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

Transcription

1 NCL Joint Commissioning Committee Thursday 5 th April pm Hendon Town Hall Committee Room 1 The Burroughs London NW4 4BG Voting Members Ms Karen Trew (Chair) Dr Mo Abedi Ms Sorrel Brookes Dr Peter Christian Dr Matthew Clark Ms Bernadette Conroy Ms Angela Dempsey Ms Kathy Elliott Dr Debbie Frost Dr Neel Gupta Ms Catherine Herman Ms Helen Pettersen Ms Sharon Seber Non-Voting Members Cllr Jason Arthur Ms Parin Bahl Cllr Janet Burgess Cllr Pat Callaghan Cllr Alev Cazimoglu Dr Jeanelle De Gruchy Ms Sharon Grant Cllr Hugh Rayner Attendees Mr Edmund Nkrumah Mr Paul Sinden Mr Andrew Spicer Apologies Mr Simon Goodwin Dr Jo Sauvage Minutes Ms Muna Ahmed Governing Body Vice Chair and Lay Member, Enfield CCG Governing Body Chair, Enfield CCG Governing Body Lay Member, Islington CCG Governing Body Chair, Haringey CCG Secondary Care Clinician, Camden CCG Governing Body Lay Member, Barnet CCG Nurse Representative Enfield CCG Governing Body Lay Member, Camden CCG Governing Body Chair, Barnet CCG Governing Body Chair, Camden CCG Governing Body Non-Clinical Vice Chair and Lay Member, Haringey CCG NCL Accountable Officer, Barnet, Camden, Enfield, Haringey and Islington CCGs Nurse Representative Haringey CCG Councillor, Haringey London Borough Council Chair, Healthwatch Enfield Councillor, Islington London Borough Council Councillor, Camden London Borough Council Councillor, Enfield London Borough Council Director of Public Health, Public Health Haringey Chair, Healthwatch Haringey Councillor, Barnet London Borough Council NCL Director of Performance, Barnet, Camden, Enfield, Haringey and Islington CCGs NCL Director of Performance and Acute Commissioning, Barnet, Camden, Enfield, Haringey and Islington CCGs NCL Head of Governance and Risk, Barnet, Camden, Enfield, Haringey and Islington CCGs NCL Chief Finance Officer, Barnet, Camden, Enfield, Haringey and Islington CCGs Governing Body Chair, Islington CCG Interim Corporate Support Officer, Islington CCG 1. Introduction AGENDA Lead Action Paper Time Page 1.1 Welcome and Apologies for Absence Chair Note Verbal Declaration of Interests Chair Note Gifts and Hospitality Chair Note Verbal

2 1.4 Minutes of Committee Meeting on 1 st Chair Approve February Minutes of Committee Meeting on 1 st Chair Approve March Notes of Committee Seminar on 1 st Chair Note March Action Log Chair Note Questions from Public Chair Note Verbal Activity and Performance 2.1 Acute Commissioning Report Paul Sinden Note Commissioning 3.1 Whittington Health Lower Urinary Tract Service (LUTS) Paul Sinden Note Planning for Paul Sinden Note Cancer Services Edmund Nkrumah Approve Risk 4.1 NCL Joint Commissioning Committee Risk Register Paul Sinden Discuss Questions from Public 5.1 Question and Answer Session Chair Discuss Verbal Any Other Business 6.1 Forward Planner 2017/18 Chair Discuss Deadline for submission of reports for the next meeting- Tuesday 29 th May Dates of Next and Future Meetings: Thursday 7 th June 2018; Thursday 2 nd August 2018; Thursday 4 th October 2018; Thursday 6 th December 2018; Thursday 7 th February Chair Note Verbal

3 NOTES 3

4 BARNET, CAMDEN, ENFIELD, HARINGEY AND ISLINGTON CLINICAL COMMISSIONING GROUPS: NCL JOINT COMMISSIONING COMMITTEE REGISTER OF INTERESTS Agenda Item: 1.2 Voting Members NAME TITLE NAME OF ORGANISATION AND NATURE OF ITS BUSINESS POSITION HELD / NATURE OF INTEREST DATE DECLARED DATE UPDATED Dr Mo Adebi Chair, Enfield Clinical Commissioning Group East Enfield Medical Practice - GP Practice GP Principal 27/06/ /06/2017 Ms Sorrel Brookes Dr Matthew Clark Ms Bernadette Conroy Dr Peter Christian Lay Member, Islington CCG Governing Body Secondary Care Doctor, Camden CCG Governing Body Lay Member, Barnet CCG Governing Body Chair, Haringey Clinical Commissioning Group Evergreen Surgery Limited - GP Practice Director and Shareholder 27/06/ /06/2017 Brick Lane Surgery Medicare Medical services LLP - Runs walk in centre at Evergreen and South East Locality access hub DM786 Limited Property management Company GP Principal 27/06/ /06/2017 Wife also a GP Principal Director and Shareholder 27/06/ /06/2017 Director, Wife is a Director, Mother and children are shareholders 27/06/ /06/2017 DM786 Health Ltd Health Consultancy (not actively trading) Director, Wife is a Director, Mother and children are shareholders 27/06/ /06/2017 Prime Point Limited Primary care medical services provider (not actively trading) Enfield Health Partnership Limited, Provider of community gynaecology service Enfield Healthcare Alliance Limited runs Chalfont Road and Boundary Court GP Practices Director/Shareholder 27/06/ /06/2017 Shareholder 27/06/ /06/2017 Shareholder 27/06/ /06/2017 Southbury GP Surgery Wife is a salaried GP 27/06/ /06/2017 South East Locality access hub Wife is a locum GP 27/06/ /06/2017 Carlton House Surgery GP Partner 27/06/ /06/2017 Help On Your Doorstep Trustee 07/07/ /07/2017 East London Music Group Trustee 07/07/ /07/ /10/ /10/2017 Lewisham and Greenwich NHS Trust Paediatric Registrar Welbodi Partnership - registered UK Charity Board Member 05/10/ /10/2017 Wife is a research fellow which is funded by the NHS National 05/10/ /10/2017 Kings College London Institute of Health Research and Tommy's Charitable Trust University of Cambridge Idependent Chair of the Building and Estates Committee 27/06/ /06/2017 North London NHS Estates Partnership Non-executive director 27/06/ /06/2017 Community Health Partnership Non-executive director 27/06/ /06/2017 Bancrofts School Governor 27/06/ /06/2017 St Paul s Way Trust School Trustee 27/06/ /06/2017 Network Homes Chair 27/06/ /06/2017 Hadley Wood Association Trustee 27/06/ /06/2017 Royal Free London NHS Foundation Trust Hospital Husband is consultant anaesthetist and Clinical Director 27/06/ /06/2017 Muswell Hill Practice GP Partner 27/06/ /06/2017 4

5 Group Federated4Health, the pan-haringey GP federation Muswell Hill Practice is a member and Practice Manager at Muswell Hill Practice is Chair 27/06/ /06/2017 WISH- urgent care provider at Whittington Hospital Muswell Hill Practice is a member 27/06/ /06/2017 Muswell Hill Practice Practice provides anticoagulant care to Haringey residents under a contract with Haringey CCG. 27/06/ /06/2017 The Hospital Saturday Fund - a charity which gives money to health related issues. The Lost Chord Charity - organises interactive musical sessions for people with dementia in residential homes. Member and wife is a Patron 27/06/ /06/2017 Wife is a patron 27/06/ /06/2017 Ms Angela Dempsey Haringey Health Connected, the federation of west Haringey GP practices The Practice Manager at Muswell Hill Practice is the Finance Director 27/06/ /06/2017 Nurse Member, Enfield CCG Governing Body Salmons Brook residents Edmonton Non-Executive Director 05/10/ /10/2017 RSM UK Consulting- RSM are the internal auditors for Barnet, Camden, Enfield, Haringey and Islington CCGs Associate Director 05/10/ /10/2017 Lyndsey Lee Foundation Trustee 05/10/ /10/2017 Ms Kathy Elliott Dr Debbie Frost Lay Member, Camden CCG Governing Body Chair, Barnet Clinical Commissioning Group Camden Patient and Public Engagement Group Member 27/06/ /06/2017 Caversham Group Practice- Patient Participation Group Member 27/06/ /06/2017 Kaeconsulting - independent consultancy Owner/Director 27/06/ /06/2017 UK Public Health Register (UKPHR) Assessor and Chair of the Registration Panel 27/06/ /06/2017 Faculty of Public Health Member 27/06/ /06/2017 PHAST - public health consultancy Associate 27/06/ /06/2017 Millway Practice GP Partner 27/06/ /06/2017 Barndoc Healthcare Ltd GP Partner is a member of the Pan Barnet Federated GPs Network Board. GP Partner colleague at Millway Practice is the Chair of Barndoc Healthcare Ltd GP Partner colleague at Millway Practice is a member of the Pan Barnet Federated GPs Network Board 27/06/ /06/ /06/ /06/2017 Mid-West GP Federation Member 27/06/ /06/2017 KPMG Son is a graduate trainee with the KPMG Banking Sector 27/06/ /06/2017 Mr Simon Goodwin NCL Chief Finance Officer, Barnet, Camden, Enfield, Haringey and Islington Clinical Commissioning Groups Chief Financial Officer for the 5 CCGs in North Central London (Barnet, Enfield, Haringey, Islington and Camden) Chief Finance Officer for the five CCGs 14/06/ /08/2017 East London NHS Foundation Trust Wife is a senior manager 14/06/ /08/2017 Dr Neel Gupta Chair, Camden Clinical Commissioning Group The Keats Group Practice Salaried GP, no other interests declared. 27/06/ /06/2017 Ms Catherine Herman Lay Member, Haringey CCG Governing Body No interests declared No interests declared 27/06/ /03/2018 Ms Helen Pettersen NCL Accountable Officer, Barnet, Camden, Enfield, Haringey and Islington Clinical Commissioning Groups No interests declared No interests declared No interests declared 27/06/2017 Dr Kevin Ritchie Dr Josephine Sauvage Clincial Vice Chair, Camden CCG Governing Body Chair, Islington Clinical Commissioning Group Bloomsbury Surgery GP Partner 13/06/ /06/2017 Haverstock Healthcare Limited GP Practice is a shareholder 13/06/ /06/2017 Central Health Evolution Limited GP practice is a member 13/06/ /06/2017 Camden Clinical Assessment Service ('CCAS') Assessor Provde 2-4 sessions per month 13/06/ /06/2017 City Road Medical Centre GP Partner 27/06/ /06/2017 Islington GP Federation City Road Medical Centre is a member practice 27/06/ /06/2017 Health Education North Central and East London Non-executive Board Member 27/06/ /06/2017 5

6 Ms Sharon Seber Primary Care Health Professional Member, South East, Haringey CCG Governing Body South Islington GP Alliance ('SIGPAL') City Road Medical Centre purchased shares to support the development of SIGPAL. The shares are held as a joint asset by the practice and not by individual partners 27/06/ /06/2017 JS Medical Practice Employee- Advanced Nurse Practitioner 05/10/ /10/2017 Dr Barry Subel Clincial Vice Chair, Barnet CCG Governing Body Ravenscroft Medical Centre GP Partner 28/07/ /07/2017 South Locality Barnet Practices Network Limited Director 28/07/ /07/2017 Royal Free London NHS Foundation Trust Hospital Wife is a specialist in haemophilia at Royal Free Hospital. 28/07/ /07/2017 Ms Karen Trew Lay Member and Vice Chair, Enfield CCG Governing Body NHSE Performer List Decision Panel (outside of North Central London) Chair of Panels 27/06/ /06/2017 Broxbourne School Hertfordshire Chair of the Governing Body 27/06/ /06/2017 Wormley C of E Primary School, Hertfordshire Chair of the Governing Body 27/06/ /06/2017 North East London ('NEL') CCGs 111 Procurement Chair and non-scoring panel member (providing assurance to NEL CCGs on process) 27/06/ /06/2017 Lloyds Pharmacy Clinical Homecare Son employed in operational role 27/06/ /06/2017 Non Voting Members NAME NAME OF ORGANISATION AND NATURE OF ITS BUSINESS POSITION HELD / NATURE OF INTEREST DATE DECLARED DATE UPDATED Councillor Jason Arthur Councillor, Haringey Council Step Up To Serve Health and Social Care Campaign Manager 26/10/ /10/2017 Royal College of Obstetricians and Gynaecologists Spouse is Methodologist/Audit Lead - National Maternity and Perinatal Audit 26/10/ /10/2017 Fabian Society Member Unison Member Haringey Council Cabinet Member for Finance and Health 26/10/ /10/2017 Ms Parin Bahl Chair, Healthwatch Enfield Enfield Consumers of Care and Health Organisation CIC Director 01/02/ /03/2018 Healthwatch Chair 01/02/ /03/2018 The Learning Revolution Trust Trustee 01/02/ /03/2018 Councillor Janet Burgess MBE Councillor, Islington Council Islington Council Executive Member for Health & Social Care & Deputy Leader of the 26/10/ /10/2017 Council The Advisory Group For The Friendship Network, Manor Garden Member 26/10/ /10/2017 Welfare Trust Unite Member 26/10/ /10/2017 Whittington Health NHS Trust Attendee at Board Meetings 01/03/ /03/2018 Whittington Park Community Centre Trustee 26/10/ /10/2017 Councillor Patricia Callaghan Councillor, Camden Council Cabinet member for Tackling Health Inequality and Promoting Councillor, Camden Borough Council Independence 05/10/ /10/2017 St Michael's Primary School Governor of St Michael's Primary School 05/10/ /10/2017 Unison Union Member 05/10/ /10/2017 Councillor Alev Cazimoglu Councillor, Enfield Council Enfield Council Cabinet Member for Health & Social Care 26/10/ /10/2017 Office of Joan Ryan MP Case Worker (Part time) 26/10/ /10/2017 Councillor Val Duschinsky Councillor, Barnet Council Imaginist Co LTD Director 26/10/ /10/2017 Barnet Council Deputy Mayor 26/10/ /10/2017 Mill Hill Preservation Society Member 26/10/ /10/2017 Conservative Councillors Association Member 26/10/ /10/2017 Mill Hill Neighbourhood Forum Committee Member 26/10/ /10/2017 Friends of Mill Hill Park Committee Member 26/10/ /10/2017 Copthall Community Sports Group Committee Member 26/10/ /10/2017 Hale Association Member 26/10/ /10/2017 Ms Sharon Grant OBE Chair, Healthwatch Haringey Bernie Grant Arts Centre Partnership Limited Director 12/07/ /07/2017 Bernie Grant Trust Trustee 12/07/ /07/2017 Public Voice Community Interest Company Chair 12/07/ /07/2017 Haringey Citizen's Advice Bureau Member 12/07/ /07/2017 6

7 Dr Jeanelle De Gruchy Councillor Hugh Rayner Foods Standards Agency- Food Hygeine Regulation Scheme subcommittee Member 12/07/ /07/2017 Metropolitan Police independent advisory committee Haringey Member 12/07/ /07/2017 Unite Trade Union Member 12/07/ /07/2017 Which? Director and Trustee 07/02/ /03/2018 Ann Clwyd MP Part time researcher 07/02/ /03/2018 Occasional research, unremunerated, on NHS Wales & other patient voice issues for a Labour MP Researcher 12/07/ /07/2017 Director of Public Health, London Borough of National Association of Directors of Public Health Vice President 27/06/ /06/2017 Haringey Councillor, Barnet Council S H Housing Ltd Director 26/10/ /10/2017 Homehurst Residents Co Ltd Director 26/10/ /10/2017 Atkinsons Alms House Trustee 26/10/ /10/2017 Fairway School Governor 26/10/ /10/2017 Deansbrook Infant School Council Representative 26/10/ /10/2017 Reserve and Cadets Association to greater London Council Representative 26/10/ /10/2017 Samuel Atkinson's Trust Trustee 26/10/ /10/2017 Mill Hill Preservation Society Member 26/10/ /10/2017 Civilian Committee of 1374 sqn ATC Chairman 26/10/ /10/2017 RAFA Hendon and District President 26/10/ /10/2017 Attendees NAME NAME OF ORGANISATION AND NATURE OF ITS BUSINESS POSITION HELD / NATURE OF INTEREST DATE DECLARED DATE UPDATED Mr Will Huxter NCL Director of Strategy No interests declared No interests declared 31/07/ /09/2017 Mr Ian Porter Director of Corporate Services, Camden CCG No interests declared No interests declared 27/06/ /06/2017 Mr Paul Sinden Mr Andrew Spicer NCL Director of Performance and Acute Commissioning, Barnet, Camden, Enfield, Haringey and Islington Clinical Commissioning Groups NCL Head of Governance and Risk, Barnet, Camden, Enfield, Haringey and Islington Clinical Commissioning Groups No interests declared No interests declared 27/06/ /06/2017 WELC CCGs Brother is Director of Commissioning (Transformation) 27/06/ /06/2017 7

8 Present: NORTH CENTRAL LONDON (NCL) JOINT COMMISSIONING COMMITEE Minutes of the meeting held in public on Thursday 1 February 2018, 15:00-17:00 Committee Room, Holbrook House, Cockfosters Road, Barnet, EN4 0DR Voting Members Ms Karen Trew (Chair) Dr Mo Abedi Ms Angela Dempsey Dr Debbie Frost Ms Bernadette Conroy Ms Kathy Elliott Dr Peter Christian Ms Catherine Herman Ms Sharon Seber Dr Jo Sauvage Ms Lucy De Groot Ms Helen Pettersen Mr Simon Goodwin Non-Voting Members Ms Parin Bahl Ms Sharon Grant Cllr Hugh Rayner Cllr Patricia Callaghan In attendance Mr Paul Sinden David Stout Ms Vicky Aldred Professor Fares Haddad Mr Rob Hurd Apologies: Cllr Janet Burgess Cllr Jason Arthur Cllr Richard Olszewski Cllr Alev Cazimoglu Dr Neel Gupta Dr Matthew Clark Ms Sorrel Brookes Dr Jeanelle De Gruchy Governing Body Vice Chair and Lay Member, Enfield CCG Governing Body Chair, Enfield CCG Nurse Representative, Enfield CCG Governing Body Chair, Barnet CCG Governing Body Lay Member, Barnet CCG Governing Body Vice Chair and Lay Member, Camden CCG Governing Body Chair, Haringey CCG Governing Body Non-Clinical Vice Chair and Lay Member, Haringey CCG Practice Nurse Member, Haringey CCG Governing Body Chair, Islington CCG Governing Body Lay Member, Islington CCG NCL Accountable Officer, Barnet, Camden, Enfield, Haringey and Islington CCGs NCL Chief Finance Officer, Barnet, Camden, Enfield, Haringey and Islington CCGs Chair, Healthwatch Enfield Chair, Healthwatch Haringey Councillor, Barnet London Borough Council Councillor, Camden London Borough Council NCL Director of Performance and Acute Commissioning, Barnet, Camden, Enfield, Haringey and Islington CCGs Senior Programme Director, North Central London STP Director of Quality, Barnet CCG Clinical Lead for Adult Elective Orthopaedic Services, University College London Hospitals NHS Foundation Trust Chief Executive, Royal National Orthopaedic Hospital NHS Trust Councillor, Islington London Borough Council Councillor, Haringey London Borough Council Councillor, Camden London Borough Council Councillor, Enfield London Borough Council Governing Body Chair, Camden CCG Secondary Care Clinician, Camden CCG Governing Body Lay Member, Islington CCG Director of Public Health, Haringey London Borough Council 8

9 Minutes: Ms Brenda Thomas Board Secretary (Interim) Enfield CCG 1 Introduction 1.1 The Chair welcomed everyone to the meeting, particularly new attendees to the Committee - Ms Vicky Aldred, Director of Quality (Interim), Barnet CCG and Ms Lucy De Groot who was deputising for Ms Sorrel Brookes, Governing Body Lay Member, Islington CCG. Apologies for absence were noted, as recorded above Members and attendees confirmed their entries in the Register of Declarations of Interest The chair invited Members to declare any interests in respect to items on the agenda. The Chair declared an interest in item 2.1 Chairing of the NCL Joint Commissioning Committee and Terms of Reference, as this relates to her position as Chair of the Committee. She would not be required to leave the meeting for this item, but would not take part in the discussion and decision. Dr Jo Sauvage agreed to chair the meeting for this item Action: Add Catherine Herman to the Declarations of Interest Register. 1.3 There were no declarations of gifts or hospitality offered or received. 1.4 Minutes of the Committee meeting on 7 December The minutes were approved as an accurate record, subject to including the discussion on diagnostic standards, for which an action should be raised and included in the action log Action: add waiting times for diagnostic testing and reporting for local providers to the action log. 1.5 Action log The Committee agreed to close actions 1 and Actions 3 and 4: Update to be provided when available Action 5: Concordia started providing service on North Middlesex University Hospital (NUMH) s behalf on 15 January 2018 at NMUH site. This is a 12 month s contract. However, notice has been served to end the contract on 15 July 2018, therefore a commissioning arrangement needs to be in place prior to this date. Royal Free London (RFL) are yet to confirm their readiness to take on this service. No change is envisaged in the short term and this is being worked through commissioning arrangements It was suggested that this item stays on the agenda to monitor any increase in delay on treatment and to ensure appropriate arrangements are in place. Action JCC/001/18: Paul Sinden to include update in the Acute Commissioning Report for the next meeting. 1.6 Questions from the public There were no questions from the public. 2 Governance 2.1 Chairing of the NCL Joint Commissioning Committee and Terms of Reference As earlier noted under Introduction, Dr Jo Sauvage chaired the meeting for this item. Ms Karen Trew had declared an interest in this item and did not take part in the discussions or decision The Committee received a report on the Chairing of the NCL Joint Commissioning 9

10 Committee and Terms of Reference noting that interviews for the Independent Chair for the Committee took place in August 2017 but an appointment was not made. At the Committee Seminar held on 7 September 2017 it was therefore agreed that a Lay Member representative from the Committee undertake the role of Chair for six months, after which the appointment of an Independent Chair would be further considered. At the seminar in September 2017 it was agreed that Karen Trew, lay representative from Enfield CCG, would Chair the Committee during this time. The appointment was effective for 2017/18 with further consideration therefore required for April 2018 onwards The terms of reference at the time stated that the Chair of the Committee would be independent with a Lay Member representative as stand-in, and a Vice Chair was yet to be nominated In discussing the recommendations put forward, the Committee: Suggested having the option of a CCG lay member of the Committee as Chair, as well as an Independent Chair, to eliminate the need for further revision to the terms of reference should circumstances change in future; Suggested that the Vice Chair was sourced from either Barnet or Camden CCG, given that the proposal was to have the Committee Chair from Enfield CCG, and that the Chair and Vice Chair for the NCL Primary Care Committee-in-Common were carried out by members of Haringey and Islington CCGs respectively The Committee: APPROVED that the Committee Chair continues to be sourced from CCG Lay Member for the 2018/19 year; APPROVED That Karen Trew, lay member representative for Enfield CCG, continued as Chair of the Committee for 2018/19; APPROVED that a further review of Chair arrangements for the Committee be undertaken in the final quarter of 2018/19; RECOMMENDED that a process be utilised by lay member representatives to appoint a Vice Chair from Barnet or Camden CCG, for reasons noted during discussion; APPROVED that the terms of reference be amended to reflect that the appointment of the Committee Chair could be a CCG lay member representative or an independent individual; NOTED that the updated terms of reference were to be sent to Governing Bodies in March 2018, with the revised terms of reference effective from April Action JCC/002/18: Andrew Spicer to rework the terms of reference and circulate the updated version to Committee members in readiness for the Governing Bodies in March Action JCC/003/18: Lay Members to nominate Vice Chair of Committee for 2018/19. 3 Activity and Performance 3.1 Acute Commissioning Report Paul Sinden provided a summary of the report and highlighted the key areas for noting. Cancer 62-day standard was showing a slowly improving position in NCL. Initial reports for December showed performance over 80% with RFL expected to achieve the 85% standard. The main deficit in performance remained the waiting list backlog at University College London Hospital (UCLH), with the updated Trust recovery plan indicating compliance by June 2018 and within this compliance on internal pathways by April Weekly calls were hosted with providers to go through inter-provider transfers on a patient by patient basis to determine common themes of delay and actions to be taken The experience during this winter had been: A&E attendances in 2017/18 remained in line with 2016/17; however, emergency admissions were higher in 2017/18, with spikes in admission in late December 2017 and 10

11 through January 2018 with the increase in admissions for respiratory problems and over 75s; Delayed transfers of care (DToCs) in 2017/18 were lower than for the previous year supported by the introduction of discharge-to-assess pathways and more continuing healthcare assessments being carried out in the community; An increase in length of stay with more people in hospital beds for more than seven days than last winter; An increase in the incidence of flu and loss of bed capacity to infection (including norovirus); An increase in ambulance turnaround delays over 30 minutes compared to last year in particular at NMUH, RFL and Barnet Hospital. A&E Delivery Boards would be looking at plans with London Ambulance Service (LAS) and hospital providers as to how to reduce ambulance turnaround times North Middlesex University Hospital (NMUH): Trust performance was the most challenged in London; however, A&E performance had been improving from 80.3% in August 2017 to 87.2% in October 2017, but there has been a subsequent deterioration since then with a performance of 72.6% in December 2017 and continued reduced performance indicated in the provisional data for January This report has previously reported on concerns raised by the General Medical Council, Health Education England and the Care Quality Commission regarding the learning environment of trainee doctors in the Trust s Emergency Department. Weekly support calls with these stakeholders continued in order to ensure progress of the agreed action plan Referral to Treatment (RTT): RTT performance continued to deteriorate, with both Royal Free London (RFL) and UCLH not meeting the standard (92% of patients waiting less than 18 weeks) in November with UCLH at 91% and RFL at 87%. Both providers had submitted recovery plans with UCLH now indicating recovery of the standard by March 2018 (previously February 2018) due to an increase in demand for Ear Nose Throat (ENT) services, and Royal Free London by August 2018 (the latter trajectory was yet to be accepted by commissioners) Patient Experience: Friends and Family Test (FFT) responses received a low positive response rate at North Middlesex University Hospital (NMUH) for outpatient appointments, maternity and A&E attendances relative to other providers in North Central London and across London. Healthwatch Enfield were working with patients in the emergency department as part of the plan to improve patient experience at the Trust London Ambulance Service (LAS): Formal contract reports were not yet available but LAS had provided a weekly report that included some monthly performance data for the programme. The snapshot in the report from December 2017 indicated that LAS were not meeting most of the waiting time standards in NCL and across London. LAS would be invited to a future meeting to discuss performance issues Never Events: Since the beginning of the financial year North Middlesex University Hospital (NMUH) and Royal Free London (RFL) had reported an increased number of Never Events. In response Barnet CCG organised an assurance visit on Never Events for 30 January 2018 and commissioned North East London Commissioning Support Unit (NELCSU) safety team to undertake an in-depth Thematic Review to be completed by March Haringey CCG were undertaking a thematic analysis of the learning following previous Never Events and were planning an assurance visit to NMUH with a focus on root causes and action plans for February Contracts and Finance: NCL CCGs had reported overall year-to-date over performance of 15.7m on acute contracts and forecast outturn over performance of 22.8m. The forecast for the year-end took into account individual CCG adjustments for the impact of Sustainability and Transformation Plan (STP) interventions later in the year and the impact of marginal rates, with the impact of the latter being a 13.5m reduction in forecast outturn across acute contracts. Forecast outturn had increased by 4.9m at month nine compared to month eight, driven by increases in Trust reported activity in the four main NCL acute 11

12 trusts, with over 60% of the increase accruing from non-elective admissions at Royal Free London (an increase in the run-rate of admissions and a backdated but legitimate switch in coding to Best Practice tariff by the Trust for respiratory admissions). Delivery of Sustainability and Transformation Plan (STP) interventions had also reduced to 61% of plan from 63% in the previous month, reducing the impact of interventions by 0.6m. At the request of the Committee a split of the marginal rate by provider by CCG would be included in the next report Action JCC/004/18: Split of marginal rate impact by provider to be included in the next commissioning report Whilst an agreement has been reached with RFL on the three main disputed items of patient transport, productivity metrics and counting and coding, the final impact of the application of marginal rate had yet to be agreed with the Trust. This was wrapped up in the ongoing discussions about a full and final year-end settlement or a settlement agreed based on year end activity levels During discussion on the Acute Commissioning paper, the Committee: Noted that Enfield Healthwatch were undertaking a piece of work on the reasons patients attended A&E and what services they accessed prior to their attendance, to improve urgent and emergency care services at North Middlesex University Hospital (NMUH). It was further noted that Healthwatch Haringey had carried out a similar exercise, with the report submitted to NMUH for comments. Evidently, a large percentage of the people interviewed had been seen and directed to A&E by their GP. The Committee conveyed thanks to Enfield and Haringey Healthwatch; Referred to the table provided on the yield of claims by CCG and queried the amount and time spent on these items and whether a better process could be in place. Simon Goodwin noted that the payment by result (PBR) system required the claims process to be in place; Noted continued concern over the quality of counting and coding at Royal Free London (RFL) and the focus this was putting on transactional processes rather than delivery of the Sustainability and Transformation Plan. Paul Sinden noted that quarter one and two reconciliations were resolved with providers with relative ease, with the exception of RFL. There was 9.2m counting and coding changes from the Trust identified at quarter one, with several iterations developed to reach an agreement and a proposal put forward to the Trust to involve a third party expert to mediate to reach an agreement; Queried whether the improvement in delayed transfers of care (DTOCs) was consistent across NCL providers, and noted that DTOCs in NCL were slightly lower than in London. Substantial work has been undertaken to reduce delays through A&E Delivery Boards and implementing discharge to assess pathways; Requested further clarity on the Never Events figures, with the nine Never Events reported regarded as high. The feeling of not having a systematic approach to addressing this issue was also expressed. The Committee was assured that Never Events and Serious Incidents (SIs) are reviewed in detail at the Clinical Quality Review Group (CQRG) and are also reviewed at individual CCG s Quality Committee. There is no benchmark for Never Events and there are 14 national categories designated as Never Events, with clear safeguards usually in the form of national policies. There was relatively little or no harm for the eight (nine reported, one deescalated) Never Events at RFL. However, these are indicators of serious lapses in clinical care which could result in significant harm, therefore should be taken seriously. NHS Improvement (NHSI) and Barnet CCG are impressed with the work being done by RFL to ensure improvement in their safety issues on surgical problems and there is ongoing clinical quality oversight arrangement to ensure this traction continues. Requested that London Ambulance Service (LAS) be pursued for communications on the introduction of the new ambulance response programme to alleviate public concern; Noted there was an ongoing theme in the narrative of the report about contract performance being dependent on delivery of Sustainability and Transformation Plan 12

13 (STP) interventions. The Committee also noted that delivery of the interventions would also impact on patient experience. The Committee therefore requested receipt of a description of the top ten STP interventions, with their activity and monetary value and expected impact on patient experience. It was noted that a presentation on the STP given at Barnet CCG would be a template for this; Reinforced that an NCL-wide approach should be taken when dealing with Providers. From this Camden CCG requested an overview of the Royal Free London contract position as an Associate Commissioner; Noted that there is discussion at the Haringey Adult Safeguarding Board, about current pressures at NMUH, the implications for safeguarding and actions being taken. It was noted that clinicians are sighted on Never Events, SIs and Near Misses via the CQRG and there is a new policy on Human Trafficking. Annual reports on safeguarding could be shared if required Action JCC/005/18: Provide the Committee with an overview of Sustainability and Transformation Plan (STP) interventions at a future meeting. Action JCC/006/18: Paul Sinden to feedback to Kathy Elliot outside the meeting, actions being taken in the short term in relation to RFL and bring back to the Committee concerns (if any) that comes out of the review, either within the Acute Commissioning report or as a separate report The Committee NOTED the report. 3.2 Transforming Care Programme Update Paul Sinden gave an overview of the report which set out: NCL performance against the bed reduction trajectory; The current position on the proposed funding transfer agreement from Specialist Commissioning to CCGs; The financial position for each CCG/Local Authority area for CCG funded patients discharged from 1 April 2016 with an admission of 12 months or more In December 2017 across NCL there were 64 people in inpatient beds against a trajectory of 65, although within this there were more people remaining in long-stay placements (31) against the trajectory of 29. In February 2018 there were four discharges into the community offset by three new admissions to inpatient placements, and one scheduled discharge that failed. The NCL-wide Positive Behaviour Support Team, established from central NHS England monies, focused on admission avoidance. Although the bed trajectory reduction was being met across NCL there was differential performance across CCGs and boroughs An updated funding transfer agreement had been received from NHS England (NHSE) following challenge from Transforming Care Partnerships across London to the previous proposal. The updated funding transfer agreement featured: Expected payment from NHSE of 1.3m, with 165k for eligible transfers in 2016/17, 470k for eligible transfers to date in 2017/18, and 639k for future transfers in the rest of 2017/18 and 2018/19; Payment for people who had been in inpatient beds for more than five years transferred into community packages of care in 2016/17 and 2017/18 (previous version only covered 2017/18); An incentive payment for a net reduction in inpatients amounting to 180k per net discharge, with this offset by a payment back to NHSE for re-admissions. This arrangement excluded patients with the length of stay in excess of five years (see above) where separate payments were agreed The funding transfer agreement from CCGs to Social Care reflected the NHSE agreement and covered transfers of care from 1 April From the agreement funds flowing from 13

