. Provider Royal Free (BCF site) Royal Free (Hampstead) Year to date M12 Forecast Outturn YTD YTD YTD Annual FOT FOT Budget Actual Var Contract Var m m m m m m UCLH NMUH BMI Other NCL Out of Sector Acute Other Acute (1.02) (1.02) Total Acute Movement in FOT FOT as at FOT as at Month 11 Month 12 Change m m m (0.52) (0.00) (0.18) (1.02) (1.07)

73 The month 12 position and forecast is based on year to date month 11 (flex) SLAM data. The Royal Free London data submission has continued to present challenges. We are using month 7 data (corrected for known errors) to inform our Forecast Outturn (FOT) for this contract. A year end settlement was reached with NMUH at 94m. This is reflected in the position above and included 1.6m of additional data challenges. Table 5: Acute Contract Performance by Point of Delivery for all acute providers Table 5 shows the financial performance of our acute contracts by POD Point of Delivery A&E/UCC Attendances Emergency Admissions Maternity & Other Admissions Planned Admissions Year to date M12 Forecast Outturn YTD YTD YTD Annual FOT FOT Budget Actual Var Contract Var m m m m m m Outpatients Drugs and Devices Critical Care Movement in FOT FOT as at FOT as at Month 11 Month 12 Change m m m (0.15) (0.17) Diagnostic Imaging (0.02) Other (3.87) (3.87) CQUIN (0.10) (0.10) Other Acute (1.02) (1.02) Total (4.51) (3.87) 0.63 (0.10) (0.10) (0.01) 0.06 (1.02) (1.07) Table 5 shows a breakdown of our costs by Point of Delivery (POD) in aggregate for our acute providers. Emergency admissions are 2.93m over plan, with 2.16m at NMUH. Planned admissions are 5.27m over plan, with 3.3m at Royal Free London - Barnet Chase Farm site. Critical Care is 3.01m over plan. This is managed in part through NCL risk share arrangements. 73

74 The FOT for Royal Free London has been adjusted to reflect the values invoiced and the risk associated with agreement of a final settlement position. Drugs and Devices are 1.27m over plan, with 0.52m at UCLH and 0.46m at NMUH. Table 6: Acute Contract Performance by POD for all acute providers Total A&E/UCC Attendances Emergency Admissions Maternity & Other Admissions Planned Admissions YTD Activity Plan YTD Activity Actual Year to date M12 YTD Activity Var YTD Budget YTD Actual YTD Var K K K K K K 146, ,094 (745) 15,182 15, ,788 26,798 3,010 43,490 46,422 2,933 20,287 21,548 1,261 26,962 29,035 2,073 32,238 35,923 3,686 36,891 42,159 5,268 Outpatients 353, ,419 2,431 39,408 40,857 1,449 Drugs and Devices 7,254 8,523 1,269 Critical Care 7,741 10,751 3,009 Diagnostic Imaging 15,030 15, Other 7,531 3,659 (3,872) CQUIN 2,529 2,424 (105) Other Acute 17,763 16,747 (1,016) Total 219, ,573 11,792 FOT Var K 81 2,933 2,073 5,268 1,449 1,269 3, (3,872) (105) (1,016) 11,792 Table 6 combines activity information with the associated finances. The level of over performance against a properly set plan is still a source of major concern for the CCG financial position. 74

75 Table 7: NMUH Contract Performance by Provider and Point of Delivery North Middlesex A&E/UCC Attendances Emergency Admissions Maternity & Other Admissions Planned Admissions Year to date M12 YTD Activity YTD Activity YTD Activity YTD Budget YTD Actual YTD Var Plan Actual Var K K K K K K 87,920 81,419 (6,500) 9,716 9,028 (687) 14,808 17,340 2,532 27,236 29,392 2,156 10,460 10, ,894 16, ,121 11, ,862 11, Outpatients 116, ,640 (498) 14,185 14, Drugs and Devices 0 1,233 1, Critical Care 3,733 4, ,289 4, Diagnostic Imaging 0 4,741 5, Other 0 2,024 (436) (2,460) CQUIN 0 2,221 2,181 (40) Total 92,400 94,128 1,728 FOT as at Month 11 FOT as at Month 12 Change m m m (907) (687) 220 2,099 2, (22) (33) (1,055) (2,460) (1,405) (25) (40) (15) 2,245 1,728 (517) North Middlesex has an overspend of 1,728k, which reflects the year end settlement reached. The over spend is predominantly in Emergency Admissions, Drugs & Devices and Critical Care. 1.6m of additional data challenges and 0.6m of fines are included in the year end settlement with NMUH. 75

