Governing Body. NHS Richmond Clinical Commissioning Group (CCG) 34 th Meeting in Public 10:30 12:30. Tuesday 1 May 2018

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1 NHS Richmond Clinical Commissioning Group (CCG) Governing Body 34 th Meeting in Public Tuesday 1 May :30 12:30 The Salon, York House Richmond Road Twickenham TW1 3AA

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3 34 th meeting in public of the NHS RICHMOND CLINICAL COMMISSIONING GROUP (CCG) GOVERNING BODY Tuesday 1 May :30 12:30 in the Salon, York House, Twickenham PART 1 AGENDA No Time Item Executive Lead Attachment 1 Standing items :30 Welcome and introductions Chair Apologies for absence and confirmation of meeting quoracy (see quorum at end of agenda) Reminder to members to put mobile phones on silent or switch them off during the meeting 1.2 Declaration of interests in matters covered on the agenda GP members: Richmond General Practice Alliance participant Note 1.3 Minutes of the CCG governing body meeting on 6 March 2018 Action log Approval Chair & GB Members Chair A 1.4 Matters arising Note Chair Verbal 1.5 Items taken in private on 6 March 2018: Integrated urgent treatment centre (UTC) and PCC finance and activity model proposal Proposal to hold a committee in common (CiC) for collaborative decision making for the following items; o o A joint IFR service for SWL Primary care extended access funding for 2018/19 South West London Sustainability and Transformation Partnership - Moving forward together into an integrated care system Planning Update 2018/19 The future of commissioning support services across South West London (SWL) National staff survey results for Richmond CCG Kingston & Richmond CCG office move Note Chair Verbal

4 No Time Item Executive Lead Attachment :40 Managing director s report Managing Director B Note :50 CCG chair s report Note Chair Verbal :55 Audit committee chair s report Note Audit Committee Chair Verbal :00 SWL health & care partnership update 2 Governance/Business :05 Primary care strategy Note Discussion :15 National staff survey results for Richmond CCG Information :25 Outcome based commissioning (physical and mental health) Information :35 Emergency Preparedness, Resilience and Response (EPRR) assurance outcome 3 Quality, Performance & Finance :45 Quality, safety and performance: SWL Performance report Information Quality, safety and performance committee summary Information SWL Accountable Officer/ Managing Director Local Director of Primary Care & Planning Local Director Corporate Affairs & Governance Local Director of Commissioning Local Director of Quality GP Lead for Quality C D E F G H :55 Finance committee summary Information Local Director of Finance I :00 Month 12 finance report Information Local Director of Finance J 4 For information :05 Primary care commissioning committee notes of meeting of February 2018 Information Lay Member for Finance, Remuneration, PC & Governance K

5 No Time Item Executive Lead Attachment :10 SWL Committee for collaborative decision making (CiC): Notes of meeting of 27 March 2018 Convenor s report Note SWL Accountable Officer L :15 Any other business Chair 4.4 Date of next meeting: Tuesday 3 July 2018, 10:30-12:30, in the Salon, York House, Twickenham 5 Public Question Time :20 Members of the public present are invited to ask questions of the CCG Governing Body relating to the business being conducted. Priority will be given to written questions that have been received in advance of the meeting. Quorum: No business shall be transacted at the meeting unless at least one-third of the whole number of the Chair and members (including at least one lay member and three GP members and either the Accountable (Chief) Officer or Chief Finance Officer are present. Representatives of members will count towards the quorum where the representative either has formal acting up status or has been agreed with the Chair as the member s representative in advance of the meeting.

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7 33 rd MEETING IN PUBLIC OF THE RICHMOND CLINICAL COMMISSIONING GROUP S GOVERNING BODY HELD ON TUESDAY 6 th MARCH 2018, 10:30 12:30 IN THE SALON, YORK HOUSE Attachment A MINUTES Attendance Log: Voting members: Dr Graham Lewis Chair A A A SA A A (GL) Sarah Blow (SB) Accountable Officer SWL A A A SA A A Alliance James Murray (JM) Chief Finance Officer SWL A A A A A A Alliance Tonia Michaelides (TM) Managing Director, Kingston & Richmond A A A A A A Charles Humphry (CH) Bob Armitage (BA) CCGs Vice chair and lay member for audit, remuneration and governance Lay Member for finance, remuneration, primary care and governance A A A SA SA SA A A A A A A Susan Smith (SS) Lay Member, Patient & A A SA A A A Public Involvement Dr Kate Moore (KM) Vice Clinical Chair (VCC) SA SA A A A A Dr Branko Momic GP A SA A A A A (BM) Dr Nicola Bignell GP A A SA A SA A (NB) Dr Stavroula Lees GP A A A A A SA (SL) Dr Zehra Rashid GP A SA SA A A SA (ZR) Dr Alireza GP - A A A A A Salehzadeh (AS) Liz Bruce (LB) Director of Adult Social SA SA SA SA SA SA Services, LBRuT Dr Anne Dornhorst Secondary Care Doctor A A A SA A A (AD) Fergus Keegan (FK) Registered Nurse & Local Director of Quality A A A SA SA A Non-voting members: Houda Al-Sharifi Director of Public Health A SD A A A A (HAS) Richmond and Wandsworth Councils John Thompson (JT) Healthwatch Member A A A A A A In attendance on : Yarlini Roberts Local Director of Finance Jo Dandridge Governance & Business Lead (notes) KEY: A = Attended, DNA = Did not attend, SA = Sent Apology, SD = Sent Deputy Page 1 of 8

8 1 STANDING ITEMS 1.1 Welcome, apologies for absence and quoracy ACTION The Chair welcomed all members present to the 33 rd meeting in public of the Richmond Clinical Commissioning Group s governing body. Apologies for absence were received as per the attendance table. It was confirmed that the meeting was quorate. 1.2 Declaration of interests in respect of items on the agenda The standard declaration of interest from GP members was noted: o Participant of the Richmond General Practice Alliance (RGPA) 1.3 Minutes of the CCG governing body meeting on 9 th January 2018 The minutes were agreed as a correct record. Attachment A 1.4 Matters arising and rolling action log All actions were either on track or completed. 1.5 Items taken in private on 9 th January 2018: SWL & St George s Mental Health NHS Trust Estate Modernisation Programme Richmond & Kingston CCG Mental Health Commissioning Function Recommendations from SWL Alliance Remuneration Committee Very Senior Manager (VSM) Remuneration 1.6 Managing Director s report Attachment B The governing body received the managing director s report and particular attention was drawn to the following points: Richmond Governing Body Update Members were advised that Charles Humphrey, Vice Chair and Lay Member for Audit, Remuneration and Governance has retired from his role on the grounds of ill health. The Chair on behalf of all Governing Body members extended his thanks to Charles for the wealth of experience, impartial advice and strategic leadership during his eleven years with Richmond CCG and its predecessor organisation, Richmond Primary Care Trust. Revised Constitution Members noted that NHS England had recently approved the amendments made to Richmond CCG s Constitution. The amends included the introduction of the South West London Alliance and adherence to the new conflicts of interest regulations. Operating Plan Guidance Members were advised that NHS England had recently shared operating plan guidance with CCGs and providers. The guidance is being worked through to agree the operating plan for and an update will be brought to the next Governing Body meeting Page 2 of 8

9 Update on Cedars Bed Move to Teddington Memorial Hospital Members noted that providers were planning for the transfer of community beds from Cedars Ward at Tolworth to Grace Anderson Ward at Teddington Memorial Hospital to be made by 31 st March A phased approach has been planned for the transfer to accommodate any need for double running. Medical cover for the beds will continue to be provided by Central Surgery and the pharmacy service will continue from Kington Hospital. ACTION Diagnostic Performance Members noted that Richmond CCG had received a letter from the Secretary of State for Health and Social Care, congratulating the team on the recent improvement in diagnostic performance. Between November and December 2017, waiting times and activity performance moved from 4.1% to 2%. Stay Well Pharmacy Campaign Members noted that the CCG had been working with health and social care partner organisations in Richmond and Kingston to support the NHS England Stay Well Pharmacy campaign which urges parents to consult a pharmacist first for minor illnesses instead of a GP or A&E. Breast Cancer in women over 70 campaign Members were advised that the CCG is also supporting the Public Health England campaign which seeks to raise awareness in women over 70 of the symptoms of breast cancer and reinforces the message that finding it early makes it more treatable. Hounslow and Richmond Community Healthcare (HRCH) Wound Care App Members were advised that HRCH had won an Outstanding Practice in Wound Care Award (Journal of Community Nursing) for its wound care buddy app which helps district nurses treat patients wounds in their own homes. 1.7 CCG Chair s Report Verbal Dr Graham Lewis provided a verbal report to the Governing Body on the following matters: Progress was being made on the arrangements for video recordings of the Governing Body meetings and this would begin at the May 2018 meeting. Bob Armitage, Lay Member for Finance, Remuneration, Primary Care and Governance had agreed to take on the additional role of Vice Chair for the Governing Body from 1 st April 2018 The Governing body NOTED the Chair s report. 2 GOVERNANCE/BUSINESS 2.1 Kingston & Richmond Transformation Musculo skeletal (MSK) model and pathway Attachment C Members received attachment C, a presentation from Julia Travers, Director of Commissioning on the development of an integrated MSK service across South West London. Members were advised that an integrated MSK service within South West London would include every area jointly developing: Page 3 of 8

10 ACTION a common specification and governance for all Single Point of Triage; a single self-management resource alternative care pathways and services The benefits outlined include more people accessing the right care, in the right place at the right time; improved patient experience and outcomes; providers working together to deliver standardised care pathways; improved referral management; all routine GP MSK referrals managed by the Single Point of Triage; improved equity of access and reduced variation; and more appropriate utilisation of diagnostic capacity. GP members commented on the joint injections pathway as it was listed within the clinical triage remit whilst a link from the booking system remained. With the move towards imaging diagnostics, it was noted that joint injections would be through guided ultrasound. A complete suite of investigations would be prepared in order to provide further clarity for GPs on what needed to be clinically triaged. Following discussion, it was agreed that more detail on the following areas would be included for implementation of the local model: physical activity links with social prescribing self care Members were informed that the Academy of Medical Royal Colleges had published a report on the health benefits and impact of physical activity. The report entitled Exercise : the miracle cure and the role of the doctor in promoting it can be found at the following link: Members noted that the next step was to monitor and evaluate the outcomes of the referrals managed by the single point of triage after six months to determine if there had been a change in practice. This evaluation would be shared with the Governing Body. The Governing Body NOTED the integrated Musculo Skeletal (MSK) service across South West London. 2.2 Urgent Treatment Centre and Primary Care Centre Update Attachment D Members received attachment D, an update on the commissioning discussions with Hounslow & Richmond Community Health (HRCH) and Richmond GP Alliance (RGPA) on the development of an Urgent Treatment Centre (UTC) at Teddington Memorial Hospital and the establishment of a Primary Care Centre in the east of the borough. Declaration of Interest : Dr Graham Lewis declared his interest as a GP and his practice is a member of the RGPA. Therefore this item was chaired by Bob Armitage, Lay Member. Members noted the proposed Urgent Treatment Centre will bring together the currently co-located but separate services of the nurse led walk-in-centre and the GP Page 4 of 8

11 hub into one new integrated service that will offer both booked appointments and the ability to walk in. The operating times of the UTC will be from 8am to 8pm, 7 days a week including all bank holidays. Members attention was also drawn to the additional accessible diagnostic facilities and specialist community service that would be available at the UTC. ACTION Members also noted the commitment to provide extended primary care services in the east of the borough. These will be booked GP and nurse appointments. The extended primary care service will operate for 8 hours, from 12noon to 8pm, 6 days a week. Though members were advised that discussion was being held at the forthcoming Clinical Executive Team meeting regarding the ratio of opening hours and days. Members were pleased with progress made on the planned opening of the new service for the east of the borough and highlighted that communications with the general public would need to be implemented before the commencement of purdah. The Governing Body NOTED the Urgent Treatment Centre and the Primary Care Centre update. 2.3 Update on progress on refreshing the primary care strategy for Richmond Attachment E Members received attachment E, an update on the refreshing of the primary care strategy. Declaration of Interest : Dr Graham Lewis declared his interest as a GP and his practice is a member of the RGPA. Therefore, this item was chaired by Bob Armitage, Lay Member. Members noted that the draft primary care strategy had been reviewed by various CCG committees over the past two months and approval of the following proposed changes were now being sought: re-wording of the listed principles two new enablers of communications and workforce new priority objectives new inclusions Members requested a descriptor is included within the strategy for what primary care at scale means for Richmond. Members also discussed inclusion of an appendix to the strategy describing the smarter ways of working use of technology and aligning with the council s strength in digital programme. The Governing Body NOTED the revised draft primary care strategy for Richmond and the final version would be brought back for approval at its next meeting on 1 st May QUALITY, PERFORMANCE & FINANCE 3.1 The governing body received attachment F, the SWL Performance Highlight Report for Month 8 and noted the following: Attachment F Page 5 of 8

12 Diagnostic Waits : The diagnostic standard had not been achieved since March In November 2017, there were 111 breaches out of 2,654 waits (97 breaches occurred at Chelsea & Westminster (C&W), 91 of which were in Non Obstetric Ultrasound). Richmond and Kingston LDU colleagues have been reviewing the Richmond CCG M8 Diagnostics position of 95.9% along with CSU BI colleagues ACTION Richmond CCG diagnostic performance is primarily affected by performance at C&W and Imperial for the CCG s patients. The main issue is non-obstetric ultrasound, predominately at West Middlesex site. Workforce issues are the main reason for the decline in performance and the Trust have an action plan in place to address this and to return to compliance. Delayed Transfers of Care : the majority of DTOCs were related to further non acute NHS care, Care Homes, patient choice, or completion of assessments in almost equal measure. The Governing Body NOTED the SWL Performance Highlight Report. Quality, Safety & Performance committee summary The governing body also received a report from Fergus Keegan, Director of Quality who provided a summary of the discussions at the Quality, Safety & Performance Committee meeting held in January The main points of note were: Referral to treatment - Richmond CCG narrowly missed the RTT performance standard in December with an outcome of 91.7%. The year to date position is one of compliance at 92.4%. Six of the eight Cancer Waiting Time targets were met in December 2017 however the Cancer 1 st treatment within 31 days and subsequent treatment for surgery was not achieved. The breach reasons are under investigation and will be confirmed when the final performance report is published. The two week wait Cancer performance standard continues to be achieved since July and all CWT Standards are now compliant year to date. The number of delayed transfers of care monthly target is 522 and year to date performance remains compliant with the Better Care Fund trajectory. A multi agency discharge event had been held to look at further improvements that could be made. December s dementia diagnosis rate is 66.7% and therefore meets the national standard. It was noted that improvements were continuing. Further work would be undertaken on improving diagnosis rates. Members noted that Child and Adult Safeguarding 6 monthly reports had not submitted any concerns about lack of assurance provided in relation to safeguarding. A new Head of safeguarding had been appointed, risks were being addressed through staff training and support provided to increase moral and closer working with clinicians and administrative staff. Members also noted that the number of slips, trips & falls at Teddington Memorial Hospital between April and November 2017 had increased but the number of patients that have repeated falls is low and controlled falls have increased accounting for one third of the number reported. The Accountable Officer congratulated the Governing Body on how well Richmond CCG were performing against targets and this was really positive in Page 6 of 8

13 comparison with other areas within SWL, however it was noted there was still the need to improve further. ACTION The Governing Body NOTED the Quality, Safety & Performance report. 3.2 Finance committee summary Attachment G The governing body received and noted attachment G, which provided a summary of discussions at the Finance Committee on 23 rd January Yarlini Roberts, Local Director of Finance took the GB through the report, with the following areas of note: The CCG was forecasting to meet its planned in year deficit of 5m. Overall the position in Month 9 had improved slightly in comparison to the forecast position reported at Month 8, with a worsening in the acute SLA position of 0.7m being offset by the removal of the NCSO cost impact from the prescribing forecast outturn ( 1m) and instead being shown as a risk. Achievement of the planned deficit remains challenging with all reserves held being used to balance the position and the acute run rate position was expected to improve by 1m in respect of higher QIPP performance during the rest of the year. The risk adjusted position improved slightly to 7.6m with the 0.7m worsening in the acute position being offset by a number of improvements including further balance sheet release mitigations identified ( 0.2m) and a reduction in the acute seasonality risk ( 0.25m). The Governing Body NOTED the Finance Committee summary. 3.3 Month 10 Finance Report Attachment H The governing body received attachment H and during discussion the following points were highlighted: The final 2017/18 financial plan submitted in March 2017 included a planned deficit of 5m which aligned to the CCG s Financial Recovery Plan and included QIPP schemes of 13.1m At Month 10, the CCG is forecasting a 5.896m deficit for 2017/18; and adverse variation of 0.896m against plan reflecting the cost pressure caused by the impact of No Cheaper Stock Obtainable (NCSO) drug costs. The year to date variance against plan of 0.737m reflects the year to date pressure of NSCO costs. NHS England have advised that this variance from plan will not impact on the CCG assurance ratings given it is an unavoidable national cost pressure Members noted that financial plans were being refreshed together with an update to the two year plans submitted to NHS England in 2017/18. The next draft submission of the 2018/19 Financial Plan will be submitted to NHS England on 8 th March 2018 and work was underway with provider colleagues to plan to meet the system control total for South West London. QIPP Performance Members were informed that in Month 10, we have achieved 6.9m year to date against a plan of 8.9m. Transactional delivery remains strong. The forecast out turn is now 9.4m and it is believed this is a realistic assessment and takes into account current risks. Page 7 of 8

14 The Governing Body NOTED the financial position at Month 10 and the challenges required to achieve the planned deficit at the end of the financial year. 4 FOR INFORMATION 4.1 Primary care commissioning committee ACTION Attachment I The governing body received attachment I, the minutes of the Primary Care Commissioning Committee meeting held in December 2017 for information. Bob Armitage, chair of the primary care commissioning committee provided members with an update from the most recent meeting held in February 2018 where the main points of discussion were the refresh of the primary care strategy and the proposal for the Urgent Treatment Centre. The Governing Body NOTED the minutes of the Primary Care Commissioning Committee meeting held on 5 December 2017 and the verbal update from the 6 th February 2018 meeting. 4.2 Any Other Business None. 4.3 Date of next meeting Tuesday 1 st May 2018, 10:30-12:30, in the Salon, York House, Twickenham 5 PUBLIC QUESTION TIME 5.1 There had been no questions submitted prior to the meeting. Denise Carr, Chair of Richmond s Mencap introduced a national campaign Treat me well which had been launched in February 2018 to raise awareness and improve the way the NHS treats people with learning disabilities in hospital settings. Tonia Michaelides, the lead for Learning Disabilities across South West London agreed to meet separately with Denise Carr in order to progress the development of local plans. Bonnie Green, PPG chair was encouraged to read in the Managing Director s Report that the CCG were supporting the Breast Cancer in women over 70 campaign but pointed out that the public do not realise that routine screening finishes at 70 years and to continue being screened they need to apply through their GP. Bonnie Green also questioned the vast difference in the number of MSK, MRI diagnostic referrals where it was reported that there were 1,700 in Kingston and 4,500 in Richmond. In response, she was advised that this was likely to change with the introduction of published guidelines from the Royal College of Audiologists. The meeting finished at 11:43. Page 8 of 8

15 ACTION LOG for Richmond CCG GOVERNING BODY in public meeting - LIVE ACTIONS Commenced: March 2014 Date of next meeting: Last updated Action No. GB88 GB94 GB95 GB96 Action Owner Date due Safeguarding Children's Annual Report Joint Kingston & Richmond Annual Report for 2017/18 to be presented to Governing Body in early Autumn BAF & Risk Register Sub committee for options to develop presentational data ie heat maps to present high risks MSK Model and Pathway The monitoring and evaluation of outcomes of referrals managed by the single point of triage would be shared with the Governing Body Primary Care Strategy Refresh Revised version of the strategy to be presented to the next Governing Body meeting in May for approval. Sian Thomas/Andrea Knock Date raised On track Overdue More than 4 weeks late On track Vicki Harvey-Piper On track Julia Travers Kathryn MacDermott On track On track Comments (i.e. why action is not resolved / completed) LIVE ACTION LOG

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17 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing Body in public Date 1 May 2018 Report Title Managing Director s Report Agenda Item 1.6 Attachment B Purpose (please indicate with X) Approval/ Ratification Discussion / Comment Information X Report Author: (name & job title) Tonia Michaelides Managing Director, Kingston & Richmond CCGs Presented by: (name & job title) Tonia Michaelides, Managing Director, Kingston & Richmond CCGs Managing Director s Report The following report highlights items of interest to governing body members and the public which are not discussed in detail in the rest of the agenda. Governing Body At its meeting on 22 February, Richmond CCG s Executive Management Team agreed to extend the lay member term of office for Bob Armitage and Susan Smith. Bob Armitage had also agreed to fulfil the role of vice chair for the CCG. Paul Gallagher, current Kingston CCG lay member and audit chair has also taken on the role of audit chair and conflicts of interest guardian for Richmond CCG, with effect from 1 April Healthy London Partnership plans for 2018/19 The CCG s finance committee has discussed the Healthy London Partnership (HLP) 2018/19 business planning paper. The proposal agreed for 2018/19 stipulates that Richmond s contribution to HLP will decrease to c 158k. There is an expectation that this reduction is not just a saving but should be used to support local transformation at LDU or STP level. HLP was formed by London CCGs and NHS England (London) in 2015 with the aim of supporting delivery of the ambitions set out in Better Health for London and the NHS Five Year Forward View. The landscape has changed significantly since then, with the establishment of Sustainability and Transformation Partnerships (STPs) and the signing of Page 1 of 2 Working together a healthier Richmond for everyone

18 the London Health and Care Devolution Agreement, as well as increasing financial challenges. The HLP 2018/19 planning round was led by the CCG accountable officers who looked at what activity should stop, be devolved to delivery elsewhere in the system or continue to be supported by HLP as once for London activity and the associated resources. The finance committee discussed the revised programme budgets, operating model, governance arrangements and work plan for 2017/18. Follow link for more detail. Tonia Michaelides Managing Director of Kingston and Richmond CCGs Page 2 of 2 Working together a healthier Richmond for everyone

19 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing Body in public Date 1 st May 2018 Report Title South West London Health & Care Partnership Update Agenda Item 1.9 Attachment C Purpose (please indicate with X) Approval/ Ratification Discussion / Comment x Information x Report Author: (name & job title) Karen Broughton Director of Strategy and Programmes South West London Health and Care Partnership Presented by: (name & job title) Tonia Michaelides, Managing Director Kingston & Richmond CCGs Summary and purpose of report The attached report sets out the progress made on the South West London-wide programmes of work which together form part of our South West London Health and Care Partnerships. These programmes sit alongside the priorities of each of the Local Transformation Boards, as well as individual organisation priorities. Only the pan- South West London programmes are represented in this report. Key sections for particular note Pages 5/6 Page 7 Page 8 The deliverables on the national five year forward view programmes (UEC, cancer, mental health, primary care, maternity and learning disabilities); The deliverables for our work on clinical pathways (MSK, ENT and diabetes) that are being developed across South West London; and The status of our enabling work streams: digital, workforce, organisational development and estates Report recommendation The Governing Body is asked to note the report and to provide feedback on the report style and level of detail provided. Financial and / or resource implications The costs of the development and delivery of the South West London Strategy for Health and Care are being met through the existing resource available to CCGs. Version: Final F - 1 Date:

20 Key risks identified & mitigation The main risk identified is the development and ownership of the local health and care plans within the given timescales. This will be mitigated by using existing partnership groups with oversight from the Health and Wellbeing Board. Equality and / or privacy impact analysis Equality and privacy impact analysis will be completed as part of the delivery plans for the local health and care plan. Committees that have previously discussed / agreed the report and outcomes SWL Programme Board Communication plan / stakeholder involvement / patient engagement A communication and engagement plan is being developed as a work stream of the Local Transformation Board. Assurance Does the report need to be taken to any additional meetings for further assurance or ratification? No CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final F - 2 Date:

21 South West London Health and Care Partnership Programme Update 24 April 2018 Governing body update Start well, live well, age well

22 Reporting on pan-swl programmes: an introduction This report sets out progress on south west London-wide programmes of work which together form part of our South West London Health and five Care Partnerships. This report comprises details on: The deliverables on the national five year forward view programmes (UEC, cancer, mental health, primary care, maternity and learning disabilities); The deliverables for our work on clinical pathways (MSK, ENT and diabetes) that are being developed across South West London; and The status of our enabling work streams: digital, workforce, organisational development and estates. These programmes sit alongside the priorities of each of the Local Transformation Boards, as well as individual organisation priorities. Only the pan- South West London programmes are represented in this pack. We have not included an update on Local Transformation Boards or working being undertaken by the Acute Provider Collaborative but can do so if Governing Body members wish. Similarly further detail is available for each individual programmes if requested. The report is written as a high level report. Feedback on the report style and level of detail provided is welcomed. CONFIDENTIAL 1

23 Key messages CONFIDENTIAL 2

24 Key messages We have refreshed our strategy. The discussion period following publication of The SWL Health and Care Partnership: one year on has now closed and we have responded to feedback. We expect that some of the feedback will be addressed in the local health and care plans that are being developed. Individual boroughs have discussed proposals for developing local health and care plans and are in process of writing their case for improvement. We are making clinical and quality improvements We held a pan-swl workshop to review the Ear, Nose and Throat (ENT) pathway, involving clinicians and managers from all providers and commissioners, on 1 March. This workshop outlined a common ENT model and options appraisal to take forward. It will report back to the next Clinical Senate. Following the identification and agreement of Children and Young People s mental wellbeing as the priority health promotion and prevention work-stream, South West London held its first workshops involving 60 stakeholders across SWL (including education, voluntary sector, health, Local Authorities). The workshops agreed key root causes of self harm and mental wellbeing in CYP that we want to focus on and identified strategies to resolve these root causes. A steering group is being set up to take this work forward. Reframed workforce priorities are being developed in conjunction with Workforce Directors and Local Authorities. The outcome of this collaboration will be taken to SWL Workforce Board, Clinical Senate and Programme Board. We continue to strengthen our leadership. We are reviewing the purpose and approach of the Programme Board which will be reported at a future meeting. We have been in discussion with range of providers on organisational development to develop and deliver a system-wide support programme and a programme to strengthen clinical leadership. We are delivering all our FYFV programme milestones Primary care, UEC and mental health transformation programmes remain in line with our delivery plan expectations. For cancer the current focus is on addressing the 62 performance target to improve care to patients and enable us to access additional cancer transformation monies. We have reviewed our bid for perinatal transformation funding with stakeholders across South West London which has been submitted to NHSE. We await the outcome decision on this. CONFIDENTIAL 3

25 Programme highlights CONFIDENTIAL 4

26 FYFV transformation programme summaries Mental Health: Community demand and capacity review underway, final report expected in April Croydon Hospital achieving Core 24 psychiatric liaison from December Perinatal MH bid agreed across whole system and submitted 9 March Outcome awaited. Continuing exploration of how to enhance IAPT referrals into long term condition pathways working group for MSK set up. The plan setting out which CAMHS actions SWL CCGs will take forward collaboratively has been reviewed and updated and the review of SWL Eating Disorder Service has begun. UEC: NHS 111 online - Online: SWL SROs and SMT agreed to proceed with procurement of pilots of NHS 111 Online and GPFV Online Consultation as single procurements. SWL UEC Transformation and Delivery Board agreed Teddington Memorial Hospital walk in centre met the requirements and would be designated as Urgent Treatment Centre from 1/4/18. Review of Alternative Care Pathways (ACPs) underway for SWL: All CCGs have validated their ACPs against those agreed and held by LAS as the first step in a SWL plan to stocktake and reduce variation across SWL. Primary Care: Croydon CCG have opened their first primary care top up hub providing additional primary care capacity out of hours in Croydon. Revised approach to NHS111 online and GP online consultations agreed following change in national direction. SWL is progressing with nationally mandated implementation of NHS pathways, and a revised project plan has been agreed and submitted setting out our process to procure and implement a solution for GP online consultations. SWL s long term vision is to implement a single integrated solution, to ensure that the system is easy for our patients to navigate. Expansion of social prescribing services from 2 to 9 GP practices in East Merton. Current pilot coming to a close and an independent evaluation to be published in April. CONFIDENTIAL

27 FYFV transformation programme summaries Cancer: Further analysis of breaches and introduction of formal reviews of Patient Transfer Lists to ensure they do not impact cancer waiting times. Focus is on addressing the 62 performance target which will improve care and enable us to access transformation monies. Business case developed for prostate programme. Recruited three posts to the team (funded by MacMillan) to deliver improved post cancer care. Maternity: Further submission of the maternity delivery plan has been made. This submission included more detailed trajectories from each of the providers and draft costings for transformation. Following the pilot, rollout of the maternity choice programme, my maternity journey has begun. The first pan-swl maternity and neonatal improving safety workshop has been scheduled for 22 May 2018 to provide an opportunity to be updated on the latest developments in maternity and neonatal care and improve our multi professional working including sharing learnings from serious incidents. Learning Disabilities: Currently performing above overall set trajectories for the number of patients discharged into the community. Development of a SWL Positive Behavioural Support (PBS) contract/service specification and implementation plan to further enhance support for patients. Worked with commissioners to improve local Dynamic Risk Registers and management processes across SWL. Development of CCG Care & Treatment Review policy, inline with national best practice. Lived experience "phase one" report received. Learning to be shared with front-line staff. Draft business case developed for a local crisis house which is currently being reviewed. CONFIDENTIAL

28 Update on SWL-wide planned care Musculoskeletal (MSK) pathways Pan SWL Clinically led meeting to enhance MSK pathway across SWL were held - clear actions have been defined, including establishing 5 clinically-led working parties reviewing gaps in Community Pain, Community Rheumatology, and Self-Management resources as well as looking to resolve disparate pathways and establish best practice guidelines for Single Point of Access and Triage. All of this work aligns with single point of access being implemented across SWL CCGs. The groups are due to report back to Clinical Senate at its next meeting to agree next steps. Ears, nose and throat (ENT) pathway Agreement for pan SWL review of ENT pathway. Outline service model being considered based on Croydon model. Merton and Wandsworth are already aligned with Croydon with two minor exceptions (age of children seen by the service and one urgent condition). Pan SWL clinical meeting convened 1 March 2018, outlining common ENT model and options appraisal to take forward. Whilst all parties agree intermediate service would make better use of resources, concerns expressed re sustainability of current services in KHFT and ESTH. Options being developed around procurement routes, taking into account these concerns. Next steps: agree common pathway and specification with Kingston and Richmond to achieve alignment and clinical governance. Diabetes Diabetic footcare project: New Charcot foot service started at St George s Hospital. Pan-SWL podiatry service mapping and referral guide being finalised. Diabetes inpatient specialist nursing project: Final postholders started in post Jan Workshop held to explore spreading the success of this project to community teams. Pan-SWL workforce survey completed to help with mapping of the diabetes nursing workforce and to establish common themes / issues that will be built upon for the evaluation of the project. Diabetes structured education project: bids for delivery of the South London Diabetes Structured Education Hub are currently being evaluated. Pan-SWL diabetes in primary care workshop held 26/03/18 which was attended by over 60 people from across South West London sharing their thoughts on how we can improve primary care for people with diabetes. The outputs from the workshop have been used by the Diabetes programme team to provide practices and CCGs with suggestions of improvements they can make, and to form a project in primary care for ideas that can be tackled at South West London level. Next steps: Out of hours podiatry trial at St George s A&E in April 2018 SWL diabetes foot care audit to take place in April First peer support network meeting for inpatient specialist nurses in April CONFIDENTIAL