14 CCGs to Social Care to date would be 1.1m; with 499k relating to transfers made in 2016/17 and 598k to transfers made in 2017/ The cost pressure based on the funding transfer proposal from NHSE was 3.6m across NCL. This increased by 1.7m to 5.2m when taking into account new patients entering the Transforming Care cohort, and incentive payments for a net reduction in inpatient placements The Committee, in discussing the report: Noted that the full 5.2m cost pressure would accrue in 2018/19; Noted the importance of patients voice to be embedded in the report. Healthwatch offered support in this regard; Queried when funding would be transferred to Councils in accordance to NHS England and local funding transfer arrangements in the context of the cost pressures to Councils and in particular, where admissions to hospitals had successfully been prevented; Noted that funding transfer agreements would be recurrent for as long as patients were not re-admitted. Noted that the Enfield CCG position needed to be clarified in relation to stranded costs following transfers into community packages Action JCC/007/18: Paul Sinden to circulate a briefing on when funding would be available and its recurrent nature. Action JCC/008/18: Paul Sinden to provide an updated position for Enfield CCG The Committee: APPROVED the funding transfer agreement for CCG funded placements with an inpatient stay of more than 12 months effective for transfers from 1 April Commissioning 4.1 Planning for The Committee received an overview of progress with planning for 2018/19. Formal planning guidance for 2018/19 from NHS England and NHS Improvement was yet to be received. The Committee would receive an update once the guidance was received. Local progress in agreeing contract baselines for 2018/19 is being made, with further work required and in the absence of clear guidance, the latest intelligence is being used The Committee then received an update on local progress to date: Resolution of the quarter one position for 2017/18 with providers as a precursor to establishing opening contract baselines for 2018/19; Opening baselines for 2018/19 had been issued to providers; Analysis of activity growth trends on contracts in 2017/18, compared to the planning assumption of 3%, to inform growth trends to be applied to contracts in 2018/19; Generation of plans for Sustainability and Transformation Plan (STP) and local CCG interventions that target a reduction in acute hospital activity in 2018/19. Supporting project initiation documents (PIDs) setting out activity and financial impact of the interventions have been shared with providers in January 2018; Contract terms for marginal rates, claims and challenges, CQUIN and key performance indicators will be rolled forwards from 2017/18 into 2018/ In response to the update the Committee emphasised that contracts for 2018/19 should be fully reflective of STP and local QIPP interventions The Committee NOTED the report. 4.2 Adult Elective Orthopaedic Services: Achieving the Best Value for Patients Mr Rob Hurd Chief Executive, Royal National Orthopaedic Hospital NHS Trust and Professor 14

15 Fares Haddad, Clinical Lead for Adult Elective Orthopaedic Services at UCLH presented the paper which set out a project proposal to establish a review of adult elective orthopaedic services across NCL, as part of the planned care workstream in the Sustainability and Transformation Plan (STP). This review would seek to identify opportunities to improve outcomes for patients; improve the quality of services by reducing unwarranted variation; and improve value for money. There was evidence of substantial benefit from other health economies that had carried out similar proposals Good practice for consultation and engagement on service changes was being followed and would include a focus on engagement with both staff and patients. CCGs would have representation on the Review Group, and assurance of the mandate from each of the Providers in NCL would be secured, with a clinical lead from each site involved in the project. The review would be clinically led and undertaken as part of the NCL STP, with final decisions on any proposed changes to be taken by the NCL Joint Commissioning Committee The supporting paper provided further detail and set out: Project governance with the Adult Orthopaedic Elective Services Review Group reporting into the NCL STP Health and Care Cabinet for clinical oversight and scrutiny. The review would have four workstreams: developing the clinical case for change, demand and capacity modelling, communications and consultation, and workforce; The intent to engage with clinicians and patients and the public through the review, with advice taken from Healthwatch and the NCL Joint Health Overview Scrutiny Committee; Project timescales and capacity. It was anticipated that the service review would be completed by March 2019, and would come back to the Committee for approval The following comments were made by the Committee during discussion: A request that the project be ambitious for outcomes and delivery. In response the project leads noted that a realistic scale of ambition would be set and options for the service model would be generated; The review would incorporate independent hospitals and assess evidence of outcomes from these providers as part of the case for change; This would be a clinically led programme of work with a focus on quality and outcomes; Assurance was sought on avoiding slippage on the timetable and the consequent impact on CCG and system finances. The Committee was assured that extra resources would be brought in to oversee the project but delivery was also dependent on the release of local clinical time, and this would be included in the project risk register; Discussion was needed at a local and NCL level about central and satellite services, and the open commitment to work with patients was welcomed. The Committee noted that conversation had started on co-producing the service model with service users; In response to a question on the aspiration to work towards an Academy and become a centre of excellence for orthopaedics, it was noted that the scale of ambition was to create world leading services for the local population and that the potential for this existed in NCL given the partnership links and local clinical expertise. The project should consider primary, tertiary and secondary interventions and how rotation of workforce could be achieved as a system, and the service model should support existing work on musculo-skeletal pathways; Whether a change in the adult orthopaedic service would have an impact on the children s services. The interdependencies on other services was noted, however the impact on children would be less compared to that of trauma services The Committee: APPROVED the establishment of the Adult Elective Orthopaedic Services Review Group. AGREED for key points (e.g. engagement methodology and final recommendations) for decision making to be brought back and report by exception. 15

16 5 Risk 5.1 NCL Joint Commissioning Committee Risk Register The Committee noted that there were no recommendations for change to the Risk Register since the last meeting and raised the following points in relation to the register: Include the impact of managing acute contracts from the proposal to in-house the Commissioning Support Unit contract function on the risk register; Review actions with obsolete dates, their impact and next steps; Review some of the risk rating and to give consideration to closing some risks; Consider how to ensure attendance of Council representatives at the Committee including substitute membership and agenda planning (for relevance); The ability to meet the aspiration in the Sustainability and Transformation Plan to invest in prevention services whilst hospital contracts remained on a payment-by-results basis, and the contribution that Health and Wellbeing Boards could make in raising the profile of prevention in the STP Action JCC/009/18: Helen Pettersen to have a conversation with the Local Authorities to assure attendance at Committee meetings The Committee NOTED the risk report. 6 Questions from public 6.1 There were no questions from the public. 7 Any Other Business 7.1 Forward Planner The Committee agreed the following: Updates on the Adult Elective Orthopaedics Services Review to be added for 2018/19; Mental Health falls outside the scope of the Committee, however, there were some mental health related decisions that the Committee should be sighted on. The workplan for 2018/19 should create space for such interdependencies. Remove business cases for Barnet, Enfield and Haringey Mental Health Trust (BEHMHT) and Camden and Islington Foundation Trust (CIFT), as these should be discussed by the CCGs and sat outside of the remit of the Committee The Committee NOTED the forward planner The Committee was notified by Andy Spicer that the logo for papers would change to meet national communication standards for NHS. 8 Date of next meeting 8.1 Thursday 5 April pm, Hendon Town Hall. 16

17 NORTH CENTRAL LONDON (NCL) JOINT COMMISSIONING COMMITEE Minutes of the extraordinary meeting held in public on Thursday 1 March 2018, 15:00-16:00 Main Hall Cypriot Community Centre, Earlham Grove, London, N22 5HJ Present: Voting Members Ms Karen Trew (Chair) Dr Mo Abedi Ms Sorrel Brookes Dr Peter Christian Ms Bernadette Conroy Ms Kathy Elliott Dr Debbie Frost Ms Helen Pettersen Dr Jo Sauvage Ms Sharon Seber Mr Adam Sharples Governing Body Vice Chair and Lay Member, Enfield CCG Governing Body Chair, Enfield CCG Governing Body Lay Member, Islington CCG Governing Body Chair, Haringey CCG Governing Body Lay Member, Barnet CCG Governing Body Lay Member, Camden CCG Governing Body Chair, Barnet CCG NCL Accountable Officer, Barnet, Camden, Enfield, Haringey and Islington CCGs Governing Body Chair, Islington CCG Nurse Representative Haringey CCG Governing Body Lay Member, Haringey CCG Non-Voting Members Ms Janet Burgess Ms Sharon Grant Ms Parin Bahl Councillor, Islington London Borough Council Healthwatch Haringey Healthwatch Enfield Attendees Ms Eileen Fiori Mr Edmund Nkrumah Mr Paul Sinden Mr Gary Sired Mr Andrew Spicer NCL POD Director, NEL Commissioning Support Unit NCL Director of Performance NCL Director of Performance and Acute Commissioning, Barnet, Camden, Enfield, Haringey and Islington CCGs STP Finance Lead, Barnet, Camden, Enfield, Haringey and Islington CCGs NCL Head of Governance and Risk, Barnet, Camden, Enfield, Haringey and Islington CCGs Apologies Mr Jason Arthur Ms Pat Callaghan Ms Alev Cazimoglu Matthew Clark Dr Jeanelle De Gruchy Angela Dempsey Mr Simon Goodwin Ms Catherine Herman Mr Ian Porter Councillor, Haringey London Borough Council Councillor, Camden London Borough Council Councillor, Enfield London Borough Council Secondary Care Clinician, Camden CCG Director of Public Health, Public Health Haringey Nurse Representative Enfield CCG NCL Chief Finance Officer, Barnet, Camden, Enfield, Haringey and Islington CCGs Governing Body Non-Clinical Vice Chair and Lay Member, Haringey CCG Director of Corporate Services, Camden CCG 17

18 Mr Hugh Rayner Councillor, Barnet London Borough Council Minutes Ms Louisa Dearman Quality and Governance Support Officer, Haringey and Islington CCGs 1 Introduction 1.1 The Chair, Karen Trew, welcomed everyone to the meeting and apologies were noted as above. 1.2 Declarations of conflicts of interest Attendees were asked to review the declarations of interest register ahead of Committee meetings and to declare if they believed they were conflicted for any items on the agenda. Janet Burgess declared that she has an interest in relation to item 2.1 on the agenda as she is a non-voting an attendee at Whittington Health NHS Trust Board meetings. The Committee considered the declaration. It noted the following: The interest represents a conflict of interest; Councillor Burgess is a non-voting attendee at the Whittington Health NHS Trust Board meetings and as such is not a decision maker; Councillor Burgess is a non-voting member of the Committee and as such contributes to discussions but is not a decision maker; As a Councillor for Islington London Borough Council she represents the views of Islington residents and that is a valuable contribution; The meeting is held in public and if Councillor Burgess was asked to leave the table she would still be able to be present at the meeting but the Committee would not have the benefit of her voice. The Committee decided that Councillor Burgess could remain and participate in the discussions on the agenda item but would play no role in decision making on the agenda item. Subsequently, Councillor Burgess remained at the meeting, contributed to the discussions on the agenda item but played no role in decision making on it. 1.3 Declarations of gifts and hospitality There were no declarations of gifts or hospitality offered or received. 1.4 Chair s opening remarks It was noted that this extraordinary meeting was called to discuss a single item the Whittington Health Lower Urinary Tract Service (LUTS) to gain a commissioner view on re-opening the clinic to new referrals prior to the Whittington Health Trust Board to be held on 28 March Questions from the public Members of the public were present at the meeting, all of whom were part of the LUTS Patient Group, representing the circa 500 members. The Chair asked members of the public if they had any questions for the Committee. The Chair 18

19 noted that if members of the public did not ask any questions at this point there would be a further opportunity to ask questions later in the meeting under agenda item 3 Question From The Pubic but noted that this would be after the decision on the Adult Medical Urology Services at Whittington Health paper had been made. Members of the public stated that they had no questions at this stage but would make a statement when agenda item 3 was discussed. 2 Adult Medical Urology Services at Whittington Health 2.1 Summary of the report Paul Sinden provided an overview of the report presented to the Committee. The LUTS clinic is provided by Whittington Health. An independent review of the LUTS service was commissioned from the Royal College of Physicians (RCP) by Whittington Health following concerns over the service after a serious incident, and concern within the Trust and from many GPs locally about the prescribing regime in the clinic as some of it sat outside of clinical guidelines and /or research governance. The report was received in October 2016 with 27 recommendations to secure a sustainable and safe service. The most notable recommendations from the RCP report were for the development of a Multi-Disciplinary Team (MDT) to support the clinic; to develop a separate specialist paediatric pathway; and to ensure a succession plan for the clinic s lead consultant as conditions for the clinic to reopen for new referrals. Paul Sinden had since met with the Patient Group and Whittington Health on a number of occasions to help deliver the recommendations in the Royal College of Physicians report. 2.2 Paul Sinden noted that progress had been made to meet the above conditions. A Whittington Health multi-disciplinary team (MDT) had been set up to support the clinic; a service specification for the adults LUTS clinic has been agreed by CCGs and the Trust; a business case for the continuation of the clinic had been developed; a succession plan for the lead consultant has been with Whittington Health and UCLH agreeing to recruit to a joint consultant uro-gynaecologist post; development of the research and governance framework with UCLH and University College London, and additional assurance on safety and governance for the clinic from Whittington Health including the alignment of the clinic clinical audit programme into the Trust s overall programme. 2.3 Paul Sinden noted that the service specification had put in place a series of safeguards to address local clinical concerns over the clinic including the MDT approach for new referrals; referrals from secondary care only (not primary care); Prescribing remained within the Trust and shared care arrangements with primary care would only be put in place on agreement of protocols with GPs. Peter Christian noted that having the clinic aligned to, or provided in, a specialised tertiary setting may also help with recruiting a lead consultant as this would be more appealing to clinicians. In response to a question from Kathy Elliot Paul Sinden agreed that the service specification would be further developed to incorporate performance indicators relating for both clinical and corporate governance. 19

20 Paul Sinden recommended that the service specification for adults be reconsidered twelve months after the clinic re-opened as a tertiary service for adults. It was noted that commissioners would work with Whittington Health, Great Ormond Street Hospital (GOSH) and the LUTS Patient Group to further develop the separate paediatric tertiary pathway at GOSH. The patient group had expressed concern over the tertiary service at GOSH as it did not replicate the treatment provided from the LUTs clinic at Whittington Health. 2.6 Whittington Health would also need to establish a quality assurance process for diagnostic testing in the clinic. This related to the use of dipstick tests to identify infection. The patient group have raised concerns about the alternative form of testing through cystoscopies on their condition. 2.7 The Committee indicated that protocols should be in place to manage any future NHS waiting lists for the clinic. Arrangements for any private patients wishing to be referred to the NHS clinic would be consistent with the NHS Constitution requirements. 2.8 The Committee requested further assurance that the clinic was properly supported by a tertiary service (joint consultant post and MDT) and recommend that the service shift to a tertiary setting as links to UCLH were built through the joint consultant post, MDT, and research framework (alongside University College London). In response Paul Sinden indicated that noted that appointment of the consultant would go to the relevant Royal College for approval in June 2018 and recruitment in September There would be cover for the lead consultant role until an appointment was made. 2.9 Adam Sharples suggested that it would be beneficial to wait until the new consultant was in post to re-open the clinic due to the concerns associated with the current service. Karen Trew noted that others on the Committee felt differently about this, and Paul Sinden indicated that this went beyond the Royal College of Physicians recommendation that a succession plan be in place In regards to a query from Helen Pettersen about the role of the multi-disciplinary team (MDT), Paul Sinden clarified that the MDT brought together a team of multiskilled professionals to use their range of expertise to support the clinic and agree treatment plans for new patients. The MDT would also broaden the clinical leadership of the service so it was not reliant on one individual. Neel Gupta noted that the existing Whittington Health MDT should be further developed to include membership from tertiary services, to support any future transfer of the service into a tertiary setting. Paul Sinden agreed that developing the tertiary support for the multi-disciplinary team (MDT) would help to replicate the service across the country as a more accessible service. The MDT was currently sitting in Whittington Health but had potential to move to UCLH following recruitment of the joint lead consultant. 20

21 2.11 Adam Sharples raised a concern in regards to the service currently covering patients all over the country and not just for North Central London. Adam Sharples noted that this Committee and the lead commissioning CCGs should be aware of these potential risks and that an eventual solution should not take NCL CCGs beyond their remit. Paul Sinden referred to developing the tertiary support to the Whittington Health multi-disciplinary team as an enabler for replicating the service in different health economies. Helen Pettersen noted that this would be something to consider going forward in discussion with NHS England which is responsible for commissioning specialised services. Helen Pettersen clarified that services provided to patients outside NCL would be paid for by their local CCG In regards to a query from Sorrel Brookes about why the clinic was not yet open to new patients, Jo Sauvage noted that this was due to the uncertainty around the capacity of the newly developed MDT to manage any new referrals on top of the workload of existing patients. As per the Royal College of Physicians (RCP) recommendations, once the MDT had been established as a robust process, its capacity could be reviewed in terms of accepting new referrals to the clinic Karen Trew summarised the discussion by noting that the Committee was able to support Paul Sinden s report s recommendations to the Whittington Health Trust Board with the following caveats: Development of the Whittington Health multi-disciplinary team (MDT) supporting the clinic to include membership from specialist / tertiary services; The clinic is properly supported by a tertiary service (joint consultant post and MDT) and recommend that the service shifts to tertiary setting as links to UCLH are built through the joint consultant post, MDT, and research framework (alongside University College London); Confirmation from Whittington Health clinicians that safeguards in place to make the service safe from local governance processes and the service specification; Ensuring separate provision for children maintained. This is being delivered through GOSH service; A quality assurance process for diagnostic testing in the clinic established by Whittington Health; Protocols are in place to manage any future NHS waiting lists for the clinic. Arrangements for any private patients wishing to be referred to the NHS clinic would be consistent with the NHS Constitution requirements; Given the above, opening the clinic to new referrals would be reconsidered after a period if the assurances were not received. This would primarily relate to delivery of the succession plan and progress with tertiary support for the clinic Helen Pettersen noted that commissioners would continue discussions with Whittington Health to gain assurance from the Trust on the above points. Feedback from the Joint Commissioning Committee would be provided to the Trust Board before it met on 28 March The decision from the Trust Board and any feedback would then be reported to the NCL CCG Joint Commissioning Committee on 5 April 2018 once all assurance had been gathered. Further discussion would be held at the June 2018 meeting if required. 21

22 2.15 Jo Sauvage noted that she sympathised with the Patient Group as this had been a lengthy process from receipt of the Royal College of Physicians report, however also noted that it was crucial to go through the process correctly, putting the safety of patients above all else The Committee agreed to continue the momentum of this work and not to lose pace. 3 Questions from the public 3.1 Members of the public noted that this process had been ongoing for two years and due to the nature of the illness has caused much distress to patients. Given this the patient group requested speedy resolution of all outstanding items to allow the decision to re-open the clinic to new referrals to be made at the Whittington Health Trust Board on 28 March 2018 and NCL CCG Joint Commissioning Committee on 5 April Patient group representatives was noted that having attended many meetings at the Trust and with commissioners, it appeared that it was often the case that decisions are delayed due to the right people not being present. Jo Sauvage noted that she appreciated it may seem like the process was very cumbersome but assured that there were a lot of discussions taking place between commissioners and Whittington Health to help deliver the conditions to re-open the clinic to new referrals. 3.3 The Committee was asked to ensure that the tertiary service for children was further developed as well as the service for adults, and that the Committee consider alignment of the paediatric clinic to the LUTS clinic at Whittington Health. Jo Sauvage noted that it was atypical for a clinician to provide care to children if they were not a registered paediatrician, therefore the plan was to further develop the existing paediatric specialist service at Great Ormond Street Hospital. Whittington Health had already made contact with Great Ormond Street Hospital and commissioners would work with both Trusts, and the patient group, to develop the service specification. 4 Any other business 4.1 Karen Trew thanked the Patient Group representatives for attending the meeting and their contribution. There was no other business. 5 Date of next meeting 5.1 NCL Joint Commissioning Committee meeting in public Thursday 5 April, 15:00-17:00 Hendon Town Hall, Committee Room 1, The Burroughs, London NW4 4BG. 22

23 NORTH CENTRAL LONDON (NCL) JOINT COMMISSIONING COMMITEE Minutes of the Seminar Thursday 1 March 2018, 16:00-17:00 Main Hall Cypriot Community Centre, Earlham Grove, London, N22 5HJ Present: Ms Karen Trew (Chair) Dr Mo Abedi Ms Sorrel Brookes Dr Peter Christian Ms Bernadette Conroy Ms Kathy Elliott Dr Debbie Frost Ms Helen Pettersen Dr Jo Sauvage Ms Sharon Seber Mr Adam Sharples Governing Body Vice Chair and Lay Member, Enfield CCG Governing Body Chair, Enfield CCG Governing Body Lay Member, Islington CCG Governing Body Chair, Haringey CCG Governing Body Lay Member, Barnet CCG Governing Body Lay Member, Camden CCG Governing Body Chair, Barnet CCG NCL Accountable Officer, Barnet, Camden, Enfield, Haringey and Islington CCGs Governing Body Chair, Islington CCG Nurse Representative Haringey CCG Governing Body Lay Member, Haringey CCG Attendees Ms Eileen Fiori Mr Edmund Nkrumah Mr Paul Sinden Mr Gary Sired Mr Andrew Spicer NCL POD Director, NEL Commissioning Support Unit NCL Director of Performance NCL Director of Performance and Acute Commissioning, Barnet, Camden, Enfield, Haringey and Islington CCGs STP Finance Lead, Barnet, Camden, Enfield, Haringey and Islington CCGs NCL Head of Governance and Risk, Barnet, Camden, Enfield, Haringey and Islington CCGs Apologies Matthew Clark Angela Dempsey Mr Simon Goodwin Ms Catherine Herman Mr Ian Porter Secondary Care Clinician, Camden CCG Governing Body Nurse Representative Enfield CCG NCL Chief Finance Officer, Barnet, Camden, Enfield, Haringey and Islington CCGs Governing Body Non-Clinical Vice Chair and Lay Member, Haringey CCG Director of Corporate Services, Camden CCG Minutes Ms Louisa Dearman Quality and Governance Support Officer, Haringey and Islington CCGs 1 Introduction 1.1 The Chair, Karen Trew, welcomed everyone to the meeting and apologies were noted as above. 1.2 Declarations of conflicts of interest 1 23

24 Attendees were asked to review the declarations of interest register ahead of Committee meetings and to declare if they believed they were conflicted for any items on the agenda. No further declarations were made. 1.3 Declarations of gifts and hospitality There were no declarations of gifts or hospitality offered or received Chair s opening remarks Karen Trew noted that there was only time to discuss one item and priority should be given to the Planning Round 2018/19 item. The Cancer update would be included on the Committee Agenda on 5 April Karen Trew noted that before the seminar started, the Committee could reflect on the Part 1 meeting in public concerning the single item discussion about the Whittington Lower Urinary Tract Service (LUTS). It was agreed that single item Committee meetings should be avoided in future, and to support this it was also agreed that agenda planning should be reviewed in order for the Committee to be able to spend time on matters adding the most value. The Chair and Vice Chair would therefore be involved in the agenda planning to ensure this sign-off. Where there are similar matters concerning acute contracts, these should be reviewed together and included on the workplan. 2 Commissioning 2.1 Planning Round for 2018/ Paul Sinden provided an update on the planning round for 2018/19 including an overview of national planning guidance from NHS England and NHS Improvement. The guidance had set out national activity assumptions with the growth rates from 2017/18 into 2018/19 over and above those proposed for local contracts, and this had made it more complex to agree contract baselines with providers that incorporated the impact of Sustainability and Transformation Plan (STP) and local QIPP schemes. 2.3 Paul Sinden noted that 2018/19 had a challenging financial backdrop for both providers and CCGs and it was proving challenging to agree a consistent contract for all the NCL providers. Neel Gupta noted that the CCGs needed to further use their partnership working as leverage with providers to ensure contracts reflected STP and local interventions. Jo Sauvage noted that this would be supported by clinicians asserting their leadership to ensure service transformation. Debbie Frost noted that clinicians at Trusts often wanted to support service developments, but were often restricted by the financial constraints within their organisations. 2 24

25 2.4 Neel Gupta noted that Payment-by-Results (PbR) contracts were the current reality and unless CCGs used a more aligned and hard-lined approach managing these types of contracts would continue to be a challenge. A course of action to deliver this could be to galvanise local support to look to alternative providers for some services to give Trusts an incentive to agree a contract that were both affordable and transformational. 2.5 In regards to short term support to ensure Sustainability and Transformation Plan (STP) and local interventions were built into provider contracts, Paul Sinden suggested that the links between clinical leadership and the negotiation and monitoring of provider contracts should be expanded and dialogue with providers should be held at different levels and not just through the contracting lens. 2.6 Jo Sauvage noted that it would be crucial for Medical Directors at Trusts to spearhead the aims of the STP in order to drive delivery. Mo Abedi noted that the STP was still the only opportunity to align NCL providers and CCGs. Jo Sauvage indicated that the Health and Care Cabinet would be discussing how clinical leadership could extend into the operating plan and contracts. Mo Abedi recommended that the Joint Commissioning Committee supports this route to aligning the STP and contracts. It was agreed that to facilitate this the Sustainability and Transformation Plan (STP) Health and Care Cabinet should meet together with the STP Finance Group. Action 01/03/18 01: Paul Sinden to develop a proposal on how the STP Health and Care Cabinet and STP Finance Group could work together to deliver acute contracts in 2018/19. This would be developed through the NCL CCG Senior Management Team before reporting back to this Committee. 2.7 In regards to Mo Abedi s query about how CCGs would be updated on the negotiation process, Paul Sinden noted that updates on contract negotiations with each provider were provided to CCG Contract Delivery Group meetings. The Joint Commissioning Committee could also receive this report. It was agreed that CCGs would be kept informed of the negotiation decisions. Action 01/03/18 02: Paul Sinden to circulate the current position of contract negotiations to the NCL JCC members. 4 Any other business 4.1 There was no other business. 5 Dates of next meetings 5.1 NCL Joint Commissioning Committee meeting in public Thursday 5 April, 15:00-17:00 Hendon Town Hall, Committee Room 1, The Burroughs, London NW4 4BG 3 25

26 26 4

27 NORTH CENTRAL LONDON JOINT COMMISSIONING COMMITTEE ACTION LOG APRIL 2018 Action Meeting No. Date 1. 1 st March 2018 Action Lead Deadline Update Whittington Health LUTS Clinic Provide an update on the LUTS Clinic to the April 2018 Committee. Paul Sinden April 2018 Meeting Update paper on April 2018 Agenda 2. 1 st March 2018 Planning for 2018/19 Develop a proposal on how the STP Health and Care Cabinet and STP Finance Group could work together to deliver acute contracts in 2018/19. This would be developed through the NCL CCG Senior Management Team before reporting back to this Committee. Paul Sinden April 2018 Meeting Initial work set out in planning update. Considered by STP Health and Care Cabinet in March A more detailed proposal to Seminar in May st March st February 2018 Planning for 2018/19 Circulate the current position of contract negotiations to the NCL JCC members. Action Log Include update on the North Middlesex University Hospital Dermatology Service in the Acute Commissioning Report for the next meeting. Paul Sinden Paul Sinden April 2018 Meeting April 2018 Meeting In planning update paper on the agenda. A briefing note will be sent to JCC members before the Committee on 5 April st February 2018 Chairing of the NCL JCC and Terms of Reference Rework the terms of reference and circulate the updated version to Committee members in readiness for the Governing Bodies in March Andrew Spicer April 2018 Meeting Completed. Changes were approved by CCG Governing Bodies in March st February 2018 Chairing of the NCL JCC and Terms of Reference Lay Members to nominate Vice Chair of Committee for 2018/19. Lay Members April 2018 Meeting Completed. Kathy Elliott, Camden CCG Lay representative, appointed as Vice Chair of the Committee 7. 1 st February 2018 Acute Commissioning Report Split of marginal rate impact by provider to be included in the next commissioning report. Paul Sinden April 2018 Meeting Completed. In acute commissioning report st February Acute Commissioning Report Paul Sinden April 2018 Completed. In planning update to the Committee. 27

28 2018 Obtain presentation on STP given at Barnet CCG and tailor to include: description of the top 10 STP interventions, their activity and monetary value and what it means for patients. Meeting 9. 1 st February 2018 Acute Commissioning Report 1. Feedback to Kathy Elliot actions being taken in the short term in relation to Royal Free London; 2. Bring back to the Committee concerns (if any) that comes out of the review, either within the Acute Commissioning report or as a separate report. Paul Sinden 1. April 2018 Meeting 2. June 2018 Meeting st February 2018 Transforming Care Programme Update Circulate briefing on when funding would be available and its recurrent nature. Paul Sinden April 2018 Meeting Funding will be made to Councils in 2017/ st February 2018 Transforming Care Programme Update Provide an updated position for Enfield CCG Paul Sinden April 2018 Meeting Completed. Meeting held with Enfield CCG in February st February 2018 NCL Joint Commissioning Committee Risk Register Speak with the Local Authorities to determine reasons for their non-attendance at Committee meetings. Helen Pettersen April 2018 Meeting th December 2017 Planning for 2018/19 The Committee to receive a summary of Planning Guidance for 2018/19 from NHS England and NHS Improvement. Paul Sinden April 2018 Meeting Overview of planning guidance included in planning update for 2018/ th December 2017 Procedures of Limited Clinical Effectiveness The Committee to receive an update on Joint Health Overview Scrutiny Committee (JHOSC) advice on any need for public consultation for workstream three (the rollout of changes approved by Enfield CCG to the rest of North Central London). Paul Sinden / Jo Sauvage April 2018 Meeting The NCL policy for procedures of limited clinical effectiveness will next be considered by the Joint Health Overview Scrutiny Committee (JHOSC) on 6 February

29 15. 7 th December 2017 North Middlesex University Hospital Dermatology Service Royal Free London to be asked to provide assurance on their readiness to provide the dermatology service (transferring from North Middlesex University Hospital) on 1 April 2018 to the February Committee. Paul Sinden April 2018 Meeting Royal Free London are yet to confirm their readiness to take on this service. No change is envisaged in the short term and this is being worked through commissioning arrangements. 29

30 NCL Joint Commissioning Committee Thursday 5 April 2018 Report title Acute Commissioning Report Date 28 March 2018 Lead director Report author Paul Sinden Director of Performance and Acute Commissioning Sarah Rothenberg NCL CSU POD Director of Finance NEL Commissioning Support Unit Tel/ Tel/ p.sinden@nhs.net Tel sarahrothenberg@nhs.net Tel Eileen Fiori NCL POD Director NEL Commissioning Support Unit eileen.fiori@nhs.net Tel Sponsor(s) (where applicable) Tel/ Report summary Introduction This report sets out an overview of provider contracts for which management was delegated to the Joint Commissioning Committee by the five Clinical Commissioning Groups (CCGs) in North Central London (NCL) in November The report therefore incorporates: Acute hospital contracts; Integrated Urgent Care service (NHS 111 and GP out-of-hours) provided by London Central and West Unscheduled Care Collaborative; London Ambulance Service. Content In line with the functions listed above the NCL Joint Commissioning Committee will consider all aspects of provider performance to ensure there is a comprehensive oversight of contract management. This will include the following four sections: 1. Quality and Performance The quality and performance section of the report provides a summary of nationally and locally reported data, describes the overall quality of the acute services in NCL and the actions being taken to deliver sustainable improvement. The report shows published Accident and Emergency performance data for February 2018, and performance data for January 2018 for the other standards with more recent un-validated information where available. 1 30

31 2. Contracts The report focuses on the performance of contracts falling within the remit of the Joint Commissioning Committee and will therefore not fully reflect the overall CCG positions. The position shown uses month eleven information (February 2018), which is reported as month ten plus one in line with reporting arrangements to show a projected month eleven position. The report provides details of: NCL-wide acute contract overview; Claims and challenges; Quarter one and quarter two reconciliations; Main risks and mitigations to contracts. 3. Financial Performance The report will provide details of: Run-rate of expenditure to support trend analysis; Performance by Trust; Performance by CCG; Narrative to support the figures. 4. Activity Performance The report provides details of: NCL-wide acute activity overview; Comparison between 2016/17 and 2017/ Quality and Performance The Committee is asked to note the CCG and provider performance as summarised in the dashboards overleaf. This section explains the issues underlying the performance and the actions being taken by providers and commissioners to improve the delivery of the standards. This section also includes the quality and performance information for the London Ambulance Service and the Integrated Urgent Care service provided by London Central West Unscheduled Care Collaborative. Patient experience as measured by the Friends and Family Test can provide a proxy for patient reported satisfaction with treatment outcomes. This has been included as part of the provider performance, where relevant. 2 31