76 Table 8: BCF Contract Performance by Provider and Point of Delivery Royal Free (BCF) A&E/UCC Attendances Emergency Admissions Maternity & Other Admissions Planned Admissions Year to date M12 YTD Activity YTD Activity YTD Activity YTD Budget YTD Actual YTD Var Plan Actual Var K K K K K K 43,974 47,270 3,297 3,784 4, ,818 6, ,802 9,576 (227) 6,268 7, ,787 6, ,866 13,138 2,272 10,107 13,210 3,103 Outpatients 153, ,486 (5,904) 14,075 14, Drugs and Devices 0 2,178 2, Critical Care 1,057 2,083 1,026 1,563 2,813 1,250 Diagnostic Imaging 0 8,873 9, Other 0 3,131 4,637 1,506 CQUIN 0 Total 59,301 66,420 7,119 FOT as at Month 11 FOT as at Month 12 Change m m m (227) (227) ,103 3, ,250 1, (985) 1,506 2,490 4,628 7,119 2,490 - The Barnet Chase Farm (BCF) position is based on month 7 SLAM and the invoices raised in month 12 by the provider as the data in month 11 was not considered reliable to report on. BCF has a FOT of 7,199k over spend. This reflects the risk associated with not reaching a year end settlement. 76

77 Table 9: RF Contract Performance by Provider and Point of Delivery Royal Free (Hampstead) A&E/UCC Attendances Emergency Admissions Maternity & Other Admissions Planned Admissions Year to date M12 YTD Activity YTD Activity YTD Activity YTD Budget YTD Actual YTD Var Plan Actual Var K K K K K K 1,684 2, ,503 1, ,743 2, ,326 3, Outpatients 14,584 16,923 2,339 1,839 2, Drugs and Devices Critical Care , Diagnostic Imaging (8) Other 0 1,399 1,331 (69) FOT as at Month 11 FOT as at Month 12 Change m m m (8) (8) - (69) (69) - CQUIN 0 Total 10,448 11,829 1,381 1,381 1,381 The Royal Free (Hampstead) position is based on month 7 SLAM and the invoices raised in month 12 by the provider as the data in month 11 was not considered reliable to report on. Royal Free (Hampstead) shows a FOT of 1,381k. Despite a properly set plan the over performance is across the board in all PODs. 77

78 Table 10: UCLH Contract Performance by Provider and Point of Delivery UCLH A&E/UCC Attendances Emergency Admissions Maternity & Other Admissions Planned Admissions Year to date M12 YTD Activity YTD Activity YTD Activity YTD Budget YTD Actual YTD Var Plan Actual Var K K K K K K 2,506 2, ,359 1,292 (67) ,203 1, ,155 3, ,605 4, Outpatients 23,422 27,317 3,895 3,647 4, Drugs and Devices 0 1,107 1, Critical Care (18) Diagnostic Imaging Other 0 39 (60) (99) FOT as at Month 11 FOT as at Month 12 Change m m m (87) (67) (37) (270) (100) (18) (196) (99) 98 CQUIN 0 Total 13,287 14,521 1,234 1,168 1, The contract has a FOT of 1,234K. The FOT position detirorated this month by 0.66m. There is significant over performance on Drugs & Devices due in part to robotic consumables. Outpatients is also over performing though is in part mitigated by the transfer of 0.23m for the Tier 3 Neurology. 78

79 5. GP Referrals through ERS Graph 1: GP Referrals Received by ERS 5000 Monthly GP Referrals Received by ERS * 3500 GP Referrals Received April May June July August September October November December January February March 2014/ /16 79