29 Enabling scheme updates Digital The SWL Information Sharing Agreement is track to be agreed by end of May 2018 by the SWL Digital IG group which will then need to be signed by each statutory organisation responsible for the data they hold or use. Connecting secondary and primary care systems across the region is on track to be completed by September Currently in procurement phase. (Interoperability phase 1) Commence Fair Processing Campaign for the public (Information Governance) In the process of writing a business case to NHS England for funding for expanding the connectivity to all health and care providers (social care, mental health, community care and ambulance services - interoperability phase 2). Likely to be submitted in May 2018 Estates Completion of capital plan and estates workbook by LTB. Development of clear local health and care estates strategies aligned to LTB s visions and models for health and care with realistic and resourced delivery plan (consistent with Londonwide estates objectives under the devolution agreement) in train. Updating individual organisations latest capital and disposal plans; developing STP prioritisation criteria; identifying funding gaps; developing SWL capital pipeline and work with LEB to develop funding streams. Workforce Reframed workforce priorities developed with Workforce Directors and Local Authorities drafted. Recruitment and retention programme in progress pilot of self rostering tool in ESTH, Grow Your Own Nurses programme funding approved for local adoption of Capital Nurse Programme. Mental Health workforce plan submitted setting out future mental health workforce need and implementation/plans and next steps in progress Making Every Contact Count proposed for Children and Young People in progress for a two year plan.` Organisational development We are in discussion with range of OD providers to develop and deliver a system-wide development programme and a programme to strengthen clinical leadership. CONFIDENTIAL 8

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31 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing Body in public Date 1 May 2018 Report Title RCCG Primary Care Strategy Agenda Item 2.1 Attachment D Purpose (please indicate with X) Approval/ Ratification Discussion / Comment X Information Report Author: (name & job title) Kathryn MacDermott, Director Primary Care & Planning Presented by: (name & job title) Kathryn MacDermott, Director Primary Care & Planning Summary and purpose of report Attached is a draft primary care strategy for Richmond. The strategy sets out the current primary care provision in the borough of Richmond, the proposed direction of travel, the strategic drivers and the current challenges we face. It also sets out a proposal for the priority actions to be taken, the investments required and a work-programme consistent with delivery of the GP Forward View, the next steps for London s Strategic Commissioning Framework and South West London s Transforming Primary Care programme as part of the SWL health and social care partnership, and Richmond s Joint Health and Wellbeing Strategy. The draft strategy has been worked up co-productively with the CCG membership through the clinical networks and membership forums, with the RGPA through a workshop and board to board meetings, with the local LMC and Richmond residents through the patient participation group network and an engagement programme focussed on quality in primary care. Membership and patient feedback included: Suggested new principles & objectives Need a Richmond interpretation of primary care at scale & primary care transformation Need to link to the OBC work Strengthen the ability for primary care to contribute to the out of hospital agenda Improving the training offer to staff Better communications to practices and from practices to patients Patients understand the stress practices are under, willing to be responsible patients need to know what this means Themes from the Clinical Network workshops included: More co-ordinated / cohesive working Sharing clinical and back office staff Sharing IMT staff Sharing prescribing management, referral management processes Skill mix within and across practices Looking at new roles physician s assistant, clinical pharmacists etc. Version: Final D - 1 Date:

32 Workforce training Need to improve staff moral Much better GP IT support Description on how we engage with patients and how we feedback what we have taken on board / done Link to the OBC physical and mental health programme of work The Membership Forum and the Patient Participation Group suggested included additional, new principles: Setting out patient responsibilities Promoting self help and self care Promoting and enabling ownership of one s own health and well being Taking a collaborative approach These have been added to the existing principles of: Safe Improving the patient experience, including accessibility Effective in delivering key outcomes Providing value for money Working to reduce health inequalities Monitored regularly to ensure all the above The existing priority objectives in the primary care strategy are considered to be business as usual and the Membership Forum suggested instead priority objectives that linked to the CQC objectives: Ensuring our services are safe Effective Caring That we are responsive to people s needs Well led Additional priorities suggested include: Establish sustainable primary care services Develop primary care at scale (part of sustainability) Effective patient engagement This has resulted in a new list of objectives included in the strategy: Ensuring our services are safe Effective Caring That we are responsive to people s needs That services are well led Establish sustainable primary care services Develop primary care at scale (part of sustainability) Effective patient engagement Provide comprehensive population based care that is accessible, coordinated care and pro-active care We aim to achieve our objectives through: Taking a collaborative approach Setting out patient and general practices responsibilities Promoting self-help and self-care Promoting and enabling ownership of one s own health and well-being Version: Final D - 2 Date:

33 Be effective in delivering key outcomes Working to reduce health inequalities and variation in outcomes and service delivery Improving the patient experience, including accessibility Providing value for money Monitor our service regularly to ensure all the above The draft strategy includes key commissioning intentions that set out what we aim to deliver: Primary care at scale Comprehensive population coverage Co-ordinated care Accessible care Pro-active care The governing body previously agreed that the primary care strategy would describe the vision of what we aim to achieve and be underpinned by annually updated implementation plans. Whilst the primary care strategy is finalised the 2018/19 implementation plan will be developed and considered at the June primary care commissioning committee. Key sections for particular note Section 9 priority objectives Section 11 commissioning intentions Section 12 delivery Report recommendation The governing body is asked to note the updates made to the strategy. Financial and / or resource implications The delegated primary care budgets will be included once confirmed. Key risks identified & mitigation None at this stage. Equality and / or privacy impact analysis Not at this stage. Committees that have previously discussed / agreed the report and outcomes Membership forum on 24 th January Patient participation group network on 30 th January & 20 th March Primary care commissioning committee on 6 th February Clinical executive team on 13 th February Clinical Networks 28 th February Governing Body 6 th March Primary Care Operational Group 20 th March Clinical Networks workshop 28 th March Primary Care Commissioning Committee 2 nd April Clinical Executive Team 10 th April Community Involvement Group 24 th April Version: Final D - 3 Date:

34 Communication plan / stakeholder involvement / patient engagement Richmond CCG has just completed an engagement on quality in primary care exercise that is included in the primary care strategy. Assurance Regular updates to the primary care commissioning committee and governing body. CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final D - 4 Date:

35 Richmond CCG Primary Care Strategy Title to be agreed. Comments to: Kathryn MacDermott Director Primary Care & Planning 1

36 Contents 1. Introduction from RCCG Chair Foreword Summary Our vision Definition of primary care Current services Health in Richmond Why do we need a primary care strategy? Priorities for primary care in south west London Commissioning intentions Delivery Primary care at scale, comprehensive population coverage: co-ordinated and pro-active care Primary care at scale, extended access Building sustainable primary care in Richmond Quality Communications and engagement Information management and technology (IM&T) Workforce Estates Primary Care finance plan Locally Commissioned Services Annual implementation plan for 2018/

37 1. Introduction from RCCG Chair To be added 2. Foreword This strategy seeks to set out the key areas of development for Primary Care in Richmond. This strategy is deliberately written at a high level and aims to describe the key areas of focus for RCCG. It will be underpinned by annually update implementation plans that will set out the key outcomes to be achieved, how, when and by whom. This strategy has been developed co-productively with the CCG membership whom have received and updated iterative drafts through the Membership Forum, Clinical Networks, a joint RGPA/LMC/Clinical network workshop, the CCG primary care commissioning committee, clinical executive team and patient participation group network meetings. The strategy has also drawn on the outcomes of the Quality in Primary care engagement programme that we have conducted from September 2017 to February At a London level, we have also just received The Next Steps to the Strategic commissioning framework that introduces an increased focus on primary care at scale. We know that our primary care teams, including wider primary care professionals, are working under increasing pressures and demand for their time. Primary care has been a key contributor to efficiency in the NHS and our local healthcare economy, and we need to ensure that we continue to promote this. We know that general practitioners and their teams will work differently in the future if we are to achieve the best outcomes for our local populations, and therefore we need to support general practices and wider primary care providers to adapt and innovate. Richmond CCG want to create the culture and conditions for primary care services and staff to deliver the highest standard of care and ensure that valuable public resources are used effectively to get the best outcomes for individuals, communities and society for now and for future generations. We are working with the Hounslow & Richmond Community Health (HRCH) and the Richmond General Practice Alliance (RGPA) to introduce new models of integrated care. Primary care services are integral to the development and delivery of these new models and we strongly believe that new models of care, will be GP led. This strategy sets out what is needed to enable primary care fulfil its role now and in the future. Transforming primary care includes all services delivered by primary care including routine, urgent and any other services delivered in primary care. It includes the provision of specialist care by GPs with a specialist interest where this is commissioned directly by NHSE and specialist care commissioned locally as enhanced services or local incentive schemes. The transformation of general practice in Richmond is a key strategic priority to support the full implementation of the South West London Sustainable & Transformation Plan (STP), Richmond s Outcomes Based Commissioning (OBC) programme, and the Richmond Urgent and Emergency Care Strategy. Improvements in quality and accessible primary care can 3

38 enable reductions in A&E attendances and non-elective admissions, as well as deliver holistic care planning, co-ordination and continuity which are founding principles for general practice in the UK. The future of our services will be shaped through collaboration, engagement and co-design with general practices, health and social care professionals, patients via local patient participation groups (PPGs) and the wider local community. In particular, we wish to support primary care s ability to enable our population to Start Well, Live Well and Age Well, to strengthen our opportunities to prevent future ill-health (or the exacerbation of existing conditions) and to develop patients abilities for self-care via access to appropriate information from community pharmacies, GP practices and the voluntary sector. 3. Summary Plain English version. Include You said we did. We will continue to work closely with and support our GP federation (the Richmond General Practice Alliance, a partnership of all GP practices in the borough) and Richmond Community Education Provider Network, as a means of developing local collaboration, training and workforce development opportunities across general practices. This document sets out the key strategic drivers and the current challenges we face current and the proposed direction of travel. It also sets out priority actions, the investment required and includes an annually updated implementation plan that is consistent with delivery of the GP Forward View, NHSE London s The Next Steps for the Strategic Commissioning Framework, the South West London s Transforming Primary Care programme as part of our Health and Social Care Partnership plan and Richmond s Joint Health and Wellbeing Strategy. 4. Our vision To put patients at the heart of service delivery using their experience to reshape, improve and transform services, whilst ensuring service are sustainable and affordable. Primary care is fundamental to the delivery of effective out of hospital services across Richmond and south west London and key to addressing the issues that we know are facing our local populations. We have a vision that supports the delivery of services through primary care networks, where services are best delivered at scale, and localised general practice (list-based care) for 4

39 care best provided very locally. Whether at scale or locally provided care will be focussed on quality driven, minimises variation and provides a consistent offer. 5. Definition of primary care Primary care is care provided in the community for people making an initial approach to a medical practitioner or clinic for advice or treatment. In the NHS, this is usually general practice (GP services). Other primary care services include dental practices, community pharmacies and optometrists, allied health professionals, physician s assistants and nurses. 6. Current services Among the national challenges facing the NHS and those of relevance to the borough of Richmond, are our ageing population with an increasingly higher life expectancy, growth in the number of people with long-term and complex health conditions, increases in social isolation across socio-economic groups, and a corresponding rise in public demand and expectations (Darzi 2008; NHS Five Year Forward View, 2014). In the borough of Richmond, there are 28 general practices with a total registered population of 214,155 patients (Jan 2017). Overall, the general health and wellbeing of our local population is above average and we will seek to build on and optimise this further. The local joint Health and Wellbeing Board strategy includes several initiatives that are important for delivery of good health outcomes. 5

40 7. Health in Richmond The below picture of health in Richmond is taken from the 2016/17 JSNA. The red text is an update on the stats. Currently with the comms team to convert into pics as below: 6

41 The 2017/18 JSNA has the below figs: Population 194,730 Life expectancy at birth o 82 years for men (1.8 years greater than London) o 85.4 years for women (1.3 years greater than London) A borough with some of highest performing primary and secondary schools in the country Safest London borough for violent crime o 4 th out of 32 for crime overall 80% working-age adults are in employment the highest rate in London 49% volunteer highest rate in London (26%) Open spaces o 40% of the borough, 100+ parks, 21 miles of river frontage o 23,000 bike journeys every day in the borough, 2 nd out of 33 in London 7

42 Start well The rate of A&E attendances (0-4 years) has increased steadily the last three years, from 518 per 1000 in 2013/14 to 732 per 1000 in 2015/16. This is now significantly higher than both the England average (588 per 1000) and the London average (707 per 1000) The average mental wellbeing score for 15-year-olds in Richmond is the fourth worst in London Prevalence of smoking in 15-year-olds, is 14.3%, which is more than twice the London average (6.1%), and 36% of 15-year-olds have tried smoking, the highest rate in England. 15-year-olds in Richmond drink more regularly than in any other London borough 9% are regular drinkers and 25% reported being drunk in the previous 4 weeks. Nearly one in five (19%) 15-year-olds in Richmond report having tried cannabis, the highest proportion in London, and third highest in the country (London and England averages 11%) In 2015/16, there were 90 hospital admissions because of self-harm in those aged year-olds, which equates to the third highest rate in London Live well 18,000 adults smoke 35% of adults drink more than the recommended 14 units of alcohol a week 22,000 people have a common mental disorder, such as depression and anxiety and there 6,517 adults identified with depression by GP More than 50% of over 16-year-olds are overweight or obese, with 19% of people in Richmond having said that they do not take part in any physical activity Nearly one in three people registered with a GP in Richmond has one or more longterm condition and nearly one in ten has three or more. National prevalence models 8

43 suggest that large numbers of people with long term conditions are undiagnosed in Richmond (e.g. 2,700 people with undiagnosed coronary heart disease, and 4,850 people with undiagnosed diabetes). Age well The population is ageing; the number of people aged 65 years or over is projected to increase by almost 50% in the next 20 years (from 28,900 in 2015 to 43,100 in 2035) It is estimated that 2,072 Richmond residents have dementia. Only 64% of people with dementia have received a formal diagnosis, which is higher than the national average but lower than the London average and below the target of 66%. Comorbidity is high, with 70% of people with dementia having one or more other long term conditions Of the population aged 85 years and over, only 34% received a council funded service at home and 7% in a care home, meaning that approximately 2,400 (59%) people aged 85 years and over are either not receiving care or are arranging care for themselves. The average age older people start to receive council-funded social care at home is 84, and 87 for people in care homes. It is estimated almost half of people aged over 75 years in Richmond live alone (6,621 people). An estimated 14% (3,442) of older people in Richmond borough are carers, providing help and support to a partner, child, friend, relative or neighbour due to age, physical or mental illness, addiction or disability. 8. Why do we need a primary care strategy? General practices in the borough of Richmond already provide a good standard of care. Quality care is achieved by focusing on the three domains of quality which are defined as: Patient safety Clinical effectiveness Patient experience Quality will also be the thread linking each work stream of the primary care strategy to ensure that we: Embed quality in the design stage of each service Ensure quality in delivery Provide quality assurance 9

44 We will build upon the work we inherited from NHS England commissioners to provide a quality improvement tool to support us to reduce variation in outcomes and service delivery, improve performance and support practices to undertake actions required to achieve high quality care. Primary care needs to be fit for purpose and able to adapt and respond to the transformation of out of hospital care and the urgent and emergency care strategy. Richmond CCG will develop a primary care dashboard aligned with our overall strategic vision to achieve high quality primary care for the benefit of all our population. Our priority objectives include: Ensuring our services are safe Effective Caring That we are responsive to people s needs That services are well led Establish sustainable primary care services Develop primary care at scale (part of sustainability) Effective patient engagement Provide comprehensive population based care that is accessible, coordinated care and pro-active care. We will achieve these through: Taking a collaborative approach Setting out patient and general practices responsibilities Promoting self-help and self-care Promoting and enabling ownership of one s own health and well-being Be effective in delivering key outcomes Working to reduce health inequalities and variation in outcomes and service delivery Improving the patient experience, including accessibility Providing value for money Monitor our service regularly to ensure all the above 9. Priorities for primary care in south west London Richmond CCG is proud to be part of the South West London Primary Care Collaborative to support primary care that: Is enabled to take collective responsibility for the health of the population and support a consistent, quality driven offer across our patch through both local, generalist general practice and primary care services delivered at scale 10

45 Is key to co-ordinating care in communities and working more pro-actively with community services, mental health, dental, ophthalmic, social care and specialist services, amongst others. Embrace new roles such as physician associates, practice pharmacists and care navigators and supports practice nurses, practice managers, PAs and receptionists who in turn can better assist GPs in their role Demonstrates an increase in the use of technology to create additional capacity and access The SWL plan aims to deliver resilient general practice, operating at scale and harnessing opportunities to underpin delivery of quality of care, good clinical governance and systems of clinical quality improvement. The plan includes four enablers: (1) Financial Transformation funding Operating at scale to reduce costs (2) Demand Self-management, education, prevention, social prescribing Technology solutions Alternative operating models (3) Estates and IT New commitment to primary care estate Online General Practice System interoperability Safe sharing of data and information (4) Workforce New roles Supported, empowered workforce Feeling valued The framework for delivery is in development and includes placing general practice at the heart of an integrated case system and considers how best to deliver care at a general practice level, through a primary care network, or via the federation RGPA. The illustration below attempts to visualise the SWL framework: 11

46 London has been unique in developing a primary care transformation fund to support delivery of the transformational change needed to deliver resilient general practice, operating at scale. Across London there is significant variation in the at scale models currently delivered or in development across CCGs. Some CCGs in London have well developed contracting models that are based at a locality, or pan borough delivering efficiency savings and creating resilience. Some CCGs have well developed clinical models, with locality MDTs (such as OBC) well embedded and a variety of pilots for rapid access to same day appointments such as the extended primary care services provided by RGPA in Teddington Memorial Hospital and Sheen Lane Health Centre. The challenge for the London CCGs is to develop a primary care provider landscape that delivers a more comprehensive clinical model through an at scale contracted model to a population at locality level (30-50k) or larger. Richmond CCG will need to work with its practices in early 2018/19 to understand how as practices they want to work together to deliver the local priorities within the overall primary care at scale ambition. 10. Commissioning intentions We aim to deliver high quality general practice services that are delivered in either each general practice or shared across networks to ensure that all Richmond patients have access to high quality, safe and appropriate care. Richmond primary care will deliver: 12

47 Comprehensive population coverage. Working at scale in locality based multi-disciplinary teams providing a service to all vulnerable patients and agreed pathways of care. Supported by shared care records and IT solutions. Co-ordinated care to identify patients who would benefit from care continuity, provide them with a named clinician responsible for their care co-ordination and the development of a holistic care plan, which will be shared with appropriate services involved in the patient s care. Patients will be regularly reviewed by a multidisciplinary team involving health and social care professionals who will co-ordinate the care they receive from the GP practice as well as linked services. We will link into the local ambulance service to identify frequent attenders and work closely with practices and community services to identify how we could manage them better in primary care. Accessible care through general practice, community pharmacies, out-of-hours services, access hubs (offering seven-day access, 8am 8 pm general practice services), with additional services available through NHS 111. We aim for patients to be able to book appointments online and via the use of mobile apps and to be able to access their medical records in a similar manner. Using touchscreens in practices to allow patients to check in on arrival will also become more prevalent. Such measures will reduce the burden on reception staff and the frustration that patients experience when trying to access healthcare. Pro-active care through our outcomes based commissioning work on pathways for the care of frail elderly patients, people with diabetes, respiratory and cardiology conditions, and end of life care. This work is already underway, co-designing pathways with clinicians, patients and their carers with direct knowledge of our local services, and bringing together primary, community and third sector organisations to work collaboratively. We will be working closely with the Council on preventative work-streams to reduce the burden on healthcare services in the longer term. As an example, improved detection of hypertension and atrial fibrillation with blood pressure (BP) machines in GP practice receptions, community pharmacies and shops and opportunistic pulse checks will help us to proactively detect and manage these conditions and reduce the incidence of strokes. We will look at investing in self-management via the use of apps such as symptom checker and sign post appropriately so that patients are encouraged to take some responsibility for their own health thereby reducing some of the demand on GP appointments. 11. Delivery 13

48 11.1 Primary care at scale, comprehensive population coverage: coordinated and pro-active care RCCG is currently developing its approach to locality based MDT working with HRCH and RGPA. Integrated multidisciplinary teams (MDTs) supporting populations of circa 50k, centred around primary care and including community health, social care, mental health, acute specialists, pharmacy / medicines management and other partners including the voluntary sector. Locality MDTs deliver care to the whole population appropriate to their needs with a specific and initial focus on a defined cohort with complex needs and at high risk of admission to hospital. This is delivered through an integrated model of care that effectively supports the cohort of individuals with complex needs by bringing together a MDT tailored to their individuals needs drawn from primary and community care, social care, pharmacy, secondary/specialist care and tailored to the individual s needs. This will include a single integrated care plan led by a care coordinator supported by an integrated digital care record accessible electronically by all members of the team and partners. The locality MDTs will provide a single point of access to health and care support for all members of the locality. They will use up to date needs assessments to understand the needs of the population in each locality, including the broad numbers with high and complex needs, and use this to shape the locality team and models of care. Practices will use a risk stratification tool to identify patients with complex health and social care needs and high risk of hospital admission. Once complex patients are identified integrated care planning for the individual care is completed with wider the MDT, including intermediate and crisis care providers and hospital discharge teams, identifying where there is an ongoing care need and would benefit from an MDT approach. 14

49 The role of general practice within this is to provide the clinical leadership and work with other providers to provide the integrated model, use the risk stratification tool to identify patients with complex health and social care needs and high risk of hospital admission. The primary care network or integrated care system describes a number of practices that are working together to support identified cohorts of patients, by pooling clinical expertise and staff the at scale working enables all practices within a locality or network to benefit from the skills and expertise of all providing higher quality care and creating a more sustainable local system The locality teams will use risk stratification to identify vulnerable patients whom would benefit from a MDT approach. 15

50 The locality model seeks to support the development of primary and community care to enable the shift from an acute based model to a proactive planned approach and alternative care settings. This is a complex transformation programme that involves engagement and ownership by multiple partners across the system including primary care, community, social care, secondary care and the voluntary sector. It is recognised that there is a need for significant workforce transformation and the opportunity for the development of new roles. Richmond CCG has commissioned the 16

51 programme of transformation work known as Outcomes Based Commissioning that is developing locality models of care. Primary care networks will support patients with complex physical and mental health needs. Patients will have access to extended appointments at least annually to develop and update care plans. These appointments will include the wider MDT where clinically appropriate. Patients will be able to book ahead for appointment with their named GP and be supported with urgent and routine secondary care advice from their GP, via Kinesis (or similar system). They will have access to advice on LTC management without needing to make a GP or clinical appointment and have access to GP specialisms across Richmond through RGPA provided services e.g. a GP who has an expertise in diabetes will be provide care to complex patients across Richmond. Patients will be treated through clearly defined pathways, including to other services (including fast track) where required. The management of their care will be discussed by MDTs that meet on an appropriate frequency to care for their high-risk patients. The staff make-up of the MDT will be dependent on a patient s needs. Patients will have named social / social care workers who will work as part of the MDT to carry out joint assessment and care planning and coordination and facilitate access to social care services for those who need them and have access to appropriate self-management education and expert patient s programmes Primary care at scale, extended access London s ambitious vision outlined in The Next Steps of the Strategic Commissioning Framework can only be delivered through providers working at scale in larger primary care organisations, to enable them to increase their capacity and capability and support sustainability across the NHS. This new way of working will enable providers to benefit from shared economies of scale across services, functions or infrastructure. Richmond CCG will continue to commission extended primary care service, 8am to 8pm, 7 days a week. The current co-located, but separate primary care hub and walk in centre located in Teddington Memorial Hospital will be redesigned as one Urgent Treatment Centre (UTC). A primary care centre offering booked GP and nurse appointments will operate from Sheen Lane Health centre. In 2018 we will complete an audit of the extended primary care services with a view to maximising opportunities for The traditional model of offering 10 minute appointments cannot be sustained as demand continues to increase. Local practitioners maintain that as needs become more complex, 17

52 sufficient time is required to undertake holistic care to reduce the frequency of appointments. Other patient groups may require less than 10 minute appointments or advice slots, and alternative models, e.g. offering telephone, or video-based Skype consultations may help to facilitate this. Our experience of extended GP access, offering GP consultations from 8am to 8pm seven days a week, shows the benefits of commissioning some general practice services at scale to serve the whole population, provided by local high-calibre clinical practitioners. The Richmond GP Alliance (RGPA) has developed an integrated IT system to allow record sharing between all general practices within the borough. We will build on this further as part of the SWL Interoperability programme of work to enable record sharing between primary and secondary care. Also, our achievements with GP Online Services, through which people can book GP appointments, order repeat prescriptions and view aspects of their medical records online, has allowed us to build on IT opportunities and streamline access to care Building sustainable primary care in Richmond The narrative in The Next Steps to the Strategic Commissioning Framework focusses very clearly on building sustainable general practices fit for the future. A key enabler for this is seen to be the delivery of primary care at scale. In Richmond, we recognise that the pressures on practices will mean that practices will need to work together in networks to provide resilience across practices and deliver comprehensive population coverage. The aim of this strategy and the detailed implementation plan for 2018/19 will be to support the development of primary care at scale and how providers are going to deliver services through Primary Care Networks, which provide comprehensive population based care in place by the end of 2018/19. RCCG will work with RGPA and member practices to establish services (back office) that could best be provided either once across Richmond via RGPA or at locality levels across network of practices Quality In 2018/19 Richmond CCG commissioned an engagement exercise on Quality in primary care was carried out with patients and public living in the boroughs, as well as primary care staff working in GP practices and pharmacies. Members of the public were invited to give their views on the most important aspects of quality in GP and pharmacy services. The information was gathered via comment cards, an online survey and guided conversations with individuals or groups at local venues and events. The aim of this piece of work was to understand how quality is defined by patients and staff. The findings from this engagement piece have been cross referenced with the outcomes from other previous local engagement activity. The overall insights will be used to inform the refresh of the Primary Care Strategy. The key findings of the engagement exercise included: 18

53 There were several themes which were felt to contribute to quality in GP practices. Many of these themes were consistent across both patients/public and primary care staff in GP practices. The skills and patient management of the GP, the appointment booking process, having quick access to appointments were all common themes that emerged and were felt to be important aspects of quality. Choice of doctor and time given for the appointment was also a theme related to quality and this was particularly important for those with specific needs or disability. Other themes of importance related to the practice environment and provision of services to support patients in prevention. In addition to the shared view of quality themes that affect the patient experience, primary care staff noted other themes. These related more to elements of effective management of the service, efficient service delivery, clinical skills and team support. Many patient and public respondents acknowledged that GPs are under pressure and there appeared to be a shared view on the patient s role and responsibility in helping practices to deliver a quality service. Patients who felt it was important to be seen quickly did so because they would not call a GP for an appointment unless it was necessary and would not expect to be seen on the same day unless they were feeling unwell and it was urgent. The main emerging themes around patient responsibility related to ensuring patients keep to appointments, turn up on time and cancel appointments if no longer required. Most of these themes were shared amongst primary care staff and respondents representing patients and public. Practice staff explained that there is a place for setting clear expectations so that patients are made aware of the importance of their responsibility in helping the practice to run effectively and on time. Both patients and staff felt it was important to be aware of, access, other services that can give medical advice and relieve the burden on GPs, for example pharmacies and 111. Those with specific needs, for example carers, young people, individuals with a disability, placed an emphasis on certain aspects of quality to ensure their experience is positive. This included ability to choose a doctor, quick access to appointments and not being rushed in their appointment. Patients thought the important aspects of quality were the skills of the pharmacists in being knowledgeable, having a good stock of medication, a prompt and efficient prescription service and advice on alternatives to replace or complement medication. Patient and public respondents defined quality in pharmacies by referencing good customer service skills such as helpful, discrete, caring. 19

54 The findings about pharmacies also revealed that many patients visited their pharmacy to receive advice about minor ailments and illnesses in the first instance. They opted to do this instead of opting to book an appointment to see a GP. Comments from patients showed that they would rather opt to see a pharmacist as they can access health advice quicker and did not want to burden the GP unnecessarily. The small number of Pharmacists who responded to the survey also indicated that they played an important role in providing triage advice and services to help support GPs such as vaccinations, blood pressure testing. Overall the quality themes relate to patients having a positive experience by having confidence in the skills of the health professional and being satisfied with the service provided. Within this there are four main areas of quality to which the themes have been applied; interpersonal skills, communication, treatment and systems/organisation. CCGs are invited to consider the quality themes that have emerged from this engagement work and use it to inform its future work in pursuing a quality drive across the boroughs. The primary care strategy implementation plan for 2018/19 will include a dedicated section on taking forward the recommendations from the Quality in Primary Care report. Across primary care, there are a range of measures available to understand local performance and quality; some based on patient experience (for instance the annual GP patient survey, or the regular friends and family test), and others based on clinical reporting. These include: Richmond CCG aims to reduce unwarranted variation in all aspects of quality and to bring measurable standards up to those of the best of local and national general practice. For patients and the public this will mean: They will receive the same high quality, safe service regardless of where they are registered or who they see They will have an improved experience of accessing general practice Their views are welcomed and are part of the solution to supporting successful general practice. For practices this will mean: Assurance that there is a focus on meaningful measures of high quality care An increase in the amount and quality of patient views Ensuring the sharing of learning from incidents, complaints, etc. Supporting the implementation of new national guidance and local best practice. In partnership with local practices, and our Quality Committee, we will develop a quality framework to inform the work of our new Primary Care Commissioning Committee. This will focus on a range of key quality domains to improve quality and safety, as follows: 20

55 11.5 Communications and engagement This plan has been coproduced with RCCG Membership through its Membership Forum and Clinical Networks, with RGPA and Surrey and Sussex LMC, patients and Richmond Healthwatch through the Patient Participation Group Network. Key messages have been fed back that the CCG needs a dedicated primary care communications strategy. This will be drafted following agreement of this primary care strategy Information management and technology (IM&T) IM&T is essential to improving and supporting the patient experience and pathway within primary care. The primary health care information/records system provides vital clinical records support, as well as a public health and quality (QOF) overview of a practice s population. In addition, it assists clinical staff to manage conditions safely and systematically. If systems are clinically supported, they should have a focus on patient care rather than administrative processes. Richmond CCG, in consultation with GP practices, suppliers and key stakeholders, will aim to ensure that all practices have robust, wellfunctioning clinical systems. Feedback from practice managers and clinicians indicates that the IT support to practices needs to be strengthened. In 2018/19 RCCG has provided additional GP IT facilitation support to practices via RGPA. Over 2018/19 we will consider the need and opportunities for 2019/ Workforce The creation of our Community Education Provider Network (CEPN) enabled the start of: A systematic approach to improving workforce development, introducing and expanding student placements and co-ordinating access to continuing personal and professional development (CPPD) for all staff Facilitation of enhanced partnership working between practices, the CCG, higher education providers and Health Education South London Enhanced sharing of resources and partnership working While significant progress has been made to increase placement capacity and facilitate expansion of the practice team to include student nurses and community pharmacists (amongst other innovative experiments in inter professional supervision), Richmond CEPN s long-term vision is to: create a sustainable infrastructure which integrates workforce planning and development with service requirements for the benefit of the population that we serve, across primary and community care providers. 21