32 Figure 1 Date of Measure Current Data Barnet Camden Enfield Haringey Islington Four-hour max wait in A&E Feb % 86.47% 84.58% 84.93% 87.44% RTT: 92% incomplete Jan % 90.13% 83.62% 91.47% 91.76% Cancer waits: 2 week All Cancers Jan % 92.88% 93.39% 93.05% 95.27% Cancer waits: 2 week breast symptomatic Jan % 90.16% 90.43% 95.06% 92.68% Cancer waits: 31 days diagnosis to treatment Jan % 98.44% 94.78% % 95.38% Cancer waits: 31 days diagnosis to treatment subsequent drug treatment Jan % % % % % Cancer waits: 31 days diagnosis to treatment subsequent surgery Jan % % % % % Cancer waits: 31 days treatment subsequent radiotherapy Jan % % 95.65% % % Cancer waits: 62 days referral to treatment Jan % 83.90% 76.92% 74.10% 66.67% Cancer waits: 62 days referral to treatment -referral from screening Jan % % % % 83.33% Cancer waits 62 days upgrade Jan % % 85.71% 78.57% % Diagnostic waits > 6 wks Jan % 99.11% 99.67% 99.41% 99.26% Data Source: Unify2 and Open Exeter NCL Provider Performance Figure 2 Measure Date of Current Data Moorfields NMUH RNOH Royal Free UCLH Whittington Four-hour max wait in A&E Feb % 82.36% 86.51% 86.05% 86.10% RTT: 92% incomplete Jan % 93.07% 91.08% 83.02% 91.04% 92.10% Cancer waits: 2 week All Cancers Jan % 91.80% 93.60% 92.20% 93.00% 94.89% Cancer waits: 2 week breast symptomatic Jan % 93.23% 84.52% 97.92% Cancer waits: 31 days 1st Definitive Treatment Jan % 98.60% % 99.12% 90.40% % Cancer waits: 31 days diagnosis to treatment subsequent drug treatment Jan % % % % Cancer waits: 31 days diagnosis to treatment subsequent surgery Jan % % 95.45% 96.88% 90.10% % Cancer waits: 31 days treatment subsequent radiotherapy Jan % % % Cancer waits: 62 days referral to treatment Jan % % 84.50% 60.90% 82.22% Cancer waits: 62 days referral to treatment -referral from screening Jan % 96.83% 81.20% Cancer waits 62 days upgrade Jan % 80.00% 90.77% 69.80% % Diagnostic waits > 6 wks Jan % 99.41% 99.63% 99.34% 99.13% 98.99% Data Source: Unify2 and Open Exeter 1.1 Accident and Emergency Performance Performance across the sector is challenging. The cold weather and snow created additional pressures with patient acuity and access for staff. Accident and Emergency delivery systems have seen some improvements, but this is not on a sustained basis. Aggregate performance for NCL Accident and Emergency providers was 88.1% in February 2018 compared with 85.7% in December There is an expectation from NHS England and NHS Improvement that during the winter, Accident and Emergency systems should deliver services to at least a 90% standard. Performance at all of the NCL Accident and Emergency services improved except for Whittington Health with a slightly lower performance of 86.1% compared with 86.5% in January There has been a lot of variation in the daily performance with some services, for example Barnet Hospital and North Middlesex University Hospital not reaching 70% on a regular basis. All NCL emergency systems were below both local trajectories and the national standard (95%). The NCL aggregate performance for February 2018 was 88.1% against an aggregate trajectory of 91.3% and the national performance for the winter of 90%. 3 32

33 Figure North Middlesex University Hospital Although the Trust has had some very poor daily performances, North Middlesex University Hospital has seen some overall improvement in Accident and Emergency performance from 72.6% in December 2017 to 82.4% in February Provisional data in March 2018 is showing a deteriorating position. Figure 4 Data Source: Unify2 and local provide data North Middlesex University Hospital, Commissioners and system partners are working on a number of elements to support improved performance and better patient experience and outcomes. These include: Using Plan, Do, Study and Act (PDSA) approaches in the Ambulatory Early Senior Assessment and Treatment service to help reduce ambulance handover breaches; Recruiting 44 health care support workers across the Trust taking up posts from January 2018; Commissioners engaging with primary care and Healthwatch colleagues to understand the reasons for some practices having high patient attendances and developing communication tools to support patients using other appropriate services; Having a non-clinical patient navigator at the front door. One of the goals is to recommend registering with a GP to those patients who have not already done so Royal Free London Royal Free London Hospitals has seen an improvement in Accident and Emergency performance from 83.86% in December 2017 to in February This was against an agreed trajectory of 94.8%. 4 Recovery action plans are being implemented for improving performance at the Barnet and Royal Free Hampstead hospital sites. These are based upon demand management, hospital patient flow, discharge management and workforce work streams and are managed by site multi-agency urgent care and emergency transformation groups. 33

34 The plans are regularly refreshed to reflect the outputs from the improvement work supported by the NHS Improvement Emergency Care Improvement Programme. The recent focus has been on: The philosophy and approach to ambulance handover with ambulance patients transferring to ambulatory care, urgent care centres and alternative care pathways; Matching staffing skill mix and capacity to patient profiles and demands particularly in the evenings; A focus on frailty pathways enhancing the range and timing of assessment and support available particularly after 5pm. The Barnet Accident and Emergency Delivery Board have also been looking at the variation in patient attendances by GP Practice and the numbers and needs of children and young people using Royal Free London Accident and Emergency services and Central London Community Health (CLCH) walk in centres in Barnet. Barnet CCG are working with the practices with the higher attendances to understand the reasons and explore the potential for reducing them. They are also engaging with GP Federations about how to particularly support the high volume of 0-4 year old children presenting to Accident and Emergency and walk in centres with lower levels of need University College London Hospital University College London Hospital has refreshed the accident and emergency recovery action plan to improve performance. Further assurance is required by commissioners on the expected impact of actions and timescales. CCGs are working with the Trust to secure this information. As part of the recovery plan there are a number of actions that have a critical impact on delivering the Accident and Emergency improvement trajectory. These include: Use of Step-Down Beds: Camden CCG commissioned Evergreen Ward Step down beds at St. Pancras. These beds continue to be utilised and regular updates provided monthly to the Accident and Emergency Delivery Board; Specialty Response: Reducing specialty delays in Emergency Department and improving response times by implementing schemes such as the use of hot clinics and speciality specific pathways that are Emergency Department led; Specialty level demand & capacity and flow: Strengthening operational resilience and capacity management across the clinical areas in the Tower through hour demand and capacity management, improving bed cleaning turnaround times, introduction of operational manager of the day and ward liaison roles and consistent board round processes across the hospital; Urgent Treatment Centre Delivery: Efficiency improvements and throughput in the urgent treatment centre by embedding a reconfigured staffing and leadership model. In addition, the completion of the Emergency Department capital project in March 2018 will create additional space in clinical areas that will support the flow of patients through the department Whittington Health Performance against the four hour Accident and Emergency target at Whittington Health NHS Trust was 86.2% in January A slight drop on December 2017 performance of 86.5%. Performance is summarised in Figure 5 below. 5 Factors impacting on performance include: Increases in over 75 admissions; Increased ambulance attendances; Increased delayed discharges; Increased length of stay. 34

35 There have been no 12 hour trolley wait breaches at Whittington Health NHS Trust since August Figure 5 Source: Published Data and Daily Sitreps (09/03/2018) The Islington Discharge to Assess Programme is on target for two of three patient pathways. There are recognised issues around the provision of community re-ablement support and social workers to support admission avoidance and discharge to assess schemes which are being addressed through Director to Director engagement between Islington CCG and London Borough of Islington. The number of patients passing through Discharge to Assess pathway one increased by 63% to 59 patients in February Daily liaison between Whittington Health, CCG and Local Authorities takes place to resolve obstacles leading to delays to discharges. All Winter Funding schemes relating to the additional Winter Funding allocations confirmed in December 2017 are in place. Weekly Multi-Agency Discharge Events (MADE) are held at Whittington Health to facilitate improved discharge flows Refreshing NHS Plans NHS England and NHS Improvement have issued guidance for refreshing operational plans for 2018/19. Commissioner and provider plans will be expected to demonstrate how they will complete the implementation of the integrated urgent care strategy that was commenced this year, and how sufficient capacity will be available to meet planned activity growth. Through measures such as reductions in delayed transfers of care, continuing to work with local authorities to reduce social care delayed transfers and focusing on those patients with the longest length of stay categorised as stranded patients. There is significant variation in length of stay between providers, particularly in the number of patients with a length of stay over seven days (stranded patients) and a length of stay over 21 days (super-stranded patients). There is an expectation that all providers and commissioners will work together to focus on reducing their length of stay, and particularly the very long lengths of stay, to release capacity for patients who are legitimately waiting for a hospital bed. To further support progress in these areas and free-up capacity, providers of community services will be invited to participate in a new local incentive scheme in conjunction with 6 35

36 their CCG whereby they will be able to reinvest savings from acute excess bed day costs to expand community and intermediate care services. This will benefit stranded and super-stranded patients in particular. A total of 210 million (nationally) of CCG Quality Premium incentive funding in 2018/19 will be contingent on performance on moderating demand for emergency care. This payment will be conditional on the CCG meeting or improving on the levels jointly planned with providers. The principal metric for this purpose will be the level of growth in non-elective activity compared to the agreed plan Winter Demand and Capacity Plans There will be no additional winter funding in 2018/19. To ensure that winter preparation has been undertaken well in advance and using existing funds, systems will need to demonstrate that winter plans are embedded both in their system plans and in individual organisations operating plans, including realistic phasing of non-elective and elective activity across the year. To support this there is a requirement for each system to produce a separate winter demand and capacity plan, triangulating the finance and activity implications along with the actions and proposed outcomes. Plans are required to be submitted by the end of April Each A&E Delivery Board will undertake after action reviews to assess performance and the impact of investment in winter 2017/18 to inform plans for 2018/19. The reviews will identify three high-impact changes, that address performance challenges from winter 2017/18, to be introduced for winter 2018/19. The results of the after action reviews will be shared with the Committee Supporting actions Accident and Emergency Delivery Boards In order to support an improvement in patient flow, Accident and Emergency Delivery Boards are focussed upon delivering: Reductions in Ambulance handover times; An increase in urgent care streaming; Enhanced ambulatory care; A reduced number of Delayed Transfers of Care and stranded patients (waiting discharge for more than six days); Increasing numbers of patients following Discharge-to-Assess pathways Ambulance Handover Accident and Emergency Delivery Boards have carried out an assessment against a number of actions that support improvements in ambulance handover and reflect the recommendations in the recent guidance on improving ambulance handover times. These actions include analysis of patient flows for those conveyed by ambulance, investigating the operational steps for handover of patients and what escalation triggers for delays are in place Discharges The simplified discharge workstream has supported the implementation of work to reduce delays in transfers of care, to increase the number of patients on discharge-to-assess pathways, and reduce the number of patients having continuing health care assessments in acute hospital services. NCL continues to meet the agreed trajectory for delayed bed days per day with a performance of against a trajectory of Camden and Islington CCGs are not 7 36

37 meeting their agreed trajectories with delivery of 10.1 against a standard of 7.51 for Camden CCG and against a target of for Islington CCG. Local Sitrep data shows that the expected Whittington Health Delayed Transfers of Care position for February 2018 will be approx. 3.3% of the bed base which is a reduction from 4.5% reported by NHSE for January From February 2018 all three pathways of the Whittington System Discharge to Assess Programme were delivering according to trajectory which has contributed to the reduction in Delayed Transfers of Care. CCGs are at different stages with implementing Discharge-to-Assess pathways and this forms part of the Urgent and Emergency Care work stream performance indicators. NHS England are placing more emphasis upon delivering and enhancing these targets in their engagement with the Accident and Emergency Delivery Board systems. 1.2 Referral to Treatment Royal Free London, Royal National Orthopaedic Hospital and University College London Hospital did not meet the standard in January 2018 with respective performance of 83%, 91% and 91% against a target of 92%. As a consequence no NCL CCGs met the Referral To Treatment standard. NCL CCGs as an aggregate only achieved 89.54% in January Provider updates are provided in section Refreshing NHS Plans for Constitutional Standards The national guidance on Refreshing NHS Plans explains that the 2018/19 national allocations allow for improvements in the volume of elective surgery being funded next year, and improvements in the number of patients waiting over 52 weeks. For some commissioning regions, a more significant annual increase in the number of elective procedures compared with recent years means commissioners and providers should plan on the basis that their referral to treatment waiting list, measured as the number of patients on an incomplete pathway, will be no higher in March 2019 than in March 2018 and, where possible, it should be reduced. Numbers nationally of patients waiting more than 52 weeks for treatment should be halved by March 2019, and locally eliminated wherever possible. Systems will be expected to demonstrate that referral to treatment plans are robust and realistic, and that they make best and flexible use of available capacity across the STP footprint in order to optimise delivery against the objectives above. In addition, Provider plans will need to consider the capacity required to deliver the growth in Non-Elective and Elective activity and the impact on workforce, finance and productivity. The NCL contracting discussions, taking place at this time, will reflect anticipated levels of growth in the planned care and emergency care pathways. These are based on trend analysis and triangulation with our Providers. Analysis has shown this varies across our acute providers and this will be reflected in our contract agreements. 8 37

38 1.2.2 Overall Referral To Treatment Waiting List Size The NCL waiting list for patients waiting for treatment at January 2018 is shown below. Figure 6 The number of patients waiting for more than 18 weeks for treatment has increased from 15,495 in December 2017 to 18,188 in January There has been an increase across most of the major NCL providers, with the exception of small reductions at Whittington Health and the Royal National Orthopaedic Hospital. This increase in waiting lists was anticipated as a consequence of the planned reduced elective activity to support urgent and emergency care during the winter period. There were a total of 38 NCL CCG patients on the referral to treatment pathways in January 2018 that had not been treated within 52 weeks of being referred. 11 of the 52 week waiters were at Imperial and 23 at Royal Free London. The number of 52 week waiters for NCL CCGs at all providers has reduced from 47 in December 2017 to 38 in January of these are patients waiting at Royal Free London, 10 at Imperial College Healthcare, one at University College London Hospitals and the remaining cases were at providers outside of NCL. Clinical harm review processes are in place for people waiting in excess of 52 weeks for their treatment, with regular reports to Clinical Quality Review Group meetings. Specific actions are recorded in the Provider commentary below Referral To Treatment Provider update Royal Free London Royal Free London has not achieved the Referral To Treatment 18 week target since August This is primarily because of the implementation of a new reporting logic in August This resulted in an overall reduction of the waiting list as the duplicated pathways were removed, but at the same time resulted in a disproportionate increase in patients whose pathways breached the 18 week standard. This affected the overall Referral To Treatment performance. 9 There were 34 patients waiting for more than 52 weeks at Royal Free London in January Royal Free London has established a clinical harm process. Monthly reports showing progress and the learning from the reviews will be considered by the Royal Free London Clinical Quality Review Group. 38

39 Commissioners received an initial recovery action plan from the Trust on 4 December This has been discussed with commissioners and colleagues from NHS England and NHS Improvement. Further work is required on validation of the Trust s data currently showing patients waiting on an 18 week pathway. Additional staff have been recruited to support this. It is anticipated that all of the initial validation work will be completed by the end of March The Intensive Support Team from NHS Improvement are making sure that the logic rules that are being used are appropriate and helping the Royal Free London team to make sure that patients are treated in chronological order where clinically possible. Work is continuing to further develop the speciality based action plans and trajectories. The Director of Commissioning at Barnet CCG is representing NCL CCGs at the Royal Free London Referral to Treatment Steering Group that oversees the development and implementation of the recovery plan. Barnet CCG are including information about the Royal Free London position on referral to treatment in the regular GP Bulletin and are working with Royal Free London to ensure that all key stakeholders are aware of the current position and the actions being taken to deliver improvement University College London Hospital University College London Hospital did not achieve the 18-week referral to treatment target for the seventh consecutive month. Performance in January 2018 slightly improved at 91.04%% but still below the threshold and the agreed Sustainability Transformation Fund Trajectory of 92.0%. There were a total of 4 non-compliant specialties in January 2018 with the dermatology specialty returning to a compliant position. Non-compliant specialties are Ear Nose and Throat services (83.9%), Neurosurgery (78.9%), Neurology (90.5%), and Other (90.9%). The 2017/18 year to date performance for University College London Hospital is 91.48%. There were three patients waiting for longer than 52 weeks. The reason for this non- compliance has been attributed to: Lack of clinical specialty to address sub-specialty waiting lists; Waiting list management practices issues; High backlog of community Ear Nose and Throat service activity. Camden CCG has received the requested specialty level recovery action plans and the backlog reduction trajectory. A return to overall compliance had initially been forecast by University College London Hospital for January 2018 but the trust has confirmed that this is at risk and compliance may now not be achieved until March University College London Hospital submitted a refreshed referral to treatment recovery action plan and trajectories to Camden CCG on 15 December 2017 and this continues to be monitored at the monthly performance meetings Other North Central London Trusts North Middlesex University Hospital, Whittington Health and the other NCL providers met the referral to treatment standard in January Close attention is being be paid to the January and February 2018 patient tracking lists to assess the impact of the winter plan to reduce elective activity to create additional capacity for the increase in emergency attendances and admissions

40 1.3 Cancer Two Week Wait Standard Royal Free London Hospitals and North Middlesex University Hospitals failed to meet the 2 week wait standard in January 2018 with respective performance of 92.2% and 91.8% against the 93% standard. The standard was also missed by Barnet and Camden CCGs. This also brought the aggregate NCL performance to just below the standard of 93%. Figure 7 Data Source: Open Exeter Cancer 62 day standard NCL trusts achieved the aggregate 62 Day Urgent referral Standard in December 2017 with a performance of 86.3% against the 85% threshold which represents an improvement in performance of 6.7% when compared to November 2017 performance of 79.6%. NCL was ranked third out of five London STPs. This is a significant achievement after non-compliance for several years. It is unlikely to be continued in January 2018 because of patients choosing not to take up appointment and treatment date offers over the festive period. NCL providers are committed to ensure that the standard is delivered on a sustained basis. At a provider level, performance in January 2018 was mixed. Royal Free London Hospitals and Whittington Health just missed the 85% standard while North Middlesex University Hospitals and University College London Hospitals remained well below the standard. Figure 8 Figure

41 Data Source: Open Exeter Four of the NCL CCGs achieved the 62 Day Urgent GP Referral standard this month. The aggregate CCG performance in December 2017 was 87.8% with a total of 20 breaches from 164 patient pathways. This performance was also above the National average of 83.9%. Haringey CCG was non-compliant with 6 breaches from 32 patient pathways (81.3%). NCL providers continue to work to the NCL Cancer STP five-point action plan which is a key driver to support sustainable recovery of the 62 Day Standard. This includes: Reducing median waits for first event to seven days; Full implementation of the optimal Prostate and Lung pathways; Straight to test for lower Gastro-Intestinal; Patient Tracking List management and tracking of backlog; Root cause analyses for 62 day breaches. A workshop on Inter Trust Transfer root cause analysis with NCL Trusts identified a number of actions to improve robustness and consistency of processes. A standard operational procedure is being developed for use across NCL. All NCL Trusts will be using common breach report documentation and common processes. They have agreed to submit the root cause analyses in a timely manner and a standard operational procedure setting out the arrangements will be finalised in March Inter Trust Transfers North Central and East London sector have an over-arching 62 day pathway cancer action plan. Within this there is a requirement to improve the timeliness of NCL patients that are referred on to a Tertiary trust. This needs to be within 38 days of referral. The North Central and East London sector is aiming for sustainable compliance of the Inter Trust Transfer standards in quarter one 2018/19. NCL Trust trajectories are based on a performance threshold of 85% for patients being transferred within 38 days. Figure 10 Data Source: NCL Providers Provider update University College London Hospital University College London Hospital achieved six out of the eight cancer waiting times standards in December The non-compliant Cancer Waiting Time standards this month were: 62 day Urgent GP referral and the 62 day Screening standard. The overall 62 Day Urgent GP referral standard performance improved this month to 79.9% albeit below agreed trajectory of 82.6%. Internal performance of 88.1% was above Sustainability and Transformation Fund trajectory of 85% set by NHS England and NHS Improvement

42 There were a total of 14 breaches from a total of 69.5 Patient Pathways this month. Six breaches were attributed to patient / clinical reasons, two and a half breaches were due to administrative or capacity pressures and the remaining six had unknown breach causes. All 62 day breaches, including all those over 100 day breaches have breach analysis undertaken, analysed and reported together at Clinical Quality Review Group on a monthly basis. University College London Hospital continue to work with referring trusts and with the sector to streamline pathways. They have a weekly operational phone call in place to manage transfers at a patient level and the sector monitoring tool is updated on a weekly basis. The external clinically led review of cancer waiting times in the Trust is complete and final outputs have been incorporated in the revised recovery action plan. The recovery action plan was subject to further scrutiny by regulators who felt that it required further development. University College London Hospital have undertaken focused work to strengthen the Gastro Intestinal pathway management and nursing team, improve capacity and scheduling and implemented a daily PTL review. Tumour pathway boards have produced timed pathways for use across the sector and the majority of these have been agreed and in use. The North Central & East London Performance Leadership Group closely monitors provider cancer waiting lists, including performance against the inter-trust transfer target of 38 days for onward referral and 24 days treatment timescales Royal Free London Royal Free London achieved six out of eight cancer waiting times target in January 2018, non-compliant targets includes the two week wait and the 62 day (Urgent GP referral). The overall patients tracking list has increased to 2400 per week in March 2018 compared to 1800 per week in January The back log reduction is stagnant and trajectory is behind target. A high volume of GP urgent referrals for Breast, Head and Neck and Lower Gastro Intestinal has been highlighted by Royal Free London. Extra capacity has been put in place to manage demand. Royal Free London Hospital secured Rapid Improvement Funding through the Recovery Fund monies in December ,000 will be invested to extend the straight to test pilot for Lower Gastro Intestinal pathway which is due to start from January 2018 and 49,000 to improve Dermatology compliance by recruiting an additional consultant who is due to start in January North Middlesex University Hospital Trust North Middlesex University Hospital achieved four out of eight cancer waiting standards. The cancer waiting standards that were not met in January 2018 were two week waits (general) two week wait (breast symptomatic) 31 day subsequent (chemotherapy) and 62 Days Wait (GP referral). Two week waits (general) performance was at 91.76% in January 2018 with 619 treated cases and 51 breaches. North Middlesex University Hospital implemented the straight to test Lower Gastro Intestinal pilot in January Commissioners met the North Middlesex University Hospital Chief Operating Officer and the cancer management team and agreed a number of actions to address the variable 62 day GP referral cancer performance. The Trust has welcomed offers of support from the University College London Hospital Vanguard and NHS Improvement, details of which are being arranged. 42

43 Whittington Health Whittington Health met all of the cancer standards except the 62 Day GP referral standard. Low numbers of cases at Whittington Health NHS Trust mean that statistically insignificant variations in performance due to patient availability or complexity have a disproportionate impact on Whittington Health NHS Trust performance. An analysis of every patient referred to another provider after 38 days of initial receipt of referral is undertaken by the Trust and shared with the North and Central East London Cancer Improvement Group. The main causes of delays have been confirmed as: Tumours identified as incidental findings; Patient choice delays; Delays due to infrequency of sector Multi-Disciplinary Team meetings. 1.4 Diagnostics The 6-week timeframe for the diagnostic standard is from when the request for a diagnostic test or procedure is made to when the patient receives the diagnostic test/procedure. For e-referrals this is from when the patient has accepted an appointment. The constitutional standard does not include the time it takes for the diagnostic report to be prepared and sent to the referrer. Trusts will have operational standards to ensure that diagnostic reports are provided in a timely manner particularly for cancer patients. All five NCL providers except Whittington Health achieved the diagnostic target of 99% in January Whittington Health reported a performance of 98.99% but has since revised and corrected the data sent to NHS England which reflects their true position of achieving the standard. As a result of continued improved provider performance, all of the NCL CCGs achieved the diagnostics standard in January London Ambulance Service With the introduction of the new Ambulance Response Programme, the method for performance reporting is being reviewed by the London Ambulance Service and commissioners. Formal contract reports will not be available until May 2018 but the London Ambulance Service has provided a weekly tripartite report that includes some monthly performance data. This provides a summary of performance against the new standards for the whole of London. Figure 11 February

44 The four new patient categories are: Category 1 Life Threatening (8% of calls); Category 2 Emergencies (48% of calls); Category 3 Urgent (34% of calls); Category 4 Less Urgent (10% of calls). February performance reflects the impact of the adverse weather experienced across London. This resulted in a small deterioration in response times. The category one 90 th Centile remained within the 15 minute national standard across London. North Central London Category 4 did not meet the required standard. Hospital handover will have a direct impact on performance, particularly across the Category 3 and Category 4 categories as Ambulances will be tied up in queues. North Middlesex University Hospital, Royal Free London Hospital and University College London Hospital are ranked 4th, 5th and 6th respectively against the hospitals with the most hours lost on arrival to handover across London. There will also be a marginal impact owing to the increased activity coming through Category 1 & Category 2, which received prioritised resource given the higher clinical acuity of the calls. Tethering The New Dispatch Model Trial was set up as part of a NCL improvement programme in response to an inequity of ambulance performance between sectors. The trial ran for nine weeks between 16 August 2017 and 17 October 2017 and consisted of three elements: North Central Dispatch Group: Dedicated allocators/dispatchers & a solo responder desk; Ambulance tethering: emergency ambulances based in North Central would only be dispatched to incidents occurring within their home sector (except Red 1 incidents); New Fast Response Unit end of shift process: Ambulance staff guaranteed a rest break during the course of their shift. The outcomes of the pilot were as follows: Category A response times were largely unchanged while Category C response times reduced; No significant association was found between the New Dispatch Model Trial and conveyance rates. While it had been hoped that the New Dispatch Model Trial would result in greater equity of performance between CCGs in North Central, this was not identified in the results. Job Cycle time remained largely unchanged in the New Dispatch Model Trial group with no clear change within any element

45 The end of shift trial was generally well received by solo responders with significant feedback citing that less late finishes and more rest breaks had a positive impact on morale. A number of recommendations have been made by the New Dispatch Model Trial group which the Trust is currently considering. These include: The Emergency Operations Centre to be permanently reconfigured to align with the STP geographical boundaries; A formal end of shift process to be considered as part of new rest break arrangements; Ambulance tethering to be permanently implemented for Category 3 and Category 4 patients. For Category 2 patients, it is recommended that dispatchers should attempt to dispatch a local vehicle first, but if unable to assign after 8 minutes, any ambulance should be dispatched; Consideration to be given to extending the open channel function on Airwave radios taking into account cost, benefit and utility. 1.6 Integrated Urgent Care Service London Central West Unscheduled Care Collaborative provides the integrated urgent care service that covers both the NHS 111 service and GP out-of-hours. London Central West Unscheduled Care Collaborative are meeting all of the agreed national and local Key Performance Indicators apart from call waiting time. The call waiting time remains a challenge because of staffing levels. A recruitment plan has been implemented. Figure 12 - January 2018 Quality and Performance Indicators Qrt 1 Qrt 2 Qrt3 Qrt4 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC Engaged calls 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Abandoned calls 0.4% 0.9% 0.8% 1.4% 1.5% 3.0% 3.2% 4.8% 3.5% 4.7% Answer Time 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Call waiting time 95.6% 91.0% 91.2% 86.3% 88.3% 81.6% 80.5% 73.3% 77.4% 76.7% Life threatening referrals 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Meeting individuals needs 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Safeguarding 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Triage rate 106.6% 108.1% 108.2% 106.4% 104.9% 104.0% 109.1% 106.8% 104.2% 104.4% Transfer to % 9.7% 10.3% 10.4% 10.9% 11.7% 11.5% 11.6% 11.7% 12.0% Attend Accident & Emergency Department 9.4% 9.8% 10.1% 10.5% 9.4% 10.1% 10.0% 9.8% 9.0% 10.2% Referred to Primary Care and other dispositions 55.5% 52.8% 52.5% 52.9% 51.9% 51.0% 51.5% 51.9% 55.4% 55.3% Warm Transfers 68.1% 66.0% 68.0% 71.6% 73.8% 66.5% 73.3% 72.2% 72.4% 78.5% Time taken for call back 10.6% 13.1% 10.8% 54.6% 54.0% 53.5% 49.1% 48.7% 46.9% 44.8% Notifications 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Patient Education 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Data Source: London Central West Unscheduled Care Collaborative Contract and Performance Report Although London Central West Unscheduled Care Collaborative is not meeting the national Key Performance Indicator (95%), it has been agreed as part of the contract monitoring that the Key Performance Indicator is locally set 85%, whilst recruitment continues. They are not yet meeting the target, however, they are reporting an improvement of 4% from the previous month. This continues to be impacted by rostering issues and a shortfall in overall staff, however their workforce plan is progressing to achieve this trajectory. The Contract Technical Group now meets monthly. The group will be analysing finance and activity levels against the agreed contract baseline to understand the drivers of the increased activity. A finance & activity report is being developed to highlight London Central West financial pressures. A Key Performance Indicator Task and Finish Group 16 45

46 has been set up to review and agree the suite of national and local key performance indicators, for implementation in April Performance of the integrated urgent care service has held up well over the winter to date compared to peer services nationally. A Serious Incident occurred at London Central West Unscheduled Care Collaborative in April NHS England requested a commissioner initiated external review in addition to the Provider Serious Incident root cause analysis investigation. NHS England requested a commissioner initiated external review in addition to the provider serious incident root cause analysis investigation. The external review was led by Professor David Colin Thome. Due to the complexity of this investigation and time limitations by internal investigation external team, this investigation has taken longer than planned. An Extraordinary Clinical Quality Review Group took place on 16 February 2018 to review the findings of the independent investigation report. The independent report, as well as the internal investigation, did not identify any harm or detriment to patients involved in the issues highlighted within the Sun newspaper report; neither did the investigations reveal significant risks or issues relating to the delivery of ongoing services. A steering group meeting has also taken place with NHS England. Enfield CCG will now prepare a report to be shared with NCL and Inner North West London CCGs at the appropriate Governing Body meetings. 1.7 Quality issues Never Events Never Events are Serious Incidents events that are wholly preventable because national guidance or safety recommendations have been put in place that provide strong protective barriers. They require special investigation and the learning from the investigations should prevent future occurrences. The Royal Free Hospital NHS Trust reported a further two never events in February Year to date, eleven Never Events have been reported of which one was deescalated. The two most recent Never Events were a retained foreign object and unintentional connection of a patient requiring oxygen to an air flowmeter. This is set against a background of an increased incidence of Never Events in the calendar year of 2016 and the Royal Free Hospitals Trust having undertaken an intense programme of addressing the occurrence of Never Events. Barnet CCG, in collaboration with NHS England and NHS Improvement, carried out an assurance visit at Royal Free Hospitals Trust on 30 January 2018 to review the eight Never Events that had been reported at that time. Three of the Never Events had been fully investigated and closed and four were currently under investigation. The process for investigating the Never Events, identifying themes and dissemination of lessons learnt was reviewed. It was agreed during the review that Barnet CCG received sufficient assurance from the Royal Free Hospitals Trust in these areas. NEL CSU safety team has been commissioned to undertake an in-depth Thematic Review to be completed by March In light of North Middlesex University Hospital reporting a fifth never event this financial year the Clinical Quality Review meeting Chair has written to the Trust and is undertaking assurance work regard to the Surgical Safety Checklist. In addition an assurance visit has been planned to review checklist procedures in the operating theatres. North Middlesex University Hospital is compiling a list of procedures in preparation for implementing the Local Safety Standards for Invasive Procedures (LocSSIPs); this work is being led by the deputy Medical Director. The Trust is planning to adopt some of the 46