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81 The graph above shows the number of GP referrals on a monthly basis to the end of March March's referrals are markedly above last year s rate. To date there have been 564 referrals more than last year which represents a growth rate of less than 1.1%. Table 11: Claims Type of Claim North Barnet & Middlesex Chase UCLH Royal Free Other Total A&E 40,172 65,914 1,755 9,939 7, ,316 Drugs 769,966 1,393, , , ,160 2,953,948 Inpatient 429,555 1,131,104 43, , ,237 2,089,790 Maternity 1,293, , ,741 97, ,707 2,555,712 Misattribution 1,674, , ,077 42, ,462 2,687,877 Other 4,966,689 1,766, , , ,242 8,026,527 Outpatient 790, , ,578 89, ,208 1,469,701 Total 9,965,077 5,866, ,110 1,119,412 2,088,552 19,908,869 The table above shows the value of claims submitted to providers in 2015/16 (M1-11). These were 19.8m from M1-M11 and have increased by 3.4m in February. 5.9m of the overall 19.8m has been accepted by providers (this includes an additional 1.6m for NMUH). 50% are related to misattributions and the rest are automated queries. The above figures do not include anything for RFL & BCF challenges as a year end settlement has not yet been reached. 6. Non Acute Contracts Table 12: Care Closer to Home Community Services Care Closer to Home Community Service Routine GP referrals directed into Service Activity Qtr1 Activity Qtr2 Activity Qtr3 Activity Jan 16 YTD Value of Service Savings against Secondary Care Ophthalmology 97% 2,264 2,815 2, , ,102 ENT 78% , ,586 Dermatology 21% ,548 26,391 Gynaecology 65% 1,132 1,184 1, , ,282 Urology 46% ,408 26,599 Total 4,659 5,612 5,166 1,605 1,609, ,960 Table 12 shows the referrals, attendances and value of activity. Compared to the tariff, the highest cost savings are in the Community Ophthalmology and Gynaecology services. 81

82 7. QIPP The Month 12 QIPP achieved 12.8m against total identified plans of 12.5m. The key areas of underperformance relate to the following: PoLCE Anticipated savings were based on the outcome of an audit at Royal Free London reviewing whether the Trust had applied the PoLCE policy correctly. The audit results were that the Trust had applied the policy correctly - therefore no savings are forecast against the original 0.5m target Locality Commissioning Schemes (LCS) Outpatients - Performance earlier in the year for the Outpatients element of LCS was encouraging. However current performance suggests the QIPP will miss its target by circa 0.492m. A&E - A&E performance suggested no likely achievement in 2015/16 at an early stage. Forecast is 0 against a target of 0.332m underperformance Acute Productivity - Royal Free London and UCLH have guaranteed minimum productivity savings included in contracts and are therefore delivered. However the NMUH value is based on actual performance and as a result we are forecasting savings 0.493m below target. Non Elective Audit - Audit Completed on 24/2/16. 4% of adult admissions at BCF were avoidable and 5% were possibly avoidable. The final QIPP resulting from the audit was expected to be confirmed as part of a year end deal with Royal Free London. At present the lead CCG and the provider have been unable to reach a deal which suits all parties. As a result Enfield CCG have reported 0 achievement against this QIPP. The key area of over performance relates to: Challenges - As noted in Month 11s report, actual challenge savings were expected to exceed target once year end deals had been discussed and activity reconciliations were completed. In Month 12 the challenges QIPP achievement increased to 5.66m leading to an over performance on challenges of 2.81m 8. Programme Corporate costs Programme corporate costs are showing an underspend to date of 437k mainly due to the managing of the recruitment of vacancies. These are now filled or being recruited to. Corporate running costs are in line with the budget both year to date and forecast. Estates Costs are 139k underspent due to agreement of lower void costs for 2015/16 with CHP. Talks with NHS Property Services continue. Details are shown in Appendix Running Cost Allowance Corporate running costs are within target. 82