56 The CCG and Council, recognise the workforce challenges that local GP practices currently face, and will increasingly face as staff approach retirement. We need to address the immediate pressures while improving recruitment and retention, supporting succession planning and seek to expand the role of other primary care professionals, including physician associates, practice and community pharmacists, care navigators, nurse practitioners, and other allied practice staff. Our planning needs to consider links to all healthcare professionals within an integrated health and social care model including hospital and community services, pharmacists and the wider community workforce. Primary care at scale provides opportunities to consider new ways of working across practices and new types of roles. RCCG will continue to work with RGPA and CEPN to develop and deliver a workforce training and development strategy Estates Our vision for estates is that there needs to be a strategic and proactive estates planning process, which can support both the sustainability of local primary care services and the cost-effective investment across the NHS estate. This work will be driven by the Richmond local estates strategy, which will focus on future requirements to ensure that both general practice and the wider health estate are fit for purpose and strategically located. To ensure that Richmond CCG maintains a clear overview of GP estate issues, a regular GP premises group has been established, with membership from NHS England, the Healthy Urban Development Unit (HUDU), NHS Property Services (NHSPS) and the London Borough of Richmond-upon-Thames (LBRuT). Through the GP premises group, Richmond CCG aims to support and enable: Better service integration which improves patient experience and service efficiency, and helps to deliver better health outcomes for patients New service models to deliver more services in community settings The release of savings and achievement of value for money through the optimum use of healthcare premises, conveniently located for patient services and able to accommodate the appropriate skill-mix of clinicians in the right care setting Strategic planning for general practice (and the wider NHS community and secondary estate) has been fragmented over recent years, with changes in organisational responsibility for estates affecting the system s ability to plan strategically. Our responsibility to commission local services through the powers of delegated commissioning brings an opportunity to improve the co-ordination of estates planning and to respond to some of the associated challenges and opportunities locally. These include: Acting on the results of the ongoing condition and utilisation surveys of general practice premises Using the opportunity of the Estates and Technology Transformation Fund to submit appropriate bids for central investment in local estates and IM&T facilities 22

57 Using the opportunity of the London Improvement Grants to support practices submit appropriate bids 23

58 12. Primary Care finance plan To be included when delegated primary care allocation confirmed. 13. Locally Commissioned Services Locally commissioned services are primary care services commissioned by Richmond CCG over and above the services required in the GMS contract. In Richmond the locally commissioned services are all commissioned from general practices. Richmond CCG invests over 2m in its locally commissioned services. The list of locally commissioned services includes: 1) Anti-coagulation 2) Cancer Care 3) Complex Leg Ulcers 4) Complex Needs 5) Diabetes 6) Diagnostics 7) Extended Hours 8) Hormone Injections 9) Wound Management 10) Shared Care 11) Referral Management 24

59 12) Bowel screening 13) Mental Health depot 14) Respiratory Take up at a practice level varies considerably with a high number of practices choosing not to deliver the cancer care and complex needs LCS. This means that we are not proving comprehensive population coverage of our locally commissioned services. In 2016 an independent review of the locally commissioned services was completed with a list of recommendations. RCCG has made a commitment not to change the LCSs in 2018/19. We will use quarter 1 and 2 to update the LCSs for the 2019/20 onward contract and have made the commitment that the new contract will be a 3-year contract to provide stability to local practices. As part of this review we will consider the current list of locally commissioned services and whether the current list provides the maximum health benefit for patients, the best value for money and contributes to the delivery of this primary care strategy. 25

60 14. Annual implementation plan for 2018/19 To be further developed with RGPA, Membership and the PPG network. Comprehensive population coverage. Outcome Actions Timescale Enablers Comprehensive population coverage Milestones for 2018/19 to be identified and agreed and aligned with Local Transformation Board and SWL Strategic Transformation Partnership finance model to avoid duplication Co-ordinated care Agree locality model Outline model identified Mental Health Engagement Community Matron Continuous Professional Development event Training set up for care co-ordination and planning function Care and Support Plan Training Implementation of Sollis risk stratification Mapping of working age mental health pathways in Richmond. April 18 Initial training dates planned for April Commissioned April 2018 Completed. Workforce training MDT working and support planning key elements. Workforce training SWL Interoperability care record 26

61 Outcome Actions Timescale Enablers HRCH Transformation Team to attend case management April 18 workshop in Kingston Additional joint work agreed to map mental health pathways for older adult services. Social Care Engagement Proposal made to test in one Locality, sharing of high user data between health and social care and running MDTs in co-located office. Awaiting decision from LBRuT Head of Performance in Adult and Children s Services. Locality Working Workshop March 2018 attended by mental health, primary care, social care and voluntary sector representatives. Establishing Richmond Locality Partnership meeting to support the co-production of the model between commissioners and provider organisations. RGPA board workshop discussed and agreed leadership approach. GP locality lead role also discussed with agreement to produce draft role outline for review and approval to allow implementation from 07/04. Implementation April 18 Accessible care Agreement on e-consultations Agreement led at SWL Q1 Pro-active care Establish joint programme of work with LA, HRCH GPFV investment 27

62 Extended access Primary care networks Outcome Actions Timescale Enablers UTC designation End of Q1 East PCCC operational April 18 Access specifications End of Q1 HLP draft specification Hub audit End of Q1 Back office functions End of Q2 RGPA Engagement with general practice on the primary care End of Q2 PCAS Transformation at scale proposals Investment Implementation of primary care at scale model(s) Q3 PCAS Transformation Investment Quality Quality pledges workshop End of Q2 Led at SWL level Workfor ce Information managemen t and technology (IM&T) International recruitment programme Clinical pharmacist programme Confirm NELCSU GPIT support April 18 Contract held by NEL CSU Agree focus of additional RCCG provided GPIT support April 18 ETTF investment GPIT strategy Q1 Estates Refresh of RCCG estates strategy GP Relationship Managers 28

63 29

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65 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing body in public Date Report Title National staff survey results for Richmond CCG Agenda Item 2.2 Attachment E Purpose (please indicate with X) Approval/ Ratification Discussion / Comment Information x Report Author: (name & job title) Vicki Harvey-Piper Director of Corporate Affairs & Governance Presented by: (name & job title) Vicki Harvey-Piper Director of Corporate Affairs & Governance Summary and purpose of report The staff survey report summarises the findings from the national staff survey 2017, carried out by Picker Institute Europe, on behalf of Richmond CCG. The Picker Institute was commissioned by 58 CCGs to undertake the 2017 national staff survey. The response rate for Richmond CCG was 76%. The average response rate for the 58 'Picker' CCG organisations was 80%. The Ways of Working group has developed an action plan to address areas for improvement in the CCG which will also have benefits for both Kingston & Richmond CCGs now that they are co-located. The staff satisfaction surveys are a part of a wider staff engagement and organisational development programme which has the overarching aim to align activities across both CCGs in light of the establishment of a local delivery unit and co-location of both CCGs at Thames House in Teddington. These include internal communications, HR processes such as appraisals, an induction programme and exit interviews and a shared learning and development programme. Key sections for particular note The top line staff engagement score for Richmond CCG has fallen marginally in the last year from 3.81 in 2016 to 3.71 in Richmond CCG compares most favourably with other similar organisations in the following areas: Percentage of staff attending work in the last three months despite feeling unwell because they felt pressure from their manager, colleagues or themselves Percentage of staff satisfied with the opportunities for flexible working patterns Percentage of staff experiencing physical violence from patients, relatives or the public in the last 12 months Staff satisfaction with the quality of work and care they are able to deliver Support from immediate managers The action plan focuses on those areas that have been identified where Richmond CCG compares least favourably with other CCGs. Version: Final E - 1 Date:

66 In Richmond the areas include: Percentage of staff experiencing bullying, harassment or abuse from staff in the last 12 months Quality of non-mandatory training, learning or development Percentage of staff agreeing that their role makes a difference to patients/service users Percentage of staff reporting good communication between senior management and staff Staff confidence and security in reporting unsafe clinical practice Report recommendation The report is provided for information. Financial and / or resource implications N/A Key risks identified & mitigation N/A Equality and / or privacy impact analysis N/A Committees that have previously discussed / agreed the report and outcomes The results and action plan were discussed at the ways of working group and executive management team. Communication plan / stakeholder involvement / patient engagement Staff will be kept up-to-date through Team Talk, team meetings, the intranet and staff updates. Feedback can be given to ways of working group representatives. The WoW group will oversee the delivery of the action plan. Assurance Does the report need to be taken to any additional meetings for further assurance or ratification? No. CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final E - 2 Date:

67 2017 National NHS staff survey Brief summary of results from NHS Richmond CCG

68 Table of Contents 1: Introduction to this report 3 2: Overall indicator of staff engagement for NHS Richmond CCG 5 3: Summary of 2017 Key Findings for NHS Richmond CCG 6 4: Full description of 2017 Key Findings for NHS Richmond CCG (including comparisons with the organisation s 2016 survey and with other CCGs) 14 2

69 1. Introduction to this report This report presents the findings of the 2017 national NHS staff survey conducted in NHS Richmond CCG. In section 2 of this report, we present an overall indicator of staff engagement. Full details of how this indicator was created can be found in the document Making sense of your staff survey data, which can be downloaded from In sections 3 and 4 of this report, the findings of the questionnaire have been summarised and presented in the form of 32 Key Findings. These sections of the report have been structured thematically so that Key Findings are grouped appropriately. There are nine themes within this report: Appraisals & support for development Equality & diversity Errors & incidents Health and wellbeing Working patterns Job satisfaction Managers Patient care & experience Violence, harassment & bullying Please note, two Key Findings have had their calculation changed and there have been minor changes to the benchmarking groups for social enterprises since last year. For more detail on these changes, please see the Making sense of your staff survey data document. As in previous years, there are two types of Key Finding: - percentage scores, i.e. percentage of staff giving a particular response to one, or a series of, survey questions - scale summary scores, calculated by converting staff responses to particular questions into scores. For each of these scale summary scores, the minimum score is always 1 and the maximum score is 5 A longer and more detailed report of the 2017 survey results for NHS Richmond CCG can be downloaded from: This report provides detailed breakdowns of the Key Finding scores by directorate, occupational groups and demographic groups, and details of each question included in the core questionnaire. 3

70 Your Organisation The scores presented below are un-weighted question level scores for questions Q21a, Q21b, Q21c and Q21d and the un-weighted score for Key Finding 1. The percentages for Q21a Q21d are created by combining the responses for those who Agree and Strongly Agree compared to the total number of staff that responded to the question. Q21a, Q21c and Q21d feed into Key Finding 1 Staff recommendation of the organisation as a place to work or receive treatment. Q21a "Care of patients / service users is my organisation's top priority" Q21b "My organisation acts on concerns raised by patients / service users" Q21c Q21d KF1. "I would recommend my organisation as a place to work" "If a friend or relative needed treatment, I would be happy with the standard of care provided by this organisation" Staff recommendation of the organisation as a place to work or receive treatment (Q21a, 21c-d) Your Organisation in 2017 Average (median) for CCGs Your Organisation in % 76% 69% 55% 79% 82% 47% 66% 51% 48% 59% 49%

71 2. Overall indicator of staff engagement for NHS Richmond CCG The figure below shows how NHS Richmond CCG compares with other CCGs on an overall indicator of staff engagement. Possible scores range from 1 to 5, with 1 indicating that staff are poorly engaged (with their work, their team and their organisation) and 5 indicating that staff are highly engaged. The organisation's score of 3.71 was below (worse than) average when compared with organisations of a similar type. OVERALL STAFF ENGAGEMENT This overall indicator of staff engagement has been calculated using the questions that make up Key Findings 1, 4 and 7. These Key Findings relate to the following aspects of staff engagement: staff members perceived ability to contribute to improvements at work (Key Finding 7); their willingness to recommend the organisation as a place to work or receive treatment (Key Finding 1); and the extent to which they feel motivated and engaged with their work (Key Finding 4). The table below shows how NHS Richmond CCG compares with other CCGs on each of the sub-dimensions of staff engagement, and whether there has been a significant change since the 2016 survey. Change since 2016 survey Ranking, compared with all CCGs OVERALL STAFF ENGAGEMENT No change! Below (worse than) average KF1. Staff recommendation of the organisation as a place to work or receive treatment (the extent to which staff think care of patients/service users is the organisation s top priority, would recommend their organisation to others as a place to work, and would be happy with the standard of care provided by the organisation if a friend or relative needed treatment.) KF4. Staff motivation at work (the extent to which they look forward to going to work, and are enthusiastic about and absorbed in their jobs.) KF7. Staff ability to contribute towards improvements at work (the extent to which staff are able to make suggestions to improve the work of their team, have frequent opportunities to show initiative in their role, and are able to make improvements at work.) No change No change No change! Below (worse than) average Average! Below (worse than) average Full details of how the overall indicator of staff engagement was created can be found in the document Making sense of your staff survey data. 5

72 3. Summary of 2017 Key Findings for NHS Richmond CCG 3.1 Top and Bottom Ranking Scores This page highlights the five Key Findings for which NHS Richmond CCG compares most favourably with other CCGs in England. TOP FIVE RANKING SCORES KF18. Percentage of staff attending work in the last 3 months despite feeling unwell because they felt pressure from their manager, colleagues or themselves KF15. Percentage of staff satisfied with the opportunities for flexible working patterns KF22. Percentage of staff experiencing physical violence from patients, relatives or the public in last 12 months KF2. Staff satisfaction with the quality of work and care they are able to deliver KF10. Support from immediate managers For each of the 32 Key Findings, the CCGs in England were placed in order from 1 (the top ranking score) to 69 (the bottom ranking score). NHS Richmond CCG s five highest ranking scores are presented here, i.e. those for which the organisation s Key Finding score is ranked closest to 1. Further details about this can be found in the document Making sense of your staff survey data. 6

73 This page highlights the five Key Findings for which NHS Richmond CCG compares least favourably with other CCGs in England. It is suggested that these areas might be seen as a starting point for local action to improve as an employer. BOTTOM FIVE RANKING SCORES! KF26. Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months! KF13. Quality of non-mandatory training, learning or development! KF3. Percentage of staff agreeing that their role makes a difference to patients / service users! KF6. Percentage of staff reporting good communication between senior management and staff! KF31. Staff confidence and security in reporting unsafe clinical practice For each of the 32 Key Findings, the CCGs in England were placed in order from 1 (the top ranking score) to 69 (the bottom ranking score). NHS Richmond CCG s five lowest ranking scores are presented here, i.e. those for which the organisation s Key Finding score is ranked closest to 69. Further details about this can be found in the document Making sense of your staff survey data. 7

74 3.2. Summary of all Key Findings for NHS Richmond CCG KEY Green = Positive finding, e.g. there has been a statistically significant positive change in the Key Finding since the 2016 survey. Red = Negative finding, e.g. there has been a statistically significant negative change in the Key Finding since the 2016 survey. Grey = No change, e.g. there has been no statistically significant change in this Key Finding since the 2016 survey. For most of the Key Finding scores in this table, the higher the score the better. However, there are some scores for which a high score would represent a negative finding. For these scores, which are marked with an asterisk and in italics, the lower the score the better. Change since 2016 survey 8

75 3.2. Summary of all Key Findings for NHS Richmond CCG KEY Green = Positive finding, e.g. there has been a statistically significant positive change in the Key Finding since the 2016 survey. Red = Negative finding, e.g. there has been a statistically significant negative change in the Key Finding since the 2016 survey. Grey = No change, e.g. there has been no statistically significant change in this Key Finding since the 2016 survey. For most of the Key Finding scores in this table, the higher the score the better. However, there are some scores for which a high score would represent a negative finding. For these scores, which are marked with an asterisk and in italics, the lower the score the better. Change since 2016 survey (cont) 9

76 3.2. Summary of all Key Findings for NHS Richmond CCG KEY Green = Positive finding, e.g. better than average. Red = Negative finding, i.e. worse than average. Grey = Average. For most of the Key Finding scores in this table, the higher the score the better. However, there are some scores for which a high score would represent a negative finding. For these scores, which are marked with an asterisk and in italics, the lower the score the better. Comparison with all CCGs in

77 3.2. Summary of all Key Findings for NHS Richmond CCG KEY Green = Positive finding, e.g. better than average. Red = Negative finding, i.e. worse than average. Grey = Average. For most of the Key Finding scores in this table, the higher the score the better. However, there are some scores for which a high score would represent a negative finding. For these scores, which are marked with an asterisk and in italics, the lower the score the better. Comparison with all CCGs in 2017 (cont) 11

78 3.3. Summary of all Key Findings for NHS Richmond CCG KEY Green = Positive finding, e.g. better than average, better than 2016.! Red = Negative finding, e.g. worse than average, worse than 'Change since 2016 survey' indicates whether there has been a statistically significant change in the Key Finding since the 2016 survey. -- No comparison to the 2016 data is possible. * For most of the Key Finding scores in this table, the higher the score the better. However, there are some scores for which a high score would represent a negative finding. For these scores, which are marked with an asterisk and in italics, the lower the score the better. Appraisals & support for development Change since 2016 survey Ranking, compared with all CCGs in 2017 KF11. % appraised in last 12 mths No change! Below (worse than) average KF12. Quality of appraisals No change Average KF13. Quality of non-mandatory training, learning or development Equality & diversity * KF20. % experiencing discrimination at work in last 12 mths KF21. % believing the organisation provides equal opportunities for career progression / promotion Errors & incidents * KF28. % witnessing potentially harmful errors, near misses or incidents in last mth No change No change No change No change! Below (worse than) average Average Average Average KF29. % reporting errors, near misses or incidents witnessed in last mth KF30. Fairness and effectiveness of procedures for reporting errors, near misses and incidents KF31. Staff confidence and security in reporting unsafe clinical practice Health and wellbeing * KF17. % feeling unwell due to work related stress in last 12 mths * KF18. % attending work in last 3 mths despite feeling unwell because they felt pressure KF19. Org and mgmt interest in and action on health and wellbeing Working patterns KF15. % satisfied with the opportunities for flexible working patterns No change No change No change No change No change No change! Below (worse than) average! Below (worse than) average Average Below (better than) average Average Above (better than) average * KF16. % working extra hours No change! Above (worse than) average 12

79 3.3. Summary of all Key Findings for NHS Richmond CCG (cont) Job satisfaction KF1. Staff recommendation of the organisation as a place to work or receive treatment Change since 2016 survey No change KF4. Staff motivation at work No change Average KF7. % able to contribute towards improvements at work KF8. Staff satisfaction with level of responsibility and involvement No change No change KF9. Effective team working No change Average Ranking, compared with all CCGs in 2017! Below (worse than) average! Below (worse than) average! Below (worse than) average KF14. Staff satisfaction with resourcing and support No change! Below (worse than) average Managers KF5. Recognition and value of staff by managers and the organisation KF6. % reporting good communication between senior management and staff No change No change Average KF10. Support from immediate managers No change Average Patient care & experience KF2. Staff satisfaction with the quality of work and care they are able to deliver KF3. % agreeing that their role makes a difference to patients / service users No change No change KF32. Effective use of patient / service user feedback Violence, harassment & bullying * KF22. % experiencing physical violence from patients, relatives or the public in last 12 mths * KF23. % experiencing physical violence from staff in last 12 mths! Below (worse than) average Above (better than) average! Below (worse than) average -- Below (better than) average -- Below (better than) average KF24. % reporting most recent experience of violence * KF25. % experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 mths * KF26. % experiencing harassment, bullying or abuse from staff in last 12 mths KF27. % reporting most recent experience of harassment, bullying or abuse No change No change No change! Above (worse than) average! Above (worse than) average! Below (worse than) average 13

80 4. Key Findings for NHS Richmond CCG NHS Richmond CCG had 37 staff take part in this survey. This is a response rate of 76% 1 which is below average for CCGs in England (80%), and compares with a response rate of 89% in this organisation in the 2016 survey. This section presents each of the 32 Key Findings, using data from the organisation's 2017 survey, and compares these to other CCGs in England and to the organisation's performance in the 2016 survey. The findings are arranged under nine themes: appraisals and support for development, equality and diversity, errors and incidents, health and wellbeing, working patterns, job satisfaction, managers, patient care and experience, and violence, harassment and bullying. Positive findings are indicated with a green arrow (e.g. where the organisation is better than average, or where the score has improved since 2016). Negative findings are highlighted with a red arrow (e.g. where the organisation s score is worse than average, or where the score is not as good as 2016). An equals sign indicates that there has been no change. Appraisals & support for development KEY FINDING 11. Percentage of staff appraised in last 12 months KEY FINDING 12. Quality of appraisals 1 Questionnaires were sent to all 49 staff eligible to receive the survey. This includes only staff employed directly by the organisation (i.e. excluding staff working for external contractors). It excludes bank staff unless they are also employed directly elsewhere in the organisation. When calculating the response rate, questionnaires could only be counted if they were received with their ID number intact, by the closing date. 14

81 KEY FINDING 13. Quality of non-mandatory training, learning or development Equality & diversity KEY FINDING 20. Percentage of staff experiencing discrimination at work in the last 12 months KEY FINDING 21. Percentage of staff believing that the organisation provides equal opportunities for career progression or promotion Errors & incidents KEY FINDING 28. Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month 15

82 KEY FINDING 29. Percentage of staff reporting errors, near misses or incidents witnessed in the last month KEY FINDING 30. Fairness and effectiveness of procedures for reporting errors, near misses and incidents KEY FINDING 31. Staff confidence and security in reporting unsafe clinical practice Health and wellbeing KEY FINDING 17. Percentage of staff feeling unwell due to work related stress in the last 12 months 16

83 KEY FINDING 18. Percentage of staff attending work in the last 3 months despite feeling unwell because they felt pressure from their manager, colleagues or themselves KEY FINDING 19. Organisation and management interest in and action on health and wellbeing Working patterns KEY FINDING 15. Percentage of staff satisfied with the opportunities for flexible working patterns KEY FINDING 16. Percentage of staff working extra hours 17

84 Job satisfaction KEY FINDING 1. Staff recommendation of the organisation as a place to work or receive treatment KEY FINDING 4. Staff motivation at work KEY FINDING 7. Percentage of staff able to contribute towards improvements at work KEY FINDING 8. Staff satisfaction with level of responsibility and involvement 18

85 KEY FINDING 9. Effective team working KEY FINDING 14. Staff satisfaction with resourcing and support Managers KEY FINDING 5. Recognition and value of staff by managers and the organisation KEY FINDING 6. Percentage of staff reporting good communication between senior management and staff 19

86 KEY FINDING 10. Support from immediate managers Patient care & experience KEY FINDING 2. Staff satisfaction with the quality of work and care they are able to deliver KEY FINDING 3. Percentage of staff agreeing that their role makes a difference to patients / service users KEY FINDING 32. Effective use of patient / service user feedback 20

87 Violence, harassment & bullying KEY FINDING 22. Percentage of staff experiencing physical violence from patients, relatives or the public in last 12 months KEY FINDING 23. Percentage of staff experiencing physical violence from staff in last 12 months KEY FINDING 24. Percentage of staff / colleagues reporting most recent experience of violence KEY FINDING 25. Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months 21

88 KEY FINDING 26. Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months KEY FINDING 27. Percentage of staff / colleagues reporting most recent experience of harassment, bullying or abuse 22

89 Action plan following 2017 national staff survey Richmond CCG Areas identified as significantly worse than previous year or worse than other similar organisations KF26 Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months KF13 Quality of non-mandatory training, learning or development KF6 Percentage of staff reporting good communication between senior management and staff KF31 Staff confidence and security in reporting unsafe clinical practice 2016* Avg score 24% 10% in 2015 Action plan 48% 20% Promote open communication with managing director to convey message that bullying will not be tolerated (staff can speak directly with Tonia on issues they feel are not being addressed) Mandatory line manager training Review level of staff experiencing harassment, bullying or abuse at WoW group Promote access to anti-bullying guardian Promote access to HR business partner Conduct internal survey Develop learning & development programme following PDPs Increase opportunities for learning & development Raise awareness of learning & development policy Quality team is being offered training opportunities to support professional training requirements. 29% 50% Create managers toolkit to assist managers in addressing issues raised by team members. Invite senior managers to attend WoW group to listen and contribute to staff initiatives being discussed and addressed New team brief system being introduced across the Alliance from May which includes feedback mechanism SMT to discuss staff feedback regularly Continue to address health & wellbeing issues via the WoW group Particularly target work-related stress and stress management and review LDU-wide stress management policy Programme of activities to promote health and wellbeing Promote employee assistance programme EMT to monitor sickness absence Increase awareness of incident reporting process Raise profile of quality agenda eg through Team Talk *not all questions can be compared with the previous year s results as the question has changed emphasis.

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91 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing Body in public Date 1 May 2018 Report Title Update on physical and mental health outcomes based commissioning programmes Agenda Item 2.3 Attachment F Purpose (please indicate with X) Approval/ Ratification Discussion / Comment Information x Report Author: (name & job title) Sue Lear Deputy Director of Commissioning Amanda McGlennon Head of Mental Health Presented by: (name & job title) Julia Travers Director of Commissioning Summary and purpose of report This paper is provided to update governing body members on the progress of the physical and mental health outcome based commissioning programmes that have been developed in Richmond since The paper presents the programmes in two distinct sections as this is how the programmes have developed. However, the paper recognises that the focus going forward will be on the alignment and integration of physical and mental health within the emerging locality model. Key sections for particular note Update sections for physical and mental health and next steps Report recommendation The governing body is asked to note the contents of the report Financial and / or resource implications None for this report Key risks identified & mitigation None for this report Equality and / or privacy impact analysis Not developed for this paper Version: Final F - 1 Date:

92 Committees that have previously discussed / agreed the report and outcomes None Communication plan / stakeholder involvement / patient engagement Both programmes have had extensive stakeholder and patient involvement in the development of the models of care Assurance The governing body will receive regular updates as the programmes progress CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: x x x x x 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final F - 2 Date:

93 Richmond Outcomes Based Commissioning Update to Governing Body 1. Physical Health 1.1 Background In 2016 NHS Richmond CCG entered into a five-year outcomes based commissioning contract (OBC) with Hounslow and Richmond Community Health (HRCH) who have formed a joint venture with the Richmond GP Alliance and work in partnership with them as Richmond Community Health in Partnership (RCHiP). The initial two years were established as a transition period for the transformation. Since the contract has been signed the transition has been extended for a further year 2018/19. This transition period will allow for other transformation partners across the system to align to this contract. The CCG remains committed to the principles set out in the outcomes based contract seeking to move to the delivery of an integrated Out of Hospital Health and Social Care service model that: Incentivises providers to work together to meet the needs of the whole person; Treats people as close to home as possible; Keeps people living independently in the community; Prevents avoidable hospital admissions; Reduces length of stay in hospitals and avoids delays to discharge; Risk stratifies the population and matches prevention according to need; Invests in prevention and home based care; Evidences user and carer satisfaction; Addresses co-morbidities; and Provides access to urgent care in the community. So far additional Investment has been made through the OBC contract to develop 5 pathways; diabetes, respiratory, cardiology, end of life and frail elderly. 1.2 Diabetes community service The plan for development of the diabetes community service is an integrated service with shared ownership between primary care and the community service across a locality. It is intended to improve diabetic care in the community reducing in-patient episodes and diabetes complications. The success of the model is predicated on the discharge of stable diabetes patients from the community service to the management of primary care and the repatriation of patients from secondary care to the community service. The diabetes service is now established and operating from two hubs. The repatriation work has started but there is a need for enhanced clinical engagement to maximise this potential. 1.3 Respiratory community service Similarly, to the diabetes model more patients with long term respiratory conditions will be supported in the community. Primary care will manage those patients with mild to moderate disease with the community service supporting this work and managing more patients with severe disease. Improved management of patients will reduce attendances and potentially emergency admissions to hospital. The work in primary care for both respiratory and diabetes is incentivised through locally commissioned service arrangements. 1 P age

94 1.4 Cardiology The investment in cardiology has been used to increase capacity within the cardiac rehabilitation service and enable patients with heart failure to benefit from the service. In addition, there is a clinically led group who are redesigning and developing a pathway for people with heart failure so that they can be managed more effectively in the community including the potential administration of IV diuretics. This includes partnership working between the two acute hospital trusts and the community service to enable access to heart failure specialist nurses in the community. The work that has been completed on the pathways to date has allowed for an increased capacity in our community services, this will form a strong foundation to support the transformation programme that we need to deliver across Richmond to meet the financial challenge we face. 1.5 Frailty and End of Life Both the frailty and end of life care work-streams have migrated into the emergent locality model. The focus has been in and will be for a wholescale change in the model of care to put patients at the centre and to wrap services around them in the place where they live. To this end we have been working closely with HRCH to design and develop a locality model of care including Care homes, End of Life Care and the Frail Elderly in our population, we also need to consider how we can include children and young people within this model. 1.6 Locality model A key element of the locality model is that of case-finding those who are vulnerable to admission to hospital this will be supported by the use of the risk stratification tool Sollis. The model will support frail older patients to live independently, understand their long-term conditions, and support them to manage their care effectively, reducing demand for urgent care support. Support for people will be developed through involvement of the voluntary sector to enhance the opportunity for people to live independently. Care for people at the end of their life is a key priority for Richmond CCG. A strategy has been developed jointly with Kingston CCG, priorities identified and work streams to progress these priorities have been established. End of life care will be progressed within the locality model and will include the roll-out of coordinate my care and advanced care planning. We believe that the locality model is the vehicle that will deliver system change and support clinicians to manage people in the community. This model of care has been tested in the Hampton and Teddington locality and there is an implementation plan to roll this out across the other localities within the borough. 2 P age

95 1.7 Roadmap for Delivery Next Steps Roll-out of the locality model across all localities Identify the opportunities for integrating physical and mental health within the locality model. Develop metrics to measure the impact of the locality model 2. Mental Health Transformation 2.1 Introduction In 2017, partners of the Richmond Mental Health OBC Alliance signed a memorandum of understanding (MOU), demonstrating their commitment and agreeing how they would work together in developing the Alliance. Members of the Alliance include: Certitude Change, Grow, Live (CGL) East London NHS Foundation Trust London Borough of Richmond Upon Thames (Provider) Richmond GP Alliance Richmond Mind South West London St Georges NHS Trust SPEAR Richmond CCG Since the last report to the governing body, the members of the Mental Health OBC Alliance have been reviewing the MH Transformation programme for 2018/ P age