47 policies developed by other trusts and has sought assistance from Barts Health to support this work Patient Experience There are a number of aspects of feedback on patient experience to consider in relation to North Middlesex University Hospital. Following the last Care Quality Commission inspection in 2016, North Middlesex University Hospital was designated with a Trust wide rating of Requires Improvement for the Caring Domain; with four of the eight core services inspected also receiving a rating of Requires Improvement ; the remaining four were rated as Good. Haringey and Enfield CCGs are keen to ensure that North Middlesex University Hospital Trust continue to work on improving patient experience particularly whilst delivery of national constitutional standards is a challenge. Emergency Department The Friends and Family Test recommendation rate for the Emergency Department has been above 60% for the past three months; January 2018 saw a recommendation rate of 67%, the highest rate since October 2015; however, both Emergency Department and Outpatient scores remain the lowest of the London providers. Healthwatch in Haringey and Enfield have provided the Trust support to better understand patient experience in order to inform improvement actions. Healthwatch Enfield have recently conducted a qualitative and quantitative review of attendance patterns and trends to look at patient journey s as expressed by individuals using urgent and emergency care services at North Middlesex University Hospital. The evidence gathered provides an insight into how local residents negotiate primary care and health services on offer to them and identifies a mismatch between what is currently available and the expectations of local people. Elective Services The outpatients department was subject to a commissioner Insight and Learning visit in 2017 which, together with the Trust s own departmental review, generated recommendations that are being actioned to improve patient experience. At 89%, inpatient data for January 2018 indicates a slightly lower recommendation rate than the previous quarter. North Middlesex University Hospital is ranked 17 out of the 26 London providers, with a 5% differential in recommendation rate. There is wide variation in inpatient response rates across the Trust but less variation in the recommendation rate which with one exception lies within %. In recent weeks there has been a small move towards more positive patient feedback being received via other routes for example NHS Choices. Maternity Services The recently published Care Quality Commission Maternity survey for 2017 indicates that there has been an improvement in women s experience of Maternity Care, compared to the 2015 findings, with incremental improvement in the majority of questions. North Middlesex University Hospital implemented a comprehensive improvement plan following the 2016 Care Quality Commission report which awarded Maternity Services a rating of Requires Improvement for Caring and Inadequate for Well Led. The Trust is making good progress with the implementing the improvement plan actions and has identified additional actions to address the less positive aspects of care identified in the 2017 Care Quality Commission survey. Complaints 18 47

48 There has been a continued reduction in the number of complaints received by the Trust. Complaints relating to staff attitude have decreased in Emergency Services, Surgery and the Cancer Unit, but remain a theme in Maternity Unity complaints. Complaint response times are recovering from a poor performance early in quarter three. A newly appointed complaints manager has led a review of the complaints management process to identify the most effective mechanisms for responding to complaints. Daily reviews of complaints cases has provided greater scrutiny of delays and enabled more timely escalation to ensure deadlines can be met. Themes and learning from complaints are discussed at Divisional Governance Meetings. The Divisions and Complaints and Patient Advice and Liaison Service teams meet weekly to target actions and support changes in practice or service delivery. 2. Contracts 2.1 Background Contract performance in 2017/18 is based on signed two year contracts for 2017/18 and 2018/19. The details are described below: Contracts were agreed with Marginal Rates of 50% for Royal Free London, North Middlesex University Hospital and Whittington Health and 75% for University College London Hospital for 2017/18. Marginal rates will apply both above and below agreed financial thresholds. This Marginal Rate agreement helps to mitigate the risk of over performance to commissioners, and offers protection to Providers if activity falls below plan; As part of the overall contract settlement, there was also an agreement to reduce the transactional burden of the claims and challenges process for both commissioners and providers in order to free up capacity for more transformational projects and support delivery of the STP. Providers and commissioners have agreed a common process across NCL for this; Ambitious Sustainability and Transformation Plan (STP) activity reductions have been included in acute provider contracts, which equate to 36m across all providers for NCL Commissioners; The individual contract plans have been re-costed to reflect the new nationally required HRG4+ level detail (Healthcare Resource Group: the currency in which activity is measured and paid for); Growth of 3% has been agreed in all contracts, with the offsetting STP reductions at a similar level. The key risk is that STP reductions are largely phased to quarters three and four of 2017/18. The financial forecast projections reported by CCGs assume STP delivery, if these schemes do not deliver the position of the CCGs will deteriorate. As part of the 2017/19 NHS Standard Contract, CCGs and those providers using the 50% marginal rate Royal Free London, North Middlesex University Hospital and Whittington Health all committed to reducing the volume of claims and challenges and associated management infrastructure servicing these. This approach recognised that risk would be managed in a different way. The principle of the agreement was that we will put it right together rather than we will follow a rigid adversarial process. Following dialogue between commissioners and providers the revised claims and challenges process was signed off on 21 July 2017 by the NCL Contract Delivery Group and STP finance group with providers with the exception of University College London Hospital whose contract states they are subject to full contractual challenges. The revised Claims Process at the Royal Free London is not reducing the transactional discussions because of the large number of data capture changes that the Trust has 19 48

49 made and data issues compared to last year. Each month the review of the Royal Free London data reveals more changes that indicate a cost implication for CCGs. All challenges are being discussed as part of the escalation process. A summary of claims raised to date for NCL CCGs for all trusts is presented in the table below. Of the 72.1m raised to date, 15.9m has been accepted (22%) by Trusts. Claims by CCG Figure 13 The table below indicates the level of claims submitted at each of the four main acute trusts (from April 2017 to January 2018) with the level of claims currently accepted. Claims and Challenges by Trust Figure Quarter One Reconciliation Process Quarter one reconciliation positions have been agreed with all providers. The principles for Royal Free London have been agreed and final discussions are taking place on the remaining issue, the inclusion of Best Practice Tariff in the Marginal Rate calculation. The value of this is 0.5m. 2.4 Quarter Two Reconciliation Process NEL Commissioning Support Unit, on behalf of commissioners, have shared quarter two reconciliation templates with NCL Providers, with the exception of Royal Free London Hospital and will agree these with Providers in March There has been a delay in agreeing these positions because of the ongoing contract discussions for 2018/ Main Risks and Mitigations The Committee is asked to note the main risks on acute contracts, and the mitigating actions being taken to address those risks: Risks The increasing dependence on delivery of STP interventions in the last quarter of 2017/18 to prevent further over performance on contracts; The cost pressure to CCGs accruing from the introduction of the new tariff, with costs being 7m over the funding adjustment received from NHSE by the five CCGs; 49

50 Potential for Elective activity growth following a pause in planned care activity at all providers to provide support for winter pressures on emergency pathways in January and March Actions The application of the marginal rates are in place to mitigate over performance. The current benefit is 12.7m. Contract negotiations are underway with all providers to agree contract values for 2018/19. An update on negotiations for 2018/19 is provided in the planning paper; Coding and counting deep dive initiated at Royal Free London, which is contributing to wider discussions regarding the closedown of the quarter one and two positions; Contract challenges issued in line with national guidance. A summary of financial performance by Trust by Point of Delivery and Trust by CCG follows. The appendix contains more detailed information and can be made available on request. 3 Financial Performance 3.1 Performance Against Contract Baselines The Committee is asked to note the following when considering the CCG finance and activity position for acute contracts as at month eleven: Data provided by providers was of sufficient quality to enable reporting of financial performance; NCL CCGs have reported overall year-to-date acute over performance of 24.3m and a forecast outturn over performance of 33.6m (see table overleaf); For the four main acute providers, NCL CCGs have reported year-to-date over performance of 23m and forecast outturn over performance of 26m (see table overleaf); The forecast for the year-end takes into account individual CCG adjustments for the impact of STP interventions in the last month of the year and the impact of marginal rates, with the impact of the latter being a 12.7m reduction in forecast outturn; Forecast Outturn has increased by 2.9m for the four main providers, 2m of this at University College London Hospital, the remaining 0.9m split between Royal Free and Whittington Health. Non-Elective spend increased this month across the four main providers, however this was broadly offset by reductions in Elective spend. Royal Free saw a material increase in emergency care that was not offset, this being the primary reason for Barnet s material movement in the main providers from last month; Quarter two reconciliations for the four main providers are expected to be concluded before the end of March. The financial implications have been included in month eleven reporting and are broadly in line with what was achieved in the quarter one process. The tables below report contract performance by CCG and by Provider. Figure

51 For information, Other Acute contains: Non Contract Activity; Service Level Agreement exclusions; Out of sector contracts including Bart s Health and Imperial College Healthcare; General Reserve at Haringey. Other Acute at month eleven in the Out of Sector contracts reduced or had small increases across all contracts, except for London North West and Homerton where increases in Non- Elective and Critical Care were higher than expected. Camden CCG have added additional spend for Individual Funding Requests approved for IVF ( 1.5m) and reflected higher cost for Readmission Avoidance schemes at the Royal Free ( 0.5m). 3.2 Financial Mitigations The Committee is further asked to note CCGs have included the following mitigations in their year-end forecasts for acute contracts, and they are summarised in the table below. Figure 16 Critical Care forecast outturn variance STP In-Contract Interventions Marginal Rate application All CCGs Adjusted for long stay patients Applied using CCG monitoring submissions Applied NEL Commissioning Support Unit estimate The adjustments for Critical Care and STP interventions have been applied to the forecast outturn only. Marginal rates have been applied to both year-to-date and forecast outturn positions. The rationale for these adjustments for each CCG is described in more detail below

52 3.3 STP interventions The planned impact of STP activity reductions in 2017/18 reduces acute contract baselines by 36m across all NCL providers. STP Interventions are heavily weighted to delivery later in 2017/18 with 27m of the 36m impact phased into quarters three and four as indicated in the graph below. The phasing of STP interventions, and risks to delivery, need to be factored into the risks of over performance on acute contracts by the year-end. The table below summarises year-end delivery assumptions by each CCG against the 33.4m planned impact of STP interventions on the four main acute contract baselines in 2017/18. Figure 18 The month eleven forecast outturn includes an assumption of 11.8m slippage against the targeted delivery of STP interventions. The forecast achievement against plan (65%) has increased 2% from last month s 63% achievement. Barnet has maintained forecast achievement at last month s levels. Camden, Enfield and Islington have increase QIPP achievement by 3%, 2% and 4% retrospectively since last month s reported levels of QIPP achievement. 3.4 Application of Marginal Rates The tables below summarises the application of marginal rates by CCG at month eleven. An additional table is provided to show the marginal rate for each CCG by provider. Figure 19 Figure 19.i 23 52

53 The forecast outturn of 33.6m over performance across acute contracts for the five CCGs is after the application of marginal rates allowed for in contracts. At month eleven marginal rates are forecast to yield an estimated 12.7m benefit to the CCGs in 2017/18. The underlying year-end over performance in acute providers on a full Payment by Results tariff would therefore be 46.2m at month eleven. 3.5 Financial Run Rates Run-rates provide a high-level view of expenditure on acute contracts. In line with the phasing of STP interventions above, the run-rate of expenditure on acute contracts was expected to reduce the run-rate in the second half of the year. This has not materialised at the levels expected as the STP intervention achievement is 65% of plan. SLAM reductions between month ten and eleven shows a reducing run-rate on two of the four main providers over 16/17 levels (figure 20). Figure

54 The run-rate analysis for month eleven shows an increase at University College London Hospital 11% and Royal Free 2%, with decreases at the North Middlesex University Hospital 9%, and Whittington Health 9%. A projected run-rate for the future months has been estimated, as requested by the Committee in October 2017, and is shown as dotted lines on the graph above. Projected run-rates are consistent with the month eleven reported forecast outturn on each contract. Run rates at month twelve are expected to follow month eleven trend with Whittington Health and North Middlesex University Hospital projected to reduce to yearend while Royal Free and University College London Hospital are projected to increase to year-end. The financial run-rate movement month on month will continue to be reviewed alongside performance against plan, as a useful indicator of underlying contract performance. This will inform the start point for contract baselines in 2018/ Individual Trust performance Updates This section summarises performance against plan for each Trust by CCG. A detailed report, available on request, provides a more granular analysis of Trust performance against plan Whittington Health Figure 21 Figure 22 At month eleven the year-end position is 1.1m over performance against plan for NCL CCGs. This is an adverse movement of 0.3m from the month ten position, which is largely driven by Critical Care. Further movement is driven by changes to the Annual Plan which varies the actual impact of Identification Rules (which CCG is charged) movement

55 Enfield CCG is under performing against plan, whilst all other CCGs are over performing. The forecast outturn position includes adjustments for accelerated delivery of the STP; which will come into effect in the later part of the year. The table below shows the split between acute and community reporting for the Trust with community activity forming part of a block contract. Figure 23 Key points of delivery causing this variance are: Accident and Emergency The forecast over performance within Accident and Emergency at month eleven is 1.0m. The year-to-date over performance of 0.9m is driven by increases in activity and also in part by a coding change notified in 2016/17 by the Trust. A 0.2m reduction to account for this coding change has been agreed across NCL CCGs as part of the quarter one reconciliation and has been adjusted for in this position. Non-Elective (Unplanned Care) The forecast over performance within Non-Elective at month eleven is 1.4m. The yearto-date over performance of 1m is driven by over performance seen in Accident and Emergency ( 1m), Geriatric Medicine ( 1m) and General Medicine ( 0.7m). This is partially offset by large under performance in Gastroenterology ( 1.3m). Outpatients The forecast over performance within Outpatients at month eleven is 1m. Year-to-date over performance was seen across a number of specialties, but in particular Trauma and Orthopaedics, where there is a large STP impact phased for achievement in quarter four. Critical Care The forecast under performance within Critical Care at month eleven is 2.4m. Critical Care is under performing across all CCGs, with a year-to-date under performance of 2.2m. However in the main, this is driven by under performance against plan for Haringey CCG. This under performance is offset by over performance in Critical Care on the University College London Hospital contract for Haringey CCG. Maternity The forecast under performance within Maternity at month eleven is 1.5m. Under performance is seen in both births and Maternity pathways with a year-to-date under performance of 1.4m Royal Free London Figure

56 Figure 25 The position reported at month eleven for Royal Free London shows a 13.5m forecast over performance against the contract plan for NCL CCGs at the year-end. Overall, there has been an unfavourable movement in forecast outturn of 0.57m from month ten to month eleven. Key points of delivery causing this variance are: Non-Elective (Unplanned Care) The forecast over performance within Non-Elective is 5.3m. Camden CCG ( 3.4m) and Barnet CCG ( 2.9m) are over performing against plan with under performance in Islington (- 0.5m), Haringey (- 0.4m) and Enfield (- 0.1m). Over performance by specialty accrues from: General Medicine 8.7m; Accident and Emergency 3.4m. Non-Elective admissions have shown a significant shift in forecast outturn from month ten to month eleven of 0.96m. This follows a 2.8m worsening of the position in the preceding two periods meaning that 3.8m cost pressure has materialised in the past three months. The current month movement is predominantly in Barnet. The main shifts in forecast outturn are for Non Elective inpatients. Non-Elective same day and short stay are not the principal drivers of the cost increase. Forecasted Non-Elective activity has fallen by 1% in month whilst the financial forecast outturn has increased indicating a more complex casemix being observed. This has been queried with the Trust. At specialty level the most significant movements are observed in: Figure

57 The NCL conversion ratio from Accident and Emergency to Non-elective for month ten is 14.45%. This is a reversal of a previous upward trend and is a return to the preceding 2017/18 average - but the conversion ratio remains higher than in the same period in 2016/17. Figure 27 Another significant portion of the in-month movement ( 0.14m) is on new specific activity for Sepsis with the biggest shifts seen in complex cases with high levels of complications and comorbidities (highlighted below): Figure 28 Outpatients The forecast over performance within Outpatients is 5.1m. This is within the specialties listed below: Trauma and Orthopaedics 1.4m; Cardiology 1.2m; Urology 0.77m; Ophthalmology 0.64m. The over performance in Trauma and Orthopaedics which is predominantly impacting Barnet CCG ( 1.1m above plan) and is evident in First ( 0.68m) and Follow Up ( 0.29m) Outpatient attendances with a single professional review. Within Cardiology the Trust has advised that they undercharged activity in 2016/17 and is now being coded in line with guidance. Agreement has been reached on the value of all counting and coding changes to be applied for quarter one and this has been adjusted within the Other category. The Ophthalmology over performance is at Enfield CCG ( 0.79m) where there is a negative plan due to the value of the service transfer. The application of STP at point of delivery level has resulted in some specialties and HRGs (specific activity) reporting 28 57

58 against negative plans. However, the overall point of delivery position accurately reflects the planned impact of STP. Accident and Emergency (A&E) The forecast over performance within Accident and Emergency is 1.9m. At specific activity level, this can be attributed to: Emergency Medicine, Category 1 Investigation with Category 1-2 treatment 1.9m; Emergency Medicine, Category 2 Investigation with Category 1 Treatment 0.16m. Analysis has shown a shift to more complex activity, with the resulting increase in costs which has been challenged as a counting and coding change. There has been a 0.51m worsening of the position for Accident & Emergency which is caused by the erroneous omission of the previously made adjustment (- 0.66m) for Urgent Care Centre activity. Patient Transport Services (PTS) As part of the quarter one settlement agreement NCL CCGs have agreed to make a 1.0m contribution to support Patient Transport Services (PTS) above the block element agreed in the contract plan. Diagnostic Imaging The forecast over performance within Diagnostic Imaging is 0.96m. The performance is driven by high levels of activity in GP Direct Access tests to a value of 1.6m. The activity variance is driven by a small number of Direct Access high volume/low cost activities. NEL CSU challenged this as a counting and coding change. Agreement has been reached on the value of all counting and coding changes to be applied for quarter one and this has been adjusted within the Other category. Regular Attenders The forecast over performance within Regular Attenders is 0.64m. There was a step change in Medical Oncology activity in December Royal Free London have responded that they undercharged activity in 2016/17; this has now been updated and is being coded correctly Electives (Planned Care) The forecast under performance within Electives is - 1.6m. Enfield CCG is 1.4m over plan with offsetting under performance in the Barnet CCG (- 2.4m), Camden CCG (- 0.2m) Haringey CCG (- 0.2m) and Islington CCG (-0.2m). Over all underperformance at specialty level accrues from: General Surgery (-0.76m); Colorectal Surgery (- 0.58m); Hepatobiliary & Pancreatic Surgery (- 0.43m); Urology (- 0.42m). Enfield CCG over performance ( 1.4m) by specialty accrues from: Trauma and Orthopaedics 1.0m; Ophthalmology 0.33m. Trauma and Orthopaedics over performance impacting Enfield CCG is within inpatient admissions ( 1.0m) and is driven by specific activity covering major hip or knee procedures. Over performance for Enfield CCG in Ophthalmology flows from the service transfer by the CCG. Enfield CCG have amended their plan for Ophthalmology and it is now 29 58

59 reporting against a zero plan. However there is still some residual activity reported within this specialty which is driving over performance. Maternity The forecast under performance within Maternity is m. Under performance is mainly within deliveries (- 1.0m). Other The forecast under performance within Other is m. Under performance in this category is driven by CCG requested adjustments and settlement of issues arising from the quarter one reconciliation: 3.0m variance on productivity metrics due to agreement that 50% of the contract level will be included in 2017/18 with the metrics for 2018/19 to be negotiated within the activity plans; Agreement has been reached on the value of Claims and Challenges to be applied for quarter one and this has been adjusted within the Other category (and therefore not applied to the activity at point of delivery or specialty level). Agreement on the treatment of these changes for the rest of the year is ongoing and is being reviewed to establish the validity of the claim or coding. CCGs have included adjustments in anticipation of claims being resolved in their favour; CCGs are benefitting by - 7.1m on adjustments made for the marginal rate activity above or below the planned level University College London Hospital Figure 29 Figure The forecast over performance at University College London Hospital at month eleven is 5m. The forecast outturn for month eleven deteriorated by 2.1m compared to month ten. The movement is a result of an adverse movement in Maternity casemix ( 0.5m); Critical Care work in progress ( 0.4m); and a reduction in the level of benefit from the 59

60 NCL marginal rate ( 0.6m); an additional 0.5m deterioration is spread across a number of Points of Delivery. The movements in the position are detailed below: Maternity As part of the quarter two reconciliation of the contract University College London Hospital notified the CSU that they had under reported the complexity of their Maternity case mix and therefore understated the financial value of the activity. The Trust has made a correction to their month ten activity and this has driven a ( 0.5m) increase in the financial forecast. This change has been accepted as part of the quarter two reconciliation of the contract. Critical Care The forecast over performance within Critical Care is 0.32m. The movement in the Critical Care forecast is a result of an increase in the number of patients currently within Critical Care that are yet to be discharged and billed. This is described as the work in progress. In month ten the Camden CCG work in progress value increased significantly, resulting in a 0.3m increase in the Critical Care forecast. The remaining movement was contained within the Haringey CCG position due to long stay Critical Care patient activity. Marginal Rate Impact The level of marginal rate impact on the NCL CCG position reduced by 0.5m between months ten and eleven. Marginal rate exclusions applied in the quarter two contract reconciliation have resulted in one additional service exclusion being applied. The additional exclusion is to exclude Evergreen Ward activity. As the University College London Hospital marginal rate gets measured against 2016/17 outturn and the Evergreen Ward service was not established in 2016/17 it cannot be included in the calculation. The areas causing the forecast variance to the plan are: Non-Elective (Unplanned Care) The forecast over performance within Non-Elective is 5.0m. For NCL the year-to-date position is seeing significant over performance in Non-Elective emergency admissions to the value of 4.2m. The casemix reported by University College London Hospital in month ten data was consistent when compared to previous months. The overall unit cost of a Non-Elective admission is in line with the planned unit cost for 2017/18. The areas causing variance to the plan are: Activity growth: Overall, for the first ten months of 2017/18, Non-Elective activity is 6% higher than in the same period in 2016/17 (around 120 admissions per month). This is having an impact on all specialties and is reflective of an underlying growth in emergency activity at University College London Hospital over the past 12 months. The provider are also reporting a similar position in their Trust wide board reports; Non-delivery of STP: The current forecasted position for STP at University College London Hospital is 56%, which translates to an under delivery of 1.3m against planned impact of around 2.5m; Accident and Emergency Casemix: The overall volume of accident and emergency attendances at University College London Hospital has been lower year to date in 2017/18 compared to the previous year, whist the clinical acuity of those presenting has increased. This results in more patients needing admission to an emergency bed at the Trust; Critical Care The forecast outturn for critical care in NCL is 5% above the annual plan, following significant over performance in earlier months resulting from spikes in activity and long 31 60

61 stay patients. The forecast also includes the impact of work in progress on the in-year financial position, which also deteriorated in month eleven North Middlesex University Hospital Figure 31 Figure 32 The North Middlesex University Hospital position at month eleven is a 6.4m over performance against the contract plan for NCL CCGs. Enfield CCG accounts for 5.7m of the 6.4m total over performance; the over performance is in all activity areas but is mostly in A&E attendances, Non Elective admissions and Outpatients, particularly Follow Up Outpatients. The areas causing variance to the plan are: Non-Elective (Unplanned Care) The forecast over performance within Non-Elective at month eleven is 6m. The combined year-to-date Non-Elective position is over performing by 5.4m. This is made up of Non-Elective 6m, Non-Elective Non-Emergency 1.1m and Non-Elective Same Day by 0.7m. This is offset by underspend in Non-Elective Short Stay 1.3m and Non- Elective Excess Bed Days 1.2m. Non-Elective 6m: Geriatric Medicine is over spent at 1.8m mainly due to the national coding change relating to Sepsis, which is causing a forecast of 0.5m of the reported variance to plan. Non-Elective Non-Emergency forecast over performance of 1.1m. This is mainly due to an over performance of General Medicine at 0.4m, over performance in Neonatology at 0.2m, and Cardiology at 0.2. Non-Elective Same Day over performance of 0.7m. This is mainly due to Accident and Emergency at 500k and General Surgery at 97k

62 This is offset by underspend in Non-Elective Short Stay of ( 1.3m) which is driven by an under performance in General Medicine by ( 542K) and General Surgery by ( 464k) Non-Elective Excess Bed Days is showing under performance of ( 1.2m). This is mainly due to under performance in General Medicine by ( 287k), Gastroenterology by ( 227k) and Geriatric Medicine by ( 207k). Outpatients The forecast over performance within Outpatients at month eleven is 5m. The combined CCG year-to-date Outpatients position is over performing by 4.7m. This is made up of a forecast over performance to plan of 1.8m within Outpatient Follow-ups. The over performance is in a range of specialities; Ophthalmology, Cardiology, Medical Ophthalmology and Respiratory Medicine, Hepatology and is primarily due to the failure of the STP interventions to deliver reductions in all specialities. The forecast over performance within Outpatient Procedure for all CCGs is 1.5m. This is mainly driven by Urology, Medical Ophthalmology and Gynaecology. The forecast over performance within Outpatient First appointments for all CCGs is 1.1m. This is mainly driven by Anaesthetics, Ophthalmology, Gynaecology and Trauma & Orthopaedics. Anaesthetics is being queried with the Trust as a pathway change relating to pain patient referrals. All of these areas have STP schemes which should be delivering a reduction in referrals. Accident and Emergency The forecast over performance within Accident and Emergency at month eleven is 1m. The year-to-date over performance within the Accident and Emergency department is 0.9m. Accident and Emergency has a forecast overspend, but is offset by underspend in the Urgent Care Centre. NEL CSU has been successful in challenging an Accident and Emergency change in coding. As part of the quarter one reconciliation process 67% of overspend across two areas of over performance has been credited. Keeping in line with the agreement, a similar adjustment has been made to the forecast position. Drugs and Devices The forecast over performance within Drugs and Devices at month eleven is 0.5m. The overspend is mainly in Ophthalmology which is subject to a query related to Enfield CCG Any Qualified Provider pathway of care transfer. Other The forecast under performance within Other at month eleven is ( 2.6m). The unmitigated position submitted by North Middlesex University Hospital Provider Submitted is an over spend at 1.1m, mainly due to Ambulatory Care Unit forecast overspend of 1.9m. This overspend is offset by adjustments of 1m giving a net yearto-date position of ( 1.9m) underspend. The CCG made adjustments to take into account the quarter one reconciliation, STP achievement and Marginal Rate. Maternity The forecast under performance within Maternity at month eleven is ( 2.5m). The Maternity Unit is under performing year-to-date by 2.3m. This is driven by a forecast underspend within Obstetrics of 1.8m and Midwife Episodes of 0.5m. 33 Diagnostic Imaging The forecast under performance within Diagnostic Imaging at month eleven is ( 0.7m). The Diagnostic Imaging is under performing year-to-date by ( 0.6m). This is driven by a forecast underspend within Direct Access of ( 417k) and Pathology of ( 396k). 62

63 3.7 Individual Commentary from CCGs Barnet CCG The total budget expenditure on Acute Contracts is 271.1m, which is net of 10.9m QIPP ( 7m is in acute contracts) gross of any re-investment. At month eleven the forecast outturn is 281.9m, which is an over performance against plan of 10.7m. The forecast outturn has increased by 1.0m since month ten predominately due to the inclusion of a long stay patient in critical care at Royal Free London, which had not been included properly in the Trust Work In Progress reports ( 0.8m). The forecast outturn includes expected QIPP slippage and impact of marginal rate. Royal Free London* The largest contract is Royal Free London ( 181.9m). Excluding the critical care patient previously noted, at month eleven (excluding QIPP) the underlying position has slightly deteriorated compared to month ten at around 4.0m over performance. This is after amending for Barnet CCG s share of the adjustments described above in the Royal Free London section of this report. There are some variance by Point of Delivery with over performance in Accident and Emergency, Non-Elective, Outpatients and those items such as claims and challenges include in other ; partially offset by under performance in elective. Other in sector University College London Hospital forecast outturn is broadly on plan. The forecast outturn for other acute trusts in sector is an over performance of 0.7m ( 0.9m net of QIPP slippage and marginal rate). *Note this analysis includes local QIPP which has not been accounted for in the summary tables earlier in this report. Other acute spend Forecast outturn for Out of Sector Acute Trusts is an over performance of 2.2m, spread across a number of organisations with relatively small over performance against each Camden CCG As at month eleven the Acute Contracting reports an over performance of 4.7m year-todate and forecast outturn of 6.5m. The forecast outturn variance comprises Acute Contracts 4.5m, NCA s 1.8m and London Ambulance Service 0.3m. Acute contracts show an adverse cumulative movement against the month ten position of 0.3m and an adverse forecast outturn movement of 1.9m. The main areas of forecast over performance continue to be the Royal Free London 1.5m, University College London Hospital 1.8m and Imperial College 0.9m. Forecast is post the application of STP QIPP and marginal rate adjustments. University College London Hospital At month eleven University College London Hospital is forecast to over perform by 1.8m, an increase of 1.1m against the prior months forecast position. This is mainly driven by forecast over performance in Non-Elective ( 2.6m) and an increase in the Marginal Rate ( 0.6m), offset by forecast underspends in Electives ( 0.8m), Accident and Emergency ( 0.1m), and Other ( 0.5m). 34 Royal Free London At month eleven the Royal Free London is forecast to over perform by 1.5m for the full year, a 0.1m increase against prior month forecast. Forecast over performance is driven by Non-Elective ( 3.4m), Accident and Emergency ( 0.7m), Outpatients ( 0.5m) and Diagnostic Imaging ( 1.7m) activities, which have been offset by forecast underspends in 63

64 Critical Care ( 0.3m), Maternity ( 0.5m) and Other, including accepted challenges to activity ( 4.1m). Imperial At month eleven Imperial College s over performance is 0.9m, a 0.1m increase against prior month forecast. The forecast is mainly driven by over performance within Non- Electives ( 1m) and Critical Care ( 0.2m), which are primarily offset by forecast under performances within Maternity ( 0.2m) and Drugs & Devices ( 0.2m) Enfield CCG At month eleven there is a forecast overspend against plan of 9.1m. However, this is based on a number of adjustments and contains further risks. North Middlesex University Hospital The contract with North Middlesex University Hospital is over performing year-to-date by 5.7m and forecast to overspend by 5.8m at year-end. The key over performing Points of Delivery are forecast to be Non-Elective (6.1m), Outpatients ( 3.3m) and Accident and Emergency ( 1.0m). This is partially offset by a forecast underspend in Maternity ( 0.8m). Included in the position are adjustments for; STP achievement at 75%, and the impact of the marginal rate at 50%. The position also reflects the forecast adjustment based on the quarter one reconciliation. Royal Free London The contract with Royal Free London is overspent by 3.8m year-to-date and forecast to overspend by 4.4m at year-end. The key over performing Points of Delivery are forecast to be Elective ( 1.6m), Outpatients ( 1.8m) and Maternity ( 0.5m). Included in the position are adjustments for; STP achievement at 75%, and the impact of the marginal rate at 50%. No other challenges are included in the position. University College London Hospitals The contract with University College London Hospital is underspent by 0.8m year to date and forecast to underspend by 0.8m at year-end. The key under-performing Points of Delivery are forecast to be Elective (0.4m) and Non-Elective Non-Emergency ( 0.2m). This is partially offset by a forecast overspend in Non-Elective ( 0.1m). Included in the position are adjustments for; STP achievement at 75%, and the impact of the marginal rate at 25%. No other challenges are included in the position Haringey CCG At month eleven the forecast outturn on acute contracts is 227.0m* which is an overspend against plan of 3.6m*. This is based on acute activity adjusted for STP delivery in the last month of the year and the impact of the marginal rate for the local acute providers. There is an element of risk associated with these adjustments. The position currently forecasts QIPP slippage of around 2.7m, largely relating to STP Planned Care. The overspends within the local acute contracts accrue from North Middlesex University Hospital ( 0.6m) Whittington Health ( 0.4m) University College London Hospital ( 1.1m) and Royal Free London ( 0.5m). The out of sector providers are also reporting overspends of 1.4m with Homerton ( 0.5m), Guys ( 0.3m), Imperial ( 0.3m) and Royal Brompton ( 0.2m). The out of sector contracts do not benefit from marginal rate protection. North Middlesex University Hospital 35 64

65 At month eleven the contract is reporting an overspend of 0.6m for both the year-to-date and the forecast outturn to year-end. Over-performance is being reported in Outpatients, Accident and Emergency and Non-Elective activity. This is offset by underspends in Elective, Maternity, Diagnostic Imaging, and Critical Care. Included in the position are adjustments for STP achievement, non-recurring Orthopaedic Trauma activity and the impact of the marginal rate at 50%. Whittington Health The contract is reporting an overspend of 0.5m year-to-date and forecast to overspend by 0.4m at year-end. Over performance is being reported in Accident and Emergency, Drugs and Devices, Non-Elective and Outpatient activity. This is offset by underspends in Critical Care, Diagnostic Imaging and Maternity. Included in the position are adjustments for STP achievement and the impact of the marginal rate at 50%. Other in sector The University College London Hospital forecast outturn over performance of 1.1m is being reported in Critical Care, Drugs and Devices, Maternity, Non-Elective and Outpatients. Royal Free London over performance of 0.5m is being reported in Patient Transport and Critical Care activity. *Note: asterisked figures for Haringey CCG do not cover all acute spend, for example, exclude winter pressures, ambulance and private providers and so will not align with figures shown in Figure Islington CCG At month eleven, the overall acute position is reporting a pressure of 4m for forecast outturn that represents the largest financial risk to the CCG. This is an adverse movement of 0.5m from the prior month and is principally attributed to increased levels of activity in Maternity and Non-Electives at University College London Hospital. The inmonth movement between the remaining contracts have been fairly static. The in-sector contracts contributes to 2.4m of the overall forecast outturn position with the main pressure continuing to accrue at University College London Hospital ( 3.0m). In addition to this, Whittington Health is over performing by 0.3m however these contracts are offset by an under-spend at Royal Free London ( 0.9m). Out of sector contracts, which do not benefit from marginal rate protection, currently contributes 1.5m to the overall adverse forecast outturn. The main pressures are reported in Barts ( 0.9m), Homerton ( 0.4m), and Guys & St Thomas ( 0.5m) which have been partially offset by an underspend in Chelsea & Westminster ( 0.2m). University College London Hospital Year-to-date reported a 2.4m over performance (Non-Elective, Outpatients, Critical Care and Drugs and Devices). Forecast outturn reported a 3.0m over performance (Non- Elective, Outpatients, Critical Care, Drugs and Devices, Elective and offset by Maternity, Diagnostic Imaging, and Accident and Emergency). This position includes QIPP and the impact of marginal rate. The majority of the pressure continues to be reflected in Non- Elective 2.2m forecast outturn, specifically within the specialities of Accident and Emergency, Clinical Pharmacology, Geriatric Medicine, Gastroenterology, and Neurology. The year-to-date position has seen a pressure in Critical Care due to a long stay patient discharged however these costs have been adjusted for the in forecast outturn to mitigate a potential upward trend. The forecast outturn also includes additional seasonality activity within Elective admissions and Outpatient appointments