83 Finance Report- Month Risks & Mitigations Table 13 sets out the key risks and mitigations. Table 13: Risks & Mitigations Risk Detail Mitigation Ref Unpredictability and history The CCG has planned on the basis of growth in Increased contract management resource. The CCG has already recruited a BAF Risk 69 of acute activity acute contracts informed by the IHAM model with Deputy Director of contracts who is experienced in managing PbR variations applied for ETO and DTR pricing. agreements. Data quality Failure to deliver QIPP Risk to the CCG s decision making ability and reporting accuracy. Although the QIPP Programme for 2016/17 has been risk adjusted, any deviation from the plan will put our projected financial plan at risk. There will be timing risks, legislative and inherent risks associated with the transformational schemes. Close working with CSU and Trusts in ensuring better quality and timely data to the Governing Body. Close working with CSU and Trusts in ensuring better quality and timely data The CCG has an experienced recovery director who has built a PMO team and process in place to ensure initiatives and projects are kept on track Clinical & Managerial staff identified for each initiative Initiative owners have weekly meetings with Recovery Director Milestones documented as part of planning process and monitored weekly BAF Risk 69 FRP NCL Transformation Fund & risk share arrangements In recent years Enfield CCG has been a key beneficiary ( 2.3m in 2015/16) The impact of setting 1% aside in 2016/17 (national guidance) means it may not be financially viable for our NCL colleague CCGs to make contributions. This has material implications for pre committed expenditure. Should Enfield have to meet preexisting commitments from its own resource limit, this would cost 3.3m. This is comprised of 2.7m for the RFL transaction costs and 0.6m contribution to the NCL PMO. None identified yet. FRP PMO Transformation Governance arrangements Concerns have been raised at the previous finance committee on the governance arrangements around PMO transformation decisions;accountability and transparency. Checks and balances exist within each CCG Finance Committee and Audit Committee process (albeit) retrospectively with oversight of potential issues TBC Additional QIPP of 7.2m directed by NHSE Further to recent direction from NHSE, the Revised Financial Recovery Plan now includes 7.2m of recurrent savings (which are unidentified) in order to bring CCG is in recurrent financial balance by the end of 2016/17. The CCG and NHSE London Region understand that this element of the plan is at extremely high risk of non-delivery. None identified yet. FRP 83

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85 11. Better Payment Practice Code The CCG has paid 90.3% of NHS invoices by number and 97.1% by value. For non-nhs creditors the CCG has paid 93.7% and 82.3% respectively. 13. Cash Flow A detailed cash flow forecast is included in Appendix 4. Recommendation Members are asked to note the report. Arati Das Deputy Chief Finance Officer 19 April