96 2.2 Alliance Priorities for the next 6-12 Months Over the next 12 months the Alliance MH transformation priorities are: Transformation of Access to MH services to work together to develop a common access pathway to MH services across health and social care for patients and those referring people to services. Initially this work will focus on developing and agreeing a common assessment and risk framework. The work stream will build on the progress already being seen in the Interface Group and will benefit from the established relationships and shared ownership of the work to date. The aim is for a common assessment framework to be in place within 6 months. Recovery Café refine the business case for a Crisis Café to provide a community alternative to admission (trend in both Richmond and Kingston is for increased inpatient admissions) and further services for people experiencing a MH crisis. The business case will incorporate learning and outcomes from the SWLStG pilot in Wandsworth and Merton and set out the options for a shared crisis café in Richmond and Kingston. A site is available with one of the Alliance partners and could be operational within 5 months of approval. The aim will be for a business case to be considered for 19/20 MH Investment Standard funding to be operational from April 19. Peer Navigation training of peer navigators to support the preventive and wider needs of people with mental health and substance misuse issues. The service would support provide lower level and preventative support, reducing impact on health and social care services. It also provides long term recovery opportunities for peer navigators and increases the employability of individuals through the peer mentoring scheme. The service could be mobilised with an estimated cost of 62k and a 3-4-month lead in. MH Placements the Alliance providers will link with a wider SWL level piece of work to develop a placement pathway with improved throughput, review and deliver of outcomes for patients. The CCG and the Council are both experiencing cost pressures on the placement budget. Substantial success has already been achieved in Lambeth following a similar model within their Alliance arrangement, which includes one of Richmond s Alliance providers. This has included a 43% reduction in patients entering residential care. Efficiencies realised could be used to fund investment and transformation within the wider MH system. Substance Misuse Richmond s IAPT provider Richmond Wellbeing Service (RWS) and substance misuse provider Change Grow Live (CGL) will work together in developing a joint programme of support for patients who are using cannabis and suffering from mild to moderate mental health issues. The need for this has been identified based on the impact cannabis use has on RWS therapeutic input. In addition, CGL are proposing the development of an in-reach assessment service at key GP surgeries to deliver harm reduction and structures support for drug and alcohol users. The proposal would provide early intervention and treatment and reduce the stigma of attending support at the main substance misuse hub. Physical Health continue to build on and develop specialist IAPT provision for Long Term Conditions. Initial results from general IAPT show a 28% reduction in health utilisation in non-mh utilisation for those treated via IAPT. It is anticipated that those with LTC s will also follow a reduced utilisation of wider health services. In addition, the programme will begin to develop how MH services should link with the development of locality models and Multi-Disciplinary teams in Richmond and 4 P age

97 Kingston. The priorities identified by the Alliance members align to the priorities and outcomes people in Richmond have told us are important. The work already undertaken by providers in the clinical interface group supports the clearer single route into services that people have told us is important to them. The commitment to a common assessment framework will provide a key element in the development of a single point of access for support in reducing referrals to inappropriate services and reducing the need for patients to repeat their story. Along with the plans for a Crisis Café the assessment framework will support people accessing the right service at the right time and avoid unnecessary admissions where possible. The other priorities support the emphasis on care in the community wherever possible and will support the wider outcomes of people with mental health problems such as employment and improved physical health. 2.3 Patient and Stakeholder Engagement The Alliance providers have continued to involve patients and service users in the development of the programme. In addition, the CCG ran a MH consultation event with Healthwatch Richmond in December 2017 to inform people in Richmond of progress to date and to affirm that the outcomes developed to guide the programme were still relevant. The event was well attended and the same themes and priorities emerged from service users, carers and the public. People continued to want improved access to services, particularly in times of crisis and support to recover in the community. The full Healthwatch report from the event and the CCG s response can be accessed at 3. Next Steps For there will be a focus on: Identifying the opportunities for integrating physical and mental health within the locality model. Development of metrics to measure impact of these priority programmes 5 P age

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99 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing Body in public Date 1 May 2018 Report Title Emergency Preparedness, Resilience and Response (EPRR) assurance outcome Agenda Item 2.4 Attachment G Purpose (please indicate with X) Approval/ Ratification Discussion / Comment Information X Report Author: (name & job title) Fergus Keegan Director of Quality Presented by: (name & job title) Fergus Keegan Director of Quality Summary and purpose of report To inform the Governing Body of the outcome of the NHS England assessment of the CCG s Emergency Preparedness, Resilience and Response (EPRR) readiness. Richmond CCG is assessed overall for the 2017 EPRR Assurance as achieving a SUBSTANTIAL level of compliance. Key sections for particular note Section 3 The key priorities for the next 12 months. Report recommendation The Governing Body is asked to note the assurance rating achieved and its inclusion in the CCG Annual Report. Financial and / or resource implications NA Key risks identified & mitigation NA Equality and / or privacy impact analysis NA Committees that have previously discussed / agreed the report and outcomes April Quality Safety and Performance Committee Version: Final G - 1 Date:

100 Communication plan / stakeholder involvement / patient engagement Disclosure at public Governing Body meeting, inclusion in Annual Report Assurance Does the report need to be taken to any additional meetings for further assurance or ratification? No CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final G - 2 Date:

101 Emergency Preparedness, Resilience and Response (EPRR) assurance outcome Update for the governing body 1. Introduction Richmond CCG had an assessment of EPRR assurance on 3rd November 2017, The assurance team comprised of; NHS England EPRR Team / Meeting Chair: Graham Leedham NHS England EPRR Team / Engagement Officer: Caroline Fiore The South patch team would like to thank the attendees listed below for their time in facilitating the 2017 assurance process. Fergus Keegan AEO Kingston & Richmond CCGs Sam Grant Quality Support Officer Kingston and Richmond CCGs Luke Lambert NEL CSU Business Resilience Lead 2. Assurance Review Team Summary: In April next year SWL CCGs will work together as the STP, Richmond and Kingston CCGs will also combine back office functions, which will result in a number of plans needing to be reviewed, due to changes in roles, responsibilities and locations. Continued progress has been made over the past twelve months with regards to EPRR 3. The key priorities for the next twelve months include: Reviewing (and combining where relevant) plans to reflect the new arrangements under the STP and the move of CCG staff to Thames House. Ensuring sign off of the CCG pandemic flu plan working with BRF partners to achieve this Ensure version control and sign off for all plans are clearly defined Ensuring a formal exercising programme is put in place Ensuring the results of the 2017 assurance are brought to the board and included in the annual report (subject to action 9 below) 4. Overall assessment Richmond CCG is assessed overall for the 2017 EPRR Assurance as achieving a Substantial level of compliance. Version: Final G - 3 Date:

102 In accordance with the requirements laid out in the National Assurance process documentation (repeated in the attached London EPRR assurance letter dated 14th July 2017), a Trust s overall level of compliance is based on the total number of Amber and Red ratings agreed at the review. In respect of Richmond CCG, for Core Standards 1-51 the CCG had 1 Amber rating: Core standard 12 Pandemic Influenza plan With regards to Deep Dive DD1-DD6, the CCG had 2 amber ratings, however this does not count towards the overall level of compliance DD1 The organisation's Accountable Emergency Officer has taken the result of the 2016/17 EPRR assurance process and annual work plan to a pubic Board/Governing Body meeting for sign off within the last 12 months. DD2 The organisation has published the results of the 2016/17 NHS EPRR assurance process in their annual report. The outcome of the assurance assessment was reported to the April 2018 Quality Safety and Performance Committee; the Governing Body is now aware and the CCG Annual Report will include this level of assurance. Fergus Keegan Director of Quality April 2018 Version: Final G - 4 Date:

103 Richmond Clinical Commissioning Groups Report Summary Meeting Title Governing Body in Public Date 1 May 2018 Report Title Quality, Safety & Performance Committee Agenda Item 3.1 Attachment H Purpose (please indicate with X) Approval/ Ratification Discussion / Comment Information X Report Author: (name & job title) Ruth Harkness Clinical Quality Manager Presented by: (name & job title) Dr Zehra Rashid, Governing Body General Practitioner Lead for Quality Summary and purpose of report This report includes the South West London performance report and the feedback from the April 2018 Richmond CCG Quality Safety and Performance Committee Key sections for particular note 1) Monthly Performance Reporting 2) Reporting from Clinical Quality Review Groups 3) Medicines Optimisation - The Choosing Wisely Consultation and subsequent Governing Body recommendations (July 2017) were cognisant of the expected national consultations which were being developed at that time. - The Committee undertook to ask the Medicines Optimisation Team to prepare a report for the Clinical Executive Team meeting to consider the new guidance now available. Following the Clinical Executive Team discussion, a further update for the Governing Body will be prepared. Report recommendation The Governing Body is asked to note the contents of these reports Financial and / or resource implications Not required as summary report. Key risks identified & mitigation South West London performance report (Richmond) 4-hour A&E standard NHS 111 Richmond Quality Safety and Performance Committee Pressure Ulcers Falls Measles Equality and / or privacy impact analysis Not required as summary report Committees that have previously discussed / agreed the report and outcomes Richmond Quality, Safety & Performance Committee. Version: Final H - 1 Date:

104 Communication plan / stakeholder involvement / patient engagement Not required as summary report. Assurance Not required as summary report. CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final H - 2 Date:

105 Highlight Constitutional Standards South West London Performance Highlight Report Month 10 page 2 A&E -4 hour standard page 3 Referral to Treatment (RTT) 18 week Incomplete page 4 Cancer Waiting Times Two week wait (2WW) & 62 Day page 5 Diagnostics waits For: South West London Senior Management Team page 6 Ambulance Handovers- London Ambulance Service (LAS) page 7 NHS 111 service page 8 Improving Access to Psychological Therapies (IAPT) page 9 Dementia and Mental Health Sponsor: Director of Commissioning Operations, South West London Alliance Author: NELCSU / SW London Performance Management & Pressure Surge Team Version: FINAL (v1.1 / ) page 10 Delayed Transfers of Care (DTOCs) page 11 Glossary page 12

106 Highlight Constitutional Standards (By CCG) A&E- All Type (4 hour standard By CCG) CCG Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Croydon 84.96% 85.25% 86.58% 88.57% 90.83% 90.48% 88.57% 90.07% 90.64% 93.57% 91.93% 88.60% 86.25% 86.21% Kingston 84.31% 88.25% 91.19% 91.10% 89.90% 91.01% 93.11% 91.75% 92.10% 92.60% 90.04% 87.05% 87.60% 85.44% Merton 88.34% 91.30% 90.93% 91.69% 91.33% 92.67% 91.54% 91.24% 91.69% 90.41% 89.62% 86.95% 85.59% 84.92% Richmond 88.01% 91.13% 92.56% 93.55% 92.39% 93.87% 94.77% 94.11% 93.61% 94.12% 93.08% 91.39% 91.70% 90.71% Sutton 93.73% 94.56% 95.52% 94.59% 94.97% 94.67% 94.56% 93.50% 94.68% 93.29% 93.28% 89.87% 89.00% 87.00% Wandsworth 86.34% 89.99% 89.33% 91.01% 90.10% 92.38% 91.02% 91.30% 90.97% 90.02% 89.24% 87.39% 86.76% 86.31% Data has been mapped from providers to CCGs using a mapping derived from Hospital Episode Statistics figures. This calculates what proportion of each provider can be attributed to a given CCG. Cancer- 62 day GP referral Period: M /18 Report: Date: 03/04/ Week Referral to Treatment (RTT) - Incomplete Pathways CCG Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Croydon 90.93% 90.91% 91.46% 91.22% 91.70% 91.91% 92.19% 92.06% 92.18% 92.80% 92.87% 92.66% 92.66% Plan 92.01% 92.00% 92.00% 90.75% 90.76% 90.78% 90.79% 90.78% 90.81% 90.82% 90.82% 90.82% 90.84% Kingston 94.03% 94.35% 94.52% 94.21% 94.18% 93.84% 93.74% 93.30% 92.97% 93.03% 93.71% 93.20% 93.32% Plan 93.00% 93.00% 93.01% 92.01% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.01% 92.00% Merton 91.89% 92.26% 92.56% 91.74% 91.97% 91.39% 91.16% 90.26% 90.08% 89.85% 89.79% 89.25% 88.59% Plan 92.04% 92.15% 92.41% 91.97% 91.97% 92.06% 92.07% 91.96% 92.09% 92.08% 92.08% 91.94% 91.94% Richmond 92.97% 92.93% 93.14% 92.42% 93.53% 93.77% 93.48% 92.44% 90.90% 91.39% 92.37% 91.69% 92.03% Plan 94.87% 94.87% 94.87% 92.03% 92.03% 92.02% 92.03% 92.02% 92.03% 92.02% 92.02% 92.03% 92.02% Sutton 92.54% 93.13% 93.30% 92.91% 92.99% 92.05% 91.98% 90.96% 90.69% 90.41% 91.33% 89.92% 88.69% Plan 92.15% 92.15% 92.15% 91.87% 91.88% 92.16% 92.16% 91.82% 92.24% 92.24% 92.24% 91.76% 91.75% Wandsworth 90.72% 91.36% 90.67% 89.90% 90.36% 90.08% 89.58% 89.02% 88.72% 88.71% 88.78% 88.90% 89.03% Plan 91.95% 92.08% 92.39% 92.04% 92.01% 92.00% 92.00% 92.01% 92.00% 92.00% 92.01% 92.00% 92.00% Diagnostics- Waits over 6 Weeks CCG Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Croydon 80.33% 84.00% 90.80% 86.79% 81.58% 89.04% 82.56% 84.62% 79.45% 78.67% 90.41% 87.80% 83.67% Plan 85.92% 85.92% 85.92% 86.44% 85.51% 86.11% 85.51% 86.11% 85.51% 86.11% 86.11% 85.48% 86.11% Kingston 85.71% 88.24% 91.30% 92.31% 100% 86.84% 92.59% 85.29% 87.50% 86.11% 82.93% 89.66% 87.88% Plan 88.46% 87.50% 88.46% 88.46% 86.67% 87.10% 86.67% 87.10% 86.67% 87.10% 87.10% 85.19% 87.10% Merton 83.33% 80.00% 92.00% 95.24% 82.14% 88.89% 75.86% 85.71% 89.66% 83.87% 93.55% 88.46% 76.47% Plan 87.10% 87.50% 87.88% 88.46% 86.67% 87.50% 86.67% 87.50% 86.67% 87.50% 87.50% 85.19% 87.50% Richmond 96.30% 90.00% 83.33% 92.31% 90.91% 92.59% 87.80% 82.86% 92.86% 91.18% 93.75% 86.36% 80.56% Plan 85.71% 85.71% 85.71% 86.21% 85.29% 85.71% 85.29% 85.71% 85.29% 85.71% 85.71% 86.67% 85.71% Sutton 80.00% 88.89% 90.91% 90.00% 91.18% 84.85% 89.13% 74.19% 86.11% 85.71% 89.74% 76.47% 77.78% Plan 87.18% 87.18% 87.18% 86.67% 85.71% 86.49% 85.71% 86.49% 85.71% 86.49% 86.49% 87.50% 86.49% Wandsworth 82.35% 88.57% 81.25% 87.10% 75.56% 82.35% 75.00% 82.76% 83.33% 91.18% 84.38% 93.55% 78.38% Plan 85.71% 86.36% 86.84% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% CCG Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Croydon 99.09% 97.58% 96.19% 94.26% 94.60% 95.90% 97.07% 98.40% 99.66% 99.56% 99.17% 99.30% 99.37% Plan 99.01% 99.01% 99.01% 99.06% 99.03% 99.02% 99.03% 99.02% 99.03% 99.02% 99.02% 99.03% 99.02% Kingston 98.73% 99.04% 99.19% 98.68% 98.49% 99.43% 99.16% 98.84% 99.33% 99.41% 99.05% 99.42% 99.61% Plan 99.11% 99.12% 99.13% 99.01% 99.02% 99.02% 99.03% 99.03% 99.01% 99.01% 99.03% 99.00% 99.03% Merton 97.17% 98.26% 98.41% 97.97% 98.32% 98.92% 98.95% 99.32% 98.95% 99.62% 98.86% 99.24% 99.79% Plan 99.01% 99.01% 99.01% 99.08% 99.14% 99.12% 99.14% 99.12% 99.14% 99.12% 99.12% 99.09% 99.12% Richmond 99.11% 99.37% 98.72% 97.77% 98.51% 98.52% 98.57% 98.79% 98.91% 96.30% 95.91% 97.97% 99.34% Plan 99.08% 99.08% 99.08% 99.14% 99.14% 99.14% 99.14% 99.14% 99.14% 99.14% 99.14% 99.14% 99.14% Sutton 99.23% 99.55% 99.70% 99.48% 99.42% 99.61% 99.36% 99.46% 99.23% 99.42% 98.88% 99.22% 99.46% Plan 99.02% 99.02% 99.02% 99.11% 99.10% 99.07% 99.10% 99.07% 99.10% 99.07% 99.07% 99.10% 99.07% Wandsworth 96.67% 98.07% 97.58% 96.50% 97.30% 97.52% 97.23% 97.83% 98.69% 99.52% 98.75% 99.41% 99.03% Plan 99.00% 99.01% 99.00% 99.00% 99.00% 99.01% 99.01% 99.01% 99.01% 99.01% 99.01% 99.02% 99.02% CCG Level Narrative CCG level narratives have been provided for the four Constitutional Standards that receive the most focus. Further detail is provided in subsequent pages about Trust level performance and any associated key actions. Croydon CCG: The CCG continues to achieve the RTT (Referral to Treatment) performance standard. The diagnostics performance standard has been achieved, both at the CCG and at CHS for the fifth consecutive month. The national A&E performance standard was not achieved at CHS with performance of 87.11% in February, below the operating plan trajectory of 94.80% for the month. Performance on Type 1 A&E attendance continues to be a priority for the system. The CCG achieved the 2WW and 2WW Breast cancer performance standards in January However, 31 Day surgery, 62 day GP referral and 62 day upgrade standards were not achieved in month. On the 62 day GP referral there were 8 breaches out of 49 pathways. The other non achieving standards had small numbers of patients breaching. Kingston CCG: The performance standards for Diagnostics and RTT were achieved in January On the cancer standards performance was achieved for the 2WW, 31 day Surgery and 62 day GP referral standards in January The 2WW breast pathway had 10 breaches out of 90 pathways while the other standards were not achieved mainly due to small numbers of breaches. A&E performance at Kingston Hospital was 84.77% in February 2018, below the 92.00% operating plan trajectory for the month. Merton CCG: The Diagnostics standard and all cancer standards with the exception of the 31 day first definitive treatment and the 62 day GP referral performance standards were achieved in January The 31 day first definitive treatment performance standard was not achieved due to 3 breaches out of 61 patients, while the 62 day standard had 8 breaches out of 34 patients. RTT performance, which does not include SGH RTT figures, has declined compared to previous months with performance of 88.59% delivered. Reported under-performance is due to non-achievement at Epsom & St Helier and Moorfields for the CCG. Epsom & St Helier, a large provider to the CCG also did not achieve the standard, delivering performance of 86.73%. The Trust expects that February and March 2018 performance will continue to decline due to the impact of the NHSE directive on elective care. The Trust has undertaken a demand and capacity analysis for each specialty, using the IMAS Tool, which suggests there is a significant capacity gap in a number of specialties. The Trust is working with individual specialties to develop a recovery plan that includes actions to clear backlogs. Richmond CCG: All cancer targets with the exception of the 31 day radiotherapy and 62 day GP referral standards were achieved in January. There were 3 breaches out of 36 patients treated on the 62 day standard and 2 breaches out of 16 patients on the 31 day radiotherapy standard. The RTT performance standard recovered in January with an outcome of 92.03% and Diagnostics target was achieved for the first time since March 17. Sutton CCG: The CCG achieved both the 31 day first definitive treatment and 31 day Drug standards in January. The remaining Cancer performance standards were not achieved. The 2WW pathway was not achieved with 34 breaches out of 474 pathways, 2WW Breast had 4 breaches out of 44 pathways and the 62 day GP referral pathway was not achieved with 8 breaches out of 36 pathways. The A&E 4-hour standard was not achieved at ESTH for All Type attendances in February 2018 with performance of 87.28% down from 89.6% in January. This is the fifth consecutive month that performance has not been achieved at the Trust. The RTT performance of 88.69% for the CCG is a decline on the previous months performance. Overall this is driven mainly by performance at ESTH, which also did not achieve the performance standard, with performance of 86.73%. The Trust expects that February and March 2018 performance will continue to decline due to the impact of the NHSE directive on elective care. The Trust has undertaken a demand and capacity analysis for each specialty, using the IMAS Tool, which suggests there is a significant capacity gap in a number of specialties. The Trust is working with individual specialties to develop a recovery plan that includes actions to clear backlogs. Wandsworth CCG: With SGH not reporting RTT performance, the CCG s RTT performance is mainly affected by outcomes at Imperial, Chelsea and Westminster, Moorfields and Guys & ST Thomas Hospitals where RTT performance for CCG patients was not achieved. All cancer standards with the exception of the 31 Day Radiotherapy, 62 Day GP referral and 62 day screening standards were achieved in January. On the 62 day pathway there were 8 breaches out of 32 pathways.. A&E performance of 83.52% in February, a slight improvement on 83.00% the previous month. The operating plan trajectory for February was 95.10%. 2

107 CHS ESTH KHFT SGH Trust Provider A&E Type Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 A&E Performance -v- Attendance A&E Performance By Type A&E - 4 Hour Standard Croydon UH - T1 76.1% 80.1% 79.9% 85.0% 80.6% 75.3% 77.5% 79.4% 87.7% 83.0% 74.3% 66.9% 69.0% Croydon Health T2/T3 Urgent Care Centre % 96.4% 96.6% 96.7% 98.5% 97.7% 99.6% 99.5% 99.8% 99.7% 99.4% 99.4% 98.9% Services NHS Trust Provider All Type 84.4% 86.1% 88.4% 91.2% 90.6% 88.3% 90.1% 90.9% 94.8% 93.0% 89.4% 86.8% 87.1% Epsom And St Helier University Hospitals NHS Trust Kingston Hospital NHS FT St George's University Hospitals NHS FT Lead LDU:Sutton Period: M /18 Named Lead:Sean Morgan Report: Date: 03/04/2018 A&E Performance Epsom - T1 93.7% 97.3% 96.3% 95.6% 96.1% 94.8% 95.5% 94.9% 92.7% 94.0% 88.7% 87.2% 89.1% St Helier - T1 95.9% 95.5% 94.3% 95.5% 94.0% 95.2% 92.5% 95.2% 93.5% 92.4% 88.2% 89.2% 83.7% Sutton - T2/T3 99.6% 99.1% 98.2% 99.8% 100% 100% 100% 100% 99.8% 100% 100% 100% 100% Provider All Type 95.2% 96.4% 95.2% 95.6% 95.0% 95.2% 94.0% 95.2% 93.7% 93.8% 90.3% 89.6% 87.3% Kingston - T1 85.4% 89.5% 89.4% 87.8% 89.0% 92.1% 90.2% 90.7% 91.8% 88.3% 85.0% 85.8% 83.0% Kingston REU - T2/T3 100% 99.7% 100% 100% 99.9% 100% 100% 100% 100% 100% 100% 100% 100% Provider All Type 87.0% 90.7% 90.4% 89.0% 90.2% 92.9% 91.3% 91.7% 92.6% 89.5% 86.3% 87.3% 84.8% St George's - T1 89.7% 87.6% 89.5% 88.6% 91.3% 88.9% 89.1% 89.0% 86.7% 85.9% 83.5% 81.3% 81.8% Q Mary Roe'ton - T2/T3 100% 100% 100% 100% 100% 99.4% 99.8% 99.9% 100% 100% 99.8% 99.9% 100% Provider All Type 90.6% 88.6% 90.5% 89.7% 92.1% 89.8% 90.0% 90.0% 88.0% 87.2% 85.0% 83.0% 83.5% South West London Total All Type 89.7% 90.6% 91.1% 91.5% 92.1% 91.3% 91.3% 91.9% 92.3% 91.0% 87.9% 86.6% 85.8% N.B. ALL DATA IS NHSE PUBLISHED DATA EXCEPT ESTH AT SITE LEVEL, WHICH IS BASED ON DAILY RETURNS AND NOT MONTHLY RETURN. A&E Attendance by Type Key Actions Actions Narrative Owner Due SW London Narrative SWL Overall A&E performance has continued to decline with performance of 85.81% in February down from 86.6% in January 2018 for All Type across the 4 SW London providers. The operating plan February 2018 trajectory for the 4 main SWL providers was for performance of 93.7%. London wide All Type performance for February was 87.3%. The Urgent and Emergency Care Delivery Board has ratified a revised approach to the repatriation of patients to address the high numbers of patients waiting for transfer at SGH. CHS Performance was 87.11% in February a slight improvement on the 86.8% in January for All Types. February 2018 performance was below the operating plan trajectory of 93.5%. Type 1 performance of 69.01% in February was an improvement on the previous month s outcome of 66.94%. Provisional Type 1 performance of 63.37% for the first week of March 2018 ranges between 80.37% to 40.16%. An Improvement Plan agreed at the A&E Delivery Board is being implemented. Further diagnostic work is being undertaken to inform key actions. Progress is monitored by the A&E Delivery Board. The completion of the new ED at CHS has slipped from February 2018 to June ESTH Did not achieve the performance standard in February 2018 with performance of 87.28% down from 89.6% in January. Additional escalation beds have been opened, funded from the national Winter monies and community services capacity has been expanded. KHFT Delivered performance of 84.77% in February, down from 87.29% in January. The operating plan trajectory for February 2018 was 92.0%. The main reasons for breaches were responses within the ED from the clinical specialties with minimal breaches relating to bed availability. An Emergency Care Programme Plan is in place. SGH - Performance was 83.52% in February, a slight improvement on the previous month s outcome of 83.0%. The operating plan trajectory for February 2018 was 95.10%. At the March Performance Meeting the trust reported that infection control from flu continues to remain a key challenge during February, additionally ambulance performance has deteriorated due to capacity and challenges offloading in ED which is affecting both non-admitted and admitted patients. The new Ambulatory and Acute Assessment (AAA) unit is now operational 7 days a week currently for 12 hours per day with expansion to 14 hours planned for May A Service Improvement Director has been appointed during February to investigate and advise on patient flow issues covering the Emergency Department and the acute adult wards and at trust level a review of performance metrics focussed on A&E 4 hour waits is underway with the intention to develop a performance dashboard. SAFER remains a key approach for the inpatient workstream starting with 6 medical wards before being rolled out. Staff attendance across winter has been supported via an active flu immunisations programme which saw it have the highest coverage in England at circa 90%. An Improvement Plan in place which identifies high impact changes with greatest improvement expected from 1) Full scale review of patient flow and discharge processes utilising SAFER (patient flow bundle) and Multi Agency Discharge Event (MADE) initiatives to give greater focus and granularity of data, 2) The introduction of high impact changes for discharges, 3 ) Recruitment, retention and re-training of staff across ED. The action plan is monitored by the A&E Delivery Board. An ambulance turnaround group has been established to improve the efficiency of handovers and to explore alternative appropriate care pathways, with improvements expected when the Trust return to their ED from the decant. Staffing levels are being continually reviewed to ensure that all key posts are covered. Additional capacity funded from Winter monies with the expectation of delivering a two percentage point improvement in performance. A Winter Stocktake was held on 20th Feb to review the experience to date and consider which elements of the Winter plan have worked well and which elements could be improved on. Focus on flow, discharges and stranded patients, with a deep-dive into the super-stranded patient group (>21 days) with NHSI collaboration in progress. Actions to address the recovery are part of the Emergency Care Programme Plan (ECPP) monitored via the Kingston and Richmond A&E Delivery Board. The hospital to home work stream through Kingston Co-ordinated Care is being rolled out throughout Q , with a similar locality team model planned in Richmond. Update reports on the 8 pillars of the ECPP are scrutinised at the K&R A&E Delivery Board, although recruitment of staff is the predominant risk to delivery, which is borne out by the local breach reports. GP hubs are working well and utilisation has increased through the winter period, which has meant the numbers into A&E are stable. The Trust continues to implement its Unplanned and Admitted Patient Care programme, (U&APC Programme) a Trust wide approach to improving flow for non-elective and admitted patients. MADE events were held in February and March All patients to be reviewed thereby raising awareness of pressure points in the system. NHS Improvement visited the Trust on to review the acute pathways out of ED. Paediatric Ambulatory Care opened w/c Adult Ambulatory Care opened Winter wash-up event to be held in April 2018 CEO, CHS and 95% in Chair of the Mar 18 Croydon A&EDB COO, ESTH Sutton Director of Commissioning Chair, A&EDB June-18 Apr 18 95% in Mar 18 COO SGH 95.0% Feb 18 Feb-18 Feb-18 Feb-18 Mar-18 Apr-18 3