66 Whittington Health The forecast outturn position has been reported as 0.3m overspent, which includes an adjustment for QIPP and the impact of marginal rate. The forecast over performance on this contract is reported within Non-Elective ( 0.4m), Outpatients ( 0.4m) and Accident and Emergency ( 0.2m) and is offset by underspends in Maternity ( 0.7m). Accident and Emergency pressure at Whittington Health is driven in the main by Emergency Medicine Category 1 Investigation with Category 1-2 Treatment and Emergency Medicine, Category 2 Investigation with Category 2 Treatment. 4 Activity Performance This section summarises the activity performance of the four main providers at an NCL level. The main focus being a comparison of activity level between the two financial years 2016 and The appendix to this report shows further, more detailed information, and can be made available on request. Accident and Emergency In NCL we have seen an increase in Accident and Emergency activity since The increases are at Whittington Health which is currently up by 5.10% compared to this time last year, North Middlesex University Hospital up by 3.29% and Royal Free London up 1.29%. University College London Hospital are 0.05% below their previous year s activity. Figure 33 Figure 34 A&E Activity Actuals : 2016/17 vs 2017/18 Daycases In NCL there has been a decrease in daycase activity since for the Royal Free London, North Middlesex University Hospital and Whittington Health hospitals

67 Royal Free activity is below 16/17 actuals by 22.50%. This drop has been caused by reduced activity in: Colorectal Surgery reduction in Colonoscopies and Flexible Sigmoidoscopies; Ophthalmology reduction in Phacoemulsification Cataract Extraction and Lens Implant; Urology reduction in Flexible Cystoscopies. North Middlesex activity below 16/17 actuals by 1.83% This drop has been caused by reduced activity in: Colorectal Surgery reduction in Colonoscopies; Urology reduction in Flexible Cystoscopies. Whittington Health is below 16/17 actuals by 10.14%. This drop has been caused by reduced activity in: Urology reduction in Flexible Cystoscopies and minor bladder procedures; Gastroenterology reduction in Colonoscopies and Flexible Sigmoidoscopies; General Surgery - reduction in Minor Skin procedures and Intermediate Anal Procedures. University College Hospital are an outlier as daycase activity is above 16/17 actuals by 6.11%. This increase has been caused by increased activity in: Urology Introduction of Therapeutic Substance into Bladder; Gastroenterology Diagnostic Endoscopic Upper Gastrointestinal Tract Procedures with Biopsy; Pain management Continuous Infusion of Therapeutic Substance for Pain Management; Clinical Haematology - Single Plasma Exchange, Leucophoresis or Red Cell Exchange. It is anticipated that these reductions are as a direct result of successful QIPP schemes. It is also anticipated that the cancellation of non-urgent planned care to support winter pressures will also reduce the number of referrals into diagnostic settings. Figure 35 Figure

68 Daycase Activity Actuals : 2016/17 vs 2017/18 Electives In NCL there has been a decrease in Elective activity since for The Royal Free London and University College London Hospital. Royal Free London activity is below 16/17 actuals by 6.30% This drop has been caused by reduced activity in: General Surgery - reduction in Laparoscopic Cholecystectomy and Intermediate Anal Procedures. University College London Hospital are below 16/17 actuals by 10.39%. This drop has been caused by reduced activity in: Urology - reduction in Major Robotic, Prostate or Bladder Neck Procedures; Gynaecological Oncology reduction in Complex, Open or Laparoscopic, Upper or Lower Genital Tract Procedures for Malignancy. Whittington Health s Elective activity is above 16/17 actuals by 3.33%. This increase has been caused by the transfer of Bariatric Surgery from NHSE to CCGs. General Surgery not recorded as CCG activity in 16/17, activity for Restrictive Stomach Procedures for Obesity. North Middlesex University Hospital activity is above 16/17 actuals by 0.82%. This has been caused by small movements in Clinical Oncology and Stroke Medicine. Figure 37 It is anticipated that the cancellation of non-urgent planned care activity to support winter pressures will also continue to reduce the number of referrals into planned care settings. Figure

69 Elective Activity Actuals : 2016/17 vs 2017/18 Non-Elective admissions In NCL, we have seen an increase in Non-Elective activity since for all our Acute providers: Royal Free London activity is above 16/17 actuals by 5.99%; North Middlesex University Hospital activity is above 16/17 actuals by 2.68%; University College London Hospital are above 16/17 actuals by 6.21 %; Whittington Health activity is above 16/17 actuals by 1.87%. Figure 39 Figure 40 Non Elective Activity Actuals : 2016/17 vs 2017/

70 Outpatient First Attendances In NCL we have seen a slight decrease in Outpatient First Appointments activity since Royal Free activity is below 16/17 actuals 2.46%. This has been as a result of activity within Maxillo Facial that is now recorded by NHSE; Whittington Health activity is below 16/17 actuals by 2.33%. This is due to a reduction in appointments in Dermatology and General Surgery; University College London Hospital are below 16/17 actuals by 1.61%. This has been as a result of activity within Maxillo Facial that is now recorded by NHSE. North Middlesex University Hospital are an outlier as Outpatient First Appointment activity is above 16/17 actuals by 7.42%. This increase has been caused by increased activity in Trauma and Orthopaedics, Gynaecology, Cardiology and Anaesthetics. Figure 41 Figure 42 Outpatients First Activity Actuals : 2016/17 vs 2017/18 Outpatient Follow Up In NCL we have seen a slight increase in Outpatient Follow Up Appointments activity since This is largely being driven by: The Royal Free with a 7.91% increase - this is due to an increase in Anticoagulant Service, Dermatology and Nephrology; North Middlesex with a 7.95% Increase - this is due to an increase in Cardiology; Medical Ophthalmology, Respiratory Medicine, Urology and Ophthalmology. Whittington Health and University College London Hospital have seen a slight decrease in activity against : University College London Hospital are below 16/17 actuals by 6.25% - this is due to a decrease in Anticoagulant Service, Maxillo-Facial Surgery, Respiratory Medicine and ENT; 41 70

71 Whittington Health activity is also below at 4.68% - this is due to a decrease in Anticoagulant Service, General Surgery and Paediatrics. Figure 43 Figure 44 Outpatients Follow Ups Activity Actuals : 2016/17 vs 2017/18 Report Development The acute commissioning report provided to the NCL Joint Commissioning Committee has been updated with changes following feedback received from previous reports. The intention is that this report is also used by CCGs to inform their respective Governing Bodies and supporting Committees of acute contract performance. The Committee is therefore asked to make recommendations for further development of the report to ensure that the Joint Commissioning Committee and CCGs receive a comprehensive and rounded assessment of provider performance. Purpose (tick one only) Information Approval To note Decision Recommendation The Joint Commissioning Committee is asked to: NOTE and COMMENT ON the report; COMMENT ON the report format. Conflicts of Interest Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy

72 Strategic Direction Identified risks and risk management actions Resource implications Engagement Equality impact analysis Report history Next steps The acute commissioning report supports delivery of the following strategic objectives: Commissioning the delivery of NHS constitutional rights and pledges; Improving the quality and safety of commissioned services; Improving health outcomes, address inequalities and achieve parity of esteem; Maintaining financial stability and ensure sustainability through robust planning and commissioning of value-for- money services. The main risks to note are included in the opening risk register for the Joint Commissioning Committee and include: Performance risks to delivery of NHS Constitution Standards for Accident and Emergency and Cancer 62-days Referral to Treatment; The delivery of the STP interventions and local CCG saving plans; The agreement of remaining Royal Free issues outside the three escalated issues that have been resolved; The increasing number of Never Events at Royal Free and North Middlesex Hospitals. For CCG finances, the report focuses on the performance of contracts falling within the remit of the JCC rather than overall CCG positions. The report is presented to the NCL JCC which includes elected GP representatives, lay members, Healthwatch, Public Health and representatives from each NCL London borough. This report was written in accordance with the provisions of the Equality Act The report has been developed with reference to contract reports provided to individual CCGs in 2016/17 and 2017/18. The Acute Commissioning Report will now be used at individual CCG Committee meetings to provide an overview of contract performance. The report will be developed in response to feedback from the JCC and CCG Committees. Appendices None. The detailed acute commissioning report can be made available on request

73 NCL Joint Commissioning Committee Thursday 5 April 2018 Appendix: Report title Whittington Health Lower Urinary Tract Service (LUTS) Agenda item 3.1 Date 29 th April 2018 Lead director Report author Sponsor(s) (where applicable) Paul Sinden Director of Performance and Acute commissioning NCL Paul Sinden Director of Performance and Acute commissioning NCL Tel/ Tel/ Tel/ p.sinden@nhs.net p.sinden@nhs.net Report summary 1. Introduction This paper summarises the work undertaken with Whittington Health following the outcome of the Joint Commissioning Committee on 1 March 201 to create the conditions for the Whittington Health Lower Urinary Tract Service (LUTS) clinic to re-open to new referrals On 1 March 2018 the Committee was able to support the recommendation to re-open the clinic to new referrals to the Whittington Health Trust Board with the following caveats: Development of the Whittington Health multi-disciplinary team (MDT) supporting the clinic to include membership from specialist / tertiary services; The clinic is properly supported by a tertiary service (joint consultant post and MDT) and recommend that the service shifts to tertiary setting as links to UCLH are built through the joint consultant post, MDT, and research framework (alongside University College London); Confirmation from Whittington Health clinicians that safeguards in place to make the service safe from local governance processes and the service specification; Ensuring separate provision for children maintained. This is being delivered through GOSH service; A quality assurance process for diagnostic testing in the clinic established by Whittington Health; Protocols are in place to manage any future NHS waiting lists for the clinic. Arrangements for any private patients wishing to be referred to the NHS clinic would be consistent with the NHS Constitution requirements; Given the above, opening the clinic to new referrals would be reconsidered after a period if the assurances were not received. This would primarily relate to delivery of the succession plan and progress with tertiary support for the clinic. 73 1

74 On 28 March 2018 the Whittington Health Trust Board agreed to the phased re-opening of the LUTS clinic to new referrals and to begin the recruitment process for the joint uro-gynaecology consultant post with UCLH on the basis that: The majority of Royal College of Physicians (RCP) recommendations had now been addressed; Commissioners had agreed a service specification that was in line with the RCP recommendations; The contract for 2018/19 between the Trust and North Central London CCGs included provision to re-open the clinic to new referrals supported by the agreed service specification. The date for re-opening the clinic was not set out at the Trust Board, and would be determined by the Trust s Associate Medical Director and lead consultant from the LUTS clinic. The phased re-opening of the clinic is achieved through the service specification criteria that new referrals would be received through secondary care with treatment agreed through the multi-disciplinary team. The Joint Commissioning Committee is asked to ENDORSE the decision to a phased re-opening of the LUTS clinic to new referrals. Section 3 sets out the outcome from the Joint Commissioning Committee held on 1 March 2018 used to inform Whittington Health Trust Board. Section 4 of the paper summarises the discussion and outcome of the Whittington Health Trust Board on 28 March Background The Lower Urinary Tract Service (LUTS) clinic is provided by Whittington Health and also undertakes clinical research overseen by University College London (UCL). The Lower Urinary Tract Service (LUTS) clinic provides treatments to patients with urinary tract infections which includes prescribing antibiotics in dosages and for durations outside of drug licencing and recognised national guidelines. The clinic provides services to adults. An independent review of the LUTS service was commissioned from the Royal College of Physicians (RCP) by Whittington Health following concerns over the service after a serious incident. Aligned to this there was concern within the Trust and from many GPs locally about the prescribing regime in the clinic as some of it sits outside of clinical guidelines and /or research governance. The LUTS patient group has been actively involved in addressing the action plan in response to the RCP recommendations. The patient group have been consistent in their view that the clinic should open for new adult referrals and that there is provision for children. The patient group are clear that the clinic, and treatment within it, reduces their risk of urinary tract infection and that standard treatment in secondary care has not helped them. Whittington Health received the report on the Lower Urinary Tract Service (LUTS) clinic on 19 October 2016, following the invited service review carried out in May The report made a number of recommendations (27) in order to secure a viable and sustainable safe service for people with lower urinary tract infections. 74 2

75 The RCP made a series of recommendations to ensure the service operated safely and effectively, and recommended that the service not take any new referrals until the recommendations made in the report were met locally. The key requirements for the service to open to new referrals were: The service be provided from a tertiary setting and/or be supported by multi-disciplinary team meetings; Provision for adults should be separate from that for children; A clear succession plan was in place to replace the lead consultant (Professor Malone Lee) on his retirement; The Trust and CCGs assured that the safety and governance concerns raised by the RCP have been satisfactorily addressed. The report to the Committee in March 2018 therefore set out progress against the pivotal recommendations from the RCP report required for the clinic to re-open for new referrals: Establishing a functioning multi-disciplinary team (MDT) to support the clinic and to ensure patient care is informed by expert opinion from a wide range of experts in line with the complex conditions being treated; Development of a service specification, and supporting business case, to put the service on a firm commissioning footing; Development of a succession plan on the retirement of the lead consultant; Further development of the research governance framework for the LUTS clinic; Assurance on safety and governance for the clinic. 3. Joint Commissioning Committee 1 March 2018 On 1 March 2018 the NCL CCG Joint Commissioning Committee was asked to consider the re-opening of the LUTS clinic at Whittington Health to new patients. The framework for decision-making was based on a requested report into the clinic from the Royal College of Physicians. The report set out a series of recommendations to strengthen the clinical and corporate governance supporting the clinic that would need to be met for the clinic to re-open to new patients in a safe and effective way. The key conditions from the Royal College of Physicians for the service to open to new referrals are listed below alongside progress against each of the conditions and comments from the Committee on the conditions for reopening the clinic: The service be provided from a tertiary setting and/or be supported by multi-disciplinary team meetings; A multi-disciplinary team (MDT) had been established at Whittington Health with a range of specialist support and with participation from primary care; The Committee felt that the MDT should include support from a tertiary centre to fully meet the RCP recommendations and Whittington Health were requested to put this in place. Provision for adults should be separate from that for children; Separate tertiary service for children at Great Ormond Street Hospital (GOSH) is in place. It was noted that the patient group did not accept the GOSH service as tertiary, as it did not replicate the treatment provided out of the LUTS clinic at Whittington Health. The CCG had therefore previously agreed 75 3

76 to work with GOSH, Whittington Health and the patient group to further develop the service. A clear succession plan was in place to replace the lead consultant (Professor Malone Lee) on his retirement; Whittington Health and UCLH have agreed to appoint a joint consultant post in Urogynaecology. This post will provide clinical leadership for the LUTS clinic; The role will be recruited to in September 2018, after approval of the new consultant post by the relevant Royal College in June The current lead consultant will remain in post until the recruitment is complete. The Trust and CCGs assured that the safety and governance concerns raised by the RCP have been satisfactorily addressed. Work to do this includes: Alignment of clinical audit in the clinic with overall Whittington Health systems; Development of service specification, and supporting business case, to place the clinic on a firm commissioning footing in the 2018/19 contract with Whittington Health. The contract baseline for 2018/19 includes funding for the clinic; Further development of the research governance framework for the LUTS clinic with UCLH and University College London; The service specification puts in place a series of safeguards to address local clinical concerns over the clinic MDT approach for new customers; referrals from secondary care only (not primary care); Prescribing remains within the Trust, shared care arrangements with primary care will only be put in place on agreement of protocols with GPs. There were also operational issues for the clinic that needed to be resolved to make the opening of the clinic to new referrals effective and safe: The efficacy of diagnostic testing work is underway to agree a quality assurance process at Whittington Health; Management of any future NHS waiting lists. Outcome of the meeting The NCL CCG Joint Commissioning Committee supported the recommendation to re-open the clinic to new referrals to the Whittington Health Trust Board with the following caveats, and noted that these were on-going actions with Whittington Health: Development of the Whittington Health multi-disciplinary team (MDT) supporting the clinic to include membership from specialist / tertiary services; The clinic is properly supported by a tertiary service (joint consultant post and MDT) and recommend that the service shifts to tertiary setting as links to UCLH are built through the joint consultant post, MDT, and research framework (alongside University College London); Confirmation from Whittington Health clinicians that safeguards in place to make the service safe from local governance processes and the service specification; Ensuring separate provision for children maintained. This is being delivered through GOSH service; A quality assurance process for diagnostic testing in the clinic established by Whittington Health; Protocols are in place to manage any future NHS waiting lists for the clinic. Arrangements for any private patients wishing to be referred to the NHS clinic would be consistent with the NHS Constitution requirements; 76 4

77 Given the above, opening the clinic to new referrals would be reconsidered after a period if the assurances were not received. This would primarily relate to delivery of the succession plan and progress with tertiary support for the clinic. The Committee requested a response to these requirements for the next meeting of the JCC to be held on 5 April Whittington Health Trust Board 28 March 2018 On 28 March 2018 the Whittington Health Trust Board agreed to the phased re-opening of the LUTS clinic to new referrals and to begin the recruitment process for the joint uro-gynaecology consultant post with UCLH on the basis that: The majority of Royal College of Physicians (RCP) recommendations had now been addressed; Commissioners had agreed a service specification that was in line with the RCP recommendations; The contract for 2018/19 between the Trust and North Central London CCGs included provision to re-open the clinic to new referrals supported by the agreed service specification. The Trust Board decision was made in the knowledge of the outcome of the Joint Commissioning Committee set out in Section 3 above. The Whittington Health Trust Board decision to support the re-opening of the clinic to new referrals was informed by the following: 4.1 Addressing the RCP recommendations A multi-disciplinary team (MDT) has been established at Whittington Health, and the Trust is working with UCLH and CCGs to ensure that the future MDT is strongly supported from the tertiary centre. Whittington Health and UCLH have agreed to appoint to a joint consultant post that will provide clinical leadership for the LUTS service in the future. A separate tertiary service for children is in place at a separate tertiary centre for children at Great Ormond Street Hospital. (Note from above the patient group did not accept the GOSH service as tertiary, as it did not replicate the treatment provided out of the LUTS clinic at Whittington Health. The CCG had therefore previously agreed to work with GOSH, Whittington Health and the patient group to further develop the service. 4.2 Development of the service specification CCGs and the Trust have agreed the service specification for the future LUTS service that supports delivery of the Royal College of Physicians (RCP) including the following: The referral into the service will be from secondary care consultants; There will be a joint Whittington Health / UCLH multi-disciplinary (MDT), and every new patient will have their treatment discussed and agreed at the MDT; That any treatment outside of nationally agreed guidelines and local MDT agree guidelines / (treatment plan) will be provided from within the context of an ethically approved clinical trial; That a shared care scheme will be developed and once in place (through agreed protocols) the patient s GP and secondary care provider will provide shared care. 77 5

78 4.3 Trust contract for 2018/19 The contract for 2018/19 between the Trust and North Central London includes an agreed amount of funding for the service supported by the service specification. The service specification is being further developed to incorporate metrics. 5. Patient Group meeting 27 March 2018 At the meeting, in addition to considering the Trust Board paper, it was noted that progress had been made on the operational requirements for the clinic to re-open to new referrals: Development of the quality assurance testing for diagnostic testing in the clinic with the Trust s Microbiology Department; Agreement that the Trust s Associate Medical Director and lead consultant from the clinic would agree protocols for the future waiting list for the clinic. It is envisaged that there will be on-going engagement with the LUTS patient group in support of further developing the tertiary service for children and to ensure the service specification for the adult service at Whittington Health was delivering the expected outcomes. 6. Monitoring the Clinic The following commissioner monitoring arrangements are being put in place for the clinic: Specific monthly meetings with Whittington Health to oversee the reopening of the clinic to new referrals and further actions on creating tertiary links to the clinic The continuation of meetings with the LUTS patient group as set out in Section 5 above; An overview for the broader commissioning function through the Clinic Quality Review Group held with the Trust; Trust internal clinical and corporate governance processes; Progress with research governance. Research governance in support of the clinic continues to develop. The results of a 10-year research study was published last week (link below). The publication was referenced by the LUTS patient group at the Whittington Health Trust Board on 28 March To support monitoring the service specification will be further developed by the end of April 2018 to incorporate metrics and indicators to: Monitor the waiting list and impact of the service specification on this; Provide an overview of clinical audits undertaken by the clinic, building on the existing Whittington Health programme; Assurance on the quality assurance process for diagnostic testing; Patient experience. As the tertiary links to the LUTS clinic are developed CCGs will talk to NHS England as to whether the service should be commissioned by Specialist Commissioning. An initial meeting with Specialist Commissioning has been requested to provide an overview of the LUTS service. 78 6

79 7. Recommendation The Joint Commissioning Committee is asked to ENDORSE the decision to a phased re-opening of the LUTS clinic to new referrals. Purpose (tick one only) Information Approval To note Decision Recommendation rev Conflicts of Interest Strategic Direction Identified risks and risk management actions Resource implications Engagement Equality impact analysis The Joint Commissioning Committee is asked to: NOTE the report; ENDORSE the decision to a phased re-opening of the LUTS clinic to new referrals. Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy. The re-opening of the Whittington Health Lower Urinary Tract Service (LUTS) clinic supports: Commissioning the delivery of NHS constitutional rights and pledges; Improving the quality and safety of commissioned services; Improving health outcomes, addressing inequalities, and achieving parity of esteem; Integrating and enabling local services to deliver the right care in the right setting at the right time. The main risks identified with the re-opening of the Whittington Health Lower Urinary Tract Service (LUTS) clinic are: Addressing the future waiting list for the clinic; Addressing the operational risks identified in the paper. Resource implications are identified as follows: The LUTS clinic is incorporated in to the 2018/19 contract baseline with Whittington Health, and is reflected in current proposals at an agreed amount; Costs to commissioners will increase in 2018/19 for: The costs of prescribing 0.3m ( 0.1m for NCL CCGs) Additional consultant sessions to cover the joint appointment between Whittington health and UCLH 0.2m ( 0.1m for NCL CCGs). This will be incorporated into tariff payments in 2019/20. Work to re-open the Whittington Health Lower Urinary Tract Service (LUTS) clinic has been undertaken with the LUTS patient group. This report was written in accordance with the provisions of the Equality Act Report history Progress on the work to re-open the Whittington Health Lower Urinary Tract Service (LUTS) clinic has been considered by: Whittington Health Trust Board; Haringey CCG Quality Committee and Islington CCG Quality and Performance Committee; North Central London (NCL) Joint Health Overview Scrutiny Committee. This report is informed by the outcome of: 79 7

80 The NCL CCG Joint Commissioning Committee on 1 March 2018; The Whittington health Trust Board on 28 March Next steps Appendices Following approval to re-open the clinic by Whittington Health Trust Board on 28 March 2018, and ENDORSEMENT of this by the Committee the next steps are: Service specification for the clinic included in the 2018/19 contract with Whittington Health; Clinic opens to new referrals in April 2018; Recruitment to joint consultant post between Whittington Health and UCLH in September 2018, with the recruitment process commencing in April 2018; Establish on-going commissioner monitoring arrangements for the clinic. Proposed time line for the re-opening of the clinic. 80 8

81 Appendix One - Timeline The table below summarises the proposed timeline for the re-opening of the clinic. This timeline was shared with the North Central London Joint Health Overview Scrutiny Committee on 26 January Milestone Paul Sinden (PS) to meet with the patient group at WH site to share LUTs (adults) service specification (adults) LUTs service specification ( adults) agreed by Commissioners.( this will be done remotely, a meeting is not required) Whittington Health Trust Board asked to review and sign off RCP action plan and approve draft Business Case to meet the service specification for LUTs (adults). Discussions with Great Ormond Street Hospital (GOSH) clinicians regarding LUTs pathway for children. Single item joint commissioning committee (JCC) meeting to: 1. Receive feedback from the Trust on the outcome of the Trust Board meeting 28 February Agree LUTs service specification can be included in the 2018/19 WH contract. 3. Receive update re liaison with GOSH Responsible organisation CCG CCG Whittington Health Whittington Health, CCG and GOSH CCG Date and plan Meeting held on 19th February 2018 with CCG and Whittington Health representatives PS has shared the draft specification with both CCG Chairs. Share wider with clinicians in week beginning 29 January 2018.Final version to be sent to Whittington Health following meeting with LUTs patient group. 28 February 2018 Whittington Health Trust Board meeting. This has now moved to 28 March 2018 Mr Rob Sherwin has made contact with GOSH to consider the development of the tertiary service. Part of Joint Commissioning Committee Seminar on 1 March 2018 to be converted into formal meeting to consider the re-opening of the LUTS clinic to new referrals. For the LUTs item the Committee will be a meeting in public. LUTs ( adults) Service Specification included in 2018/2019 contract LUTs (adults) - phased reopen. MDT review list of patient on waiting list before tertiary referrals are accepted Consultant Job Description (adults) agreed by Royal College of Obstetrics and Gynaecology. Recruitment to joint Consultant post completed CCG April 2018 Whittington Health April 2018 Whittington Health June 2018 Whittington Health and UCLH September

82 NCL Joint Commissioning Committee Thursday 5 th April 2018 Report title Planning Round for 2018/19 Agenda item 3.2 Date 29 th March 2018 Lead director Report author Sponsor(s) (where applicable) Paul Sinden Director of Performance and Acute Commissioning Paul Sinden Director of Performance and Acute Commissioning Tel/ Tel/ Tel/ p.sinden@nhs.net p.sinden@nhs.net Report summary North Central London CCGs Planning Round for 2018/19 1. Introduction This paper provides an overview of planning guidance from NHS England and NHS Improvement for 2018/19 and an overview of local preparations for 2018/19 following the update received in December Planning guidance for 2018/19 Guidance was received from NHS England and NHS Improvement on 2 February The guidance provides a refresh to existing planning guidance for 2017/18 and 2018/19 and covers: Application of the 1.6b additional funds for the NHS announced in the autumn 2017 budget. This equates to 15.6m additional allocation to North Central London CCGs; Confirmation of the need to deliver the service priorities set out in the Five Year Forward View Next Steps published in March 2017; Priorities set by the Government in the November 2017 budget; Insight from ongoing public engagement, involvement and feedback including from Healthwatch. In December 2016 CCGs signed two-year contracts with providers for 2017/18 and 2018/19. The updated planning guidance for 2018/19 will be reflected in provider contracts through: Re-negotiation of contract baselines to reflect the guidance as well as 2017/18 outturn and the further development of Sustainability and Transformation Plan (STP) interventions; A national contract variation that updates all contracts for changes to the national contract in 2018/19. This includes the introduction of the Ambulance Response Programme, new guidance for all providers for learning from deaths, the mandated use of the e-referral service for outpatient referrals from October 2018, implementing the National Workforce Disability Equality 82

83 Standard, and delivery of the mental health crisis care concordat. The national contract variation has been signed by North Central London providers; Note that contact terms for marginal rates, claims and challenges, CQUIN and key performance indicators will be rolled forwards from 2017/18 into 2018/ Planning principles for 2018/19 The update to national planning guidance for 2018/19 is based on consideration of the following factors: Funding should deal with current levels of unfunded care (deficits) that need funding going into 2018/19, with this addressed through the creation of a 400m sustainability fund for CCGs and an 650m extension to the existing provider sustainability fund; Setting realistic plans for growth in emergency care (A&E attendances and emergency admissions) supported by additional CCG funds and incentivised through provider sustainability funds and CCG Quality Premium metrics; Protecting planned investment in mental health, cancer and primary care: All CCGs to meet the mental health investment standard where mental health spending grows faster than CCG funding growth, this will be subject to independent validation by CCG auditors; Cancer service developments funded include completing the national upgrade of radiotherapy machines, faster diagnostics for lung, prostate and colorectal cancers, and a new bowel cancer screening programme; Implement GP Forward View priorities for 2018/19 including establishing primary care networks and extended access. Be realistic about what can be achieved with the remaining available funds. Investment in electives should stabilise or reduce waiting lists and reduce the number of patients waiting over 52 weeks by 50%; Pay rises set above the currently budgeted 1% cap will be funded separately. 2.2 Resource allocation of 2018/19 An overview of changes to resource allocations are set out below: Nationally allocations increase by 2.14b equating to real-terms growth of 2.4% and age-weighted revenue growth of 1.4%: CCG allocations increase by 603m to deliver the service priorities for mental health, cancer, primary care, non-elective pathways and elective pathways in section 2.1 above. NCL CCGs have received 15.6m from this additional allocation, and allocations for 2018/19 are summarised below: CCG Core Services Allocations for 2018/19 Opening allocation 2018/19 Additional funding Final allocation 2018/19 Growth from 2017/ % Barnet 491,687 3, , % Camden 361,663 2, , % Enfield 409,218 3, , % Haringey 361,883 3, , % Islington 349,754 2, , % NCL Total 1,974,205 15,615 1,989, % Creation of CCG sustainability fund ( 400m) for CCGs that have a deficit control total, with the fund set at a level to bring deficit CCGs back into in-year financial balance. Payment of the fund is contingent on CCGs delivering their initial control total. NCL CCGs do not have a deficit control total set for 2018/19 83

84 so will not receive any of the sustainability fund, as is the case for all London CCGs; CCGs will also no longer be required to underspend 0.5% of their allocation, releasing this money to fun cost pressures and/or service transformation. NCL CCGs will be able to release the contingency fund in 2018/19. CCGs will also be no longer required to hold a further 0.5% contingency for non-recurrent expenditure; Increase the provider sustainability fund by 650m to make the total fund 2.45b. The increase covers the predicted provider shortfall against delivering control totals of 623m in 2017/18. As in previous years payment of the fund to providers will be dependent on delivery of financial control totals and delivery of minimum A&E performance (30% of funds contingent on A&E performance in 2018/19 that is the better of 90% or performance in 2017/18); An uplift to specialist commissioning, 354m, to cover the costs of service pressures, including the introduction of new drugs likely to receive NICE approval, over and above original planning assumptions; The planned increases to the allocation to general practice in 2018/19 has been maintained to fund cost uplifts to GP contracts and funding service developments in the GP Forward View (extended access and investment in estates and technology); Other direct commissioning led by NHS England and covering dental, optical services, pharmacy, armed forces, public health, and health and justice commissioning receives 71m nationally; Primary care allocations for primary care medical services (GP contracts) in 2018/19 are unchanged. 2.3 Cost pressures in 2018/19 The uplift to allocations in 2018/19 is based on the following assumptions for cost pressures: Non-electives. Allocations allow for 2.3% growth in admissions and ambulance activity and 1% growth in A&E attendances in line with national trends experienced in 2017/18, although growth in non-elective admission is weighted towards zero length-of-stay (7.3%) rather than in admissions for one day or more (1%). The growth assumptions in the national guidance are net of the impact of STP interventions, and will be used as a benchmark for CCG operating plans and contract agreements with providers; The guidance also targets a reduction in delayed transfers of care and length of stay for emergency admissions; Electives. Allocations allow for up to 4.9% growth in outpatient attendances and up to 3.6% growth in elective admissions to address referral-to-treatment waiting list backlogs. GP referrals are forecast to increase by 0.8%. Existing recovery plans indicate that the waiting time standard (92% of waits are less than 18 weeks) will be regained by UCLH in March 2018 and Royal Free London by August Again these national benchmarks are assumed to be net of STP interventions. Locally STP interventions for planned care will contribute to reducing waiting list backlogs and reduce activity growth along elective pathways. Locally contracts with providers seek to maintain RTT positions in 2018/19 compared to 2017/18 rather than recover the 92% standard where it is being missed; The activity changes for elective and non-elective pathways set out in the guidance are national averages and guidance allows for local trends to be reflected in contract negotiations with providers; The tariff uplift for contracts is 0.8%, up from 0.1% included in the original guidance for , to cover the increased costs of clinical negligence (CNST) cover for providers; Pay the uplift covers the 1% headline pay settlement only, and does not reflect any settlement above the current 1% cap for public sector workers; 84