86 86

87 Appendix 1 Income and Expenditure Position Summary Trust / Service Month YTD Full Year Budget Actual Variance Variance Rating Budget Actual Variance Variance Rating Budget Forecast Variance Variance Rating '000 '000 '000 % '000 '000 '000 % '000 '000 '000 % Revenue Resource Limit Revenue Resource Limit Total Confirmed Anticipated (31,399) (31,399) 0 0.0% (31,399) (31,399) 0 0.0% (361,502) (361,502) 0 0.0% (361,502) (361,502) 0 0.0% (361,502) (361,502) 0 0.0% (361,502) (361,502) 0 0.0% CCG Delegated Budgets Acute & Integrated Care Providers Acute & Integrated Care NHS SLA - In Sector 15,836 17,214 1, % 190, ,150 12, % Acute & Integrated Care NHS SLA - Out of Sector 1,000 1, % 11,998 12, % SLA Exclusions 17 (662) (678) % % SLA Reserve 0 0 (0) 0 0 (0) Acute Re-admissions & Threshold 143 (392) (536) % 1, (1,282) -74.5% Acute LAS (10) -1.1% 10,801 10,791 (9) -0.1% Acute InHealth % % Acute Winter Pressures 1,023 1, % 1,480 1, % Non Contracted Activity % 2,755 2, % Acute & Integrated Care Total 19,214 19, % 219, ,573 11, % Non Acute Mental Health 4,052 4, % 46,856 47, % Learning Disabilities % 2,996 3, % Continuing Care 1,515 1, % 18,763 19, % End of Life care (9) -8.0% 1,286 1,278 (8) -0.6% Community Services 2,009 2,005 (5) -0.2% 24,111 24, % Other Commissioning 0 0 (0) 0 0 (0) Primary Care - OOHs, 111 & LESs % 3,397 3,106 (291) -8.6% Primary Care - Prescribing 3,294 3, % 39,530 39, % Primary Care - GPIT (28) -38.0% (28) -3.2% Primary Care - Primary Care Strategy (8) -7.7% 1,279 1,274 (5) -0.4% Sexual Health % % Strategic Investments (437) -53.5% 10,005 9,233 (772) -7.7% Non Acute Total 13,139 13, % 149, , % Programme Corporate Costs (82) -19.8% 5,471 5,035 (437) -8.0% QIPP (0) (0) Programme Corporate Costs Total (82) -19.7% 5,471 5,035 (437) -8.0% Total Commissioning Expenditure 32,770 33, % 375, ,896 11, % Corporate Costs CCG Running Cost (Excl CSU) % 4,533 4,514 (20) -0.4% CCG Running Cost (CSU) (13) -6.2% 2,486 2, % Corporate Costs Total (11) -1.9% 7,019 6,999 (20) -0.3% CCG Non Running Cost (PropCo) 95 (6) (101) % 1,145 1,006 (139) -12.1% Estates Costs Total 95 (6) (101) % 1,145 1,006 (139) -12.1% Un-issued Budget (731) % 11,670 0 (11,670) % Reserves and Contingencies Total (731) % 11,670 0 (11,670) % Total Expenditure 34,182 34,182 (1) 0.0% 394, ,901 (1) 0.0% Unadjusted Surplus / (Deficit) Deficit (2,783) (2,783) (1) 0.0% (33,400) (33,399) (1) 0.0% 190, ,150 12, % 11,998 12, % % 0 0 (0) 1, (1,282) -74.5% 10,801 10,791 (9) -0.1% % 1,480 1, % 2,755 2, % 219, ,573 11, % 46,856 47, % 2,996 3, % 18,763 19, % 1,286 1,278 (8) -0.6% 24,111 24, % 0 0 (0) 3,397 3,106 (291) -8.6% 39,530 39, % (28) -3.2% 1,279 1,274 (5) -0.4% % 10,005 9,233 (772) -7.7% 149, , % 5,471 5,035 (437) -8.0% 0 0 (0) 5,471 5,035 (437) -8.0% 375, ,896 11, % 4,533 4,514 (20) -0.4% 2,486 2, % 7,019 6,999 (20) -0.3% 1,145 1,006 (139) -12.1% 1,145 1,006 (139) -12.1% 11,670 0 (11,670) % 11,670 0 (11,670) % 394, ,901 (1) 0.0% (33,400) (33,399) (1) 0.0% 87