108 Referral to Treatment (RTT) 18 week Incomplete RTT- By Trust Provider Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 KHFT 94.80% 95.04% 95.11% 94.63% 94.67% 94.55% 94.36% 94.47% 93.69% 94.00% 94.63% 94.47% 94.77% CHS 92.03% 92.04% 92.14% 92.01% 92.24% 92.24% 92.01% 92.05% 91.60% 92.03% 92.01% 92.01% 92.55% ESTH 90.94% 91.40% 92.01% 91.24% 91.51% 91.01% 90.71% 89.54% 89.06% 89.05% 89.30% 88.03% 86.73% SGH RMH 96.82% 97.01% 96.58% 95.83% 96.73% 96.77% 96.75% 96.78% 97.22% 97.30% 97.15% 95.87% 96.00% Total 92.47% 92.71% 92.96% 92.48% 92.70% 92.44% 92.17% 91.74% 91.26% 91.44% 91.65% 90.96% 90.61% RTT By Specialty - (Commissioners) Treatment Function Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Cardiology 95.5% 94.8% 94.6% 93.8% 93.6% 93.3% 93.1% 92.5% 91.7% 92.7% 92.7% 92.7% 90.9% 4/6 Cardiothoracic Surgery 91.1% 92.4% 86.6% 77.2% 75.0% 76.7% 80.0% 84.2% 82.1% 82.9% 79.7% 81.8% 87.7% 3/4 Dermatology 92.7% 94.4% 94.6% 94.3% 95.7% 95.6% 95.0% 93.7% 91.9% 91.7% 92.1% 92.2% 92.7% 3/6 ENT 87.8% 87.1% 87.4% 88.5% 89.1% 89.4% 88.8% 86.4% 85.4% 86.1% 86.7% 86.9% 86.3% 0/6 Gastroenterology 94.6% 94.8% 95.4% 94.1% 94.6% 94.3% 94.5% 93.4% 93.0% 93.3% 93.0% 92.2% 91.2% 3/6 General Medicine 97.6% 96.5% 96.1% 95.3% 97.1% 96.4% 95.2% 93.8% 92.7% 93.4% 95.4% 95.6% 95.1% 5/6 General Surgery 90.2% 90.0% 89.1% 89.0% 89.7% 89.5% 88.9% 89.1% 89.8% 89.2% 89.1% 87.2% 86.5% 0/6 Geriatric Medicine 97.2% 97.5% 98.8% 97.1% 98.9% 98.9% 97.1% 98.7% 97.8% 96.8% 94.3% 92.7% 94.3% 5/6 Gynaecology 89.7% 90.5% 90.0% 89.0% 89.2% 89.1% 89.7% 89.2% 88.8% 89.5% 90.7% 90.0% 90.5% 1/6 Neurology 92.7% 93.4% 94.4% 92.8% 92.5% 91.8% 92.0% 90.6% 90.0% 89.5% 90.2% 89.5% 91.0% 2/6 Neurosurgery 83.8% 80.4% 83.2% 84.1% 85.0% 87.1% 85.9% 82.2% 81.2% 85.9% 84.3% 81.0% 83.7% 0/6 Ophthalmology 95.9% 95.5% 95.6% 94.2% 94.0% 93.9% 93.0% 92.1% 91.2% 90.4% 90.6% 90.8% 90.3% 2/6 Oral Surgery % 100.0% 100.0% % 100.0% 100.0% 100.0% /0 Other 92.3% 92.8% 93.7% 93.2% 93.5% 93.1% 93.5% 93.6% 94.3% 94.6% 94.9% 94.5% 94.4% 6/6 Plastic Surgery 90.5% 90.2% 88.3% 88.0% 88.7% 88.9% 87.6% 87.8% 88.1% 86.5% 86.6% 86.5% 87.0% 0/6 Rheumatology 96.5% 96.1% 96.4% 96.3% 96.0% 96.3% 95.9% 95.6% 94.9% 95.9% 95.5% 95.1% 94.5% 3/6 Thoracic Medicine 97.1% 97.5% 97.6% 97.1% 97.6% 96.9% 97.0% 96.8% 95.1% 94.4% 92.6% 91.9% 91.9% 3/6 Trauma & Orthopaedics 86.6% 87.1% 86.7% 87.4% 87.7% 87.6% 87.9% 86.9% 87.5% 88.1% 89.1% 87.8% 87.4% 1/6 Urology 91.1% 91.7% 91.2% 90.8% 92.1% 91.6% 91.3% 91.8% 90.7% 90.6% 91.0% 90.5% 90.5% 2/6 Total 91.9% 92.2% 92.4% 91.9% 92.3% 92.1% 92.0% 91.4% 91.1% 91.3% 91.7% 91.2% 91.0% 3/6 RTT Incomplete Pathways January CCG Pass Rate Lead LDU: Merton and Wandsworth Period:M /18 Named Lead: John Atherton Report: Date: 03/04/2018 SW London Narrative At CCG level in SW London: At 91.0% January s RTT performance while not achieving target has remained relatively stable compared to the 91.2% performance in December. SGH activity continues to not be reported and therefore is not included in the SW London figures. Croydon, Kingston and Richmond CCGs achieved the performance standard in January At provider level in SW London: Aggregate RTT Performance was 90.61% in January for the 4 main providers, which means that they did not achieve the performance standard, for the sixth consecutive month. The RTT performance standard was not achieved at ESTH for the 10th consecutive month with January 2018 performance of 86.73%, the lowest outcome year to date. CHS: Performance improved slightly in January 2018 with an outcome of 92.55%. At Trust level ENT, Oral Surgery and T&O remain significantly below 92% largely due to reported capacity issues. ESTH: Performance was 86.73% in January down from 88.03% in December. The Trust highlighted at the March 2018 Planned Care Working Group that it expects that February and March 2018 performance will continue to decline. This is due to the impact of the NHSE directive on elective care, winter pressures continuing into February and patients cancelling appointments, especially with the snow in early March. There were no significant staffing issues. The Trust has undertaken a demand and capacity analysis for each specialty, using the IMAS Tool, which suggests there is a significant capacity gap in a number of specialties. The Trust is working with individual specialties to develop a recovery plan that includes actions to clear backlogs. SGH: The Trust has a first cut of the PMM PTL in place and visible to the operational teams as of Tuesday 13th February The PTLs are refreshed daily, and starting to be used operationally to schedule patients, especially new outpatients and the admitted PTL. The Trust confirmed that now this major milestone has been reached that the focus can now divert from technical issues to continued validation and training to bring about improved management of pathways. Work continues validating the PTL and lists of non-responding patients from phase 1 will be sent to GPs for clinical validation. New governance arrangements, including PMO resource have been put in place to ensure the priority issues are delivered by the Trust and Cymbio before 31st March Progress is being managed through the weekly operational delivery group chaired by the COO. The Trust continues to validate the longest waiters and significant work is required on the continuing PTL and the over 52 week waiter position. As a benchmark the new PMM PTL is approximately 13,000 larger than previously reported position (May16) predominantly on nonadmitted PTL as expected. 52 Week Waits: At SWL CCG level there were 12 patients reported on UNIFY waiting over 52 weeks in January. Croydon CCG has 4 patients waiting over 52 weeks, two of the patients were at CHS one was treated in February and the other has a TCI in March. The other 2 CCG patients were at KCH, one is awaiting a TCI the other is not a 52 week breach, as it was reported in error. Richmond CCG had 3 patients in total waiting over 52 weeks in January. Two patients were at Imperial, 1 patient was treated/clock stop and the other is awaiting a TCI date. There other Richmond CCG patient was at KHFT and has a TCI of Sutton CCGs had two patients waiting over 52 weeks at ESTH, one patient has delayed treatment until April 2018 and the trust is to provide an update on the other patient. Kingston CCG had one patient waiting over 52 weeks at KHFT. This patient has a TCI in April. Merton CCG has 1 patient waiting over 52 weeks at ESTH. The Trust is to provide an update on the other patient. Wandsworth CCG had patients at Imperial with a TCI in March Action Actions Narrative Owner Due CHS Introduction of new PTL system Key Actions CHS reports that the new Patient Tracking List (PTL) continues to be tested by the central RTT team. This was due to be rolled out in January, but has slipped to March. The Trust is working to achieve 93% in Q2, by improving validation through training and earlier management of capacity in light of demand. CHS / GM Cancer & RTT Performance Mar-18 RTT Incomplete Pathways > 52 weeks by SW London Commissioners SWL CCGs Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 NHS CROYDON CCG NHS KINGSTON CCG NHS MERTON CCG NHS RICHMOND CCG NHS SUTTON CCG NHS WANDSWORTH CCG SWL Total ESTH Recovery plan SGH RTT Reporting and recovery plan The Trust is producing a new RTT Recovery Plan Activity to maintain the RTT incomplete waiting list has been agreed in the 2018/19 contract. The Trust has agreed business cases for additional Consultant staff in several specialties, and is putting in place a range of actions in the interim until those staff are in post including use of Locums, in-sourcing and additional ad hoc sessions to increase capacity in the short term. ESTH / Director of Planned Care Apr-18 Early conversations have taken place to move to electronic outcome forms. The Trust is currently focusing on improving the paper based forms and embedding them. RTT recovery plan numbers have been agreed with specialties up to 31st March These will have to be re-run for the last 4-6 weeks of the year to reflect the PTL from the new PMM as of 12th February DNA management has been re-emphasised through the operational structure, as per the access policy, but more work is required to fully embed this as routine. The old (current PTL) had been validated down beyond 42 weeks and validation will be a major focus until 31st March 2018 to further assure its accuracy. Strategic Outline Case has been written for the Cerner implementation at QMH and is to be presented at the next F&I (Finance & Investment) in 2 weeks SGH/ Mar 18 Elective Care Recovery Board Mar- 18 Feb

109 Cancer -Two week wait (2WW) & 62 Day 2 Week Wait (Provider) Provider Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Lead LDU:SWL Alliance Period: M /18 Named Lead:Simon Cook Report: Date: 03/04/ Day Wait (CCG) CHS 93.74% 97.33% 98.66% 98.15% 97.08% 96.46% 96.87% 95.51% 95.10% 97.71% 96.82% 95.91% 96.32% ESTH 96.15% 97.85% 95.95% 93.33% 94.74% 95.50% 95.45% 96.44% 96.61% 96.10% 96.70% 97.60% 94.00% KHFT 98.54% 97.96% 99.35% 99.05% 99.41% 98.22% 98.96% 97.89% 98.88% 97.72% 98.50% 98.95% 97.61% SGH 87.90% 87.94% 86.00% 75.44% 76.64% 67.39% 80.27% 89.71% 93.98% 96.05% 97.35% 98.51% 94.76% RMH 97.74% 97.36% 98.03% 97.77% 96.55% 97.99% 97.47% 97.32% 96.20% 97.88% 95.74% 96.68% 89.98% Total 93.84% 95.11% 94.86% 90.84% 91.09% 88.86% 92.16% 94.88% 95.95% 96.95% 97.16% 97.62% 95.00% 2 Week Wait by Tumour Site (CCG) Tumour Site Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Brain/Central Nervous System 92.9% 100.0% 99.1% 90.9% 96.3% 95.0% 90.9% 91.7% 93.3% 96.0% 100.0% 100.0% 100.0% 6/6 Breast 97.6% 96.0% 96.5% 94.8% 92.9% 88.2% 90.3% 97.6% 97.5% 98.8% 98.3% 98.2% 95.1% 4/6 Childrens 100.0% 100.0% 98.6% 87.5% 96.0% 86.4% 96.8% 91.7% 100.0% 96.3% 96.3% 95.5% 96.2% 5/6 Gynaecological 91.7% 93.7% 96.4% 89.4% 89.9% 90.3% 96.9% 96.3% 95.7% 94.4% 97.1% 98.0% 98.4% 6/6 Haematological 100.0% 98.3% 97.9% 88.0% 98.6% 93.9% 98.4% 100.0% 100.0% 98.6% 100.0% 98.1% 96.6% 5/6 Head & Neck 98.7% 98.5% 97.4% 94.2% 93.5% 93.1% 93.5% 91.1% 95.9% 96.1% 98.9% 98.8% 98.4% 6/6 Lower Gastrointestinal 87.6% 94.1% 94.4% 89.6% 91.8% 81.9% 87.2% 87.9% 93.9% 96.3% 94.9% 94.7% 90.5% 3/6 Lung 99.2% 100.0% 99.0% 98.4% 94.4% 93.9% 95.8% 95.5% 98.0% 98.4% 99.2% 98.1% 94.5% 4/6 Other 100.0% % 100.0% 100.0% % 100.0% 100.0% % 100.0% 100.0% 1/1 Sarcoma 96.8% 92.3% 96.0% 100.0% 97.3% 84.0% 88.9% 96.2% 89.5% 96.8% 96.0% 91.7% 82.4% 4/5 Skin 87.7% 88.1% 85.2% 79.7% 80.7% 85.7% 88.4% 95.7% 96.7% 97.4% 96.0% 97.6% 96.9% 6/6 Testicular 94.7% 100.0% 96.3% 83.3% 95.0% 100.0% 100.0% 95.0% 95.2% 96.0% 100.0% 100.0% 100.0% 4/4 Upper Gastrointestinal 91.1% 97.8% 95.4% 92.8% 95.1% 94.2% 97.3% 94.0% 89.8% 94.1% 96.4% 98.8% 91.2% 2/6 Urological (exc. testicular) 97.5% 98.1% 97.8% 97.7% 95.2% 92.8% 98.0% 97.4% 96.5% 96.2% 98.7% 98.6% 98.5% 6/6 Total 93.1% 94.7% 94.3% 90.4% 90.4% 88.5% 91.6% 94.1% 95.8% 96.6% 97.2% 97.5% 95.4% 5/6 SW London Narrative The 2WW Performance Standard: At SW London CCG level: The 2WW performance standard was achieved at aggregate level with performance of 95.4% with the exception of Sutton CCG. The 2WW Breast Symptomatic performance standard was achieved with performance of 95.0% however, Sutton CCG did not achieve the standard with an outcome of 90.9% (4 breaches out of 42 pathways. 3 patient choice breaches at RMH and 1 admin breach at SGH.). At SW London provider level: The 2WW performance standard was achieve at aggregate level with an outcome of 95.0%, however it was not achieved at RMH in January with 90.0% (48 breaches out of 479 pathways). London wide performance was 93.6% and National performance was 93.8% in month. The Breast Symptomatic standard was achieved at aggregate level with performance of 93.4%. London performance of 90.2% and National performance of 91.9% were both under target in month. However, the standard was not achieved at KHFT 90.80% (16 breaches out of 174 pathways) and RMH 88.41% (16 breaches out of 138 pathways). The 62day Performance Standard: At SW London CCG level: The performance standard was not achieved at aggregate level with performance of 80.9% (43 breaches out of 225 pathways) in January. Kingston CCG achieved the standard in January with 87.9% while the other CCGs achieved the following: Croydon CCG % (8 breaches out of 49 pathways), Merton CCG % (8 breaches out of 34 pathways), Richmond CCG 80.6% (7 breaches out of 36 pathways), Sutton CCG 77.8% (8 breaches out of 36 pathways) and Wandsworth CCG 80.0% (8 breaches out of 37 pathways) At SW London Provider level: The performance standard was not achieved in January with an outcome of 80.0% (55 breaches out of 275 patients). This is below London's performance of 82.0% and national performance of 81.0%. CHS and KHFT achieved the standard in month. Performance was below standard at RMH % (19.5 breaches out of 66 pathways), ESTH 76.9% (13.5 breaches out of 58.5 pathways) and SGH 78.4% (12.0 breaches out of 55.5 pathways) Forward view for February 2018 Provisional data for February 2018 shows that the SW London sector is likely to be non-compliant with the 62 day standard. However this will be subject to change and validation as more data becomes available. The February position is expected to improve on the January performance. January CCG Pass Rate 62 Day Wait by Tumour Site (CCG) Tumour Site Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Brain/Central Nervous System % % % - - 0/0 Breast 100.0% 100.0% 97.6% 96.8% 100.0% 100.0% 97.6% 97.4% 95.3% 95.2% 90.6% 97.0% 86.8% 3/6 Childrens % % 100.0% 0.0% % 1/1 Gynaecological 75.0% 88.9% 62.5% 86.7% 76.9% 81.3% 53.8% 81.8% 80.0% 92.3% 86.7% 72.7% 75.0% 2/5 Haematological (inc. acute leukaemia) 87.5% 85.7% 100.0% 100.0% 71.4% 88.9% 93.3% 81.8% 85.7% 76.9% 100.0% 90.0% 85.7% 4/6 Head & Neck 58.3% 41.7% 71.4% 55.6% 61.5% 33.3% 65.0% 71.4% 75.0% 73.3% 78.6% 50.0% 75.0% 2/4 Lower Gastrointestinal 81.3% 75.0% 75.0% 86.7% 92.3% 78.3% 93.8% 96.3% 84.2% 100.0% 96.4% 92.0% 86.4% 4/6 Lung 69.2% 86.7% 61.5% 91.7% 73.3% 61.5% 64.7% 60.0% 78.6% 52.6% 65.4% 70.6% 69.2% 3/6 Other 100.0% 100.0% % 0.0% 100.0% 100.0% - 0.0% 100.0% % 1/2 Sarcoma 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 60.0% 50.0% 100.0% 100.0% 33.3% 1/2 Skin 100.0% 95.7% 96.2% 97.7% 98.0% 100.0% 96.7% 90.0% 92.5% 92.6% 95.5% 95.5% 87.5% 2/6 Upper Gastrointestinal 30.8% 83.3% 92.9% 81.3% 66.7% 92.3% 80.0% 58.8% 50.0% 90.0% 90.0% 86.7% 66.7% 3/5 Urological (inc. testicular) 83.6% 84.1% 88.1% 88.4% 80.6% 85.4% 79.2% 81.5% 85.4% 81.7% 90.5% 83.7% 80.6% 2/6 Total 83.8% 86.4% 88.7% 90.0% 85.3% 87.5% 83.6% 83.1% 85.0% 84.9% 89.1% 87.1% 80.9% 1/6 Key Actions Action Narrative Owner Due Compliance against 62 day Standard Improved performance against 38 day trajectories within SWL Diagnostics Cancer Transformation in support performance. (RM Partners Cancer Alliance Projects) Weekly conference calls for shared care PTL s have been established across SWL to strengthen escalation around shared patient care. As part of the weekly conference calls for shared care PTL s each patient who is referred post day 38 is discussed to identify real time delay reasons. TCST are offering Trusts support with diagnostic optimisation. They are meeting with Croydon in April to look at CT. Funding from RMP is supporting each Trust individually with diagnostic capacity in a number of areas. RM Partners Cancer Alliance Projects are supporting key transformation work streams which will drive improvements in performance, including : 1. RAPID prostate pathway at ESTH and SGH 2. Supporting CHS and SGH with the lower GI timed pathway / STT (Straight To Test). 3. A Head & Neck task force has been established to improve the service across SW London. Cancer General Managers, CSU, Cancer General Managers, CSU, TSCT/CHS RMP/Trusts RMP Went live on 9 th March 2018 Went live on 9 th March 2018 Apr-18 Mar 18 January CCG Pass Rate 1. RAPID is operational at both Trusts, expected performance improvements April On-going 3. On-going 5

110 SW London Diagnostic Performance (By CCG) Diagnostic waits SWL CCG Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 NHS CROYDON CCG 99.1% 97.6% 96.2% 94.3% 94.6% 95.9% 97.1% 98.4% 99.7% 99.6% 99.2% 99.3% 99.4% NHS KINGSTON CCG 98.7% 99.0% 99.2% 98.7% 98.5% 99.4% 99.2% 98.8% 99.3% 99.4% 99.0% 99.4% 99.6% NHS MERTON CCG 97.2% 98.3% 98.4% 98.0% 98.3% 98.9% 99.0% 99.3% 98.9% 99.6% 98.9% 99.2% 99.8% NHS RICHMOND CCG 99.1% 99.4% 98.7% 97.8% 98.5% 98.5% 98.6% 98.8% 98.9% 96.3% 95.9% 98.0% 99.3% NHS SUTTON CCG 99.2% 99.5% 99.7% 99.5% 99.4% 99.6% 99.4% 99.5% 99.2% 99.4% 98.9% 99.2% 99.5% NHS WANDSWORTH CCG 96.7% 98.1% 97.6% 96.5% 97.3% 97.5% 97.2% 97.8% 98.7% 99.5% 98.7% 99.4% 99.0% Total 98.3% 98.4% 97.9% 96.9% 97.2% 97.9% 98.1% 98.6% 99.2% 99.2% 98.6% 99.2% 99.4% SW London Diagnostic Waiting List and Performance Lead LDU:Merton and Wandsworth Period: M /18 Named Lead:John Atherton Report: Date: 03/04/2018 SW London Diagnostics Waits < 6 Weeks (By Test) Diagnostic Test Name Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Audiology Assessments 98.1% 98.1% 98.6% 96.1% 95.1% 97.5% 97.8% 96.8% 97.7% 98.9% 99.9% 100.0% 99.7% 5/6 Barium Enema 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% % 100.0% 100.0% 100.0% 2/2 Colonoscopy 93.8% 96.9% 96.4% 97.3% 97.4% 97.8% 97.2% 98.1% 98.0% 98.0% 99.0% 98.6% 98.3% 2/6 CT 99.5% 99.9% 99.7% 99.6% 99.6% 99.9% 99.8% 99.7% 99.2% 99.6% 99.7% 99.5% 99.9% 6/6 Cystoscopy 91.9% 93.3% 93.2% 87.9% 90.9% 83.8% 91.0% 91.8% 88.4% 94.4% 95.1% 97.1% 94.0% 2/6 DEXA Scan 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 6/6 Echocardiography 99.9% 93.3% 90.1% 83.4% 79.6% 89.0% 91.2% 95.7% 99.7% 99.7% 99.2% 99.4% 99.5% 6/6 Electrophysiology 100.0% 90.9% 77.8% 100.0% 87.5% 62.5% 75.0% 55.6% 75.0% 100.0% 100.0% 100.0% 100.0% 4/4 Flexi Sigmoidoscopy 89.5% 94.5% 96.9% 97.9% 99.5% 98.4% 96.5% 98.6% 98.1% 98.8% 99.0% 98.1% 97.7% 1/6 Gastroscopy 97.0% 98.6% 98.1% 94.2% 95.3% 95.4% 95.3% 96.4% 98.0% 98.2% 97.9% 96.9% 97.8% 3/6 MRI 97.2% 98.5% 98.9% 98.9% 99.4% 99.3% 99.4% 99.6% 99.6% 99.3% 99.3% 99.6% 99.7% 6/6 Non Obstetric Ultrasound 99.2% 99.5% 99.1% 98.8% 99.2% 99.8% 99.6% 99.6% 99.9% 99.3% 99.1% 99.4% 99.7% 6/6 Peripheral Neurophys 99.5% 100.0% 100.0% 99.2% 98.3% 99.3% 98.0% 98.9% 98.8% 99.4% 99.8% 99.6% 99.6% 4/6 Sleep Studies 94.3% 100.0% 98.4% 98.1% 97.4% 100.0% 94.6% 98.5% 98.6% 96.8% 73.6% 93.8% 92.7% 3/6 Urodynamics 94.6% 91.6% 88.3% 86.5% 77.1% 77.9% 82.0% 80.1% 84.8% 93.8% 95.5% 97.4% 93.4% 2/6 Total 98.3% 98.4% 97.9% 96.9% 97.2% 97.9% 98.1% 98.6% 99.2% 99.2% 98.6% 99.2% 99.4% 6/6 SW London Diagnostic Waiting List and Performance (By Provider) Provider Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 KHFT 99.68% 99.73% 99.79% 99.27% 99.27% 99.45% 99.18% 99.06% 99.53% 99.27% 99.21% 99.85% 99.68% CHS 99.79% 97.50% 96.01% 93.79% 94.37% 95.67% 97.08% 98.40% 99.89% 99.88% 99.78% 99.44% 99.55% ESTH 99.29% 99.78% 99.87% 99.73% 99.72% 99.82% 99.67% 99.69% 99.33% 99.54% 99.58% 98.98% 99.43% SGH 94.83% 97.22% 97.10% 95.87% 96.67% 97.79% 97.28% 98.01% 98.64% 99.69% 98.11% 99.91% 99.85% Total 98.00% 98.46% 98.12% 97.05% 97.39% 98.14% 98.25% 98.73% 99.30% 99.62% 99.11% 99.49% 99.63% January CCG Pass Rate SW London Narrative At CCG Level in SW London: Performance was achieved at aggregate level across SW London CCGs with an outcome of 99.4% up from 99.2% in November. Performance was achieved at all CCGs including Richmond. This is the first time since March 17 that the CCG has achieved the standard. At SWL level, there were 140 breaches out of 22,829 waits. Endoscopy accounted for 59 breaches, Non Obstetric Ultrasound accounted for 26 and Sleep studies for 20 breaches. At Provider level in SW London: Performance was achieved at SW London provider level in January with an outcome of 99.63% with all the main providers achieving target. CHS: The Trust highlighted recently that they were planning to replace one of their two CT scanners. In order to mitigate against a material lengthening in CT scan waits during the 8-12 weeks of the replacement programme, Croydon Healthcare Services increased CT activity, so that currently CT waits are around one week, providing a buffer to protect performance during the reduction in capacity. However, at the start of February 2018 the remaining scanner stopped working. Mitigations were put in place in partnership with SGH and LAS to manage this outage, while awaiting the delivery of a part from Paris. The impact of this, if any will be reported in February 2018 performance data. Key Actions Objective Actions Narrative Owner Due CHS - CT Delivering Diagnostics whilst replacing one of two CT Scanners CHS have commenced replacement of one of their two CT scanners. Waits have been reduced to protect performance and an enhanced maintenance and support contract is in place to protect the remaining capacity provided by the remaining one operational CT scanner. Progress with the replacement as well as with CT waits will be monitored at each of the two meetings with the Croydon Healthcare Services that occur each month. In addition, the second CT scanner stopped working in early February 2018 with mitigations put in place in conjunction with SGH and London Ambulance Service so as to maintain Croydon Healthcare Services and patient safety during the outage. The issue has been resolved and the CT scanner is operational but monitoring continues via the performance meetings. CHS General Manager Cancer and RTT / Diagnostic /Radiology Manager CHS COO Jan March 18 Trust Performance Meetings Feb-18 6

111 Ambulance Handovers - London Ambulance Service (LAS) Lead LDU: Croydon Period: M /18 Named Lead:Elaine Clancy Report: Date: 03/04/2018 LAS Conveyances by Provider LAS patient handover within 15 minutes Data is not validated LAS 30 Minute Breaches By Provider Data is post validation LAS 60 Minute Breaches By Provider Data is post validation This section reports upon and considers London Ambulance Service (LAS) conveyances only. Some Hospital sites will also have conveyances from SECAMB and/or others, however these are not included in the above data. SW London Narrative February saw LAS handover breaches decrease across South West London (SWL) compared with January, whilst over a longer trend, demonstrating an increase compared with M11 of the previous financial year. February, compared to the previous month, saw a decrease of 11.0% (900 )LAS attendances in SWL. There were 12.5% (62) fewer 30 minute breaches and an equal amount of 60 minute breaches (74). The majority of these occurred at St Helier (61). Across SW London, comparing February 2017/18 with the same month of the previous year, 2016/17: Total attendances have increased by 3.3% 30 min breaches have increased from 190 to 435 (an increase of 130%) 60 min breaches increased from 17 to 74. (an increase of 335%) Handovers within 15 minutes have decreased from 46.6% to 40.6% Increases in 'Hear and Treat' and 'See and Treat' contribute to demand management, freeing up more resources to respond to emergency calls. In Month 11 'Hear & Treat' rates for LAS were 4% compared with the 5% national average. The proportion of face to face calls managed without the need to transport a patient to a type 1 or 2 A&E department was 26% compared to 30% national average. (From the new ambulance system indicators time series data for February 2018.) Trust Actions Narrative Owner Due Croydon Health Services Kingston Hospital St Helier St George's Key Actions CHS has an improvement plan via optimised ED layout, standardising core processes, managing queue situations effectively. Care Homes use of 111 has reduced conveyances 20%. The new Emergency Department is expected to support A&E performance. Chief Operating Officer Handovers are monitored via daily information provided by KHFT, AD Emergency including conveyances, % handover within 15mins, >30 minutes, Care >60 minutes and data completeness. The Trust wishes to work more closely with SECAMB on delays. Work on a frailty in-reach and rapid response / re-ablement model is in development to improve the flow in the ED. Modifications to the estate will also reduce pressure on ED. Actions to release capacity in ED for ambulance arrivals include, increasing ambulatory care capacity, using consultant rapid assessment on the front door, and transfers to AMU for patients requiring a medical specialty assessment. The Trust are reviewing ambulance handover processes to reduce delays. There is a capital project to provide additional capacity for ambulatory care away from the ED to reduce pressure and ensure sufficient capacity for urgent patients. Chief Operating Officer Director of Delivery Completion of ED layout improvements is now expected June 2018 Mar-18 Mar-18 Mar-18 7

112 NHS 111 percentage Clinical Contact NHS 111 service Lead LDU: Period M /18 Named Lead: Jonathan Bates Report: Date: XX/04/2018 SW London Narrative Easter saw Vocare as the lowest performing 111 provider in London for calls answered in 60 secs and abandonment rates. This is despite daily Easter assurance calls with Vocare where we reviewed and uplifted forecast demand in line with local analysis, identified that the risks to rota fill were the main challenge to meeting target service level and agreed on a service model which would maximise patient safety and minimise onward impacts into ED and 999. In order to secure staffing, Vocare had introduced a number of incentives; as unplanned staff absence seems have been the main reason for the Easter underperformance, these were clearly insufficient. Call demand over Easter, to date, has broadly been in line with the revised forecasts, but further analysis is underway to identify all factors contributing to the unacceptable performance. One area which is being scrutinised is the Average Handling Time (AHT) for calls taken over Easter which was much higher than seen so far this year and significantly impacted on Vocare s ability to answer calls in line with demand. This may be as a result of more new and inexperienced staff taking calls, more calls from patients who had to wait for a long time or call back and the consequent appeasement time prior to the standard triage work or an, as yet, unknown root cause. 5% Calls Answered Within 60 Seconds & Calls Abandoned After 30 Seconds 93.7% 94.5% 94.7% 89.2% 88.1% 87.2% 2.0% 1.9% London- Answered in 60 seconds SWL- Answered in 60 seconds Target- Answered (95%) 92.6% 92.1% 91.7% 92.5% 84.2% 85.2% 2.8% 3.0% 2.8% 88.0% 87.8% 88.5% 2.0% 2.2% 1.9% 1.2% 1.1% 1.2% 1.3% 1.3% 1.4% 1.3% 90.7% 89.5% 2.4% 1.7% 1.8% Volume of Calls 2.7% 2.5% 111 Dispositions (Outcomes) 7.2% 4.8% 4.0% 4.0% Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 London Abandoned after 30 seconds SWL - Abandoned after 30 seconds Target- Abandoned (5%) 86.9% 85.5% 84.6% 81.5% 81.6% 72.6% 71.3% 6.6% 6.3% Feb-18 Answered in 60 seconds SEL 80.2% NEL SWL 71.3% NWL 66.2% NCL 62.6% London 72.6% Feb-18 Abandoned after 30 seconds SEL 2.3% NEL 79.3% 6.1% SWL 6.6% NWL 7.7% NCL 9.5% London 6.3% Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 London- Calls Answered 134, , , , , , , , , , , , ,317 London- Ambulance Dispatches 12,404 13,237 13,168 13,852 12,509 13,227 12,412 12,762 14,586 14,644 17,786 17,635 15,470 London- Recommended to 11,908 13,235 13,442 14,290 13,763 14,165 12,634 12,893 14,183 13,307 14,690 15,947 13,392 attend A&E London- Recommended to 64,405 69,896 75,635 73,948 63,369 68,477 62,607 62,057 69,513 68,278 90,302 88,792 78,768 attend Primary Care SWL- Calls Answered 23,984 25,719 29,416 28,369 25,410 27,110 25,024 24,876 26,448 26,601 32,398 31,653 28,106 SWL- Ambulance Dispatches 2,107 2,279 2,402 2,524 2,173 2,454 2,304 2,380 2,646 2,827 3,423 3,337 2,821 SWL- Recommended to attend A&E 1,910 2,127 2,307 2,451 2,302 2,517 2,180 2,257 2,418 2,352 2,460 2,627 2,349 SWL- Recommended to attend Primary Care 10,922 11,428 13,710 13,014 11,453 12,549 11,528 11,639 12,795 12,581 16,161 15,530 13, % 76.8% 95% Vocare has been asked to provide a perspective on their performance over Easter which is being pursued. We are collating a full briefing on all elements identified to date, and actions yet to come, to inform our next steps and the forthcoming CPN. In addition, the Director of Commissioning Operations will be speaking with the MD of Vocare on Thursday 5 th April to emphasise further our concerns, seek assurance on business as usual performance and preparation for May Bank holidays and the need for significant improvement. Performance over Easter only serves to highlight Vocare s current inability to fulfil their contractual requirements. An issue that is being taken forward with a refreshed contractual approach. The existing CPN based on answering calls within 60 seconds has clearly not been effective and as such as withdrawn on 3 rd April A new CPN is currently in draft and will be issued shortly. The CPN will focus on key activity measures, including call answering within 60s, but will also include a number of quality measures to support patient safety. Vocare will be asked to provide a thorough root cause analysis and develop a recovery plan that is tightly aligned to the issues causing poor performance and identifies clear, achievable timelines for sustained improvement. Design and implementation will be supported and monitored closely by the commissioners with a view to ensuring that this CPN delivers the necessary improvement. This process will be overseen by the newly formed IUC Steering Group, who ultimately will take responsibility for securing a safe and timely 111/IUC service for SWL patients. At Month 11: % Calls transferred to Clinical Contact: 40.2% of calls were transferred in February 18. This target will be extended to 50% by end of Q4 2017/18; assurance is being sought from Vocare that this level of performance can be secured and that the benefits of clinical contact are reflected in patient pathways and outcomes. % Calls Abandoned after 30 seconds: 6.6% of calls were abandoned after 30 seconds in February. SW London has failed to meet the target of 5% since December % Calls Answered within 60 seconds. 71.3% of calls were answered within 60 seconds in February. Vocare has consistently not met this standard since commencement of the contract. With the exception of December (Christmas) 2017 this represents a new low in terms of performance. Elsewhere in London performance is significantly and consistently better. Action Action narrative Owner Due The new CPN is to be issued by 6 th April reflecting Commissioners process. New CPN to be escalating concerns regarding both general and Easter performance. issued Timely response to the CPN will be sought through the contractual Commissioners Apr-18 Root Cause Analysis to be completed Recovery Plan Developed Operational Monitoring of Provider Monitoring of Recovery Plan Key Actions A detailed RCA undertaken by Vocare which identifies drivers for under performance. This will be agreed by commissioner prior to it becoming the basis for actions needed to improve performance. RCA used to inform recovery actions. Roles and responsibilities, timelines and outputs clearly identified. Recovery plan to be signed off by commissioners. The plan should include both short term and long term developments to address immediate and deep rooted issues. Daily calls continue with Vocare to monitor the remainder of the Easter period, pursue further in-depth investigation and analysis. These will continue on to support planning the May Bank Holiday weekend services. Their need will be reviewed alongside the efficacy of the Recovery Plan monitoring. Commissioners will review the recovery plan on a weekly basis to monitor progress, identify areas which are not progressing in line with the plan, support the provider to address these and meet the standards required Vocare & Commissioners Vocare Regional Director & Commissioners Commissioners Commissioners & Vocare Apr-18 Apr 18 Apr-18 Jul-18 8