85 Growth in secondary care (non-specialist) drugs expenditure is covered through the tariff uplift. For primary care prescribing growth is offset by efficiencies, guidance on reforms to drugs prescribed over the counter and the ending of the cost pressure accruing from generic drugs in short supply; Projected increases in clinical negligence scheme for trusts (CNST) contributions are reflected in national tariff changes; Allocations cover the additional costs to CCGs accruing from the delegation of Primary Care IT Enabling Services; Allocations cover cost pressures for continuing healthcare including any increases to funded nursing care rates, with partial mitigation assumed from local efficiency opportunities; There will be no additional in-year funds to cover winter 2018/19, so we need to ensure coverage for the schemes we wish to continue from the additional winter funds received in 2017/18; CCG Quality Premiums will be restructured in 2018/19 to provide an increased focus on non-elective demand management (emergency admission avoidance; Commissioning for Quality and Innovation (CQUIN) performance thresholds will be updated for flu vaccinations, sepsis, and reducing the use of antibiotics. For 2018/19 the 0.5% risk reserve CQUIN will be withdrawn with the allocation added to the engagement CQUIN. Also the safe discharge indicator for hospital providers will be withdrawn in 2018/19 with the funds spread across the other CQUIN indicators, with this concession made as there are incentives to support effective discharges elsewhere and to reduce financial pressures on providers. 2.4 Integrated System Working The refreshed planning guidance for 2018/19 reinforces the move towards system-wide working through Sustainability and Transformation Plans and the roll-out of Integrated Care Systems (formerly Accountable Care Systems). Integrated Care Systems are defined as those in which commissioners and NHS providers working closely with GP networks, Local Authorities, and other partners agree to take shared responsibility for how they operate their collective resources for the benefit of local populations (in ways that are consistent with their individual legal obligations). The guidance sets out system incentives and flexibilities for Integrated Care Systems including the ability to use system rather than organisational financial control totals and a more autonomous regulatory relationship with NHS England and NHS Improvement. Areas not covered by an Integrated Care System, including North Central London, will be expected to use respective Sustainability and Transformation Plan (STP) leadership to support system-wide working. Within this STPs should: Ensure a system-wide approach to developing operating plans; Implement service improvements that require a system-wide effort including implementing primary care networks and increasing system-wide resilience ahead of next winter; Identify system-wide efficiency opportunities including reductions in unwarranted variation and avoidable demand; Undertake a strategic system-wide review of estates to support delivery of integrated care models and shared use of assets; Enhance governance arrangements, aligned decision-making, and engagement with communities. Whilst payment-by results remains the default option of acute hospital contracts local systems are encouraged to consider payment reform to support STP delivery and integrated system working. The guidance explicitly references 85

86 development of local tariffs for advice and guidance services and ambulatory emergency care both of which are service developments being undertaken in North Central London. 2.5 Process and Timetable The national timetable prescribes that contract variations, for the agreement of contract baselines for 2018/19, should be signed no later than 23 March In addition commissioners and providers will need to submit operating plans for 2018/19 that reflect contract baselines (plans for commissioners and providers triangulate) and organisational control totals. Plans for 2018/19 will focus on: Alignment of planning assumptions between commissioners and providers; CCG will submit plans for finance, activity, and performance against NHS Constitution targets; Providers will submit plans as per CCGs plus workforce plans to address supply and retention problems; Plans for winter 2018/19 that are embedded in system plans and using existing funds, as there will be no additional winter funding in 2018/19. The table below sets out the planning timetable for 2018/19: Item Date Local decision to enter into mediation for 2018/19 2 March 2018 contract variations Draft 2018/19 organisational Operating Plans submitted 8 March 2018 Draft 2018/19 STP contract and plan alignment template 8 March 2018 submitted National deadline for signing 2018/19 contract variations 23 March 2018 and contracts 2018/19 Expert Determination paperwork completed 27 April 2018 and shared by all parties where mediation required Final Board or Governing Body approved Operating 30 April 2018 Plans submitted 2018/19 winter demand and capacity plans submitted 30 April 2018 Final 2018/19 contract plan alignment template 30 April 2018 submitted Final date for experts to notify outcome of 8 June 2018 determinations (mediation) for 2018/19 update /19 deliverables Our plans for 2018/19 already reflect the two-year priorities set out in planning guidance for and the Next Steps on the Five Year Forward View published in March The refreshed planning guidance for 2018/19 is appended to this report, and this sets out deliverables for 2018/19 and progress made in 2017/18. Deliverables for 2018/19, over and above delivery of the NHS Constitution standards focus on: Mental Health - delivery of investment standard (parity of esteem); improving access to psychological therapies, child and adolescent mental health services, eating disorders, early interventions for psychosis, physical health checks, individual placement and support (employment) services, and specialist perinatal mental health services; further develop mental health crisis and liaison services in acute hospitals; maintain dementia diagnosis rates; reduce the use of out of area placements. Cancer delivery of waiting time standards; implement straight-to-test pathways for lung, colorectal and prostate cancers; earlier diagnosis at stage 86

87 1 or 2; roll-out of FIT for bowel cancer screening; progress to all breast cancer patients moving to a stratified follow-up pathway. Primary Care full extended access coverage; delivery of 3 per head investment; full coverage of primary care networks; investment of sustainability and resilience funding; workforce recruitment in general practice including doctors, clinical pharmacists, mental health therapists, and physicians; invest in primary care facilities including estates and technology transformation schemes. Urgent and Emergency Care recovery of A&E 95% standard by March 2019; move NHS 111 services towards the national standard (targeted delivery April 2019); delivery of new ambulance response time standards; deliver a safe reduction in ambulance conveyance to emergency departments; deliver reductions in delayed transfers of care, continuing healthcare assessments carried out in hospital beds, and length of stay for emergency admissions; further develop mental health crisis and liaison services in acute hospitals; further roll-out of seven-day services. Transforming Care for People with Learning Disabilities deliver targeted reduction in hospitalisation; improved coverage of annual health checks from GPs; investment in community teams to support admission avoidance; improved access top Community Care, Education and Treatment Reviews (CETR) for children with a learning disability and/or autism; continue to tackle premature mortality by supporting the review of deaths of patients with learning disabilities. Maternity increase continuity of care during pregnancy; improve access to specialist perinatal mental health services; deliver improvements in safety to support targeted reduction in stillbirths, neonatal deaths, maternal deaths and brain injuries by 2020; agree trajectories to improve the safety, choice and personalisation of maternity services. 3. Progress with Provider Contracts for 2018/19. In December 2016 two-year contracts were signed with providers for 2017/18 and 2018/19. The contracts allowed for the negotiation of contract baselines for 2018/19, which would be added to the two-year contracts through a contract variation. The national deadline for agreeing contract variations for 2018/19 was 23 March Section 2.5 above sets out the process and timeline for agreeing contract baselines for 2018/19. Contract variations not agreed by 23 March 2018 entered into a mediation process with NHS England and NHS Improvement to be completed by the end of March If local mediation with NHS England and NHS Improvement does not resolve the contract differences with providers contracts will enter the national expert determination (arbitration) process where binding decisions on contract differences that will have to be enacted locally will be made. The table below provides a summary of the contract position as at 23 March Given the mediation process, and local efforts to agree contract baselines for 2018/19 the position, any updates to positions will be provided at the Committee. Contracts agreed by 23 March 2018 Contracts not agreed by 23 March 2018 UCLH Royal Free London Moorfields Eye Hospital North Middlesex University Hospital Royal National Orthopaedic Hospital Whittington Health Camden & Islington Foundation Trust CLCH. 87

88 Barnet, Enfield and Haringey Mental Health Trust CNWL These contracts entered into the local mediation process with NHS England and NHS Improvement. The Table includes acute and non-acute contracts, an overview of acute contracts, in line with the delegated responsibility of the Joint Commissioning Committee, is provided below. 3.1 Acute contract overview All acute provider contracts for 2018/19 have the following construct and context: A start-point of 2017/18 outturn at full cost, with the impact of the marginal rate from 2017/18 added back to create a full cost baseline. Outturn for 2017/18 is based on the forecast as at month nine (December 2017); An agreement to adjust the contract for the final outturn position for 2017/18 as at month twelve if this position differs from the month nine by more than 0.5% of the contract baseline. Contract variations triggered will be actioned by adjusting the thresholds for marginal rates; The agreement to adjust contracts for the final outturn position was made necessary by the use of marginal rates in contracts making the setting of contract baselines more sensitive than for full payment-by-results contracts due to the need to balance risk between growth and deductions for STP/local QIPP interventions; The tariff uplift of 0.8% as set out in national planning guidance (prices increase by 0.8% in 2018/19 compared to 2017/18); Activity growth has been added into contracts in line with local trends seen in 2017/18; Regulators (NHS England and NHS Improvement) will calibrate activity assumptions against delivery of operating plan assumptions for recovery of the A&E four-hour waiting time standard, delivery of the waiting standards for cancer, and maintaining performance on referral-to-treatment waiting lists in 2018/19 compared to 2017/18. Calibration will be measured by contract constructs reflecting local activity trends in 2017/18 and the activity assumptions included in the national planning guidance (with the assumptions being net of STP/QIPP interventions: A&E attendances +1.1%; Non-elective admissions +2.3%; Outpatient attendances +4.9%; Electives (daycase and admission) +3.6%; Growth for outpatient attendances and electives assumes recovery of the referral-to-treatment waiting time standard. Local contracts do not include recovery of the RTT position where this is being missed at UCLH and Royal Free London) so growth in these areas will be lower than national expectations. Waiting lists will be maintained in 2018/19 in NCL; The impact of STP and local CCG QIPP interventions in reducing acute activity flows (see Section 3.9 below for more detail on interventions); Addressing service and cost pressures for patient transport, acute psychiatric liaison and ambulatory care; Resolution of prior year issues for Royal Free London. The tables below summarises the position on contracts as at 23 March 2018 based on the above. A single figure is entered where agreement has been reached with Trusts. Where agreement has yet to be reached the Trust position is set out in red (below the CCG position). An updated table will be provided for the meeting to reflect any changes in contract positions compared to 23 March 2018: 88

89 UCLH Whittington Health North Middlesex Royal Free London Moorfields Eye Hospital Tariff Uplift +0.8% +0.8% +0.8% +0.8% +0.8% Growth +2.8% +2.9% +2.9% +2.2% +3.0% Interventions -3.9% -4.0% -3.9% -4.0% -3.0% -2.0% -2.0% -2.0% Net activity -1.1% -1.1% -1.0% -1.8% +0.0% Contract baseline 2018/19 Forecast outturn 2017/ m +0.9% 214.8m 219.1m Gap 4.3m +0.9% 197.0m 201.2m Gap 4.2m +0.2% 370.6m 381.7m Gap 11.1m 20.0m 204.2m 214.3m 190.0m 364.5m 17.9m 3.2 UCLH The contract variation for 2018/19 for UCLH was agreed in line with the national planning timetable by 23 March The table below summarises the contract baseline for 2018/19, with context provided by 2017/18 outturn. m Barnet Camden Enfield Haringey Islington NCL 2018/19 contract baseline 2017/18 forecast outturn The contract for 2018/19 is based on: Forecast outturn at month nine, with provision to move to the month 12 final outturn if year-end position varies from the month nine by more than 0.5% of the contract baseline; The contract baseline for 2018/19 is 0.8m below forecast outturn; A tariff uplift of 0.8% compared to 2017/18; An average growth rate of 2.9% across the contract; The contract baseline is reduced by 3.9% for the impact of Sustainability and Transformation Plan and local QIPP interventions; Section 3.7 sets out growth and intervention assumptions in the contract across activity categories; The contract addresses cost pressures on patient transport (a pass through cost) and funding to sustain the local model for acute psychiatric liaison; A mediation meeting on the contract was held on 28 March with NHS England and NHS Improvement and the outcome is set out in Section 3.8 below. 3.3 Royal Free London The contract variation for 2018/19 for Royal Free London (RFL) was not agreed in line with the national planning timetable by 23 March The table below summarises the position as at 23 March, with a 11.6m gap between commissioner and Trust positions. The contract gap accrues from differential assumptions on the level of STP and local QIPP interventions included in the contract with the CCG position based on 4% of contract baseline against the Trust assumption of 2%. m Barnet Camden Enfield Haringey Islington NCL 2018/19 contract baseline CCG Trust Gap 5.6m Gap 2.0m Gap 2.4m Gap 0.6m Gap 0.3m Gap 11.1m 2017/18 forecast outturn The contract for 2018/19 is based on: 89

90 Forecast outturn at month nine, with provision to move to the month 12 final outturn if year-end position varies from the month nine by more than 0.5% of the contract baseline; The contract baseline for 2018/19 is 6.1m (1.6%) above forecast outturn based on the CCG position. This increases to 17.2m (4.7%) when based on the Trust position; A tariff uplift of 0.8% compared to 2017/18; An average activity related growth rate of 2.2% across the contract; The contract baseline is reduced by 4% for the impact of Sustainability and Transformation Plan and local QIPP interventions, but the Trust baseline is limited to a 2% reduction; Section 3.7 sets out growth and intervention assumptions in the contract across activity categories; The contract addresses prior year issues resolved in 2017/18 for patient transport (a pass through cost), agreed counting and coding changes for the under recording of activity and costs in earlier years, metrics, and funding to sustain the local model for acute psychiatric liaison; 3.4 North Middlesex University Hospital The contract variation for 2018/19 for (NMUH) was initially agreed in line with the national planning timetable by 23 March 2018, with the contract baseline set at 197m. On 26 March the Trust indicated, after a meeting with NHS Improvement, that they had changed the amount of STP and QIPP interventions they would accept in the contract from 3.9% to 2%, leaving a contract gap of 4.2m. The gap by CCG is being worked through and will be shared with the Committee. m Barnet Camden Enfield Haringey Islington NCL 2018/19 contract baseline CCGs197.0 Trust Gap 4.2m 2017/18 forecast outturn The contract for 2018/19 is based on: Forecast outturn at month nine, with provision to move to the month 12 final outturn if year-end position varies from the month nine by more than 0.5% of the contract baseline; The contract baseline for 2018/19 is 7m (3.7%) above forecast outturn based on the CCG position. This increases to 17.2m (4.7%) when based on the Trust position; A tariff uplift of 0.8% compared to 2017/18; An average activity related growth rate of 2.9% across the contract; The contract baseline is reduced by 3.9% for the impact of Sustainability and Transformation Plan and local QIPP interventions, but the Trust baseline is limited to a 2% reduction; Section 3.7 sets out growth and intervention assumptions in the contract across activity categories; The contract addresses prior year issues resolved in 2017/18 for counting and coding changes agreed in 2017/18 in line with payment-by-results guidelines. 3.5 Whittington Health The contract variation for 2018/19 for Whittington Hospital was not agreed in line with the national planning timetable by 23 March

91 The table below summarises the position as at 23 March, with a 4.3m gap between commissioner and Trust positions. The contract gap accrues from differential assumptions on the level of STP and local QIPP interventions included in the contract with the CCG position based on 3.9% of contract baseline against the Trust assumption of 2% ( 3.8m), and acute psychiatric liaison ( 0.4m) where the Trust is requesting CCGs to pick up its contribution to the service in 2017/18. m Barnet Camden Enfield Haringey Islington NCL 2018/19 contract baseline CCG 11.0 Trust 11.2 Gap 0.2 CCG 10.9 Trust 11.1 Gap 0.2 CCG 4.7 Trust 4.8 Gap 0.1 CCG 84.5 Trust 86.0 Gap 1.5 CCG Trust Gap 2.3 CCG Trust Gap /18 forecast outturn Forecast outturn as at month nine (no provision to adjust for month 12); The contract baseline for 2018/19 is 0.5m (0.2%) above forecast outturn based on the CCG position. This increases to 4.8m (2.2%) when based on the Trust position; A tariff uplift of 0.8% compared to 2017/18; An average activity related growth rate of 2.9% across the contract; The contract baseline is reduced by 4% for the impact of Sustainability and Transformation Plan and local QIPP interventions, but the Trust baseline is limited to a 2% reduction; Section 3.7 sets out growth and intervention assumptions in the contract across activity categories; The contract addresses service and cost pressures for the mental health lounge (from system resilience monies), patient transport (a pass through cost), agreed counting coding changes from 2017/18 in line with payment by results guidelines, and ambulatory; The community element of the contract maintains investment of 1.2m to support delivery of STP interventions. 3.6 Moorfields Eye Hospital The contract variation for 2018/19 for Moorfields Eye Hospital was agreed in line with the national planning timetable by 23 March m Barnet Camden Enfield Haringey Islington NCL 2018/19 contract baseline 2017/18 forecast outturn The contract for 2018/19 is based on: Forecast outturn at month nine, with provision to move to the month 12 final outturn if year-end position varies from the month nine by more than 0.5% of the contract baseline; The contract baseline for 2018/19 is 2.1m above forecast outturn, with the majority of the uplift accruing from reinstating Enfield CCG Any Qualified Provider funding into the contract baseline; A tariff uplift of 0.8% compared to 2017/18; An average growth rate of 3% across the contract; The contract baseline is reduced by 3% for the impact of Sustainability and Transformation Plan and local QIPP interventions. 3.7 Activity trends This section compares activity trends built into contracts for 2018/19 to the national planning assumptions and local trends from 2017/18. 91

92 In the November 2017 Budget CCG allocations in England increased by 603m to deliver the service priorities for mental health, cancer, primary care, non-elective pathways and elective pathways set out in the planning guidance. This included delivering the constitution targets for A&E (and manage winter pressures, cancer, and maintaining referral-to treatment performance in 2018/19 compared to 2017/18. NCL CCGs received 15.6m from this additional allocation. In response to the additional funding the national planning guidance set out national growth trends from 2017/18 that local plans would be calibrated against to determine if plans were consistent with delivery of NHS Constitution performance. The activity assumptions included in the national planning guidance were net, showing growth after the impact of STP and local QIPP interventions: A&E attendances +1.1%; Non-elective admissions +2.3%; Outpatient attendances +4.9%; Electives (daycase and admission) +3.6%; The national planning assumptions for activity have made it more difficult to negotiate activity reductions into provider contracts for 2018/19 compared to 2017/18: The national planning assumption for A&E attendances assumes growth of 1.1% from 2017/18 to 2018/19. CCG plans reduce A&E attendances in provider contracts year-on-year by between 0.4% and 2.8%; The national planning assumption for non-elective admissions assumes growth of 2.3% from 2017/18 to 2018/19. CCG plans reduce non-elective admissions year-on-year by between 0.4% and 1.8%. The exception to this is UCLH where net growth year-on-year is 7.25% reflective of the growth seen in 2017/18 compared to 2016/17; The national planning assumption for outpatient attendances assumes growth of 4.9% from 2017/18 to 2018/19. This allows for recovery of the referral-totreatment standard where required. CCG plans reduce year-on-year by between 0.4% and 1.8%. The exception to this is North Middlesex University Hospital where net growth year-on-year is 1% reflective of the growth seen in 2017/18 compared to 2016/17. CCG growth for 2018/19 would be less than national assumptions as the contracts with UCLH and Royal Free London do not assume recovery of the referral-to-treatment standard; The national planning assumption for electives assumes growth of 3.6% from 2017/18 to 2018/19. This allows for recovery of the referral-to-treatment standard where required. CCG plans assume a year-on-year trend below the national assumption (between growth of 0.4% and a reduction of 1.8%). CCG growth for 2018/19 would be less than national assumptions as the contracts with UCLH and Royal Free London do not assume recovery of the referral-totreatment standard; Activity trends from 2017/18 to 2018/19 National UCLH Whittington Health North Middlesex University Hospital Royal Free London A&E +1.1% -2.5% -0.4% -2.8% -1.8% attendances Non-elective +2.3% +7.25% -0.4% -1.6% -1.8% admissions Outpatient +4.9% -2.5% -0.4% +1.0% -1.8% attendances Electives +3.6% +0.1% -0.4% -0.3% -1.8% 3.8 Mediation 28 March

93 Contracts not agreed by 23 March 2018 were automatically placed into mediation with NHS England and NHS Improvement. According to the planning guidance mediation was not binding but could indicate the outcome if contracts subsequently went through the expert determination process for binding arbitration. Mediation meetings were held with Whittington Health and Royal Free London on 28 March 2018, and will be held with North Middlesex University Hospital and CLCH on 9 April and 10 April respectively. The outcome of the mediation meetings from NHS England and NHS Improvement are summarised below: Both Whittington Health and Royal Free London had limited the reduction in the contract baseline for the impact of Sustainability and Transformation Plan (STP) and local QIPP interventions to 2% compared to 3.9%/4% in CCG offers. The mediation outcome recommended a joint primary and secondary care clinical review of the interventions to determine an agreed amount to include in contract baselines, with the agreed outcome to be in place by 30 April 2018; Whittington Health had requested 389k additional funding for the acute psychiatric service at the Trust. Mediation found in favour of CCGs and commissioner funding would remain at 2017/18 levels. CCGs have already agreed to carry out a review of acute psychiatric liaison services, and associated funding, in 2018/19 to arrive at a consistent model for 2019/20; Both NHS England and NHS Improvement supported the use of marginal rates in acute contracts as a construct that supported delivery of the Sustainability and Transformation Plan. This was in response to the Whittington Health proposal to revert to a full payment-by-results contract if the result of the clinical review was that the higher amount of STP and local interventions were deducted from the contract baseline. Actions flowing from the mediation meetings are: The recommendation to carry out a joint clinical review of STP and local QIPP interventions with Whittington Health and Royal Free London can be anticipated as an action for the contract with North Middlesex University Hospital where the mediation request also focuses on the application of STP and local interventions to the contract baseline; Identification of primary care clinical leads to undertake the joint clinical review of STP and local QIPP interventions; Consider the impact of the marginal rate on delivery of STP and local QIPP interventions in the light of the clinical review, and whether the marginal rate supports or detracts from the delivery of the interventions. The clinical review of Sustainability and Transformation Plan (STP) and local QIPP interventions builds on existing discussions in the STP Clinical Leadership Summit held in March The summit was asked to consider: How clinical leads in the STP could support the filter down and acceptance of STP interventions by constituent organisations; How this could then translate into STP interventions being incorporated into contracts and therefore operating plans. The outcome focused on how the combined clinical leadership in the STP might be better able to: Systematise engagement with clinical stakeholders within respective organisations or networks; Inform and drive the clinical priorities for the STP in 2018/19 and beyond; Increase the ability to work with enablers to ensure alignment with the chosen priorities; 93

94 Consider how to strengthen visibility and leadership in driving the delivery of transformational change, moving away from the dominance of transactional debates that currently override clinically led transformation The next step is to translate this into an operational plan to support delivery of provider contracts in 2018/ STP and local CCG interventions This section provides an overview of the Sustainability and Transformation Plan (STP) and local QIPP interventions. An overview was requested by the Committee at the February 2018 meeting. Appended to the report is a presentation on the STP made to Barnet CCG. It was agreed at the meeting in February 2018 that the presentation would be shared with the Committee. The presentation provides an overview of the Sustainability Plan (ambition, partners, and the importance of system-wide working and clinical leadership). The presentation then goes on to provide an overview of the main interventions in the three key service workstreams: Planned Care: Clinical advice and navigation extending GP access to specialist advice as an alternative to outpatient referral; Clinical redesign of pathways to focus on preventative and proactive care for chronic kidney disease, musculoskeletal disease, urology and cardiology; Roll-out and further develop the NCL CCG policy for procedures of limited clinical effectiveness; Tele-dermatology new technology for examining skin complaints; The review of adult elective orthopaedic services approved by the Committee in February Urgent and Emergency Care: Integrated urgent care to bring together and enhance urgent care services provided outside of hospital to create a single unified urgent care service; Admission avoidance - to develop same day emergency care services in both acute and community settings to enable rapid assessment, diagnosis, and treatment to avoid overnight stays in hospitals; Simplified discharge to develop improved discharge processes to reduce delays in patients leaving hospitals when they are medically stable. CCGs are implementing this through discharge to assess pathways; Last phase of life to bring specialist advice to staff who are looking after patients in the last year of their lives, in order to ensure the best possible care and support to patients and reduce inequalities of care provision. Care Closer to Home: Extended access to primary care all CCGs have developed and improved access to core general practice including through primary care hubs; Care Closer to Home Integrated Networks (CHINs / Neighbourhoods) care delivered across networks of practices, with teams including GPs, practicebased pharmacists, community services staff, mental health, social care, the voluntary sector, and acute (specialist advice and guidance); Quality Improvement Support Teams (QISTs) the teams work with general practice to improve quality, reduce variation and build resilience supported by information and analytics. An early template of this would be medicines management teams employed by CCGs. 94

95 Many of the interventions above will support delivery of the national planning priorities listed in Section 2 above. 4. Next steps The next steps to complete the planning round are to: Action the outcome of the contract mediations with Whittington Health and Royal Free London held on 28 March, and in particular set up the clinical review of Sustainability and Transformation Plan (STP) and local QIPP interventions to determine the level included in opening contract baselines. The reviews and agreed outcomes are to be completed by 30 April 2018; Complete contract documentation for all contracts; Preparation for the mediation meeting with North Middlesex University Hospital (NMUH) on 9 April 2018 and CLCH on 10 April 2018; Consider, based on the outcome of the joint clinical reviews of STP and local interventions, whether the marginal rate in hospital contracts is delivering CCG and STP objectives; Progress work on alternative contract forms to payment-by-results in preparation for the 2019/20 contract round. Purpose (tick one only) Recommendation Information Approval To note The Joint Commissioning Committee is asked to: Decision NOTE and COMMENT ON the planning update for 2018/19. Conflicts of Interest Strategic Direction Identified risks and risk management actions Resource implications Engagement Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy. Planning for 2018/19 will support delivery of: The North Central London Sustainability and Transformation Plan; Local CCG priorities including joint commissioning priorities with Local Authorities; Recovery of the overall financial position for North Central London. The main risks to generating plans for 2018/19 within CCG resource envelopes are: Delivery of the targeted activity reductions and cost savings from STP interventions and local QIPP in 2017/18; Developing further QIPP and STP interventions proposals for 2018/19; Triangulation of CCG and Trust views on 2017/18 forecast outturn and the impact of 2018/19 Sustainability and Transformation Plan workstream interventions; Triangulation of local activity assumptions against the activity increase assumed in national planning guidance Ensuring agreements in two-year contracts for 2017/18 and 2018/19 signed in December 2016 are carried forward from 2017/18 into 2018/19. Plans for 2018/19 will need to be calibrated against CCG resource envelopes. Plans should reflect the priorities identified through engagement with patients and public. Local CCG engagement timelines will be built into the process for generating system intentions, as well as being informed by on-going engagement structures. 95

96 Equality impact analysis This report was written in accordance with the provisions of the Equality Act Report history Next steps Appendices The planning process for 2018/19 has been considered jointly by commissioners and providers through the Sustainability and Transformation Plan Finance Group. Next steps in the development of plans for 2018/19 will be to: Action the outcome of the contract mediations with Whittington Health and Royal Free London held on 28 March, and in particular set up the clinical review of Sustainability and Transformation Plan (STP) and local QIPP interventions to determine the level included in opening contract baselines. The reviews and agreed outcomes are to be completed by 30 April 2018; Complete contract documentation for all contracts; Preparation for the mediation meeting with North Middlesex University Hospital (NMUH) on 9 April 2018 and CLCH on 10 April 2018; Consider, based on the outcome of the joint clinical reviews of STP and local interventions, whether the marginal rate in hospital contracts is delivering CCG and STP objectives; Progress work on alternative contract forms to payment-by-results in preparation for the 2019/20 contract round. Refreshed planning guidance for 2018/19 from NHS England and NHS Improvement; Sustainability and Transformation Plan overview presented to Barnet CCG. 96

97 Refreshing NHS Plans for 2018/19 Published by NHS England and NHS Improvement 97

98 Refreshing NHS plans for 2018/19 Version number: 1.1 First published: 2 February 2018 Updated: 9 February 2018 Prepared by: NHS England and NHS Improvement This document is for: Foundation Trusts, NHS Trusts, Direct Commissioners and CCGs and should be read in conjunction with the NHS Operational Planning and Contracting Guidance Publications Gateway Reference: and This information can be made available in alternative formats, such as easy read or large print, and may be available in alternative languages, upon request. Please contact or england.contactus@nhs.net 98

99 Contents 1 Introduction Financial Framework Planning Assumptions for emergency care and Referral to Treatment Times Delivery of Next Steps Priorities Integrated System Working Process and Timetable Annex 1: 2018/19 Deliverables

100 1 Introduction 1.1 The NHS already has two-year contracts and improvement priorities set for the period 2017/19. These were based on the NHS Operational Planning and Contracting Guidance published in September 2016 and reflected in the March 2017 document Next Steps on the NHS Five Year Forward View. 1.2 The November 2017 budget announced additional NHS revenue funding of 1.6 billion for 2018/19, which will increase funding for emergency & urgent care and elective surgery. In addition, for other core frontline services such as mental health and primary care, the Department of Health & Social Care (DHSC) is making a further 540 million available through the Mandate over the coming financial year. It is now our collective responsibility to ensure we deliver the best possible health service within the funds available. This joint NHS England and NHS Improvement updated guidance sets out how these funds will be distributed and the expectations for commissioners and providers in updating their operational plans for 2018/ In line with the priorities set out by the NHS England Board on 30 November 2017, for 2018/19 we will build on the progress made in 2017/18 and protect investment in mental health, cancer services and primary care in line with the available resources and agreed plans. Recognising the scale of unmet need in mental health, the importance of cancer services and the intense pressures on primary care we believe it would be unacceptable to compromise progress on these services. This means a continued commitment to deliver the cancer waiting time standards, achievement by each and every CCG of the Mental Health Investment Standard, service expansions set out by the Mental Health Taskforce and General Practice Forward View commitments, consistent with the expectations already set out in the planning guidance. 1.4 Given that two-year contracts are in place, 2018/19 will be a refresh of plans already prepared. This will enable organisations to continue to work together through STPs to develop system-wide plans that reconcile and explain how providers and commissioners will collaborate to improve services and manage within their collective budgets. Additional freedoms and flexibilities, described in this guidance, will support the most advanced Integrated Care Systems to lead this process. 1.5 Our energies must remain focused on improving the quality of care for patients and maintaining financial balance, whilst working in partnership to strengthen the sustainability of services for the future. 2 Financial Framework Financial Framework for CCGs 2.1 The resources available to CCGs will be increased by 1.4 billion, principally to fund realistic levels of emergency activity in plans, the additional elective activity 100

101 necessary to tackle waiting lists, universal adherence to the Mental Health Investment Standard and transformation commitments for cancer services and primary care. This additional investment will be made available in the following ways: the requirement for CCGs to underspend 0.5% of their allocations has been lifted for 2018/19, releasing 370 million of CCGs resources to fund local pressures and transformation priorities. The requirement to use a further 0.5% of CCGs allocations solely for non-recurrent purposes has also been lifted; 600 million will be added to CCG allocations for 2018/19 (which otherwise remain unchanged), distributed in proportion to CCGs target allocations (which have been updated to reflect the latest population estimates and other data) 1 ; and a new 400 million Commissioner Sustainability Fund (CSF) will be created, partly mirroring the financial framework for providers, to enable CCGs to return to in-year financial balance, whilst supporting and incentivising CCGs to deliver against their financial control totals. 2.2 CCGs will be expected to plan against financial control totals communicated at the outset of the planning process 2 alongside revised allocations. CCGs collectively will be expected to deliver financial balance after the deployment of the Commissioner Sustainability Fund, and control totals will be set on this basis. Drawdown of cumulative underspends will be available subject to affordability, and where agreed with the relevant NHS England regional team. 2.3 CCGs control totals will take into account each CCG s financial performance in 2017/18. Any CCG that is overspending in 2017/18 will be expected to improve its in-year financial performance by at least 1% of its overall allocation, and those with longer standing and/or larger cumulative deficits will be given a more accelerated recovery trajectory. Commissioner Sustainability Fund 2.4 Where it is agreed that a CCG is unable to operate within its recurrent allocation for 2018/19 it will be required to commit to a credible plan, agreed and aligned at STP level, to deliver a stretching but realistic deficit control total set by NHS England and it will then qualify to access the Commissioner Sustainability Fund provided it delivers its financial control total. 2.5 All CCGs will be expected to achieve a minimum of financial balance with zero deficits, following deployment of any CSF allocations. Full details on the operation of the CSF will be published shortly. 1 Revised CCG allocations have been published alongside this document on a provisional basis and for planning purposes, subject to confirmation at the NHS England public Board meeting on 8 February CCGs will be informed of their control total by NHS England in writing, shortly after this guidance is published. 101