88 Appendix 2 QIPP Performance Month 12 (based on Month 11 activity data) Month 11 QIPP Scheme Planned Year to Date Forecast Last QIPP Plan Saving Variance Plan Actual Variance Month RAG Rating Comments Transformational Integrated Care (1,066) (977) (977) 0 (1,066) (1,066) 0 Savings based on substitution of existing CCG costs into Better Care Fund - Agreed at H&WB POLCE (500) (452) (7) 445 (500) (8) 492 Net decrease in costs and activity year on year ( 7k) Gastroenterology (60) (52) 0 52 (60) 0 60 No forecast for OP reductions due to pilot served notice. Continued issues with FCP data Ophthalmology (328) (301) (324) (23) (328) (354) (26) Reduction in cost and activity seen YTD Respiratory (41) (38) 0 38 (41) 0 41 Latest update from PM and analytics suggests this is no longer delivering savings - Scheme closed Urgent Care (600) (550) (486) 64 (600) (530) 70 circa 40% of attendances going through UCC (during opening hours) - No update since M9 Locality Commissioning - Outpatient (634) (519) (130) 389 (634) (142) 492 YTD shows QIPP currently under performing overall due to one locality (South) Locality Commissioning - A&E Attendances (332) (272) (332) Data indicates no reductions Transformational QIPP Total (3,562) (3,160) (1,924) 1,235 (3,562) (2,100) 1,462 Transactional Acute Medicines Management (160) (147) (147) 0 (160) (160) 0 YTD currently over performing (excludes Month 11 challenges) Primary Care Medicines Management (1,134) (1,039) (1,039) 0 (1,134) (1,134) 0 PC Meds on target at present Acute Productivity (1,800) (1,650) (1,198) 452 (1,800) (1,307) 493 SLAs agreed - min. BCF, RFH and UCLH. NMUH NEL Audit Emergency Admissions (500) (459) (500) Audit now undertaken and savings under negotiation in potential year end deal Corporate (349) (320) (320) 0 (349) (349) 0 CCG operating within running costs allowance (RCA) at Month 12 CSU Contract Reduction (373) (342) (342) 0 (373) (373) 0 QIPP delivered - Reduction in CSU signed SLA Direct Access Radiology MRI MSK (32) (21) 0 21 (32) (16) 16 Started in February No data as yet Void Space (Estates) (460) (384) (385) (1) (460) (420) k savings reported YTD as discussions with relevant parties continue Improved Contract Management - Data Challenges (2,850) (2,613) (5,184) (2,571) (2,850) (5,655) (2,805) Challenges data is currently being discussed as part of year end deals Direct commissioning of PACE services (156) (143) (276) (132) (156) (301) (145) Agreement in place Decommission TREAT services (175) (161) (270) (110) (175) (295) (120) 16/17 savings secured, with 15/16 reduction discussions ongoing Reduce OPAU investment through PbR billing (150) (138) (90) 48 (150) (99) 52 Agreement between CCGs and RFH regarding direct billing now in place Commission new Wet AMD spec (100) (86) 0 86 (100) Forecast reduced following meeting with Moorfields. Savings look unlikely in 2015/16 Reduce outpatient activity prior to procurement/re-procurement (290) (249) (141) 108 (290) (188) 103 Targeted OP reductions in Specialties where benchmarking suggests CCG are outliers - Derm only NICE guideline review of high cost drugs (65) (56) (60) (4) (65) (65) 0 Work ongoing - CCG are confident savings will be in excess of current forecast Cease prescribing of OTCs, health supplements & gluten free food (135) (113) (113) 95 (135) (135) 0 Awaiting detailed savings breakdown from Meds Mgt. Healthy London Partnership refund (201) (185) (185) 0 (201) (201) 0 Refund from NHS England ( 201k confirmed Jan 16) Transactional QIPP Total (8,938) (8,107) (9,751) (1,549) (8,938) (10,699) (1,762) Total QIPP (12,500) (11,266) (11,675) (314) (12,500) (12,798) (299) Additional Schemes Identified Recovery of non-eccg CHC mental health beds (1,000) (857) (1,000) 0 1,000 Discussions escalated to CCG CO and LBE CO for agreement Additional Schemes identified Total (1,000) (857) (1,000) 0 1,000 88

89 Finance Report- Month 12 Appendix 3: Statutory Duties & Statement of Financial Position Table 1: Statutory Duties Statutory Duty Month 11 YTD Forecast Plan Capital Expenditure m NIL NIL NIL NIL Cash Drawdown m n/a BPPC by number nhs n/a 90% n/a n/a BPPC by value nhs n/a 97% n/a n/a BPPC by number non nhs n/a 94% n/a n/a BPPC by value non nhs n/a 82% n/a n/a Table 2: Statement of Financial Position Sta te me nt of Fina ncia l Position a s a t 31-Ma rch Note 000 Curre nt a sse ts: Trade and other receivables 8 4,211 Cash and cash equivalents Tota l curre nt a sse ts 4,490 Tota l a sse ts 4,490 Curre nt lia bilitie s Trade and other payables 10 (53,758) Tota l curre nt lia bilitie s (53,758) Non-Curre nt Asse ts plus/le ss Ne t Curre nt Asse ts/lia bilitie s (49,268) Asse ts le ss Lia bilitie s (49,268) Fina nce d by Ta x pa ye rs Equity General fund SOCITE (49,268) Tota l ta x pa ye rs' e quity: (49,268) Table 3: Aged Debtors report 89

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