113 IAPT (By CCG) Lead LDU: Kingston and Richmond Period: M /18 Named Lead: Fergus Keegan Report: Date: 03/04/2018 % Waited Less than 6 Weeks for Treatment (75% threshold) % Waited Less than 18 Weeks for Treatment (95% threshold) IAPT 6 Week Waiting Time Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Croydon CCG 94.0% 94.3% 92.5% 97.7% 95.0% 98.0% 92.7% 93.6% 93.6% 95.5% 91.4% 95.6% 94.6% Kingston CCG 94.3% 95.2% 92.6% 96.7% 96.4% 96.3% 100.0% 96.7% 94.3% 88.0% 91.7% 97.1% 95.2% Merton CCG 92.3% 85.7% 89.2% 85.7% 89.2% 90.3% 87.9% 81.0% 80.0% 61.9% 61.1% 74.7% 80.5% Richmond CCG 96.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Sutton CCG 96.3% 95.5% 97.0% 92.9% 100.0% 94.6% 96.2% 96.2% 100.0% 93.1% 93.9% 100.0% 98.1% Wandsworth CCG 95.3% 93.8% 93.7% 94.2% 92.6% 89.6% 81.6% 80.5% 76.6% 78.2% 84.2% 93.4% 91.8% South West London 99.5% 99.0% 98.8% 100.0% 99.1% 100.0% 100.0% 99.5% 99.1% 98.5% 98.5% 99.8% 99.6% Recovery Rate (50% threshold) IAPT Recovery Rate Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Croydon CCG 45.5% 43.8% 45.0% 48.7% 40.5% 50.0% 50.0% 53.5% 46.3% 50.0% 41.9% 51.7% 47.2% Kingston CCG 45.2% 44.4% 52.2% 50.0% 50.0% 46.2% 42.1% 44.8% 45.5% 43.5% 47.8% 49.6% 57.0% Merton CCG 50.0% 48.0% 57.6% 45.0% 45.5% 46.7% 43.3% 50.0% 47.4% 45.0% 52.9% 51.8% 45.5% Richmond CCG 56.0% 50.0% 60.9% 70.0% 57.7% 50.0% 58.8% 56.3% 56.4% 50.0% 61.3% 57.9% 57.1% Sutton CCG 48.0% 47.4% 45.2% 53.8% 52.0% 57.6% 45.8% 52.2% 46.9% 44.4% 44.8% 46.8% 50.0% Wandsworth CCG 39.5% 39.5% 41.5% 42.2% 39.3% 31.7% 34.4% 34.3% 36.6% 43.5% 42.6% 51.8% 48.9% South West London 46.5% 44.5% 48.4% 50.0% 45.7% 46.4% 46.6% 47.6% 46.3% 46.1% 47.8% 51.4% 50.8% IAPT 18 Week Waiting Time Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Croydon CCG 100.0% 100.0% 100.0% 100.0% 97.5% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Kingston CCG 100.0% 100.0% 96.3% 100.0% 100.0% 100.0% 100.0% 96.7% 97.1% 96.0% 95.8% 99.3% 99.3% Merton CCG 100.0% 96.4% 100.0% 100.0% 97.3% 100.0% 100.0% 100.0% 100.0% 95.2% 94.4% 100.0% 100.0% Richmond CCG 96.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Sutton CCG 100.0% 100.0% 97.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.6% 100.0% 100.0% 100.0% Wandsworth CCG 100.0% 97.9% 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% 97.9% 100.0% 98.2% 99.5% 99.1% South West London 99.5% 99.0% 98.8% 100.0% 99.1% 100.0% 100.0% 99.5% 99.1% 98.5% 98.5% 99.8% 99.6% Rolling Quarterly Access Rate (3.75% for , 4.20% for ) IAPT Access Rate (Rolling Quarter) Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Croydon CCG 2.94% 2.70% 2.44% 2.00% 1.92% 2.31% 2.60% 2.69% 2.41% 2.48% 2.44% 2.39% 2.51% Kingston CCG 3.75% 3.75% 4.10% 3.70% 3.60% 3.81% 4.28% 4.33% 3.94% 4.10% 4.15% 3.97% 3.96% Merton CCG 2.50% 2.70% 2.87% 2.44% 2.02% 1.69% 2.08% 2.19% 2.58% 2.93% 3.41% 3.59% 3.43% Richmond CCG 3.57% 3.64% 4.05% 4.35% 4.60% 4.76% 4.46% 4.58% 4.42% 4.85% 4.92% 4.66% 4.51% Sutton CCG 2.22% 2.57% 3.82% 4.70% 5.21% 5.11% 5.23% 5.44% 5.60% 5.42% 5.30% 4.78% 5.03% Wandsworth CCG 2.85% 2.70% 3.04% 2.77% 2.94% 2.90% 3.34% 3.62% 3.89% 4.04% 4.03% 3.79% 3.76% South West London 2.93% 2.91% 3.20% 3.06% 3.11% 3.18% 3.45% 3.61% 3.63% 3.78% 3.83% 3.67% 3.68% IAPT DATA FOR NOV 2017 JAN 2018 IS FROM LOCAL UNVALIDATED DATA RETURNS TO NHS ENGLAND SW London Narrative Key Actions Kingston CCG: Kingston CCG has agreed additional funding for staffing with the Kingston service, enabling increased access in with the expectation of reducing waiting times. Staff have been recruited, bringing waiting list numbers down and increasing access rates. The service has reduced the waiting list backlog and recovery has now increased. Weekly returns from the Kingston service show that the 4.2% access target and the 50% recovery target will be met for quarter 4. Croydon CCG: The CCG and SLaM have been working towards a compliant run rate of 4.2% in. Q4. The action plan to deliver this requires inputs from both commissioner and provider to promote the service to increase self-referrals and GP referrals, following recruitment of 21 additional therapists between Nov - Mar. A number of opportunities to raise the profile of the service were taken, including a leaflet drop to all Croydon residences, promotional materials shared with all GP practices and community pharmacists, increasing sign-posting by other health and social care professionals. This work continues to ensure the Q1 national target is met. Weekly monitoring demonstrates that the service has seen the referral levels needed to achieve the national run rate of 4.2%. However, due to the time it has taken to influence demand, Croydon are now forecasting 3.6% for Q4.Recovery Rates are expected to improve as the service increases in size and stabilises. Merton CCG: The rolling IAPT access rate currently remains below the 2017/18 Q4 national target, whilst every effort has been made meet the agreed NHSE Q4 benchmark of 4.1% through a number of improvement initiatives detailed below, confidence levels that the provider will achieve this are now very low. Latest data available is currently implying a 2017/18 Q4 position of 3.5% 3.7%. During January 2018 the second provider (IESO) contract went live which included a mailshot to approximately 78,500 households to raise awareness of services available (completed w/c: ). Additionally, the Merton IAPT services have been further promoted at the GP Forum w/c: , promotion stalls have been set up at the Nelson Health Centre and Civic Centre to help increase the number of referrals being received, GP practice visits have taken place as well as expanded social media campaigns. Weekly performance meetings and monthly contract meetings continue to take place between the provider and CCG. Sutton CCG: There has been an increase in drop-out rates which has contributed to the reduction in the recovery target. There has also been an issue with recruitment, with two vacancies being covered by locums. An audit is planned to look at reasons for drop-outs. Wandsworth CCG: Talk Wandsworth and practice-based counsellors are on track to deliver the 4.2% access rate in Q4. Talk Wandsworth have also significantly improved their access rate and we are working with practice based counsellors to address data quality issues affecting reporting of recovery rates. CCG Action Actions Narrative Owner Due Increasing Access Rate for Q4 (Croydon) Achieving access and recovery rates in Q4 (Wandsworth) Increased capacity through two provider model (Merton) Increased workforce/ capacity (Sutton) Recruitment of therapists is complete. Focus has been on increasing demand for the service through promotion to GPs and to the public. This promotional work continues to ensure Q1 2018/19 meets the 4.2% target. Workforce, referral rates and performance is monitored with the provider weekly. The CCG has engaged with the Intensive Support Team to work with Talk Wandsworth and Practice Based Counsellors to ensure access targets are met for Q4 and to ensure recovery rate improves to over 50%. Head of On-going Performance, (Mar-18) Assurance and Emergency Planning Commissioning Lead Mental Health The Merton IAPT provider Addaction has commissioned an online Director of IAPT provider (IESO) to increase capacity and access from Jan-18 Performance to Mar-18. Under this two provider arrangement they have Improvement committed to delivering 4.1% access rate for end of Q4 2017/18. Wandsworth CCG and Merton CCG Additional funding for the increased IAPT access target for 17/18, will increase capacity and reduce waiting times. Recruitment of additional workforce underway, 1 WTE has been recruited to with an impact on performance expected from early March. The CCG has issued a Contract Query Notice requesting an action plan to recover performance for Q4. Provider is now submitting weekly performance data against trajectory as requested Director of Commissioning Sutton CCG Mar-18 Jan-Mar 18 Feb-18 9

114 Dementia and Mental Health Lead LDU:Kingston and Richmond Period: M /18 Named Lead:Fergus Keegan Report: Date: 03/04/2018 Estimated Dementia Diagnosis Rate (66.7% threshold) Care Programme Approach (CPA) 7 Day Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan Q Q Q Q Q Q3 Croydon CCG 66.6% 66.8% 67.0% 66.8% 65.9% 66.7% 66.9% 67.5% 67.0% 67.7% 67.6% 67.7% 67.6% Kingston CCG 60.5% 59.5% 59.4% 59.3% 60.0% 62.6% 61.4% 61.4% 62.9% 63.0% 63.7% 63.2% 63.1% Merton CCG 70.3% 69.8% 69.6% 68.6% 68.8% 69.2% 68.9% 69.3% 70.0% 70.2% 70.4% 72.0% 70.8% Richmond CCG 68.7% 68.6% 68.9% 67.7% 67.7% 67.5% 66.7% 66.7% 66.2% 65.9% 67.0% 66.7% 67.5% Sutton CCG 73.5% 73.8% 73.6% 73.2% 73.0% 73.6% 74.6% 74.9% 75.6% 75.9% 75.8% 74.4% 75.1% Wandsworth CCG 70.1% 69.8% 70.3% 71.5% 72.0% 72.4% 72.7% 72.7% 72.8% 74.0% 73.8% 73.8% 73.8% South West London 68.2% 68.1% 68.2% 67.9% 67.8% 68.6% 68.5% 68.8% 69.0% 69.4% 69.5% 69.5% 69.5% SWL New Referrals Received (Mental Health Service Data Set) Croydon CCG 97.73% 98.91% 97.78% 95.88% 95.51% 95.65% Kingston CCG 94.81% 95.35% 96.92% 96.00% 97.44% 97.18% Merton CCG 96.91% 96.70% 96.88% 95.65% 98.81% 96.70% Richmond CCG 97.44% 96.05% 93.98% 97.85% 95.16% 92.41% Sutton CCG 95.83% 96.61% % 98.46% 98.46% 96.67% Wandsworth CCG 95.10% 94.87% 95.81% 94.42% 95.95% 94.70% South West London 96.22% 96.25% 96.69% 95.97% 96.77% 95.40% Early Intervention in Psychosis (50% of people start treatment within 2 weeks) Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Croydon CCG 87.5% 88.9% 50.0% 40.0% 50.0% 85.7% 50.0% 75.0% 45.5% 55.6% 81.8% 100.0% 37.5% Kingston CCG 83.3% 66.7% 100.0% 60.0% 70.0% 60.0% 75.0% 75.0% 100.0% 75.0% 80.0% 100.0% 57.1% Merton CCG 100.0% 100.0% 66.7% 0.0% 80.0% 80.0% 40.0% 100.0% 66.7% 50.0% 42.9% 50.0% 57.1% Richmond CCG 0.0% 100.0% 66.7% 50.0% 80.0% 66.7% 50.0% 75.0% 80.0% 0.0% 60.0% #DIV/0! 75.0% Sutton CCG 50.0% 87.5% 60.0% 100.0% 85.7% 71.4% 100.0% 100.0% 83.3% 75.0% 100.0% 75.0% Wandsworth CCG 66.7% 100.0% 54.5% 100.0% 60.0% 69.2% 57.1% 42.9% 69.2% 57.1% 72.7% 22.2% 33.3% South West London 76.0% 90.9% 61.1% 61.1% 68.2% 74.4% 56.8% 74.1% 69.8% 58.1% 69.8% 66.7% 52.8% SW London Narrative Dementia: Kingston: The Kingston dementia nurse is in post, and has reviewed potential dementia patients in all Kingston GP Practices. The nurse has also liaised with Kingston Memory Assessment Service, provided by SWL & St Georges. A practice Mental Health KPI has been developed and implemented in GP Practices, which includes a dementia KPI in order to raise rates. A dedicated GP is assessing the cognition of patients in nursing homes and will notify their GP of the diagnosis if found to have dementia. The dementia diagnosis rate has dropped slightly between December 2017 and January 2018 compared to November 2017, which is as a result of a small reduction in those on the register, but a larger increase of the estimated dementia list size (the denominator), provided by NHS Digital. Croydon CCG did not meet the 50% EIP target for M10 due to 5 patients not being seen in 2 weeks, out of a total of 8 patients referred in the month. 2 of these were due to DNAs, 3 were due to process issues at the provider. The provider achieved the target across all CCGs. Croydon s year to date performance is 61.0%. Wandsworth CCG did not achieve the 50% EIP target in January due to 3 patients waiting over 2 weeks to be seen. 2 patients did not immediately engage with the service as they were not available and 1 patient transferred between boroughs, which delayed the start of their treatment CPA 7 Day Access: Wandsworth CCG missed the CPA 7 day standard in Quarter by one person. CPA follow up is a standing agenda item on the monthly South West London and St Georges performance meeting, with a report on each breach and actions shared with commissioners at that point. All CCGs achieved the 7 day standard for Action Actions Narrative Owner Due Review of patients in Care Homes. (Kingston) Employment of dedicated Dementia nurse. (Kingston) Information sharing from HRCH and SWL & St Georges. (Richmond) Key Actions Dedicated GP resources are assessing patients in care and nursing homes to ensure that they are correctly recorded as having dementia. Kingston CCG Has employed a dementia nurse to increase diagnosis rate by: 1. Liaising with stroke rehab team, falls service and Parkinson s clinic to discuss if cognitive function is reviewed and communicated back to GP 2. Working with substance misuse teams/services and consider joint working with CMHT as cognitive impairment in patients with alcohol misuse is often missed. Devising a standard template for HRCH to use to feedback dementia diagnosis confirmation to surgeries to enable them to update their QOF registers. Continue to send out the patient lists from SW London St. George's MHT Memory Clinics on a monthly basis and to include those with mild cognitive impairment for follow up assessment. Head of Mental Health Commissioning Head of Mental Health Commissioning Senior Commissioning Manager Continuing Completed: Nurse in post Completed 10

115 DTOCs - KHFT DTOCs - SGH FT DTOCs ESTH DTOCs - CHS Delayed Transfers of Care Lead LDU:Sutton CCG Period : M /18 Named Lead:Sean Morgan Report: Date: 03/04/2018 Key Actions CCG Action Narrative Owner Due Establish multiagency working group Croydon: Awaiting social care placement responsible for 172 days (acute). Patients not covered by NHS and Community Care Act (NHS) for 120 days.(acute) 183 patients were awaiting completion of assessment (NHS non-acute). 1. Mental health patients processes being reviewed, to reduce waits and evaluate potential for weekend admissions. 2. The new DOO at CHS is the lead for the High Impact Changes Program (HICP) which incorporates all the DToC actions. 3. Regular MADE events to expedite DTOCs with long LoS. CCG and LA providing on-site support. 4. Discharge to Assess pathway 2 rolled out on all wards, design work on pathway 3 underway. Director of Operations, Croydon Health Services, Sam Goldberg 1. On-going 2. On-going 3. On-going 4.Completed LA Delayed transfers of care per day per 100,000 CCG population (Jan-18) 18+ Jan-18 Dec-17 Target Local Authority (LA) Social Social Social NHS Care Total NHS Care Total NHS Care Total CROYDON KINGSTON RICHMOND MERTON SUTTON WANDSWORTH CCG/ESTH Task and Finish group has been set up Sutton CCG: Waiting for further NHS non-acute care for 41 days and patient or family choice (NHS acute) responsible for 44 days. Awaiting care package in own home (Social Care acute) 60 days. Non-acute DToCs were 8 days all attributable to Social Care. Implement refreshed Joint Delivery Plan Richmond CCG: The majority of DTOCs were related to Further non acute NHS care, Care homes, Patient choice or Completion of assessments in almost equal measure. Richmond Council is ahead of the NHS England winter 2017 DToC trajectory, Richmond CCG is above planned levels. Increase in enablement capacity Wandsworth CCG: Awaiting care package in own home responsible for 79 days (acute) of which NHS for 47 and Social Care for 32, Patient or family choice (NHS) for 59 days and waiting further NHS non-acute for 48 days. NHS responsible for 63 non-acute (mostly awaiting residential placement, 59) and Social Care for 80 days Awaiting nursing home placement for 42). Reduce DToCs Merton CCG: Waiting for further NHS non-acute care responsible for 66 (acute) and awaiting care package in own home (Social Care) for 60 (acute). Non-acute DToCs was 66 days of which NHS was responsible for 8, Social Care for 28, and awaiting care package in own home (Social Care) for 15 days. 1. High Impact Change Model implementation is in progress. Action plan developed. 2. Improve communication/unblock process issues twice weekly multi agency, MDT discharge meeting at St Helier Hospital. 3. Weekly Director level escalation meetings (super stranded reviews) 4. LBS and SCCG have agreed to place without prejudice based on checklist outcome with the use of the shorter DST form. 5. Work with community and social care providers to ensure robust recruitment /retention procedures in place. LBS is implementing a new Adult Social Care commissioning strategy to improve homecare capacity. 1. Support the developments against the High Impact Change Model to improve services to support people ready for discharge from hospital, including developing the Discharge to Assess model, Better at Home and enhance equipment provision to support earlier discharges. 2. This includes additional social work posts in the RRR Team to increase capacity to support improvements in transfers of care from hospital, reduce waiting times for assessment and reduction in DToCs. 3. Actions in progress on-going & being closely monitored by AEDB. Chair, Sutton A&EDB Chair, Richmond Accident and Emergency Delivery Board 1. Increase in enablement capacity to support hospital discharges Chair, including a plan to facilitate weekend discharges into Enablement Service Mitigate by step-down beds and 24-hour enablement packages / care packages in own home investment from the ibcf to increase staff / number of PoC. 2. Daily calls and weekly escalation call in place 1. Improve communication / unblock process issues A daily conference call between CLCH, CHC and LB Merton to discuss patient discharges. 2. Daily call and weekly escalation meeting CLCH and LB Merton and Merton CCG. 3. LB Merton and Merton CCG have agreed to place without prejudice based on checklist outcome with the use of the shorter DST form. 4. Reablement capacity LB Merton increased by 100 hours W/C 20 December 17 Review of DToC information Kingston DToC information is sent from Kingston Hospital and is Kingston CCG: The majority of DToCs were reviewed by community teams and adult social care for response. related to non-acute NHS care, the vast majority of these were waits for Neuro-rehabilitation bed, or waits for CHC. Kingston CCG and The Royal Borough of Kingston are ahead of the NHSE DToC trajectory. CCGs average daily rate (as per the London expectation) is 5.1, compared to the trajectory of 8.5 for Nov The RBK average is 0.8 compared to the 1.5 target Wandsworth and Merton A&EDB Reviewed at the Sutton A&EDB 3. On-going 5. April 2018 Reviewed monthly at the Richmo nd A&EDB 1. Reviewed monthly at the AEDB Completed 2.On-going Chair, 1.On-going Wandsworth 2.On-going and Merton 3.On-going A&EDB 4.Done Chair, Kingston A&EDB Reviewed monthly at the Kingston A&EDB 11

116 Commonly used NHS Acronyms Glossary click here to find more > Acronym Definition Acronym Definition ABT Assessment and brief treatment teams NELCSU North & East London Commissioning Support Unit AEDB A&E Delivery Board NHS ENGLAND National Health Service England ASIP Accelerated service improvement NHS IMPROVEMENT National Health Service Improvement AWOL Absent without leave OAP Out of Area Placements CAMHS Child and Adolescent Mental Health Service OPEL Operational Pressures Escalation Levels Framework CCG Clinical Commissioning Group OPI Operational Performance Indicators CHS Croydon Healthcare Services PALS Patient Advice and Liaison Service CMHTs Community Mental Health Teams PICU Paediatric intensive care unit CPA Care Programme Approach PMO Programme Management Office CPN Contract Performance Notice PTL Patient Tracking List CQUIN Commissioning for Quality and Innovation QIAs Quality Impact Assessments CRT Community recovery teams QMH Queen Mary Hospital, Roehampton CSU Commissioning Support Unit RMH Royal Marsden Hospital DoLS Deprivation of liberty standards RMP Royal Marsden Partners DTOC Delayed Transfer of Care RRR Richmond Rapid Recovery ECIST Emergency Care Intensive Support Team RRT Rapid Response Teams ECP Emergency Care Programme RTT Referral to Treatment EIP Early intervention in psychosis SGH St George's University Hospitals NHS Foundation Trust ESTH Epsom & St Helier Hospital NHS Foundation Trust SI Serious incidents HCH Hillingdon Community Health SLAM South London and Maudsley NHS Foundation Trust HRCH Hounslow and Richmond Community Health SLF South London Forum (Cancer) HTT Home Treatment Team SOF Single Oversight Framework IAPT Improved access to psychological therapies SPA SPA - Single Point of Access IST Intensive Support Team SSOC Shifting settings of care KHFT Kingston Hospital Foundation NHST Trust SWL South West London KPI Key Performance Indicator TCI To Come in LD Learning Disabilities UEC Urgent and Emergency Care MHA Mental Health Act WW Week Wait NHS Acronym Buster App The NHS has produced a new jargon busting App. The free App, produced by the NHS Confederation spells out what things mean and gives definitions for more than 700 commonly used acronyms and abbreviations in the NHS. You can download it for free from itunes to your iphone/ipad or from Google Play Store to your Android phone/tablet so you have the definition of over 700 commonly used NHS acronyms and abbreviations at your fingertips. Just search NHS Acronym in the itunes app or Google Play Store

117 FOR FURTHER INFORMATION: NEL Commissioning Support Unit Performance Management & Pressure Surge South West London 120 The Broadway, 1st Floor The Broadway, Wimbledon, London SW19 1RH

118 Richmond Quality Safety and Performance Committee Summary The Quality Safety and Performance Committee met on Tuesday 17 th April and reviewed the papers presented to the Committee. 1) Monthly Performance Reporting Incidence of healthcare associated infections The CCG has met the full year target of 31 for Clostridium difficile (C. difficile) with the 2017/18 position at 30. Referral to Treatment (RTT) and Diagnostic Waits Year to date performance remains strong at Kingston and Chelsea & Westminster Trusts, with continued significant pressure Imperial College Trust. A waiting list improvement programme and action plan are in place which includes management of the clinical review process, providing assurance that patients who wait over 52 weeks are not coming to harm. The Trust progress against the 6-week diagnostic standard has decreased to 98.5% from 99% in February. Sleep studies and cystoscopy have small numbers waiting over 6 weeks. Year to date performance is 98.1% 52 Week waits Richmond CCG had 4 patients waiting over 52 weeks in February The reasons are currently under investigation. Cancer Standards The CCG has met 5 of the 8 cancer waiting time standards for February (M11) 2017/ Day Wait - 2nd/Subsequent Treatment - Treatment type only (Commissioner The CCG failed to meet the three 31-day standards. There have been 6 breaches, of which 4 have been classed as avoidable; 3 attributable to the Royal Marsden administrative errors; TCST are following up with Royal Marsden Hospital how the administrative errors occurred and what remedial action is being taken. One for Imperial with the reason unknown. Cancer 2 Week Wait The standard has been achieved since July and all are now compliant year to date. A&E waiting times Winter 2017/18 was particularly challenging nationally and had a significant impact on the urgent and emergency care system more locally mimicking that which was seen in the rest of the country. There were marked increases in flu and norovirus and higher than expected demand on critical care capacity. A&E performance for England was the lowest recorded since recording commenced and the total performance for the country was 84.3% for quarter 4. Locally, the surge plans developed with all local partners, overall were effective this winter and resulted in a cohesive way of working. The A&E Delivery Board (covering Kingston and Richmond and Surrey Downs) will be conducting a review of winter performance and developing new plans and initiatives for the coming year. London Ambulance Service Demand: 95,619 Incidents were provided with a face-to-face response. This was 1.6% below the plan for March (98,188). (Taxis provided an additional 1,009 responses.) The year to date position for demand is 1,130,698. This is 1.8% above the year to date plan position (1,110,600) (This is including taxis). Version: Final H - 1 Date:

119 8,660 incidents were categorised as Category 1 and provided with a face-to-face response. Performance: The Mean response time for C1 was 7 minutes 26 seconds against the 7-minute national standard. This has remained steady when compared to the previous month. The C1 90 th Centile increased in March, however, it remained well within the 15-minute National Standard. The C2 performance measures remained the same from February and March. The C4 90 th Centile has performed within the 3-hour standard each month since the implementation of ARP (November 2017). Delayed Transfers of Care (Bed days per 100,000 adult population). The number of days delayed in February 2018 was 422 against a monthly target of 355 and year to date performance for the local authority is now just above the Better Care Fund trajectory. There was a slight increase in delays attributable to the NHS and slight decrease in social care delays. A focus on this area remains important for the A&E Delivery Board and partners. NHS Continuing Healthcare The CCG monitors an improvement action plan and a range of actions to support delivery of the required trajectory. As previously reported through the year, this will remain an area of challenging performance. The 28-day referral standard has improved and achieved 100% in March and the decision support tool place of assessment standard has not achieved the <15% target. Improved Access to Children s and Young Peoples Mental Health Services An updated Recovery Plan was submitted to NHS England on 13 th April 2018 and we await the feedback and response. The CCG is currently investigating IT access for the voluntary sector for reporting children s and young people s access to services they deliver. This will improve the recording for this group of residents. Funding was approved to recruit four Children s Wellbeing Practitioners who have been assigned to Richmond Schools to support children who have not previously accessed Mental Health services. 2. Reporting from Clinical Quality Review Groups Hounslow and Richmond Community Healthcare Trust (HRCH) Attributable avoidable pressure ulcers appear to have increased. There will be a review of reporting arrangements. Root cause analysis of all pressure ulcers will be reviewed at the serious incident review group. There has been an increase in inpatient falls over the last 2 quarters there had been a request for a report to the April meeting. There was a delay in implementing the new friends and family system, it has been running since October 2017 after an initial dip in response rates it is now reported to be improving. There will be monthly updates to the CQRG from the performance report. Staff sickness is the only exception reported and this was due to seasonal variations. Overall figures should be within the expected normal range for the year. There is monthly review within the CQRG and individual departments/services within the internal clinical performance review for effective sickness absence management. Compliments were received to the Immunisation Service, who were high performing, falling just short of a national award - the service have been nominated for a Royal College of Nursing award St Georges Hospital The National Cardiac Surgery Mortality report; April March 2016 raised concerns relating to high numbers of infection rates and deaths. The Care Group Lead for the Cardiac Surgery Version: Final H - 2 Date:

120 presented to the CQRG, learning from case reviews led to introduction of multi-disciplinary pathways to improve team dynamics. There is recognition that further work to improve team working is required, the CQRG were assured that close monitoring is in place to address the issues The National Maternity & Perinatal Audit in Nov 2017 was presented to the CQRG the Trust compares favourably with similar units and against national standards for 3rd/4th degree perinatal tears (3.7%UK vs 3.0%SGUH) and Apgar score <7 at 5 mins (1.2%UK vs 1.2%SGUH). Post-partum haemorrhage >1500mls (2.8%UK vs 3.5%SGUH) was a higher rate due to the Trust being a regional centre for managing women with abnormal and invasive placenta. Other quality metrics related to the audit provided assurance that maternity services are in line with national standards. South West London Integrated Urgent Care Recruitment and attrition for the 111workforce remains a concern. There has been 9% increase over projected activity for the month. The 60 second response was 76.83% (target 95%). The call abandonment rate was 4.57% (target 2%). Further assurance has been requested on support for call advisors. The regional manager has advised that a review of pay and conditions has been requested and is planned. The end to end audit of 10 calls requiring Health Care professional and ambulance disposition showed that use of pin numbers by nursing homes was low. There was a training podcast for care home staff produced in March The Quality Safety and Performance Committee discussed ways the CCG could support the use of these numbers by nursing homes to improve outcomes for patients. Kingston Hospital Foundation Trust The predicted number of pressure ulcers in January 2018 was higher than any month this financial year and the Trust is acting to improve this performance: - by increasing tissue viability nurse time in A and E - to ensure the correct equipment is available and - documentation of assessments are timely and accurate - Staff also undertake reflective practice and sharing of learning There has been a rise in the incidence of falls in January 2018, although the number remains less than January 2017 (77 vs 86). The Head of Nursing reviews all falls weekly: - there is a multidisciplinary falls group focussing on availability of walking aids - a falls awareness week is due in April a new e-learning platform for staff - 'Safety Cross' on the Care of the Elderly Wards to support falls management. Quarter /18 Infection, Prevention and Control The methicillin-resistant staphylococcus aureus (MRSA) bacteraemia target for the coming year will be decreased by 1 for most Trusts, and will mean less intensive monitoring and reporting will be required. However, as Kingston Hospital trust has had three MRSA bacteraemia s where lapses in care were identified this year, they will continue to report as they do now. Measles is on the increase in young adults who missed vaccinations in the early 1990 s, vaccination is recommended especially for those who were not vaccinated at the scheduled time or who did not complete vaccination. Those at risk are also people who were vaccinated overseas. The CCG will review how to support Primary care in promoting uptake and request Public Health support in targeting the local university population. Version: Final H - 3 Date:

121 Quarter /18 Complaints, Patient Advice and Liaison Service & MP Letters Report All 7 complaints received by the CCG for quarter 4 were related to Continuing Health Care (CHC). There is more work to be done on the process from receipt of complaint, to the recording and response, to ensure all complaints regarding CHC are dealt with in a timely way. This is due in part to the office move and part to the potential multiple reception points for CHC complaints (PALS, complaints lead, head of service or individual CHC team members). The Patient Advice and Liaison Service have had 97 enquires, these have been largely for general information requests, signposting to services or general access queries. There are several callers who call regularly and use PALS for social support. There have been six MP letters for Quarter 4 of which: - Three related to funding - One related to Commissioning - One related to continuing health care, and - One related to Individual Funding Request All letters were responded to within an agreed time frame. Medicines Optimisation NHS England have recently published guidance on Responsibility for prescribing between primary and secondary/ tertiary care. As part of the annual review of our local South West London interface prescribing policy, these guidelines have been incorporated into contracts. Based on latest finance reports, the CCG expects to report a balanced prescribing budget for the year end. The CCG is on track to achieve the Quality Premium for the reduction of inappropriate antibiotic prescribing for urinary tract infections (UTI) in primary care and sustained reduction of inappropriate prescribing in primary care. However, the CCG is unlikely to achieve the target in the CCG improvement and assessment framework on broad spectrum antibiotics for 2017/18 and further work is planned to improve in this area. The Choosing Wisely Consultation and subsequent Governing Body recommendations (July 2017) were cognisant of the expected national consultations which were being developed at that time. On 30 th November 2017, NHS England issued new guidance to CCGs on items which should not be routinely prescribed. The outcome of the national gluten free consultation was issued by the Department of Health in February On 27 th March 2018, further NHS England guidance to CCG s on over the counter items was issued. The Committee undertook to ask the Medicines Optimisation Team to prepare a report for the Clinical Executive Team meeting to consider the new guidance now available. Following the Clinical Executive Team discussion, a further update for the Governing Body will be prepared. Version: Final H - 4 Date:

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123 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing Body in public Date 1 st May 2018 Report Title Finance Committee Summary Agenda Item 3.2 Attachment I Purpose (please indicate with X) Approval/ Ratification Discussion / Comment Information x Report Author: (name & job title) Liam Bayly, Head of Finance Presented by: (name & job title) Yarlini Roberts, Local Director of Finance Summary and purpose of report This paper provides a summary of the Finance Committee that took place on the 27 th March. The following areas were covered: Month 11 Finance Report The month 11 report was reviewed by the committee: The CCG is reporting position of 5.896m deficit for 2017/18 An adverse variance of 0.9m reflects the No Cheaper Stock Obtainable (NCSO) drugs cost pressure. The CCG have been advised by NHSE that this variance form plan will not impact on the CCG assurance ratings given it is an unavoidable national pressure. Kingston Hospital 2017/18 Year end position has been agreed. Chelsea and Westminster is reporting an overperformance of 3.6m. Year-end agreement has not been reached yet. Plan for next year includes a partial block on West Middlesex. 2018/19 Finance Plan The draft financial plan has been submitted on the 8 th March The committee reviewed a summary of the plan the challenge to achieve the control total, and discussed next steps before the final plan submission on the 30 th April. 2018/19 Contract Sign Off Process The deadline for signing contracts was the 23 rd March The committee reviewed a schedule of the contracts status, with all main acute, mental health and community contracts agreed. The most material contracts for the CCG unagreed were Imperial and London Ambulance, both were being resolved by the host CCGs in North West London. Key sections for particular note See above Version: Final I - 1 Date:

124 Report recommendation The governing body is asked to note the discussions that took place at the Finance Committee Financial and / or resource implications As above Key risks identified & mitigation The key risks are outlined on page 13 of the Month 11 finance report. If all the risks were to materialise with the current mitigations available the CCG would report a 6.4m deficit rather than the planned 5.9m deficit currently reported. Equality and / or privacy impact analysis N/A Committees that have previously discussed / agreed the report and outcomes Finance Committee, 27 th March 2018 Communication plan / stakeholder involvement / patient engagement N/A Assurance The 2017/18 financial position is reported to NHS England as part of their monthly assurance of the CCG financial recovery. CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final I - 2 Date:

125 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing Body in public Date 1 May 2018 Report Title Month 12 finance report Agenda Item 3.3 Attachment J Purpose (please indicate with X) Approval/ Ratification Discussion / Comment Information x Report Author: (name & job title) Liam Bayly (Head of Finance) Presented by: (name & job title) Yarlini Roberts (Local Director of Finance) Summary and purpose of report RCCG is due to submit draft accounts and report to NHS England by 24th April in line with national timetables. At month 12, a deficit of 4.4m was reported, which is a 0.6m improvement on the planned 5.0m deficit. 1,156k of the reported deficit is due to release of the 0.5% non-recurrent reserve, as required by NHS England. RCCG therefore met the statutory duty to remain within its revenue resource limit. RCCG met the capital spending target; capital expenditure of 0.236m was within the Capital Resource Limit of 0.236m. Running cost expenditure of 4.224m was within the running cost target allocation of 4.314m. The CCG met the Better Payments Practice Target and cash targets. RCCG does not expect to achieve planned QIPP savings of 13m. Key sections for particular note Financial Scorecard page 3 Report recommendation The governing body is asked to note the financial position at Month 12. Financial and / or resource implications As outlined above. Key risks identified & mitigation The key risks are outlined on page 13 of the report. If all the risks were to materialise with the current mitigations available the CCG would report a 7.8m deficit rather than the planned 5m deficit currently reported. Version: Final J - 1 Date:

126 Equality and / or privacy impact analysis N/A Committees that have previously discussed / agreed the report and outcomes Finance and Performance Committee on 23rd April Communication plan / stakeholder involvement / patient engagement N/A Assurance The 2017/18 financial position is reported to NHS England as part of their monthly assurance of the CCG financial recovery. CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final J - 2 Date:

127 RCCG Finance Report Month Yarlini Roberts Local Director of Finance Produced by: Liam Bayly Head of Finance Anisha Fraser-Morris - Senior Management Accountant Finance Report - Month 12 as at 31st March

128 Contents Month 12 Scorecard Month 12 Finance Summary How We Spend Our Money Pie Chart Summary Financial Position Acute Commissioning Non Acute Commissioning Primary Care Commissioning Running Costs Other programme costs QIPP Capital Better Payment Practice Finance Report - Month 12 as at 31st March

129 Finance Scorecard March 2017/18 Financial Strategy - 18/19 draft financial plans were submitted to NHS England on 8 th March, with the final submission due on the 30 th April. All business rules were met. - Net QIPP savings of 18.6m are needed to meet business rules in 18/19 with 7.8m of QIPP remaining unidentified. - SWL STP is in discussion around adopting a system wide approach to build resilience in all 5 member CCGs achieving Control Totals. - All main acute, community and mental health contracts have been agreed with the exception of Imperial. Financial Governance - Scheme of delegation and other financial polices are aligned with LDU and alliance CCG s - Changes to accounting policies and Scheme of Reservation and Delegation were approved by Audit Committee in March /19 Planning- we are taking a robust approach to setting the plan for 18/19, working with colleagues in SMT to identify possible budget reductions as well as working collaboratively with partners across the system. Financial Performance - The outturn Financial Position for the CCG at Month 12 is 4.447m deficit which is a favourable movement on the planned position and is in an agreed breech of its business rules for 2017/18 with NHS England. - All reserves have been used, full benefit of 1.5m prior year balances have been released and the full contingency released in to enable delivery of the deficit. - Better Payment Practice Code target was achieved in month The NHS England cash target was achieved for Month There has been slippage on some QIPP schemes. - We have achieved an estimated 9.28m YTD against a YTD Plan of 9.6m. Financial Risk - The 2017/18 position is now known. Accounts will be audited during May and the CCG expects to receive an unqualified opinion - Reserves have been fully utilised to cover the acute over performance seen in month 12 including the half of the 1% on recurrent reserves which released as per NHS England guidance in Month /19 plan meets all business rules, however there is a large degree of risk in the planned position. Total QIPP needed of 18.6m with unidentified QIPP of 7.8m, with a further 1.5m of high risk QIPP schemes.18.6 Finance Report - Month 12 as at 31st March

130 Month 12 Summary March 2017/18 RCCG is due to submit draft accounts and report to NHS England by 24th April in line with national timetables At month 12, a deficit of 4.4m was reported, which is a 0.6m improvement on the planned 5.0m deficit. 1,156k of the reported deficit is due to release of the 0.5% non-recurrent reserve, as required by NHS England RCCG therefore met the statutory duty to remain within its revenue resource limit RCCG met the capital spending target; capital expenditure of 0.236m was within the Capital Resource Limit of 0.236m Running cost expenditure of 4.224m was within the running cost target allocation of 4.314m The CCG met the Better Payments Practice Target and cash targets RCCG does not expect to achieve planned QIPP savings of 13m Finance Report - Month 12 as at 31st March

131 How we spent our money March 2017/18 Richmond CCG: 2017/18 Expenditure Split 130.5m was spent on hospital services for the Richmond population, in local hospitals and around the country Prescribing 8% Other (including social care) 3% Primary Care 11% Running Costs 2% Total Acute Commissioning 49% 26.6m was spent on mental health services and care for people with learning disabilities 24.1m related to continuing healthcare, for adults and children with long-term conditions Community 8% Continuing Care 9% 21.2m was spent on community services Mental Health 10% 21.8m of expenditure related to prescribing 30.1m related to Primary Care Total Acute Commissioning Mental Health Continuing Care Community Prescribing Primary Care Other (including social care) Running Costs 8.6m was spent on Other Programme services such as NHS 111, BCF, EoLC) 4.2m expenditure related to Running Costs Finance Report - Month 12 as at 31st March

132 Summary Financial Position March 2017/18 12 MONTHS TO 31st MARCH 2018 VARIANCE 2017/18 Budgets - Source and Application of Funds BUDGET ACTUAL (Adverse) Favourable '000 '000 '000 Revenue Resource Limit 262, ,739 0 APPLICATION OF FUNDS -PROGRAMME Acute Commissioning 126, ,522 (3,562) Non Acute Commissioning 77,179 79,354 (2,175) Primary Care Commissioning 51,626 51,850 (225) Other Programme Costs 3,277 1,235 2,042 Total Commissioned Services 259, ,961 (3,919) Running Costs 4,314 4, Reserves, Contingencies and Provisions: Total Reserves 4, ,383 Total Application after Reserves 267, , In Year Surplus/(deficit) after reserves movements - Programme (5,000) (4,447) 553 C/Fwd Surplus/(deficit) after reserves movements - Programme (8,388) (8,388) 0 Cumulative Surplus/(deficit) after reserves movements - Programme (13,388) (12,835) 553 Note: the resource limit of 262,739 includes b/fwd. surplus of 8,388k This is the surplus that will be reported in the annual accounts As per NHS England guidance 0.5% of the 1% non recurrent reserves were fully uncommitted at the beginning of the financial year, but guidance for Month 12 instructed to release in full at year end. 6 Finance Report - Month 12 as at 31st March 2018

133 Acute Commissioning March 2017/ /18 Acute Commissioning Budgets Application of Funds 12 MONTHS TO 31st MARCH 2018 Budget Actual Variance 000's 000s 000s Kingston Hospital 46,758 48,183 (1,424) Chelsea & Westminster 32,300 35,226 (2,926) Imperial 10,073 10,276 (203) Queen Mary's (ex CSW) 6,329 5, St. George's 6,523 7,356 (833) LAS 5,813 5,890 (77) Total Main Trusts 107, ,390 (4,594) Epsom Orthopaedic 2,104 2,269 (165) Ashford & St. Peters 1,782 1,788 (6) Guy's & St. Thomas' 2,030 2,092 (62) Kings Moorfields 1,667 1, Royal Brompton Royal Marsden 1,570 1,731 (161) Royal Surrey (47) UCL 1,507 1,903 (395) Barts (102) Epsom & St. Helier GOSH (11) North West London (7) Royal Free (28) Royal National Orthopaedic (85) Total Other Providers 13,844 14,706 (862) Reported position for acute Trusts reflects the Agreement of Balances exercise. Commissioning reserves and non recurrent benefits have been used to offset overperformance. Total Acute Contracts 121, ,096 (5,457) ISTC (50) Charges exempt overseas visitors Pregnancy Advice Service NCAs 3,171 3, Private Providers (20) Secondary Care Drugs RCAS Acute Trust SLAs Prior Year Acute NCAs Prior Year GUM recharge to Local Authority (1,437) (1,550) 113 GUM Expenditure 1,437 1,550 (113) C&W MFF adjustment (744) (744) 0 Acute Reserve 1, ,740 Acute Other 5,322 3,427 1,895 Total Acute Commissioning 126, ,522 (3,562) Finance Report - Month 12 as at 31st March

134 Non-Acute Commissioning March 2017/ RY9NFT 2017/18 Non Acute Commissioning Budgets Application of Funds Periods to Date Budget Actual Variance 000's 000s 000s MENTAL HEALTH West London Mental Health (24) SWL & St.G's SLA 14,445 14,504 (59) SWL & St.G's SLA -Prior Year 0 1 (1) SWL & St.G's - ADHD Mental Health Crisis Homes (14) Mental Health Investments Mental Health Block SLAs 15,626 15, Child And Adolescent Mental Health Dementia Psychological Therapies Access Improvement 3,493 3, Learning Difficulties 3,021 2, Mental Health Services - Adults 2,885 2, Mental Health Services - Not Contracted Activity (60) Mental Health Services - Older People 1, Mental Health Services - Specialist Mental Health Services - Vol Sector Mental Health Services - Collaborative Fees Mental Health Placements and Other Mental Health 11,584 11, Total Mental Health 27,210 26, Mental Health placements budgets for adult and older people are both reporting underspends. The main reason for this is the identification of fewer Adult and Elderly placements, than were previously forecasted for following a review of joint funded placements with the local authority. Dementia is reporting a 74k FOT underspend and has not changed from previous month. CONTINUING CARE CHC Adult Fully Funded 17,043 19,323 (2,280) CHC Adult Personal Health Budget (326) CHC Asessment & Support (141) CHC Children 1,553 2,071 (518) Funded Nursing Care 1,193 1,193 0 Total Continuing Care 20,899 24,164 (3,265) COMMUNITY YHC SLA - Older People (61) MSK AQP (125) Podiatry AQP (66) HRCH Contract - Adult SLA 17,832 17, HRCH Contract - Children SLA and S.A.L.T 2,928 2, LbR Contribution Step Down Beds at TMH (80) (30) (50) NCA Community invoices (49) Moorfields-Community@TMH&QMR Total Community 21,545 21, HOSPICES Trinity Hospice Princess Alice Hospice (26) Total Hospices (26) COMMUNITY GERIATRICIANS PALLIATIVE CARE BETTER CARE FUND 5,811 5, CONTRACT (10) CHILDREN PROGRAMME PROJECTS OTHER NON ACUTE Interpreting Services (3) Patient Transport Urgent Care 0 (2) 2 Sleep Clinic (53) Heart Failure Pilot 0 (27) 27 Total Other Non Acute (17) Total Non Acute Commissioning 77,179 79,354 (2,175) Finance Report - Month 12 as at 31st March

135 Primary Care Commissioning March 2017/ /18 Primary Care Commissioning Budgets - Application of Funds Periods to Date Budget Actual Variance 000's 000s 000s GP Prescribing 21,157 20,152 1,005 Central Drugs RHND (1,100) 279 (1,379) Prescribing Incentive Scheme WiC - Prescribing Oxygen Prescribing IT Total Prescribing 21,578 21,803 (225) Prescribing spend includes the NCSO cost pressure of 839k and the release of the CAT M benefit of 194k. IT Total Primary Medical Services Diagnostic Services LES (9) Shared Care (75) Diabetes LES Respiratory (203) Mental health Referral management (297) Extended Hours LES (Tier 2) Complex Wound Care Cancer Care Bowel Cancer Leg Ulcer Enhanced Service Reserve Anti-Coagulant Monitoring (20) Demand Management Complex needs Hormone Injection (11) Other Professional Fees (3) Phlebotomy (38) Primary Care Reserves - LES Total Enhanced Services 2,389 2,629 (239) Primary Care Investment ( 3 p/head) ETTF-EMS Total PRIMARY CARE INVESTMENTS Dermatology GPwSI ENT GPwSI Ultra Sound Minor Surgery GPwSI Vasectomy Service Kew Hostel Total Other Primary Care Commissioning DXS & Kinesis Care Navigator Extended GP Hubs 1, Total Other Primary Care Development 1,160 1, General Practice - GMS 16,134 15, General Practice - PMS 1,515 1,521 (6) QOF 1,865 1,883 (19) Premises 4,515 4, Enhanced Services Seniority Personally Administered Drugs (2) Other Administered Funds Other Delegated Primary Care (741) 150 (891) Delegated prior year GMS 0 (14) 14 Delegated prior year PMS 0 5 (5) Total Delegated Primary Care 24,624 24,665 (40) Total Primary Care Commissioning 51,626 51,850 (225) Finance Report - Month 12 as at 31st March

136 Running Costs March 2017/ /18 Running Costs Budgets - Application of Funds Periods to Date Budget Actual Variance 000's 000s 000s Running Costs target spend is set at per head of population, or 4.314m. Source of Funds - Revenue Resource Limit 4,314 4,314 0 ADMINISTRATION & BUSINESS SUPPORT COMMUNICATIONS & PR STRATEGY & DEVELOPMENT EDUCATION AND TRAINING TOTAL CORPORATE AFFAIRS CEO/ BOARD OFFICE (46) CHAIR AND NON EXECS (7) TOTAL CEO, CHAIR & GOVERNING BODY MEMBERS (53) CLINICAL SUPPORT TOTAL CLINICAL LEADS COMMISSIONING TOTAL COMMISSIONING TEAM CORPORATE COSTS & SERVICES 1,390 1,486 (96) OPERATIONS MANAGEMENT FINANCE (14) QIPP IM&T (21) IM&T PROJECTS (16) TOTAL CORPORATE & CSU COSTS 2,264 2,324 (59) PATIENT AND PUBLIC INVOLVEMENT QUALITY ASSURANCE (2) TOTAL QUALITY TEAM GENERAL RESERVE - ADMIN TOTAL GENERAL RESERVE - ADMIN Richmond CCG has met the target to keep running costs expenditure within the allocation. For Month 12, the CCG is reporting 90k favourable outturn variance. This is mainly caused by slippage on admin & support (vacancies) and QIPP (vacancies and reduced staff hours) offset by pressures on corporate (legal costs) and finance (interim cover IT costs of Thames House move have been included in the running costs spend. Running Costs budgets have been adjusted to reflect the new structure working under the local delivery unit (LDU). Both KCCG and RCCG have co-located to Thames House on 26 th March 2018, the costs of the lease commencing in January 2018 have been included in the position. APPLICATION OF FUNDS - RUNNING COSTS 4,314 4, Surplus/(deficit) Finance Report - Month 12 as at 31st March

137 Other Programme Costs March 2017/ /18 Other Programme Costs Commissioning Budgets Application of Funds OTHER PROGRAMME COSTS Periods to Date Budget Actual Variance 000's 000s 000s Other Programme Costs includes Non Recurrent Programmes such as SWL Collaborative Commissioning, Healthy London Partnership (HLP), London Levies (LL) and Clinical Running Costs such as Safeguarding and Medicine Optimisation. Non Recurrent Prior Year 0 (1,510) 1,510 Total Non reccurrent 0 (1,510) 1,510 Clinical Running Costs Programme Projects - CSU SLA Programme Projects - London Levies Medicines Management - Clinical Safeguarding Clinical Leads Clinical Corporate Costs 1,090 1,126 (36) NHS Property Services Recharge Quality Premium SWL Collaborative Commissioning Total Clinical Running Costs 3,277 2, Clinical Overhead - The Community Health Partnerships property charge has reduced this year, resulting in an. The reduced NHS Property Services void space charge from September as East London FT moved into St John s is also included in the position. We have released 1.5m Prior Year benefits from all Commissioning areas into Non Recurrent. Total Other Programme Costs 3,277 1,235 2,042 Finance Report - Month 12 as at 31st March

138 QIPP Commentary February 2018 Overview: At the time of preparing the month 12 report, we have achieved an estimated 9.28m YTD against a YTD Plan of 9.6m (excluding Unidentified) and or 13.15m if you include the unidentified QIPP. Please note; that the YTD figures are currently estimated for year end as the report is being prepared on the 27 th March in advance of final figures being available. The report will be refreshed later in April once the final figures are known. Fluctuations in the final figures should be relatively minor and caused by changes in the SUS data. Assuming the estimated figures hold then we can draw some key conclusions from the final years report; What went well? Richmond delivered 96% of the identified plan value for the year Transactional QIPP was very successful achieving 140% of the identified plan Balance Sheet Transfers was the main driver of this as it wasn t on the original plan The only Transactional scheme not to meet plan is the RHND Scheme but that was only by 10% and the variation wasn t caused by non-delivery it was simply natural variation in acute activity. CHC delivery has really improved in the last 6 months, with the in-housing of the brokerage team and the strengthening of the internal team. There is still significant work to do but they are definitely moving in the right direction. DXS/ Kinesis is one of the few transformational QIPPs to have delivered. Though it didn t meet the plan figure which was probably too high it did achieve 50% of plan and it is reportedly well liked by GPs who use it. POLCE-We believe that the reported figures may be under-valuing the impact and it could be as high as 300K- 400K. We are working with the project lead to track a new methodology which will include the impact of challenges for 18/19. What could have gone better? We didn t have credible plans and a clear process in place for addressing unidentified QIPP OBC schemes under-delivered; this includes Cardiology, Diabetes and Respiratory. Despite mobilising the changes the anticipated savings were not realised. The underlying reasons for this were flaws in the assumptions under-pinning the business cases which meant that the plan was set too high and delays to mobilisation and implementation which further compounded under-delivery. Dermatology, Ophthalmology and MSK all had significant slippage in year which meant that business cases were not signed off until after 6 months way through the year and then further issues around implementation arose meaning that these schemes are expected to deliver for 18/19. Schemes like Integrated Front End were included on the plan at the start of the year but the detail underpinning how the savings would be realised was not fully worked up and therefore it was more aspirational in nature. There are now tighter systems in place around how the plan is set and how business cases are signed off which should mitigate the impact of these issues re-occurring in 18/19. That said there is still a further journey to go on this and the PMO are looking to facilitate an end of year Lessons Learned exercise to try and further strengthen and improve the programme. Finance Report - Month 11 as at 28th February

139 QIPP Performance March 2018 Richmond CCG QIPP Programme to March Transactional Transformational Net QIPP Plan YTD Actual YTD Variance to Plan RAG Benefits Delivery AQP Cap 0 50,000 50,000 Green Green CHC 1,400,000 1,400,000 0 Green Green Contract change 300, , ,000 Green Green FRP - Reduce AVLOS at Teddington 1,500,000 1,500,000 0 Green Green HRCH Contract Reduction 500, ,000 0 Green Green LD 482, ,000 99,175 Green Green Medicines 628, , ,142 Green Green Mental Health 700, ,932 9,932 Green Green RCAS Assessors 0 131, ,000 Green Green RHND NEL 400, ,165-37,835 Amber Green Balance Sheet Releases 0 1,800,000 1,800,000 Green Green Transactional Total 5,911,350 8,398,765 2,487,415 Plan YTD Actual YTD Variance to Plan RAG Project RAG Project RAG A&E 20, ,000 Closed Closed Children's/Paediatrics 300, ,381 51,381 Green Green Dermatology 70, ,000 Red Red ECI / PoLCE 500, , ,655 Amber Green ECI / PoLCE-IVF 313,996 52, ,313 Red Green Frail Elderly 100, ,000 Red Amber FRP - Cardiac- acute on chronic admissions 432, ,649 Red Amber FRP - Diabetes 103, ,214 Red Amber FRP - Early Respiratory Disease 92, ,436 Red Amber FRP - Reducing short stay admissions & AEC 45, ,414 Closed Closed Gastroenterology 162, ,000 Merged Merged Integrated Front End service (UCC, GP-OOH- 325, ,000 Closed Closed Triage) 0 Mental Health 16, ,000 Closed Closed MSK Pathway Re-design 300, ,000 Red Amber New Care Model: End of Life 100, ,000 Red Amber Out-patient Referral Management (DXS & 650, ,216 Amber Green Kenisis) 286,784 Pathology 50, ,000 Closed Closed Primary Care Centres Red Red FRP - Ophthalmology 150, ,000 Red Amber Transformational Total 3,730, ,193-2,846,516 Summary: 9.282m achieved YTD vs 13.16m Plan with 3.5m Unidentified Transactional: CHC has really improved steadily in the last 6 months All schemes bar RHND have met the plan Note: We are reporting some noncurrent benefits against Balance Sheet Releases. Transformational: Cardiac, Resp and Diabetes mobilised but never delivered the anticipated financial impact Outpatient DXS didn t meet plan which is set too high but did perform well POLCE didn t achieve plan but we suspect that this is due to the counting methodology being used. We are planning to use a more accurate approach for 18/19 based on the value of challenges. Subtotal Identified Schemes 9,642,060 9,282, ,102 Unidentified Schemes 3,516, ,826,516 Total 13,158,570 9,282,958-3,875,612 Finance Report - Month 12 as at 31st March

140 8 Capital March 2018 The CCG s capital expenditure was within the Capital Resource Limit of 236k. The capital expenditure was largely IT equipment and software for the CCG, to enable the delivery of the agile and integrated working as part of the South West London Sustainability Transformation Programme (STP) and Alliance. Produced by Finance April

141 Better Payments Practice March 2017/18 Richmond Mar-18 NHS NON-NHS TOTAL NUMBERS FOR THE MONTH Total number of invoices paid in the month ,350 Number of invoices paid within target ,334 Numbers %age for the month 95.27% 99.72% 98.81% VALUES FOR THE MONTH ( 000s) Total value of invoices paid in the month 16,355 6,889 23,245 Value of invoices paid within target 16,405 6,889 23,294 Value %age for the month % % % CUMULATIVE NUMBERS TO THE MONTH Total number of invoices paid YTD ,222 Number of invoices paid within target ,797 Numbers %age Cumulative 94.11% 97.41% 96.52% CUMULATIVE VALUES TO THE MONTH ( 000s) Total value of invoices paid YTD 179,871 61, ,780 Value of invoices paid within target 177,508 60, ,342 Value %age Cumulative 98.69% 98.26% 98.58% Under the Better Payments Practice Code (BPPC), CCGs are expected to pay 95% of all creditors within 30 days of the receipt of invoices. This is measured both in terms of the total value of invoices and the number of invoices by count. The month of March is reported in the table. The BPPC percentage achievement for Richmond in terms of number of invoices paid within target is 98.81%. Cumulatively this stands at 96.52% GREEN = target of 95% met (have paid all creditors within 30 days), RED = target not met Finance Report - Month 12 as at 31st March

142

143 12 TH MEETING IN PUBLIC OF RICHMOND CLINICAL COMMISSIONING GROUP S PRIMARY CARE COMMISSIONING COMMITTEE (PCCC) Attachment K Held on Tuesday 6 February 2018 from 10:00 to 12:00 In the Salon, York House MINUTES Attendance Log: PCC Members (voting) 25/4 27/6 22/8 03/10 05/12 06/2 Bob Armitage (BA), Lay member for Finance, A A A A A A Remuneration, Primary Care and Governance (Chair) Susan Smith (SS), Lay member for PPI (Vice Chair) SA A A SA A A Tonia Michaelides (TM), Managing Director SA SA SA A SA A Yarlini Roberts (YR), Director of Finance (DoF) SA A SD A A A Fergus Keegan (FK), Director of Quality (DoQ) SA DNA A (4.4 & 2.3) A A A Anne Dornhorst (AD), Secondary Care Doctor N/A N/A N/A A SA A Pete Smith (PS), Independent GP SD A A A A SA Gareth Hull (GH), Independent GP A SD SD SA SA SA Non-voting Kathryn MacDermott (KMac), Director of Primary Care and Planning Page 1 of 8 A A A A A A John Anderson (JA), Healthwatch Richmond A SA A SA A A representative Julius Parker (JP), Surrey & Sussex Local Medical A A A A SD A Committee (LMC) Terry Silverstone (TS), Local Pharmaceutical Committee A A SD SA A A (LPC) Maggie Ennis (ME), Patient Participation Group (PPG) A A SD A A A representative Bonnie Green (BG), Patient Participation Group (PPG) N/A N/A A A A N/A representative Maureen Chatterley (MC), Patient Participation Group N/A N/A A N/A N/A A (PPG) representative William Cunningham-Davies (WCD), SWL Alliance SA A SD SA A A Primary Care Contracting Team Joe Reed (JR), SWL Alliance Primary Care Contracting SA A SD SA A A Team Dr Graham Lewis (GL), CCG Chair A A A A SA A Dr Kate Moore (KM), Vice Clinical Chair (VCC) A A SA A SA A Dr Nicola Bignell (NB), RCCG Governing Body GP N/A N/A N/A N/A A A Dr Alireza Salehzadeh (AS), RCCG Governing Body GP N/A N/A N/A N/A A A In Attendance: Emma Richmond (ER), Chief Pharmacist, RCCG A SA A A A A Attracta Asika (AA), Head of Commissioning Primary and Urgent Care, RCCG A A A A A A Caroline O Neill, Engagement Manager, RCCG A A A SA From item K SA A A A A A A Lindsay Marshall (LM), Corporate Office Mgr (notes), RCCG KEY: A = Attended, DNA = Did not attend, SA = Sent Apology, SD = Sent Deputy, N/A = Not needed Additional attendees on Vicki Harvey-Piper (VHP), Director of Corporate Affairs and Governance Caroline Tasker, Project Manager

144 Ashley Hayward, Primary Care Commissioning Manager Steven Bow, Business Intelligence Manager (item 4.6 only) Youssof Oskrochi, Richmond Council (item 4.6 only) Item Item/Discussion no. A STANDING AGENDA ITEMS 1.1 Welcome and apologies for absence; Confirmation of meeting quoracy Bob Armitage, Chair, welcomed members to the twelfth meeting in public of the Richmond CCG Primary Care Commissioning Committee (PCCC). Apologies for absence were received as per the attendance chart. The meeting was confirmed as quorate. Attachment/ Action 1.2 Declaration of interest in matters on the agenda Declarations of interest for all Richmond CCG GPs were noted as: o Members of the Richmond General Practice Alliance o providers of locally commissioned services (LCS) o providers of primary care GMS services o interests in local primary care finance In addition, the following declarations were noted: o Terry Silverstone, LPC: elected governor of Kingston Hospital for Richmond. o Anne Dornhorst, Richmond CCG Secondary Care Doctor: Working with the NW London diabetes lead on transformation plans across the CCGs. In relation to the conflicts of interest pertaining to the agenda, the chair considered the general nature of the report relating to these items did not require further action with regard to these declarations and the members concerned could remain at the table. 1.3 Minutes of the primary care commissioning committee meeting on 5 December 2017 It was agreed that an amendment would be made to the bottom line of page 3, where the words community prescribing would be changed to community pharmacy. Subject to this amendment, the minutes were agreed as a correct record. 1.4 Matters arising and rolling action log The PCCC received attachment B and the action log was updated. Attachment A Attachment B 1.5 Items taken in private on 5 December 2017: The PCCC noted that the items taken in private on 5 December as follows: GP OOH procurement Practice resilience scheme GP practice issues: o Twickenham Park improvement grant o Parkshot application to extend boundary o Hampton Hill Medical Centre KPI transition proposal o GP IT briefing 2 Primary Care Commissioning 2.1 Update from the SWL Alliance primary care contracting team - GP contract updates Attachment C The committee received the GP contract updates and WCD took the PCCC through the report, which showed that there had been seven partnership Page 2 of 8