102 Provider Sustainability Fund and Financial Framework for NHS Providers million will be added to the 1.8 billion Sustainability and Transformation Fund to create an enhanced 2.45 billion Provider Sustainability Fund, targeted at the same objectives as the existing Sustainability and Transformation Fund. The additional 650 million must deliver at least a pound-for-pound improvement in the aggregate provider financial position and will be reflected in 2018/19 provider control totals 3. As in 2017/18, 30% of the total 2.45 billion fund will be linked to A&E performance. Full details will be published separately via an update to the existing Sustainability and Transformation Fund guidance. To access the performance element, each provider will need to achieve A&E performance in 2018/19 that is the better of either 90% or the equivalent quarter for 2017/18. The provider sector will plan and deliver a balanced income and expenditure position for 2018/19 after deployment of the 2.45 billion Provider Sustainability Fund. 2.7 Providers will be expected to plan on the basis of their 2018/19 control totals. Provider plans must make clear whether the Board has confirmed acceptance of its control total. NHS Improvement will use the completed financial planning template to capture this decision. If the control total has not been accepted, this is likely to trigger action under the Single Oversight Framework. 2.8 Providers who accept their control totals and so have access to the Provider Sustainability Fund for 2018/19 will continue to be exempt from the application of an agreed range of contractual performance sanctions, as set out in the existing NHS Standard Contract. NHS England will shortly consult on changes to the Contract to extend this exemption to all national contractual performance sanctions except those relating to mixed sex accommodation, cancelled operations, Healthcare Associated Infections and the duty of candour, on the basis that continuing NHS Improvement oversight, including the NHS Improvement Single Oversight Framework, will ensure that NHS providers continue to perform to acceptable levels against all national standards. Neither providers nor commissioners should include the expected impact of contractual sanctions in their plans, whether or not the provider has accepted its control total and so has access to the Provider Sustainability Fund. Providers who accept control totals (and associated conditions) will also be eligible to be considered for any discretionary capital allocations. Capital and Estates 2.9 The 2017 Autumn Budget provided an extra 354 million of public capital in 2018/19 and set out the Government s commitment to delivering its share of the NHS property and estates investment recommended in the Naylor review. NHS England and NHS Improvement are working together with DHSC and HMT to prioritise the allocation of additional STP capital. In updating 2018/19 operational plans, STPs and providers should not assume any capital resource 3 Providers will receive a letter from NHS Improvement informing them of changes to their previously notified 2018/19 control totals shortly after this guidance is published 102

103 above the level in the current 2018/19 operating plans unless NHS England and NHS Improvement have given written confirmation of additional resource The approval of additional STP capital will be contingent on the STP having a compelling estates and capital plan. The STP plan must be fully aligned with the overarching strategy for service transformation and financial sustainability. This plan must set out how the individual organisations in the STP will work together to deploy capital funding to support integrated service models, maximise the sharing of assets and dispose of unused or underutilised estate. In addition, plans will need to demonstrate both value for money and savings to the STP over a reasonable payback period, taking full account of the life cycle costs associated with any new asset. STPs will also be expected to ensure that they maximise opportunities for self-funding of schemes using their own capital and receipts from land disposals and are fully considering the use of private finance where this provides value for money. Further information on the next steps regarding STP capital will be communicated separately Providers are asked to actively consider the requirement for funding critical estate backlog within their capital plan and explain their strategy for investment in backlog work and risk mitigation including how they will reduce operational expenditure relating to estate and facilities. National Tariff 2.12 The two-year National Tariff Payment System which came into effect from 1 April 2017 remains in place for next year. Local systems are encouraged to consider local payment reform, in particular to complement the introduction of advice and guidance services. Local systems are also encouraged to introduce appropriate local tariffs for emergency ambulatory care where they have not already done so, to replace the current A&E and non-elective tariffs for appropriate conditions. The next round of interventions eligible for direct reimbursement through the Innovation and Technology Payments, a programme designed to incentivise take-up of the latest innovations across the NHS, will be published by 31 March. Underlying Assumptions 2.13 Local systems are expected to continue to implement the priority efficiency programmes within the 10 Point Efficiency Plan. This includes taking every opportunity to maximise provider operational productivity, guided by the Model Hospital portal, and to participate fully in associated programmes. It also includes the implementation of Getting It Right First Time recommendations; participation in networked arrangements for procurement, corporate services and diagnostic services; achieving best practice in clinical and other workforce productivity standards (including reducing agency staff usage); and improving the safety and efficiency of providers estate and facilities. Providers and STPs should also consider how to make best use of the digital and technological systems and innovations available to them. In addition to the moderation of emergency demand discussed below, the use of RightCare, elective care 103

104 redesign, urgent and emergency care reform, medicines optimisation, and more integrated primary and community services are also key areas of focus CCGs should assume that the current high level of discretionary prices for generic drugs in short supply will not persist in 2018/19. In 2018/19, CCGs will receive the remaining period of temporary benefit from changes made to Category M generic drug prices designed to recover excess community pharmacy margin from previous years (i.e. the Cat M clawback will not continue beyond 2017/18). Beyond this, no assessment has yet been made of whether upward or downward adjustments to generic drugs prices will be needed in 2018/19 to reflect under or over-delivery of community pharmacy margin delivered in 2016/17 and 2017/18. So no allowance for this should be included in CCG plans In December 2017, NHS England issued guidance on Items that should not routinely be prescribed in primary care: Guidance for CCGs. This guidance is aimed at reducing the routine prescribing of 18 ineffective and low clinical value medicines, such as some dietary supplements, herbal treatments and homeopathy. It is assumed CCGs will save up to 141 million a year from this programme. NHS England has also launched a public consultation (closing 20 March 2018) on reducing prescribing of over-the-counter medicines for 33 minor, short-term health concerns, as well as vitamins and probiotics. Depending on the outcome of the consultation, it is assumed this could save the NHS up to 136 million a year. CCGs should consider how to locally implement guidance on the 18 ineffective and low clinical value medicines and consider the potential impact of any developments concerning over the counter medications following the consultation It is assumed that all CCGs continue to work with the NHS England Continuing Healthcare strategic improvement and QIPP programmes to increase standardisation of processes and adopt best practice to deliver the targeted reduction in growth, thus mitigating cost and volume pressures, including the impact of any increases to Funded Nursing Care rates Where the activity, cost and efficiency assumptions made by an STP do not enable each of its organisations to meet the control totals set by NHS England and NHS Improvement, the STP will need to agree additional cost containment measures and highlight any implications. This includes potential impacts on the range or level of services to be provided, and where surpluses will be created to offset any unavoidable deficits within the STP. When considering options to deliver control totals, STPs must ensure the alignment of commissioner and provider assumptions. They must also ensure that plans continue to meet the requirements for A&E, RTT and cancer set out in this letter and that patients are able to exercise choice as set out in the NHS Constitution We are working through the implications of the Government s commitment on NHS pay described in the 2017 Autumn Budget and will publish further guidance in due course. Until this is available the impact of any changes to NHS pay beyond the published assumptions should be excluded from 104

105 plans. It is essential that the 2018/19 pay costs in financial planning returns are an accurate reflection of the cost of the current, published pay assumptions Further details about CQUIN, Quality Premium, national contract and winter planning are set out in section 6. Specialised Commissioning 2.20 The contracting approach for specialised services continues into 2018/19, aligned to implementation of the Carter review. Specialised commissioners and providers will need to review the 2018/19 activity plans and agree any contract variations required in accordance with the contractual process and to the national timetable. Activity plans for 2018/19 will be reviewed as part of routine in-year contract management, incorporating delivery of QIPP planning and appropriate CQUIN benefit realisation. Locally priced services reform to reduce cost per weighted activity unit, multi-year medicines optimisation approach underpinned by CQUIN, and further reforms to the medical device supply chain, will continue. It remains a priority to have robust and high quality data flows to support accurate reimbursement, in particular of tariff-excluded high cost drugs and devices. 3 Planning Assumptions for Emergency Care and Referral to Treatment Times Emergency Care 3.1 The combination of clarity on control totals for providers and commissioners, underpinned by the increased provider sustainability fund and the new commissioner sustainability fund, paid for using additional budget funding, should enable health systems to fund and plan for this year s activity in a way that enables improved A&E performance in 2018/19. In addition, the allocations for 2018/19 allow for 2.3% growth in non-elective admissions and ambulance activity and 1.1% growth in A&E attendances. This is in aggregate for England and reflects recent trends, but activity growth patterns to be reflected in plans will in practice vary by commissioner and provider. 3.2 Our expectation is that the Government will roll forward the goal of ensuring that aggregate performance against the four-hour A&E standard is above 90% for the month of September 2018, that the majority of providers are achieving the 95% standard for the month of March 2019, and that the NHS returns to 95% overall performance within the course of STPs, commissioner and providers should review assumptions for levels of A&E attendances and nonelective admissions to ensure they reflect recent trends, adjusting as appropriate for demand management and other efficiency schemes that have been agreed between CCGs and providers. Given the differential implications for both bed capacity and cost, organisations will be required to plan and report non-elective admissions of less than one day separately from those of one day or more. Plans will also be collected on planned bed numbers to ensure 105

106 sufficient capacity is available throughout the year to meet anticipated demand for emergency and elective care. 3.3 Commissioner and provider plans will be expected to demonstrate how they will complete the implementation of the integrated urgent care strategy that was commenced this year, and how sufficient capacity will be available to meet planned activity growth through a combination of additional beds and/or: reductions in delayed transfers of care (DTOCs), both through reducing NHS-driven DTOCs and through continuing to work with local authorities to reduce social care DTOCs, with the aim of reducing the proportion of beds occupied by DTOC patients to 3.5%; reductions in average length of stay, including a focus on those patients with the longest length of stay as identified in the stranded patients metrics. 3.4 It is clear that there is significant variation in length of stay between providers, particularly in the number of patients with a length of stay over seven days (stranded patients) and a length of stay over 21 days (super stranded patients). We expect all providers and commissioners to work together to focus on reducing their length of stay, and particularly the very long lengths of stay, to release capacity for patients who are legitimately waiting for a hospital bed. 3.5 To further support progress in these areas and free-up capacity, providers of community services will be invited to participate in a new local incentive scheme in conjunction with their CCG whereby they will be able to reinvest savings from acute excess bed day costs to expand community and intermediate care services. This will benefit stranded and super-stranded patients in particular. 3.6 A total of 210 million of CCG Quality Premium incentive funding will be contingent on performance on moderating demand for emergency care. This payment will be conditional on the CCG meeting or improving on the levels jointly planned with providers. The principal metric for this purpose will be the level of growth in non-elective activity compared to the agreed plan. Referral to Treatment Times 3.7 The 2018/19 allocations now allow for improvements in the volume of elective surgery being funded next year, and improvements in the number of patients waiting over 52 weeks. A more significant annual increase in the number of elective procedures compared with recent years means commissioners and providers should plan on the basis that their RTT waiting list, measured as the number of patients on an incomplete pathway, will be no higher in March 2019 than in March 2018 and, where possible, they should aim for it to be reduced. Numbers nationally of patients waiting more than 52 weeks for treatment should be halved by March 2019, and locally eliminated wherever possible. The planning assumption for England as a whole is for 4.9% growth in total outpatient attendances (4.0% per working day) and up to 3.6% growth in elective admissions (2.7% per working day). It is also assumed that GP referrals will increase by 0.8% (i.e. no change per working day). The planned growth levels required will vary locally and therefore activity plans should be reviewed 106

107 to ensure delivery of these objectives, adjusting as appropriate for demand management and other efficiency schemes which have been jointly agreed between commissioners and providers. Systems will be expected to plan and report separately on day case and inpatient elective activity, based on their trend performance, the profile of expected referrals and the composition of their existing waiting list. Systems will be expected to demonstrate to regional teams that their RTT plans are robust and realistic, and that they make best and flexible use of available capacity across their STP footprint in order to optimise delivery against the objectives above. 3.8 Provider plans will need to consider the capacity required to deliver the growth in non-elective and elective activity and the impact on workforce, finance and productivity. Alongside these capacity considerations it remains essential that providers manage within their agency ceilings. 4 Delivery of Next Steps Priorities 4.1 The NHS is already working to two-year priorities as set out in last year s planning guidance and the March 2017 Next Steps on the Five Year Forward View. This document confirms the deliverables for 2018/19. These are set out in Annex 1, together with the progress made against 2017/18 deliverables. 5 Integrated System Working 5.1 In 2018/19, we expect all STPs to take an increasingly prominent role in planning and managing system-wide efforts to improve services. STPs should: ensure a system-wide approach to operating plans that aligns key assumptions between providers and commissioners which are credible in the round; work with local clinical leaders to implement service improvements that require a system-wide effort; for example, implementing primary care networks or increasing system-wide resilience ahead of next winter; identify system-wide efficiency opportunities such as reducing avoidable demand and unwarranted variation, or sharing clinical support and back office functions; undertake a strategic, system-wide review of estates, developing a plan that supports investment in integrated care models, maximises the sharing of assets, and the disposal of unused or underutilised estate; and take further steps to enhance the capability of the system including stronger governance and aligned decision-making, and greater engagement with communities and other partners, including where appropriate, local authorities. STPs should also take steps to resource their own infrastructure. Although these should be mainly drawn from their constituent organisations, NHS England will be making a further nonrecurrent allocation within each STP to support its leadership in 2018/19 on the same basis as last year. 107

108 Integrated Care Systems 5.2 We will reinforce the move towards system working in 2018/19 through STPs and the voluntary roll-out of Integrated Care Systems. Integrated Care Systems are those in which commissioners and NHS providers, working closely with GP networks, local authorities and other partners, agree to take shared responsibility (in ways that are consistent with their individual legal obligations) for how they operate their collective resources for the benefit of local populations. 5.3 We are now using the term Integrated Care System as a collective term for both devolved health and care systems and for those areas previously designated as shadow accountable care systems. An Integrated Care System is where health and care organisations voluntarily come together to provide integrated services for a defined population. 5.4 We see Integrated Care Systems as key to sustainable improvements in health and care by: creating more robust cross-organisational arrangements to tackle the systemic challenges facing the NHS; supporting population health management approaches that facilitate the integration of services focused on populations that are at risk of developing acute illness and hospitalisation; delivering more care through re-designed community-based and homebased services, including in partnership with social care, the voluntary and community sector; and allowing systems to take collective responsibility for financial and operational performance and health outcomes. 5.5 There are currently eight areas designated as shadow accountable care systems, plus the two devolved health and care systems based on STP footprints (Greater Manchester and Surrey Heartlands). These systems should prepare a single system operating plan narrative that encompasses CCGs and NHS providers, rather than individual organisation plan narratives. The system operating plan should align key assumptions on income, expenditure, activity and workforce between commissioners and providers. System leaders should take an active role in this process, ensuring that organisational plans underpin and together express the system s priorities. All Integrated Care Systems are expected to produce together a credible plan that delivers the system control total, resolving any disputes themselves, and no shadow Integrated Care System will be considered ready to go fully operational if it is unable to produce such a plan. 5.6 To reinforce this approach to system planning, NHS England and NHS Improvement will focus on the assurance of system plans for Integrated Care Systems rather than organisation-level plans. We expect that Integrated Care Systems will assure and track progress against organisation-level plans within their system, ensuring that they underpin delivery of agreed system objectives. 108

109 NHS England and NHS Improvement will support system leaders in this task. We have developed a new approach to oversight and support for Integrated Care Systems, based on the principles of setting system-wide goals, streamlining the oversight and support provided by NHS England and NHS Improvement (supported by an integrated framework that brings together the separate frameworks for trusts and CCGs), and working with and through the local system leadership to provide any support or interventions in individual providers or localities. 5.7 Integrated Care Systems will be supported by new financial arrangements: all Integrated Care Systems will work within a system control total, the aggregate required income and expenditure position for trusts and CCGs within the system, as communicated by NHS England and NHS Improvement 4. They will be given the flexibility, on a net neutral basis, and in agreement with NHS England and NHS Improvement, to vary individual control totals during the planning process and agree in-year offsets of financial over-performance in one organisation against financial underperformance in another; in 2018/19, systems are encouraged to adopt a fully system-based approach to the PSF and CSF under which no payment will be made unless the system as a whole has delivered against its system control total. If the system achieves its control total, but individual trusts or CCGs do not, the system will still retain its full share of the PSF ( 2.45 billion in aggregate) and any applicable CSF awards, but NHS England and NHS Improvement will agree with the leadership how those trusts and CCGs shares will be apportioned between local organisations; systems adopting this full incentive structure will operate under a more autonomous regulatory relationship with NHS England and NHS Improvement. NHS England and NHS Improvement will also support fully authorised Integrated Care Systems by exercising their intervention powers alongside the system leadership. For example, where there is a case for regulatory intervention in a trust or CCG to address financial underperformance or issues of quality, the leadership of the Integrated Care System will play a key role in agreeing what remedial action needs to be taken; and all approved Integrated Care Systems will be required to operate under these fully-developed system control total incentive structures by 2019/20. However, in 2018/19 systems that are not ready to proceed with full system incentives and shared intervention arrangements will alternatively be allowed to adopt an interim approach under which only the additional funding that has been put into the PSF ( 650 million in aggregate) will be linked to system financial performance. On this option, no payment will be made from this enhanced funding unless the system as a whole meets its control total. If individual trusts or CCGs miss their organisational control totals, but the system still achieves overall, their share will be apportioned in consultation with the system leadership. However, on this interim option 4 Integrated Care Systems will be informed of their system control total by NHS England and NHS Improvement in writing, shortly after this this guidance is published 109

110 if the individual trusts or CCGs meet their organisational control totals, but the system does not overall, they will retain access to the relevant share of the existing 1.8 billion PSF and any applicable CSF awards. New Integrated Care Systems 5.8 There is strong appetite amongst other systems to join the Integrated Care System development programme and we anticipate that additional systems will wish to join during 2018/19 as they demonstrate their ability to take collective responsibility for financial and operational performance and health outcomes. STPs that can demonstrate their readiness to join the programme should speak to their regional teams to confirm expressions of interest from all organisations in the STP. We will aim to review any applications to join the programme by March We envisage that over time Integrated Care Systems will replace STPs. 5.9 The next cohort of Integrated Care Systems will be selected from STPs with: strong leadership, with mature relationships including with local government. The leadership team should have effective ways of involving clinicians and staff, the third sector, service users and the public. It should also have the right capability and infrastructure to execute on priorities; a track record of delivery, with evidence of tangible progress towards delivering the priorities in Next Steps on the Five Year Forward View. These systems should be meeting NHS Constitution standards or provide confidence that by working as an integrated system they are more likely to be recovered; strong financial management, with a collective commitment from CCGs and providers to system planning and shared financial risk management, supported by a system control total and system operating plan; a coherent and defined population that reflects patient flows and, where possible, is contiguous with local government boundaries; and compelling plans to integrate primary care, mental health, social care and hospital services using population health approaches to redesign care around people at risk of becoming acutely unwell. These models will necessarily require the widespread involvement of primary care, through incipient networks. Public Engagement 5.10 As systems make shifts towards more integrated care, we expect them to involve and engage with patients and the public, their democratic representatives and other community partners. Engagement plans should reflect the five principles for public engagement identified by Healthwatch and highlighted in the Next Steps on the Five Year Forward View. 110

111 6 Process and Timetable 6.1 The task for commissioners and providers is to update the 2018/19 year of existing two-year plans to take account of the points set out above and to ensure that operating plans: are stretching and realistic, and show a bottom line position consistent with the control totals set by NHS England and NHS Improvement; are the product of partnership working across STPs, with clear triangulation between commissioner and provider plans and related contracts to ensure alignment in activity, workforce and income and expenditure assumptions and with assurance from STP leaders that this is the case whilst ensuring the updated plans and contracts are aligned between commissioners and providers. As a result of the activity moderation incentives in the new Commissioner Sustainability Fund and the revised Quality Premium scheme, it is now more critical than ever that activity and finance plans are aligned between commissioners and providers; and include appropriate phasing profiles to reflect seasonal changes in demand, especially related to winter, and ensuring efficiency savings are not back-loaded into the later part of the financial year. Contract Variations 6.2 Where the 2018/19 plans have changed and these changes need to be reflected in the finance, activity or other schedules for the second year of twoyear contracts, a contract variation should be agreed to this effect, and signed no later than 23 March The NHS Standard Contract sets out clear rules relating to the updating of a contract for a second year, and our expectation is therefore that there should be no disputes between commissioners and providers about these variations. 6.4 Where commissioners and providers fail to reach timely agreement the dispute resolution process in the contract should be followed. Starting with escalated negotiation, the process then moves into mediation. Mediation may be undertaken within STPs if both parties are in agreement, or where this is not possible, it may be arranged with a third party. Where, exceptionally, agreement is not reached through mediation, organisations will be expected to follow the Expert Determination process set in the dispute resolution guidance, which will be published shortly. NHS England and NHS Improvement will view use of mediation, and in particular determination, as a failure of local system relationships and leadership. This guidance also provides detailed advice about the rules within the Contract on varying a contract for its second year. 6.5 On 3 January 2018, NHS England published a National Variation to the Standard Contract. This was principally to give effect to changes to the ambulance response standards, but took the opportunity to incorporate other national policy requirements which had been announced since the planning round. In particular, these related to: prohibiting the sale of sugary 111

112 drinks on NHS provider premises; prohibiting the provision or promotion of certain legal services from NHS provider premises; and mandating participation by NHS providers in the Nationally Contracted Products Programme. Commissioners and providers are legally bound to incorporate these changes into local contracts. Plan Submissions 6.6 All commissioners (CCGs and direct commissioning including specialised) and all providers are required to submit a full suite of operating plan returns to the deadlines in the national timetable (see below); and also adhere to the contract variation deadlines and processes. We will update technical planning guidance to support the submission of templates to ensure plans are completed on a consistent basis and to a high standard. The data collected will be used to inform decision making and will also form the plan against which 2018/19 delivery is judged. All organisations must ensure submissions are accurate, detailed and consistent with their Board approved plans. 6.7 For providers the first and final plan submission will include finance, activity, workforce and triangulation returns alongside an update to the existing two-year plan narrative. For providers that are part of an Integrated Care System the provider plan narrative will be updated with a system plan narrative that describes the key changes to the existing plan, which will be assured jointly by NHS England and NHS Improvement. 6.8 Provider workforce plans will need to consider the significant workforce supply and retention challenges in the NHS. For 2018/19, providers are expected to update their workforce plans to reflect latest projections of supply and retention, taking into account the supply of staff from Europe and beyond, changes to NHS nursing and allied health professional bursaries, improvements expected in agency and locum use. Plans should also be updated to take account of the strengthening of bank arrangements and opportunities identified for improved productivity and workforce transformation through new roles and/or new ways of working. It is important that workforce plans are detailed and well-modelled and align with both financial and service activity plans to ensure the proposed workforce levels are affordable, efficient and sufficient to deliver safe care to patients. The workforce plans submitted will be used nationally for pay modelling during the year. 6.9 Commissioners will need to submit draft and final commissioner operating plan updates, using the financial, performance activity and milestone plan templates. These and the supporting guidance will be issued separately. Draft and final finance, performance and activity plans must be consistent, and triangulated with provider expectations For STPs, para 2.17 sets out the requirement to ensure alignment in activity, income and expenditure assumptions across STPs. Building on the 2017/18 in year contract alignment approach, we will be asking STP leaders to return a contract and plan alignment template to demonstrate that updated plans and contracts are aligned financially between commissioners and providers. 112

113 CQUIN and Quality Premium 6.11 NHS England will shortly be publishing an update to the 2017/19 CQUIN guidance. This update is required to provide indicator thresholds for some indicators for year 2 of the scheme. As part of the update, NHS England will clarify the requirements around the influenza vaccination indicator. In addition, NHS England has made some changes to the anti-microbial resistance indicator to take account of supply issues. The sepsis indicator will also be updated to require providers to replace locally devised protocols with a National Early Warning Score 2 (NEWS 2) by March In September 2017, the National Quality Board strongly endorsed NEWS 2 as a standardised system between clinicians in the acute setting to help early detection of deterioration/ identification of sepsis. Organisations will also be required to make a one-off data return in relation to the healthy food and drink indicator at the end of Q In addition, in light of the specific challenges around delivering provider side balance, NHS England has agreed with NHS Improvement to offer a temporary relaxation of an element of the scheme for acute providers. Our shared position is that this concession is being made in 2018/19 only. On the basis that there are multiple initiatives supporting the discharge agenda, we have agreed to suspend the proactive and safe discharge indicator for acute providers, with the remaining five indicators in the scheme increasing their weighting from 0.25% to 0.3% as a temporary measure for 2018/ This change will have implications for the linked indicators in Community and Care Home settings. We are issuing an updated indicator for Care Home providers. For Community providers, we expect CCGs to either take this opportunity to include a local CQUIN indicator in their contracts, or increase the weights of the remaining five indicators in the scheme to 0.3% The 0.5% risk reserve CQUIN will be withdrawn in 2018/19. The 0.5% will be added to the engagement CQUIN, which will increase as a result to 1% Our collective expectation is that the degree of conditionality in CQUIN will return to its 2017/18 levels from 2019/20. These temporary suspensions are not an indication of our future intentions for the CQUIN scheme, in respect of the quantum, the number of indicators, or their respective weightings In line with our policy intent that CQUIN is realistically earnable, NHS England and NHS Improvement will be trialling a new triangulated provider/ commissioner finance return, to confirm whether CQUIN awards have been earned during the year As previously indicated, the 2018/19 Quality Premium scheme will be restructured to include an incentive on non-elective demand management. Given the significant emphasis we wish CCGs to give to this issue, the nonelective measure will make up the majority of the Quality Premium scheme, with a potential award of 210 million nationally. We will retain a number of the existing quality measures, which will be linked to the remainder of the potential 113

114 Quality Premium funding, and we will continue to moderate payment through the operation of the existing Finance and Quality gateways. We will shortly publish updated guidance which will set out the full details of the revised scheme. Winter Demand & Capacity Plans 6.18 There will be no additional winter funding in 2018/19. To ensure that winter preparation has been undertaken well in advance and using existing funds, systems will need to demonstrate that winter plans are embedded both in their system plans and in individual organisations operating plans, including realistic phasing of non-elective and elective activity across the year To support this there is a requirement for each system to produce a separate winter demand and capacity plan, triangulating the finance and activity implications along with the actions and proposed outcomes. Guidance on submitting these winter plans will be available by March Timetable Item Date ICS system control total changes and assurance statement submitted By 1 March 2018 Local decision to enter into mediation for 2018/19 contract variations 2 March 2018 Draft 2018/19 Organisational Operating Plans submitted 8 March 2018 Draft 2018/19 STP Contract and Plan Alignment template submitted 8 March 2018 National deadline for signing 2018/19 contract variations and contracts 23 March /19 Expert Determination paperwork completed and shared by all parties 27 April 2018 Final Board or Governing Body approved Organisation Operating Plans submitted 30 April /19 Winter Demand & Capacity Plans submitted 30 April 2018 Final 2018/19 STP Contract and Plan Alignment template submitted 30 April 2018 Final date for experts to notify outcome of determinations for 2018/19 update 8 June

115 Annex 1: 2018/19 Deliverables Reminder of 2018/19 deliverables drawn from Next Steps on the NHS Five Year Forward View published in March 2017 The NHS already has two-year priorities, set out in last year s Planning Guidance and the March 2017 publication of the Next Steps on the NHS Five Year Forward View. This Annex confirms these deliverables for 2018/19. For national targets we will, where appropriate, provide disaggregated STP and CCG-level improvement targets and templates to ensure plans are completed on a consistent basis. 1. Mental Health Overall Goals for We published Implementing the Mental Health Forward View in July 2016 to set out clear deliverables for putting the recommendations of the independent Mental Health Taskforce Report into action by 2020/21. The publication of Stepping Forward to 2020/21 5 in July 2017 provides a roadmap to increase the mental health workforce needed to deliver this. Making parity a reality will take time, but this a major step on the journey towards providing equal status for mental and physical health. These ambitions are underpinned by significant additional funding for mental health care, which should not be used to supplant existing spend or balance reductions elsewhere. Progress in 2017/18 On track to ensure an extra 35,000 children and young people are able to access services this year. 70 new or extended community eating disorder services funded and commissioned. 81 new beds for Children and Adolescent Mental Health Services (Tier 4) and at least another 50 beds will open by Deliverables for 2018/19 Additional funding has now been built into CCG 2018/19 allocations to support the expansion of services outlined in this planning guidance and the specific trajectories set for 2018/19 to deliver the Five Year Forward View for Mental Health. Progress to be made against all deliverables in the Next Steps on the NHS Five Year Forward View and the Implementing the Mental 5 Stepping Forward to 2020/21: Mental Health Workforce Plan for England (Health Education England). 115

116 end of March Expanded specialist perinatal care with over 5,000 additional women accessing these services between April and December Contracts awarded for four new Mother and Baby Units. Continued to meet the waiting time standard for early intervention in psychosis. Physical health checks and interventions for patients with severe mental illness in secondary care, with 60% of people in inpatient settings and 42% in community mental health teams receiving this to date. Health Education England (HEE) expects to provide over 600 training places for Improving Access to Psychological Therapies (IAPT) practitioners. At least 800 practitioners in primary care settings by March mental health new care models up and running and an additional 7 go live by April CCGs have continued to meet the dementia diagnosis standard, which was at 68.3% by December Seven Global Digital Exemplar Mental Health Trusts, funded to identify trusts which they will partner with as fast followers. Health Forward View in 2018/19 with all CCGs and STPs required to: Each CCG must meet the Mental Health Investment Standard (MHIS) by which their 2018/19 investment in mental health rises at a faster rate than their overall programme funding. CCGs auditors will be required to validate their 2018/19 year-end position on meeting the MHIS. Ensure that an additional 49,000 children and young people receive treatment from NHS-commissioned community services (32% above the 2014/15 baseline) nationally, towards the 2020/21 objective of an additional 70,000 additional children and young people. Ensure evidence of local progress to transform children and young people s mental health services is published in refreshed joint agency Local Transformation Plans aligned to STPs. Make further progress towards delivering the 2020/21 waiting time standards for children and young people s eating disorder services of 95% of patient receiving first definitive treatment within four weeks for routine cases and within one week for urgent cases. Deliver against regional implementation plans to ensure that by 2020/21, inpatient stays for children and young people will only take place where clinically appropriate, will have the minimum possible length of stay, and will be as close to home as possible to avoid inappropriate out of area placements, within a context of additional beds. Continue to increase access to specialist perinatal mental health services, ensuring that an additional 9,000 women access specialist perinatal mental health services and boost bed numbers in the 19 units that will be open by the end of 2018/19 so that overall capacity is increased by 49%. 116

117 117 Continue to improve access to psychology therapies (IAPT) services with, maintaining the increase of 60,000 people accessing treatment achieved in 2017/18 and increase by a further 140,000 delivering a national access rate of 19% for people with common mental health conditions. Do so by supporting HEE s commissioning of 1,000 replacement practitioners and a further 1,000 trainees to expand services. This will release 1,500 mental health therapists to work in primary care. Approximately two-thirds of the increase to psychological therapies should be in new integrated services focused on people with co-morbid long term physical health conditions and/or medically unexplained symptoms, delivered in primary care. Continue to ensure that access, waiting time and recovery standards are met. Continue to work towards the 2020/21 ambition of all acute hospitals having mental health crisis and liaison services that can meet the specific needs of people of all ages including children and young people and older adults; and deliver Core 24 mental health liaison standards for adults in 50% of acute hospitals subject to hospitals being able to successfully recruit. Ensure that 53% of patients requiring early intervention for psychosis receive NICE concordant care within two weeks. Support delivery of STP-level plans to reduce all inappropriate adult acute out of area placements by 2020/21, including increasing investment for Crisis Resolution Home Treatment Teams (CRHTTs) to meet the ambition of all areas providing CRHTTs resourced to operate in line with recognised best practice by 2020/21. Review all patients who are placed out of area to ensure that have appropriate packages of care.