145 Item no. Item/Discussion changes. Slides 3 and 4 showed that contract variations had been sent to all Richmond practices regarding the termination of obligation to provide out-ofhours services. Due to the legal status of the agreement the whole practice had to agree and therefore not all practices had returned them yet, however there had been informal notification of the intention. Kate Moore (KM) questioned how up to date the report was and thus its usefulness as a planning tool, as it seemed to date back to 1 st October She was keen that they were notified at the first opportunity of any changes. WCD assured the meeting that the summary was up to date but he acknowledged the need to make the format clearer. Attachment/ Action 2.2 NHS E-Referral Paper Switch Off (PSO) project Attachment D The committee received a report on the NHS e-referral (ers) Paper Switch Off (PSO) project, which was part of the move towards a paperless NHS. From 1 October 2018, providers would no longer be paid for activity which resulted from referrals made other than through the electronic referral system (e-rs). Ashley Hayward (AH), Primary Care Commissioning Manager, took the committee through the paper. She explained that the project was being rolled out in waves, with Richmond currently in wave 2 with a deadline of paper switch off on 31 March Nicola Bignell (NB) drew attention to the fact that hospitals were still using more than one system which was creating extra work. It was pointed out that patients - RS queries should be directed back to the national or provider phone line or portal rather than enquiries coming back to general practice. The contract stated that hospitals should have a dedicated phone line for queries from patients. Patients who were not connected to the web could use the national phone line and in some cases could ask their practice to book their referral. Vulnerable patients could ask for assistance. In addition, practices will be provided with an information sheet for patients. In response to a query about whether broadband speed would be an issue, it was noted that it should not affect e-rs as long as the smart card works. It was noted that, in the event of a system failure, an referral system could be used. It was suggested that the PCCC have sight of the communications issued, in case there was a need for further local communications. AH was in the process of reviewing best practice communications and collating copies of the letters that come from the e-rs system. AH asked for members to send her feedback and anonymised examples of problematic issues to the generic secure address so that she could address it with the hospitals and NHS Digital. It was noted that there were a significant number of DNAs that were taking up time and work. Terry Silverstone (TS) raised that a number of patients had mentioned their dissatisfaction to him, particularly around appointment letters arriving too late which had led to the appointment being marked as a DNA. 2.3 GP Out of hour s procurement Verbal The committee noted that this was still in development and an update would be brought back to a future meeting. 2.4 Locally Commissioned Services (standing item) Attachment E Referral management LCS Page 3 of 8

146 Item no. Item/Discussion The PCCC received the 2017/18 RCCG Referral Management LCS which was developed to support practices with their outpatient referral processes. The paper summarised the feedback and lessons learnt from the service. It was proposed to accommodate the differences between practices by having both a core and an optional element to the referral management schemes in 2018/19. Alireza Salehzadeh (AS) drew attention to the fact that there were still some DXS and referral forms missing, and undertook to send the forms to Caroline Tasker (CT), and CT would follow up with providers. A comment was made that pathways need to be loaded onto the electronic referral system (e-rs). It was noted that a DXS generated form could be attached to e-rs or a generic letter sent. It was agreed that it would be beneficial to have all the forms saved together. Queries or questions should be sent to CT or AH Minutes of last meeting (22 November) The PCCC received the minutes of the meeting of the LCS group on 22 nd November Attachment/ Action Attachment F 2.5 Primary care strategy Extended Primary Care Commissioning Intentions SWL primary care access fund It was noted that attachment G had been withdrawn as the funding stated in the paper was not confirmed at this stage. It was reported that the SWL primary care access fund was being allocated at a national level and would fund the urgent treatment centre at Teddington and the primary care centre on the east of the borough. CCGs across SW London were awaiting confirmation of the amount of money devolved to STP areas. In the meantime the CCGs would plan on the basis of last year s allocations. It was noted that it appeared that Richmond had a higher primary care fund than elsewhere as it had applied for and secured funding from the Prime Minister s Challenge fund which was in its final year. Tonia Michaelides (TM) emphasised that funding amounts had not yet been confirmed and further guidance was awaited imminently. It had been agreed to equalise the primary care access funding across SW London. The PCCC welcomed Sheila Gormley (SG) from Hounslow & Richmond Community Healthcare NHS Trust (HRCH). Work was ongoing between the CCG and HRCH to develop the model for the urgent treatment centre (UTC) at TMH and commissioning decisions would need to be made to ensure that it would deliver the services required for Richmond patients. She went through the four options under consideration. Two were currently financially viable and two would not be viable without further investment. Initial scoping work had been done to cost the options. All four models included GPs and nurse practitioners. There had been a review of services currently provided, and the demand, waiting times and appointment times. It was noted that not all hub appointments were being used, some as a result of DNAs, and there was capacity in the system to use appointments more efficiently. The PCCC discussed the options. There was a comment that if no east side hub was developed some patients would attend A&E. It was noted that patients currently have access to the walk-in services at QMR. Conversations were underway with Wandsworth CCG around this service, and it would continue to be available to Richmond patients after the development of the east side hub. There was a need to be clear about access points for patients. KMac pointed out that commissioning decisions needed to be made by the CCG relating to the Page 4 of 8

147 Item no. Item/Discussion east side hub, around the services offered, the opening hours, number of staff, GPs, nurse practitioners, to balance between financial envelope and needs of the patients. Once the allocation was firmed up, more clarity could be achieved. Action: It was agreed that KMac and SG would liaise over producing further figures for circulation to the committee. Attachment/ Action KMac 3 Finance & Performance 3.1 Extended Primary Care Access Report Attachment H Richmond extended primary care hub audit The PCCC received the report into the proposed hub audit. Caroline Tasker project manager, explained the background to the Richmond hubs and their funding streams, and that there is a possibility that the primary care access monies in 2019/20 might be reduced as the primary care access monies are equalised across SWL. It was therefore proposed to carry out an audit of the hub activity to inform commissioning decisions on the service for 2019/20. It was intended to include the following in the audit: - Practice based audit to review patient pathways following an appointment at one of the hubs - A review of when appointments are not attended - A review of reasons patients attend one of the hubs - Practices where patients are high or low users of the hubs The PCCC discussed possible further aspects to include in the audit. One suggestion was reviewing the patient experience as a measure of the quality of the service. Attention was drawn to a survey carried out by the PPG network in 2016 which may be useful reference material for CT. A further suggestion was to review equity of access as practice usage varied significantly. It was felt that there was a need to revisit and define the purpose of the hubs, ie whether it was to extend capacity, cover gaps or to offer equal access. It was suggested that it may be worth reviewing practices systems for making bookings to the hubs. It was noted that practices have sight of the hub statistics and over-utilisation is flagged up. It was noted that were practices sharing premises with a hub may find that their patients are using the hub instead of the practice, and this is discussed with the patient if appropriate. It was also recognised that patients may access hubs because they are open outside of the core general practice hours. It was also noted that workload may be generated by hub clinicians because they were generally not as experienced as practice GPs as they tended to be locums. An additional idea was to audit which patients were repeatedly accessing services. TM was keen that the service provided by a hub appointment was equal to that provided by a GP appointment, to make it a seamless and equitable service within the offer. The next steps were to run the audit in Q Extended access highlight report Attachment I The PCCC received the dashboard detailing access to the GP extended primary care services provided through the two existing Richmond hubs and utilisation of the hubs. It was noted that utilisation was fairly consistent during the week. The PC team would identify themes and report back to the April PCCC to help inform commissioning for the hubs. Page 5 of 8

148 3.2 Primary Care Finance update Attachment J The PCCC received the month 9 primary care finance update and Yarlini Roberts (YR) took the committee through the report. She reported that the position was significantly different from the previous report in that month 9 showed an underspend against plan of 407k, the main reason being the change in the position on the prescribing budget. Prescribing was forecasting a favourable variance of 919k which was mainly driven by a change in methodology on the impact of No Cheaper Stock Obtainable (NCSO) drugs as the CCG had been advised to move the NCSO pressure from the outturn to the risk position. CCGs had been asked to absorb these costs if possible, which would be discussed at the next finance committee. TS highlighted that the NCSO issue was causing considerable concern and hardship amongst community pharmacists (CPs), and was impacting on patient care. YR added that guidance had been issued on the NCSOs to say it was not expected to continue so there was no expectation to allow for any of the extra cost for next year. JP questioned whether it was correct to use money from the 3 per head to cover the shortfall in the extended GP hub costs, as he felt it did not concur with NHSE guidance. YR confirmed that access was part of the GPFV. YR gave a verbal update on the refreshed funding for delegated commissioning. The allocation was staying the same and one positive result was that the ban on CCG s keeping the category M money had been lifted. The CCG had been informed that it would receive funding for the primary care element of the ringfenced 5 year forward view money in the near future. 4 Quality & Governance 4.1 Primary Care Risk Log Attachment K The PCCC received the primary care risk log which was an excerpt from the 4Risk portal, and KMac took the committee through the risks. PR23 (Deployment of DXS and Kinesis pathway and referral management tools to GPs) & PR47 (Implementation of NHS E referral): It was noted that there was a South West London wide decision to move from Kinesis to e-rs Advice and Guidance. KMac had therefore asked her team to develop a project plan to support the transition. Concerns were raised about the lack of response experienced with e-rs Advice and Guidance. It was noted that transformation work with the providers would include ensuring job plans were updated appropriately. This may entail a practical discussion with the medical directors of the acute s to affect a culture change. Advice and Guidance would be integrated with the clinical systems and once there was full functionality the system should benefit practices. Problematic issues had been fed back to NHS Digital. AS volunteered to be involved in championing the system to the CCG s membership. It would be discussed at a future joint governing body seminar. PR27: IM&T strategy - GPIT; GP on line: The CCG would continue to commission the service from NECSU but GP IT facilitation was now also being provided by the CCG hosted in RGPA. Page 6 of 8

149 4.2 Patient participation group (PPG) network highlights report (standing item) Attachment L The PCCC received the PPG report which provided highlights from the January 2018 PPG network where 10 practices were represented. Maureen Chatterley (MC) took the committee through the report and particular attention was drawn to the following issues: Communications: Patients were invited to be involved in communications and strategy and GP out of hours, which was positive. Refresh of primary care strategy: The PPG had asked whether there was an opportunity to explore if the current model of primary care is fit for purpose, including whether small practices were sustainable going forward. If not, they queried whether a transition strategy should be developed. It had been suggested that 4 or 5 small practices could work together. TM commented that the CCG considered clinical and financial sustainability as key. There was emerging thinking around networking in 50k populations and looking at how we can support a list based approach and a community focus to support practices. It was suggested that this may be a topic for a PCCC seminar, looking at identifying the problem and finding solutions. The next step for the PC strategy was to take a draft to the PCCC on 3 April and to the May Governing Body meeting for final approval. Acorn Medical Practice The practice had confirmed that two medical students based there would be working on the Young Carers Project which would focus on identifying and supporting young carers from the practice population. 4.3 Primary Care communications update Attachment M The PCCC received the Primary Care communications update which provided a summary of key communications activity undertaken since April 2017 relating to primary care. It described the methods used to communicate with patients and the public and how the CCG works with its partners, providers, local authority and Healthwatch. Activities were driven by various national, London and local initiatives. Vicki Harvey-Piper, Director of Corporate Affairs and Governance, took the committee through the report, including work going forward on the UTC and PCC. TS expressed thanks for the pharmacy campaigns which had been very positive. MC raised that one of the questions from patients was around pathways and how to signpost patients to access the most appropriate services. She suggested that when new services were developed a process diagram was developed around which patients should go where and who is responsible for them, to be available on the website. 4.4 Primary care operational group (PCOG): Notes of meeting of 21 November 2017 Attachment N The PCCC received and noted the minutes of the PCOG meeting on 21 November. 4.5 Proposal to hold a Committee in Common (CiC) for Collaborative Decision Making for the additional Primary Care Extended Access Funding for 2018/19 Attachment O The PCCC received and agreed the proposal to hold a Committee in Common (CiC). TM explained that the South West London CCGs were seeking Page 7 of 8

150 agreement from within the STP to convene a Committee in Common (CiC) to agree the approach to additional Primary Care Extended Access Funding for 2018/19. This will be allocated to CCGs within South West London. It was anticipated that the total funding for 2018/19 would be communicated in the next few weeks and the intention was to hold the CiC in the first week of April. London had agreed to devolve to STP level the taking of the decision around the money. In view of the fact that it related to primary care funds, the PCCC was asked to agree to recommend to the governing body the setting up of the CiC in public. The PCCC approved the proposal to hold a committee in common. 4.6 Pharmaceutical Needs Assessments Attachment P The PCCC received and noted the Pharmaceutical Needs Assessments (PNA) Steven Bow, Business Intelligence Manager, and Youssof Oskrochi, Richmond Council, took the committee through the findings of the report. It was noted that every Health and Wellbeing Board (HWB) in England has a statutory responsibility to publish a PNA for the population in its area. The PNA reviews current and future needs for pharmaceutical services within the borough and maps the pharmaceutical services currently provided, in order to establish any gaps in provision. The next assessment is due by 1st April Another strand of work was to look at how the PNA was used by Richmond CCG for commissioning intentions. The development of the PNA had been overseen by a joint Kingston and Richmond steering group, with representatives from the councils, CCGs (primary care and pharmacy leads) and HealthWatch as core members, and LPCs, Local Medical Committees (LMCs) and other deliverers of pharmacy services as key stakeholders. It was also out for consultation. They had reached the conclusion that there were no gaps in essential service provision. TS offered his congratulations to the council for fulfilling this piece of work through internal council managers. The PCCC noted and endorsed the findings of the PNA. 5 To note 5.1 Any other business There was no other business. 5.2 Dates of next meetings (all meetings from 10:00 until 12:00): 3 April 2018 The Salon, York House 5 June 2018 the Salon, York House 5.3 Reference document: Glossary of terms The committee received the glossary of terms with abbreviations used in recent meetings. Attachment Q 6 PUBLIC QUESTION TIME 6.1 There were no members of public present and no questions. The meeting ended at 12:05 [Final version approved by PCCC on ] Page 8 of 8

151 Richmond Clinical Commissioning Group Governing Body Date 1 May 2018 Attachment L Report Title Lead Director Author South West London Committee for Collaborative Decision Making (SWL CCDM) Governing Body Report Louise Fleming Carol Varlaam, Lay Member and Independent Convenor for the SWL CCDM Purpose Approval Discussion Noting Executive Summary: The role of the SWL CCDM is to make decisions on behalf of the six SWL CCG Governing Bodies, in areas where they wish to collaborate with their neighbouring CCGs, in order to make collaborative organisational or commissioning decisions. Such decisions will be taken by individual Committees of each CCG Governing Body that have been instructed to meet in common. The SWL CCDM Terms of Reference state that: Each Committee [in Common] will present the agreed minutes to its Governing Body The CIC Convenor will, in addition, provide a written summary report to each Governing Body following each meeting of the [SWL CCDM] business. This should highlight: Issues Decisions Risks and Assurance. The second meeting was held on 27 March This report is a summary of the meeting for the participating CCG Governing Bodies to accompany the meeting minutes. There were two items on the agenda for the 27 March 2018 Committee: Primary care at scale funding and the development and implementation of a SWL IFR Triage Process and Panel. Key Issues: The meeting had two agenda items: 1. Delivering Primary Care at Scale funding across SWL CCGs The Committee unanimously approved the recommended approach in the presented paper for apportioning the Delivering Primary Care at Scale funding across SWL CCGs 2. SWL IFR Triage Process and Panel The Committee unanimously approved the development and implementation of a SWL IFR Triage Process and Panel.

152 Conflicts of Interest: None. Recommendation: The Governing Body is asked to note the Convenor s report and the CCDM minutes from the meeting of the 27 March Corporate Objectives This paper will impact on the following: Risk This paper links to the following CCG risks: Risks and assurances were set out in the presentations given at the meeting. Financial Implications The approval of the approach for Primary Care funding at Scale for all SWL CCGs. The approval of the development and implementation of a SWL IFR Triage Process and Panel will create savings across SWL as there will be a reduction in Panel meetings (from the current 24 meetings a month to 6 meetings a month). Has an Equality Impact Assessment been completed Are there any known implications for equalities Not required. EIAs will be undertaken where relevant for the SWL IFR policy and procedure changes. Patient and Public Engagement and communication Patient and Public engagement will be undertaken where relevant for the IFR policy and procedure changes. Committees previously considered at None. Supporting Documents None.

153 SOUTH WEST LONDON COMMITTEE FOR COLLABORATIVE DECISION MAKING 27 March 2018, 17:30 19:30 Rooms 6.2/ the Broadway, SW19 1RH MINUTES Members in attendance Name Designation Organisation Carol Varlaam Convener Wandsworth CCG Roger Eastwood Lay Member Croydon CCG CCG Committee Chair Elaine Clancy Clinical Member Croydon CCG Andrew Eyres Managerial Member Croydon CCG Dr. Agnelo Fernandes Non-Voting Clinical Member Croydon CCG Clare Gummett Lay Member Merton CCG CCG Committee Chair Julie Hall Clinical Member Merton CCG Sarah Blow Managerial Member Merton CCG Susan Gibbin Lay Member Sutton CCG CCG Committee Chair Dr. Chris Elliott Managerial Member Sutton CCG Dr. Les Ross Clinical Member Sutton CCG David Knowles Lay Member Kingston CCG CCG Committee Chair James Murray Managerial Member Kingston CCG Dr. Naz Jivani Non-Voting Clinical Member Kingston CCG Susan Smith Lay Member Richmond CCG CCG Committee Chair Fergus Keegan Clinical Member Richmond CCG Stephen Hickey Lay Member Wandsworth CCG CCG Committee Chair Sam Page Clinical Member Wandsworth CCG James Blythe Managerial Member Wandsworth CCG Dr. Nicola Jones Non-Voting Clinical Member Wandsworth CCG Attendees Name Designation Organisation Adrian Attard Director Healthwatch Sutton Jamie Gillespie Vice Chair Healthwatch Wandsworth Josephine Baxter Public Representative Zoli Zambo Project Manager SWL STP PMO Louise Fleming Director of Quality and Governance SWL Alliance Jonathan Bates Director of Commissioning Operations SWL Alliance Lucie Waters Managing Director Sutton CCG Paul Linehan Interim Head of Governance SWL CCG Alliance Emma Haran Governance Support SWL CCG Alliance Apologies Name Designation Organisation Deputy attending None received. Page 1 of 6

154 Item Title Action 1. Welcome, Introduction and Apologies Carol Varlaam 1.1. The convenor welcomed all to the meeting. No apologies were received for this meeting. The meeting was quorate. The convenor explained that the meeting was being filmed for uploading onto CCG websites. The convenor informed the Committee that, following the Committee s decision, questions will be invited on today s agenda. Priority is usually given to written questions received in advance of the meeting; however, no written questions were received for this meeting. Members of the public are usually invited to ask questions on the agenda; however, no members of the public were in attendance for this meeting. 2. Declarations of Interest Carol Varlaam 2.1. All members and attendees may have interests relating to their roles. These interests are declared on the register of interests. While these general interests do not need to be individually declared at meetings, interests over and above these, where they are relevant to the topic under discussion, should be declared. No other declarations of interest were received from the Committee. 3. Funding to Deliver Extended Access and Primary Care at Scale in 18/19 Lucie Waters 3.1. The Funding to Deliver Extended Access and Primary Care at Scale in 18/19 paper was presented by Lucie Waters. The main points from the discussion were as below: There will be 8m of funding available for SWL which will be going to the STP rather than directly to CCGs. SWL have flexibility in using the money as a system, as long as assurance is regularly given on the system's compliance with the specification This funding is to be used to deliver the Extended Access specification for 18/19, and make tangible progress towards delivering Primary Care at Scale SWL are delivering the GP Forward View (GPFV) Primary Care extended access requirements of 8am 8pm The Healthy London Partnership have done some good work to explain what is meant by delivering Primary Care at Scale; this includes a focus on quality, patient outcomes and improvements, shared corporate functions and effective governance and stewardship SWL have a Transforming Primary Care Delivery Group (TPCDG), which meets monthly, with membership from across SWL: a CCG Chair as clinical lead; the SWL Primary Care Transformation Senior Responsible Officer (SRO); CCG Primary Care leads and the SWL Transformation team The TPCDG are working through the granularity of the requirements of delivering Primary Care at Scale and what it means to SWL; as well as how the system will start to make progress against the maturity framework This is a build on, not a substitution of, funding regulators will want regular assurance it is being used as per the framework. Page 2 of 6

155 3.2. Questions and comments The Committee from Wandsworth asked if this is a one-off piece of work or an ongoing commitment. They added that they felt very comfortable with the proposals and recommendations in their CCG discussions; and asked for confirmation that, as well as the monitoring and assurance taking place in the SWL TPCDG group, Governing Bodies will also be able to review and discuss the monitoring and assurance. LW responded that this will be a positive opportunity to transform Primary Care in SWL and SWL want to use this opportunity to make real inroads in Transforming Primary Care over the next 12 months. It is recognised that it is a big ask and significant change for Primary Care. The SWL Primary Care team have assurance from the London team that this will be recurrent funding and it is up to CCGs to decide how it is used. It can be used for non-recurrent spend to do with the delivery; e.g. interim Project Managers. There was an expectation for a modest increase next year set out in the original GPFV framework. The TPCDG will discuss how plans should develop over several years. The TPCDG will expect local ownership and for every CCG to monitor this work through their Primary Care Commissioning Committees and Governing Bodies. Healthwatch stated that they felt that the biggest barrier to extended access is robust information sharing, and asked how much extra money will be going into I.T. In terms of extended access; each service organises a process to ensure appropriate data sharing is in place. For Primary Care at Scale going forward, the principles of operating clinical and contracting models at scale may have Information Governance / data sharing challenges depending on what models CCGs choose. One of the workstreams in Transforming Primary Care is the development of digital platforms to access primary care. This work has additional funding associated with it. It is recognised that it is important that the digital platforms are integrated with the Primary Care at Scale plans. Healthwatch asked if SWL are confident there is the man power to deliver the Transforming Primary Care workstream; e.g. are there enough GPs. There is a separate workforce workstream in the Transforming Primary Care programme that looks at recruitment and retention, as well as the retirement of GPs and the Primary Care workforce as a whole. The principle of Primary Care at Scale is that the clinical and commissioning models are flexible, thus you get improvements in GP work-life balance and staff satisfaction. There is some evidence that where Primary Care at Scale operates already, GPs opt to remain in practice longer. This work will help to make sure that SWL are building a system that attracts and keeps GPs of the future and ensures a resilient General Practice, as well as attracting and keeping other Primary Care staff (e.g. nurses, Heath Care Assistants, pharmacists) The Committee in Common were asked to consider approving the following approach for apportioning Delivering Primary Care at Scale funding across the SWL CCGs: CCGs will all receive 5.41 per head funding in 18/19 CCGs will follow local governance arrangements to oversee the development of local plans The SWL STP will have a QA process aligned to the London process; money will be released upon evidence of investment and assurance that plans meet the London specifications and will deliver the required benefits Spend and delivery will be monitored on an ongoing basis by the Alliance SMT. The STP will, in turn, be monitored at London level; 50% funding will be released upon demonstration of robust plans, and 50% will be released at Month 6, upon assurance that delivery is to plan Page 3 of 6

156 The SWL TPCDG should review progress and options for accelerating primary care transformation over the next six months to get maximum advantage from 19/20 funding. The convenor asked the Committee members if they approve the recommended approach for apportioning the funding. Each Committee was asked to vote in turn: Croydon support Kingston support Merton support Richmond support Sutton support Wandsworth support. The Committee unanimously approved the recommended approach for apportioning the Delivering Primary Care at Scale funding across SWL CCGs. 4. Developing a South West London (SWL) Individual Funding Requests (IFR) Triage Process and Panel Jonathan Bates and Zoli Zambo 4.1. Jonathan Bates and Zoli Zambo presented a paper on developing a SWL IFR Triage Process and Panel. The main points from the discussion were as below: A SWL IFR triage process and panel would be streamlining what is currently done across SWL and would be a system-wide QIPP saving; it will also improve quality and consistency for patients The proposal is to move to one triage panel process across SWL there are currently three panels and to move to one formal IFR panel; the frequency will be based on the current workload (there are currently weekly triage panels and fortnightly formal panels) Having one panel with the same set of clinicians will raise expertise and consistency in decision making One panel will reduce costs 24 meetings a month will be reduced to six meetings a month There will be greater service resilience by drawing on skills and personnel across SWL Fertility cases will not be included In November 2017 the SWL Committee in Common agreed a SWL-wide ECI policy; one of the consequences of implementing this policy is that a smaller group of patients will go through the SWL IFR panel process as they will instead go through prior approval Next steps are set out as in appendix one of the paper. There will be workshops with current panel members to finalise the process. The plan is to have implementation by July This includes appointing panel members, governance and documentation Questions and comments The Committee from Sutton asked if the proposed IFR panel will have an independent chair structure as it is an independent funding review panel; and whether there will be a rotation of clinical leads or someone from outside of the CCGs chairing. It was clarified that the SWL IFR panel is not an independent panel. The panel membership proposed is set out in the paper. The team have checked with the current IFR panels and they feel that the membership proposed is right and they support it. Going forward, should the proposal be agreed today, it will be considered how other CCGs run their panels. For example, NWL and Kent rotate the chairs of their panel and NEL CSU provides the admin for the panel. Page 4 of 6

157 The Committee from Sutton asked if there had been any communication with member practice GPs about these proposals; there has not been any specific communications to the GP population or discussion through Medicines Management Committees. Yes Jonathan Bates wrote out to all members of IFR panels, including GPs, asking for their views. These views have been collated and are in the paper with responses. The GPs will also be invited to the workshops with IFR panels; this is a second opportunity for panel members to be involved in the design of the process. For the wider GP population, this will be part of the mobilisation and communications plan if the paper is agreed here today. The team will adopt a similar approach to the ECI paper to ensure that the general GP membership is aware of what is proposed. Dr. Nicola Jones added that the new process has been discussed at Governing Body level. What tends to happen with the wider GP membership is that they do not get involved in the panel, as they are not the referring clinician, this is usually the hospital consultants / secondary care clinicians; but GPs will get feedback on decisions from the panels. As they do not get involved in the IFR process this should have no effect on the SWL GP population and there should be no changes to how the service is accessed by the patient. She added that GPs have complained about the current IFR process for many years and it has been bought by GP members to Governing Body meetings. She feels therefore that the SWL GP membership would support this new process. If a decision is made to implement the new process there needs to be communications to GPs and their feedback sought on the new system to ensure it is doing what they need it to do. The Committee from Sutton asked what the role of the lay member on the IFR panel would be; is there a view as to who would be a preferred lay member and could they be the chair? Zoli Zambo clarified that the lay member on the panel does not have to be a governing body lay member. He was not sure what input the lay member would provide as he is not a member of the panel; he said he presumed they would represent the patient view. The Committee from Kingston asked about the implementation of the new IFR process and panel being monitored and managed by the Directors of Commissioning (DOCs) group; they asked would that group monitor the impact after the change? Can SWL evidence things such as improved timeliness and consistency of decision making? Can this be included in the group's remit? It was confirmed that there is an agreement and plan to evaluate implementation at three and six months, including the above criteria and any enhancements SWL want to add e.g. CCG Governing Body reports. DOCs have said they will find this helpful. The Committee from Wandsworth are hugely supportive of the new process but had two comments: in the pool of members, it is important to have the balance of a big enough group of people versus getting the right experts and a consistent approach therefore training and policy must be tight; also there are concerns around the transition period. Historically it has been quite difficult for patients to go through this system; and the Committee would want to ensure patients are seen quickly. The team completely agree; that is why there will be a workshop with all of the current panel members before anything new is implemented. In respect of the transition period, SWL have senior leadership and overview and senior resource involved in this; the STP PMO will be hiring a permanent manager to oversee the panels and process. The DOCs are a senior group monitoring the transition to manage it safely. There is also the option to default to the current process if needed but that is not the plan. Around 100 patients a year in SWL go through the IFR panel process, so the system should be able to manage these patients well and safely through the process in the paper. Page 5 of 6

158 The Committee from Merton added that the panel lay members provide a unique role and are selected from members of the public; they will have developed some unique skills and she is concerned that these skills could be lost. She asked how lay members will be integrated into one panel; e.g. rotations. There is no intention to lose the lay members' unique skills; this is why SWL are holding the workshops, to see how to draw on and retain that expertise, at the same time as making the process as efficient as possible. There would be a process after the workshops to agree the final set of arrangements to ensure the panel is drawing on those skills. However, moving from 24 to six meetings a month may mean that it is not possible to include all current members. It will make the panels more resilient as there will be a pool of lay members to choose from and will mean peer support is available. Healthwatch asked if there is a central budget for IFR cases or would each CCG continue to meet the cost of any treatment agreed by the panel. Clinician funding comes from individual CCGs; the administration element is provided by NELCSU and funding for this is pooled across SWL. Treatment payment remains with the CCG. CCGs may want to consider a pooled budget and risk share in the future; however, at this point that is not the proposal The convenor asked the Committee members if they approve the development and implementation of a SWL IFR Triage Process and Panel. Each Committee was asked to vote in turn: Croydon support Kingston support Merton support Richmond support Sutton support Wandsworth support. The Committee unanimously approved the development and implementation of a SWL IFR Triage Process and Panel. 5. Public Questions 5.1. Usually at this point in the meeting, any members of the public present are invited to ask questions of the Committee relating to the business being conducted, with priority given to written questions that were received in advance of the meeting. However, at this meeting, there were no members of the public present and no questions were received in advance of the meeting. 6. Any Other Business 6.1. No other business was raised at this meeting. 7. Close of meeting 7.1. The convenor thanked the members of the Committee for their attendance. The meeting closed at 18:16. Minutes agreed by: Carol Varlaam Role: Convenor Date: 12/04/18 Page 6 of 6

159 South West London Committee for Collaborative Decision Making Governing Body Report Author: Carol Varlaam, Independent Convenor Date of Committee: 27 March 2018 Introduction The Governing Body of each of the six Clinical Commissioning Groups (CCGs) in South West London (Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth) have resolved to create a Committee for Collaborative Decision Making that will participate in a Committees in Common arrangement. The second meeting was held on 27 March This report is a summary of the meeting for the participating CCG Governing Bodies to accompany the meeting minutes. Items Funding to Deliver Extended Access and Primary Care at Scale in 18/19 The paper was presented to the committee for agreement. The CCGs reflected that this will be a positive opportunity to transform Primary Care in SWL and SWL want to use this opportunity to make real inroads in Transforming Primary Care over the next 12 months. Developing a SWL Individual Funding Requests Triage Process and Panel The proposal was presented to the committee for agreement. It was noted that current IFR panel members will be invited to a series of workshops to ensure the new process is robust. The CCGs asked that the wider GP membership is informed of the changes and are invited to give feedback once the new process is implemented. Decisions 1. The Committee unanimously approved the recommended approach in the presented paper for apportioning the Delivering Primary Care at Scale funding across SWL CCGs 2. The Committee unanimously approved the development and implementation of a SWL IFR Triage Process and Panel. Risks and Assurance Risks and assurances were set out in the presentations given at the meeting. Further actions There were no further actions following this meeting of the South West London Committee for Collaborative Decision Making. Date of next meeting The South West London Committee for Collaborative Decision Making will only be convened when there is a decision to be made as per the introductory paragraph above. Dates have provisionally been held for 19 June and 28 November; meetings will be convened on these dates if needed. Carol Varlaam April 2018 Page 1 of 1

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