118 Deliver annual physical health checks and interventions, in line with guidance, to at least 280,000 people with a severe mental health illness. Provide a 25% increase nationally on 2017/18 baseline in access to Individual Placement and Support services. Maintain the dementia diagnosis rate of two thirds (66.7%) of prevalence and improve post diagnostic care. Deliver their contribution to the mental health workforce expansion as set out in the HEE workforce plan, supported by STP-level plans. At national level, this should also specifically include an increase of 1,500 mental health therapists in primary care in 2018/19 and an expansion in the capacity and capability of the children and young people s workforce building towards 1,700 new staff and 3,400 existing staff trained to deliver evidence based interventions by 2020/21. Deliver against multi-agency suicide prevention plans, working towards a national 10% reduction in suicide rate by 2020/21. Deliver liaison and diversion services to 83% of the population. Ensure all commissioned activity is recorded and reported through the Mental Health Services Dataset. 2. Cancer Overall Goals for Advance delivery of the National Cancer Strategy to promote better prevention and earlier diagnosis and deliver innovative and timely treatments to improve survival, quality of life and patient experience by 2020/

119 Progress in 2017/18 Cancer survival at its highest ever with latest figures showing that one-year cancer survival is up by over 2,000 people a year. 95.1% of people seen by a specialist within two weeks of an urgent GP referral for suspected cancer, with 5.1% more patients being seen in the 12 months to November 2017 than in the previous 12 months. Ten multidisciplinary rapid diagnostic and assessment centres in place across the country by March 2018, supporting patients with complex symptoms through to diagnosis. We are on track to deliver the largest radiotherapy upgrade programme in 15 years modern radiotherapy have now funded 26 new machines in 21 trusts in 2017/18. Half of the country s Cancer Alliances have begun to roll out personalised follow-up after cancer treatment. Added 22 more drugs to the Cancer Drugs Fund, which have benefitted nearly 7,500 more patients, taking the total since the reformed CDF launched in July 2016 to 15,700 patients having benefited from 52 drugs treating 81 different cancers. Deliverables for 2018/19 Ensure all eight waiting time standards for cancer are met, including the 62 day referral-to-treatment cancer standard. The 10 high impact actions for meeting the 62 day standard should be implemented in all trusts, with oversight and coordination by Cancer Alliances. The release of cancer transformation funding in 2018/19 will continue to be linked to delivery of the 62 day cancer standard. Support the implementation of the new radiotherapy service specification, ensuring that the latest technologies, including the new and upgraded machines being funded through the 130 million Radiotherapy Modernisation Fund, are available for all patients across the country. Ensure implementation of the nationally agreed rapid assessment and diagnostic pathways for lung, prostate and colorectal cancers, ensuring that patients get timely access to the latest diagnosis and treatment. Accelerating the adoption of these innovations helps meet the 62 days standard ahead of the introduction of the 28 day Faster Diagnosis Standard in April Progress towards the 2020/21 ambition for 62% of cancer patients to be diagnosed at stage 1 or 2, and reduce the proportion of cancers diagnosed following an emergency admission. Support the rollout of FIT in the bowel cancer screening programme during 2018/19 in line with the agreed national timescales following PHE s procurement of new FIT kit, ensuring that at least 10% of all bowel cancers diagnosed through the screening programme are detected at an early stage, increasing to 12% in 2019/20. Participate in pilot programmes offering low dose CT scanning based on an assessment of lung cancer risk in 119

120 CCGs with lowest lung cancer survival rates. Progress towards the 2020/21 ambition for all breast cancer patients to move to a stratified follow-up pathway after treatment. Around two-thirds of patients should be on a supported self-management pathway, freeing up clinical capacity to see new patients and those with the most complex needs. All Cancer Alliances should have in place clinically agreed protocols for stratifying breast cancer patients and a system for remote monitoring by the end of 2018/19. Ensure implementation of the new cancer waiting times system in April 2018 and begin data collection in preparation for the introduction of the new 28 day Faster Diagnosis standard by Primary Care Overall Goals for Stabilise general practice today and support the transformation of primary care and for tomorrow, by delivering General Practice Forward View and Next Steps on the NHS Five Year Forward View. Progress in 2017/18 52% of the country now benefitting from extended access including appointments on evenings and weekends, beating the target of 40% for 2017/18. Primary care workforce: o Over 770 additional GP trainees started specialist training since 2015 baseline (3,157 in total in 2017/18); o Begun GP international recruitment, with the first 100 GPs being recruited; Deliverables for 2018/19 Progress against all Next Steps on the NHS Five Year Forward View and General Practice Forward View commitments. This includes all CCGs: Providing extended access to GP services, including at evenings and weekends, for 100% of their population by 1 October This must include ensuring access is available during peak times of demand, including bank holidays and across the Easter, Christmas and New Year periods. Delivering their contribution to the workforce commitment 120

121 o Launched the GP Retention Scheme; o Recruitment of an additional 505 clinical pharmacists, in addition to the 494 already in post. Investment in general practice continues to increase on track to deliver the pledged additional 2.4 billion by CCGs investing in line with expectations set out in the 2017/18 NHS s Planning Guidance, for additional primary care transformation investment ( 3/head) over two years. Invested in upgrading primary care facilities, with 844 schemes completed and a further 868 schemes in development. to have an extra 5,000 doctors and 5,000 other staff working in primary care. CCGs will work with their local NHS England teams to agree their individual contribution and wider workforce planning targets for 2018/19. At national aggregate level we are expecting the following for 2018/19: o CCGs to recruit and retain their share of additional doctors via all available national and local initiatives; o 600 additional doctors recruited from overseas to work in general practice; o 500 additional clinical pharmacists recruited to work in general practice (CCGs whose bids have been successful will be expected to contribute to this increase); o An increase in physician associates, contributing to the target of an additional 1000 to be trained by March 2020 (supported by HEE); o Deliver increase to 1,500 mental health therapists working in primary care. Investing the balance of the 3/head investment for general practice transformation support. Actively encourage every practice to be part of a local primary care network, so that there is complete geographically contiguous population coverage of primary care networks as far as possible by the end of 2018/19, serving populations of at least 30,000 to 50,000. Investing in upgrading primary care facilities, ensuring completion of the pipeline of Estates and Technology Transformation schemes, and that the schemes are delivered within the timescales set out for each project. Ensuring that 75% of 2018/19 sustainability and resilience funding allocated is spent by December 2018, with 100% of the allocation spent by March

122 Ensuring every practice implements at least two of the high impact time to care actions. In all practices, delivering primary care provider development initiatives for which CCGs will receive delegated budgets, including online consultations. Where primary care commissioning has been delegated, providing assurance that statutory primary medical services functions are being discharged effectively. Lead CCGs expected to commission, with support from NHS England Regional Independent Care Sector Programme Management Offices, medicines optimisation for care home residents with the deployment of 180 pharmacists and 60 pharmacy technician posts funded by the Pharmacy Integration Fund for two years. 4. Urgent and Emergency Care Overall Goals for Redesign and strengthen the urgent and emergency care system to ensure that patients receive the right care in the right place, first time. Progress in 2017/18 More patients able to speak to a clinician about their urgent and emergency care needs when calling NHS % of answered calls now receive clinical input, up from 22% last year. Piloted and evaluated NHS 111 Online in a number of areas, with 27% of the population now able to access urgent and emergency care advice through this online portal. Deliverables for 2018/19 Ensure that aggregate performance against the four-hour A&E standard is at or above 90% in September 2018, that the majority of providers are achieving the 95% standard for the month of March Also Trusts are expected to improve on their performance each quarter compared to their performance in the same quarter the prior year in order to qualify for STF payments. 122

123 110 Urgent Treatment Centres (UTCs) designated according to the revised standard specification. Ambulance Response Programme implemented in all English mainland ambulance trusts. 105 Trusts received capital funding of 96.7 million to implement front-door clinical streaming. Over 90% of Trusts now have this in place. 1,491 beds have been freed up as a result of reducing delayed transfers of care (DTOC). 30 million awarded to 74 areas to increase number of acute hospitals meeting the Core 24 standard for 24/7 mental health liaison teams. 97% of A&Es, 98% of the initial cohort of UTCs and 96% of e-prescribing pharmacies now have access to primary care records through either summary care records or local record sharing portals. Implementation of the NHS 111 Online service to 100% of the population by December Access to enhanced NHS 111 services to 100% of the population, with more than half of callers to NHS 111 receiving clinical input during their call. Every part of the country should be covered by an integrated urgent care Clinical Assessment Service (IUC CAS), bringing together 111 and GP out of hours service provision. This will include direct booking from NHS 111 to other urgent care services. By March 2019, CCGs should ensure technology is enabled and then ensure that direct booking from IUC CAS into local GP systems is delivered wherever technology allows. Designate remaining UTCs in 2018/19 to meet the new standards and operate as part of an integrated approach to urgent and primary care. Work with local Ambulance Trusts to ensure that the new ambulance response time standards that were introduced in 2017/18 are met by September Handovers between ambulances and hospital A&Es should not exceed 30 minutes. Deliver a safe reduction in ambulance conveyance to emergency departments. Continue to make progress on reducing delayed transfers of care (DTOC), reducing DTOC delayed days to around 4,000 during 2018/19, with the reduction to be split equally between health and social care. Continue to improve patient flow inside hospitals through implementing the Improving Patient Flow guidance 6. Focus specifically on reducing inappropriate length of stay for admissions, including specific attention on stranded and

124 124 super stranded patients who have been in hospital for over 7 days and over 21 days respectively. Continue to work towards the 2020/21 deliverable of all acute hospitals having mental health crisis and liaison services that can meet the specific needs of people of all ages including children and young people and older adults; and deliver Core 24 mental health liaison standards for adults in 50% of acute hospitals, subject to hospitals being able to successfully recruit. Ensure that fewer than 15% of NHS continuing healthcare full assessments take place in an acute setting. Continue to progress implementation of the Emergency Care Data Set in all A&Es (Type 1 and Type 2 by June 2018; and Type 3 by the end of 2018/19). Increase the number of patients who have consented to share their additional information through the extended summary care record to 15% and improve the functionality of e-scr by December Implement a proprietary appointment booking system at particular GP practices, 50% of integrated urgent care services and 50% of UTCs by May 2018, supported by improved technology and clear appointment booking standards issued by December Continue to rollout the seven-day services four priority clinical standards to five specialist services (major trauma, heart attack, paediatric intensive care, vascular and stroke) and the seven-day services four priority clinical standards in hospitals to 50% of the population.

125 5. Transforming Care for People with Learning Disabilities Overall Goals for Our goal is to transform the treatment, care and support available to people of all ages with a learning disability, autism or both so that they can lead longer, happier, healthier lives in homes not hospitals. Progress in 2017/18 22% increase in the number of annual health checks delivered by GPs to improve access to community alternatives to hospital and tackle premature mortality. New and expanded community teams to support people with a learning disability at risk of admission to hospital, backed by 10 million transformation funding. 6% reduction in inappropriate hospitalisation of people with a learning disability, autism or both, between March and November 2017, totalling a 14% reduction since March In addition, over 100 people previously in hospital for 5 years or more were discharged between March and November Tackling premature mortality by beginning to systematically review and learn from deaths of patients with learning disabilities by March Deliverables for 2018/19 All Transforming Care Partnerships (TCPs), CCGs and STPs are expected to: Continue to reduce inappropriate hospitalisation of people with a learning disability, autism or both, so that the number in hospital reduces at a national aggregate level by 35% to 50% from March 2015 by March As part of achieving that reduction we expect CCGs and TCPs to place a particular emphasis on making a substantial reduction in the number of long-stay (5 year+ inpatients). Continue to improve access to healthcare for people with a learning disability, so that the number of people receiving an annual health check from their GP is 64% higher than in 2016/17. CCGs should achieve this by both increasing the number of people with a learning disability recorded on the GP Learning Disability Register, and by improving the proportion of people on that register receiving a health check. Make further investment in community teams to avoid hospitalisation, including through use of the 10 million transformation fund. Ensure more children with a learning disability, autism or both get a community Care, Education and Treatment Review (CETR) to consider other options before they are admitted to hospital, such that 75% of under 18s admitted to hospital have either had a pre-admission CETR or a CETR immediately post admission. 125

126 Continue the work on tackling premature mortality by supporting the review of deaths of patients with learning disabilities, as outlined in the National Quality Board 2017 guidance. 6. Maternity Overall Goals for Continue to make maternity services in England safer and more personal through the implementation of the Better Births. Progress in 2017/18 Continuing the year on year safety improvements to maternity services including, since 2010, a 16% reduction in stillbirths, 10% reduction in neonatal mortality and 20% reduction in maternal deaths. Seven maternity early adopters established covering 125,000 births a year to implement specific elements of Better Births and service improvements. Pilots of continuity of carer established to over 3,000 women. 44 Local Maternity Systems established bringing together commissioners, providers and service users to lead and deliver transformation of maternity services in every part of the country. We will exceed the planned goal of 2,000 more women receiving specialist perinatal care in 2017/18, with over 5,000 additional women accessing these services between April and December Four new mother and baby units also funded. Deliverables for 2018/19 Deliver improvements in safety towards the 2020 ambition to reduce stillbirths, neonatal deaths, maternal death and brain injuries by 20% and by 50% in 2025, including full implementation of the Saving Babies Lives Care Bundle by March Increase the number of women receiving continuity of the person caring for them during pregnancy, birth and postnatally, so that by March 2019, 20% of women booking receive continuity. Continue to increase access to specialist perinatal mental health services, ensuring that an additional 9,000 women access specialist perinatal mental health services and boost bed numbers in the 19 units that will be open by the end of 2018/19 so that overall capacity is increased by 49%. By June 2018, agree trajectories to improve the safety, choice and personalisation of maternity. 126

127 N.B. This is not a comprehensive list of Next Steps deliverables for 2018/19, simply an aide memoire covering these service improvement areas. CCGs and STPs should also continue to work to reduce inequalities in access to services and in people s experiences of care. 127

128 Barnet Health Board - informal seminar STP: Update and links to local delivery 128

129 Ambition of the STP Improve the health of the local population Ambition for the STP is built on existing CCGs, Local Authorities and Providers values and strategy Maximise care out of hospital Reduce health inequalities A partnership of the NHS and local authorities, working together with the public and patients where it s the most efficient and effective way to deliver improvements. 129

130 North London Partners context: 1. Diverse populations with some common and some varied challenges 2. Complex health and social care landscape with overlaps between hospital areas and borough boundaries 3. Providers, commissioners and local authorities all in different financial positions 4. Five NCL CCGs now working under joint arrangements with a single accountable officer and chief finance officer 5. Need to transform, improve and integrate care where this improves health and wellbeing outcomes and sustainability of services 6. Potential to share best practice, innovate and benefit from economies of scale 130 3

131 System wide working Changes to focus on the outcome for population and wider system, not on individual organisations/institutions Co designing services with patients, providers, clinicians, CCGs and Local Authorities. Aim is to speed up local implementation and spread of good practice through fastest first principle NHS provider organisations agreeing joint programme of work on productivity, over and above individual organisation savings plans (e.g. patient transport, facilities) CCG Commissioner Leads co-ordinating the co-design of services for improved outcomes and system efficiencies (e.g. Barnet CCG leading work on Urology, Stroke, Chronic Kidney Disease As the STP covers the whole of North Central London, lead responsibility for scrutiny of the STP overall sits with the Joint Health Overview and Scrutiny Committee; the Barnet representatives are Cllrs Alison Cornelius and Graham Old. 131

132 Clinical and leadership across North London Partners Fundamental to development and implementation of every aspect of the STP Clinical Input into each workstream essential with leadership across NCL CCGs (Barnet clinical leads for Planned Care and Cancer) Challenge and assurance of STP initiatives via Health and Care Cabinet (NCL CCG chairs and medical directors) STP Advisory Board includes Chairs of all CCGs Looking at systematic approach to quality improvement across all of the STP, with initial focus on Health and Care closer to Home 132

133 Clinical and senior leadership in place across North London Partners Clinical workstreams NCL Health and Care Cabinet: Richard Jennings and Jo Sauvage STP Clinical Leads and Co-Chairs Health and care Children and Prevention Planned care Mental Health Maternity closer to home young people NCL Programme Board and Advisory Board Input and membership of clinical working groups from across NCL CCGs, Providers and LAs Cancer Urgent and Emergency Care North London Councils Adult Social Care group Social Care Clinical leads Dr Karen Sennett (Islington) Dr Tom Aslan (Camden) Dr Richard Jennings, (Whittington) Dr Debbie Frost (Barnet) Dr Katie Coleman, (Islington) Borough based leads for each CCG Dr Vincent Kirchner (C&I) Dr Jonathan Bindman (BEH) Dr Oliver Anglin (Camden) Professor Donald Peebles Mai Buckley (Royal Free) Professor Geoff Bellingan (UCLH) Dr Clare Stephens (Barnet) Dr Samit Shah (Islington) Dr Chris Laing (UCLH) Dr Alex Warner (Camden) SROs Dr Julie Billet (Camden and Islington) Prof. Marcel Levi (UCLH) Tony Hoolaghan (H&I) Paul Jenkins (TAVI) Charlotte Pomery (Haringey LA) Rachel Lissauer (Haringey) Kathy Pritchard Jones UCLH Sarah Mansuralli (Camden) Dawn Wakeling (Barnet) 133

134 Development of plans for 2018/19 Three STP workstreams have at this point have identified material activity and finance impact - these have been developed through clinically led programmes of work. This has provided a joined up consistent approach across NCL including one set of plans Many are 2 nd year of existing schemes, plus new ideas generated from STP workstreams on UEC, HCC2H and Planned Care; and from individual CCGs These have been informed by pathways successfully implemented elsewhere with a focus on activity/system cost reduction as a guiding principle Provider view on how we build confidence in change crucial involvement in review of schemes As part of this, it has been important to highlight system impact i.e. any issues of stranded costs and stepped cost reductions Outputs of meetings -joint work between workstream leads and provider leads to: strengthen plans; understand impact; test logic; understand areas requiring more work 134

135 Current summary analysis of STP interventions The below is a summary analysis of the interventions across urgent and emergency care, planned care and health and care close to home. Barnet Camden Enfield Haringey Islington Total 17/18 M7 Acute FOT % of FOT % Royal Free 8,415,833 3,914,860 5,877, , ,596 19,022, ,899, % NMUH 31,561 9,547 7,848,058 4,265, ,925 12,423, ,923, % UCLH 598,001 3,645, , ,570 2,895,748 7,822, ,918, % Whitt (excl. Comm) 132, ,774 19,195 2,835,731 3,330,127 6,538, ,109, % Moorfields 15,660 17,672 37, , , ,643 incl. in other Other 86,709 1,135, , , ,668 2,974, ,781, % Total 9,280,466 8,943,563 14,604,100 8,891,639 7,611,680 49,331,448 1,122,631, % 17/18 CCG FOT 278,479, ,363, ,258, ,880, ,649,742 1,122,631,742 Value of Schemes as % of all acute spend 3.3% 4.6% 5.8% 4.3% 4.0% 4.4% 17/18 CCG M7 FOT 220,304, ,390, ,912, ,298, ,945, ,850,429 Main 4 Providers 4.2% 5.7% 7.0% 4.6% 4.6% 5.2% DRAFT initial figures only, to be revised through Jan/Feb 135 N.B. Ongoing work to refine and enhance plans will mean figures continue to iterate. 8

136 Ensuring alignment between STP and CCG Ongoing work to ensure alignment via DCFO and QIPP leads and workstream directors CCG leads involved in leading work and clinical redesign Meetings every two weeks across NCL for QIPP leads and Deputy CFOs Also work to align and coordinate across CCGs e.g. working effectively with Enfield where this can deliver more effectively. 136

137 Planned Care Achievements so far: Barnet approach to improving how GPs order tests (and reduce waste) implemented across borough and now being extended to NCL Tele-Dermatology new technology for examining skin complaints piloted at Royal Free to be rolled out across NCL Urology pathways across NCL being redesigned with specialists from Royal Free Hospital and implemented from Jan 2018 New model of GPs being able to access specialist advice implemented at first site in Jan, hospitals across NCL to go live through Next steps: Clinical redesign of the following pathways to focus on preventative, proactive care: Chronic Kidney Disease Musculoskeletal Disease Urology Cardiology Further work to minimise unnecessary testing and trips to hospital through better use of technology

138 Planned care The aim of this workstream is to support local systems with improvement planning to reduce variation across both primary and acute care and support the right care, right time, and right place for patients objective. Some of the NCL wide projects are: Tele- Dermatology Urology Clinical advice and navigation Diagnostics Chronic Kidney Disease Musculoskeletal Disease Cardiology We are also planning to undertake a review of NHS elective orthopaedic services across North Central London. The (proposed) review will examine options to improve quality of care, outcomes and efficiency. Below is an example of how the Teledermatology workstream has developed: Cohort : adults, Single service spec, single tariff 4 providers dermatology depts. working as a collective All skin referrals divided into lesions or rashes 2 new pathways created Underpinned by a teledermatology service Design Test Secure transfer of an image using ers to secondary care Triage with diagnosis, advice, management plans and prescriptions Reduce the pressure on 2 week wait dermatology referrals Cost effective, scalable Image quality and transfer Collective working models e.g. rota Pathway, service spec & tariff Create a data set for measuring the impact of the service Refine 138 Launch March 2018 Single service launch across NCL NHSE funding to evaluate Behavioural and organisational change Developing new KPI to measure system change Providers working as a collective to provide a standardised service Activity & uptake Evaluate

139 PROGRESS IN 2017/18 Progress at Sept 17: Service specification and contract finalised Procurement complete Tender awarded to the Barnet GP federation Service mobilisation complete Service operational Access LCS implemented Outstanding 17/18: Service reviewed Finances agreed for 2018/19 Progress at Sept 17: Expression of interest for CHIN pilot complete Burnt Oak CHIN GP practices given support of CCG to initiate CHIN pilot Burnt Oak priority areas identified as Diabetes (in-line with D-QIST bid) and Paediatric Urgent Access Pilot Outstanding 17/18: CCG sign off CHIN business case Services mobilised (likely Jan/ Feb) Review of service impact Finalise CHIN 139 governance Progress at Sept 17: D-QIST proposal submitted to the NCL Diabetes Transformation Board Proposal agreed by Board Federation and CLCH engaged with a view to providing the service and delivering the 3TT outcomes for Diabetes Burnt Oak focus of service for 2017/18 Outstanding 17/18: Services mobilised (likely Jan/ Feb) Review of service impact

140 Example neighbourhood integration: Care Network (CHIN) model CHINs are required to look at population health intervention and outcomes STP, CCG, CHIN QOF + targets: CHIN shared registers with templates to deliver QOF + Shared management/ input to delivery of targets annually Contracts aligned Pharmacist working across the practices within the CHIN. Working with registers, proactively reviewing patients. Practice based pharmacist CHIN TEAM Community Services staff (Specialist nurses, Physio etc.) Specific service lines working in primary care, alongside the CHIN practice teams to improve population health outcomes. Acute (specialist advice and guidance) 5 x General Practice team (GPs, PNs, HCAs) & QIST Mental Health Consultant/ specialist advice and guidance to GPs/ other CHIN staff in managing patients in primary care and avoiding unnecessary referrals. Voluntary Sector link worker/ navigator Voluntary sector care navigator linked to CHIN and able to proactively social prescribe. 140 Social Care Social care linked to CHIN to support and link to local authority support for proactive support. Mental Health input in to the team via a link worker or primary care mental health support through clinics within the CHI. Proactive population support. 13

141 Example 1: CHINS development status Burnt Oak CHIN Clinical lead: Dr Aash Bansal Focus: Diabetes and Paediatrics Population: 50,000 Involving: 5 practices Operational since: Jan 18 Road map: All system partners involved by April 2019 Contract with: TBC Contract: TBC CHIN 2 Clinical lead: Dr Anita Patel Focus: Frailty Population: TBC Involving: 7 practices Go live: Quarter Road map: All system partners by April 19 Contract with: TBC Contract: TBC CHIN 3 Clinical lead: Dr Alexis Ingram Focus: Long Term Conditions Population: TBC Involving: TBC Go live: Quarter Road map: All system partners by Apr 19 Contract with: TBC Contract: TBC CHIN 4, 5 and 6 Final CHINs, which would complete full borough coverage is currently being scoped and will be established during Established To be established in 2018 To be established in 2018 To be established in 2019 Barnet QIST Clinical lead: Dr Anuj Patel Focus: Diabetes Operational since: Feb 2018 Contract with: Not applicable NHS E Pilot through Diabetes Transformation Funding Established 141

142 Urgent and Emergency Care 1: Integrated urgent care 2: Admission avoidance 3: Simplified Discharge 4: Last Phase of Life To bring together and enhance current urgent care services which are outside of hospital, in order to create a single, unified urgent care service for NCL citizens To develop same day emergency care services in both acute and community settings to enable rapid assessment, diagnosis and treatment and avoid the need for overnight stays in hospital To develop improved discharge processes to reduce delays in patients leaving hospital when they are medically stable To bring specialist advice to staff who are looking after patients in the last year of their lives, in order to ensure best possible care and support to patients and reduce inequalities of care provision Achievements so far: Next steps: NCL is one of the first areas nationally to launch the new integrated urgent care model (this includes warm transfers for mental health and star divert numbers for clinical professionals) Piloting new improved discharge processes to prevent delays at all NHS trusts in NCL (discharge to assess pathway) A single NCL-wide referral form for rehabilitation services after hospital stays reducing delays across boroughs Patients phoning NHS 111 out of hours can be booked directly into a GP appointment if necessary in Barnet 142 Patients phoning NHS 111 will be able to be booked directly into a GP appointment if necessary in hours (across NCL) Continued implementation of pathways that mean patients do not have to wait to be assessed before leaving hospital New Ambulatory Care models will mean people can receive emergency treatments without being admitted to a hospital bed overnight Redesign of community service to prevent admissions to hospital Implementation of nursing support to care homes and Single Point of Access for specialist palliative care advice

143 Scheme Area NCL lead Extended Access CC2H Barnet QIPP plans Kate Colem an / Jenni Frost POLCE Planned Mark Eaton NCL value Barnet Value Outline 4.1m 0.7m To ensure everyone has easier and more convenient access to GP services, including appointments at evenings and weekends Make it easier for people see a GP from 8am to 8pm, seven days a week GP appointments that fit in with individuals family and work lives Reduce demand for A&E, for patients who are able to be seen by a GP 30 minutes per 1,000 population of GP capacity per week, per CCG 5.3m 1.0m To ensure the NCL PoLCE policy reflects the latest evidence base. To ensure the NCL PoLCE policy is efficiently and consistently implemented across NCL by both providers and commissioners. To minimise spend in areas where clinical evidence clearly shows there is limited benefit to patients to enable the funding to be diverted into services that will benefit patients. By: Workstream 1 Ensure Consistent Application of the Current Policy Workstream 2 Updating the existing Policy based on New Evidence Workstream 3: Rolling out changes agreed by Enfield CCG across NCL Workstream 4: Reviewing a wider range of procedures 143

144 Scheme Area NCL lead Diagnostics Plan Sophie Barnet QIPP plans - pathology Adult admissions avoidance rapid response services Reducing Non- Elective Admissions for Children ned UEC UEC Donnell an Matthe w Clark, Annie Roy, Muyi Adekoye i Claire Wright, Richard Tipping NCL value 4.2 m 3.6 m 3.5 m Barnet Value Tbc but low Outline Streamline pathology direct access testing electronically and reduce spend on inappropriate pathology GP direct access tests. Implement clinically developed protocols for GP direct access pathology test requests to ensure only appropriate tests are undertaken within appropriate timescales both for initial diagnosis and condition monitoring. Reduce orders for unnecessary / duplicate pathology tests by ensuring all pathology results are visible to all clinicians involved in patient care and only tests clinically indicated based on a patients individual symptoms or condition are undertaken. Improve patient experience of diagnostic pathways, ensuring appropriate tests are undertaken in a timely way which supports the delivery of the best possible treatments and patient outcomes. 0.5m Consistent service provision of the rapid response model across NCL through a defined set of core principles. A single point of access for a NCL wide rapids for primary care, LAS, other community services and acute providers (both for discharge support and admission avoidance). In reach support for emergency departments in assessing and identifying those that can be discharged home. Integrated support for discharge in supporting discharge to assess pathways for a quicker and robust discharge 0.9m Estimations of the proportion of emergency department attendances which are unnecessary (patients with low urgency problems which are unlikely to require admission and are more suitable for other services, such as general practice services, telephone advice helplines or pharmacies) and potentially avoidable vary from 15% to 40%. Within these estimates the largest subgroup is children presenting with symptoms of minor illness (highest for one and two year olds but also elevated between mid-teens and mid-twenties) Some children appear to be bypassing general practice and heading straight to the emergency department, while others are having numerous encounters with different healthcare professionals before also ending up at hospital. 144

145 Next steps for the Programme in 2018/19 Work with all our partners and public to design plans Ensure plans are clinically led and evidence based Communicate with our stakeholders and communities about the changes ahead Align our plans and ensure these contribute to financial sustainability Continuing to explore scope for NCL working and greater impact 145

146 Provider productivity Initiative Procurement UCL Partners Procurement Service Digital Access to UCLH contract with Atos Facilities management Collaborative approach to reprocurement of hard and soft FM services RFL group model Corporate services efficiencies Patient transport Reprocurement of patient transport contract Decontamination New RFL facility to be made available to other providers Diagnostics Procurement of a shared pathology service Review scope for collaborative work on imaging Medicines optimisation Invest to save proposals in relation to high cost medicines and biosimilars Workforce Resourcing including bank tender, shared recruitment policies, temporary staffing pay strategy Learning & development including mandatory training, shared resources Emergency acute rotas Review of opportunity to combine emergency medical rotas 146 Organisations involved RFL, WH, GOSH, NMUH, Moorfields, Links to other providers UCLH, BEH, Others TBC RFL, WH, UCLH, C&I RFL, NMUH RFL, WH, NMUH, Moorfields, (RNOH TBC) RFL, Others TBC WH, BEH, TBC RFL, UCLH, WH, NMUH, Moorfields, RNOH, CCGs All providers RFL, Whittington, NMUH, UCLH 19

147 Appendix: Barnet QIPP plans QIPP Scheme (Description/Classification) Clinical Lead Project Manager Care Closer to Home Barnet CHINs (incl STP QIST) Dr Tal Helbitz Daniel Glasgow Anticoagulant Support in the Community TBC Carol Kumar/ Kelly Poole STP Extended Access Dr Kate Coleman Kelly Poole CCH Total Urgent and Emergency Care New Model for Admissions <2 Hours TBC Beverley Wilding Reducing Non-Elective Admissions for Children Dr Murtaza Khanbhai Richard Tipping Reduction in General Medicine Non-Elective Admissions TBC Beverley Wilding Restructuring of PACE & TREAT TBC Muyi Adekoya RAID Switch to Tariff (from Block) at RFL TBC Richard Pearson STP Adult Admission Avoidance Dr Barry Subel Muyi Adekoya STP Ambulatory Emergency Care Dr Aashish Bansal Beveley Wilding STP Simplified Discharge (using Resilience Funding) TBC Beverley Wilding STP ED Streaming Dr Barry Subel Bhavini Shah STP High Intensity Users Dr Aashish Bansal Beverley Wilding STP Last Phase of Life Dr Caroline Stirling Jenne Patel STP Integrated Urgent Care (IUC) Dr Aashish Bansal Bhavini Shah STP Stroke Early Supported Discharge (ESD) - No PID. System BC due 5 Feb 2018 Dr Rob Simister Jenne Patel UEC Total Planned Care Dermatology Dr Swati Dholakia Teresa Callum MSK Dr Giovanna Russo Teresa Callum Pain TBA Lisa Savage Ophthalmology Dr Sharif Anwar Yasmeen Farooqi Cardiology Dr Amit Shah Lisa Savage Respiratory Dr Amit Shah Lisa Savage Breast Surgery Dr Clare Stephens Teresa Callum Children s OPDFU/OPDFA/OPDPRO Reduction Dr Murtaza Khanbhai Richard Tipping Physiotherapy (Acute) Dr. Nick Dattani Teresa Callum Vascular Surgery Dr. Nick Dattani Teresa Callum Demand Management Phase III Dr. Nick Dattani Teresa Callum Local Diagnostics & Pathology Programme TBA Neha Chennubotla STP Urology Dr Nik Dattani Teresa Callum STP Gastroenterology & Colorectal Surgery Melissa Patel Yasmeen Farooqi STP Clinical Advice & Navigation TBA Neha Chennubotla STP PoLCE Programme (Workstream 1) TBA Teresa Callum STP PoLCE Programme (Workstream 2) TBA Teresa Callum STP PoLCE Programme (Workstream 3) TBA Teresa Callum STP PoLCE Programme (Workstream 4) TBA Teresa Callum STP CKD Programme - PID with refined modelling to be drafted in TBA Teresa Callum STP Diagnostics Programme (Pathology) TBA Yasmeen Farooqi STP Diagnostics Programme (Imaging) TBA Yasmeen Farooqi

148 NCL Joint Commissioning Committee Thursday 5 th April 2018 Report title NCL Cancer Programme Update Agenda item 3.3 Date 29 th April 2018 Lead director Report author Sponsor(s) (where applicable) Report summary Paul Sinden Director of Performance and Acute Commissioning Ed Nkrumah Director of Performance Tel/ p.sinden@nhs.net Tel/ edmund.nkrumah@nhs.net N/A Tel/ N/A The purpose of this report is to update the Committee on the range of initiatives being undertaken across North Central London (NCL), in close collaboration with key stakeholders including UCLH Cancer Collaborative (covering NCL and North East London footprint), Transforming Cancer Services Team (London) and acute Trusts in the sector. These initiatives are informed by the National Cancer Strategy and the Five Year Forward View which has been translated into Annual Operating Plans and the CCG Improvement and Assessment Framework. The primary aim of these strategies is to improve outcomes for patients diagnosed with cancer through; - Prevention initiatives, - Faster diagnosis, and - Better treatment and care for people diagnosed with cancer. This report also makes the clinical case for the cancer transformation programme by outlining the key challenges relating to increasing rate of cancer diagnoses and the health and social care demands associated with improving life expectancy of cancer survivors. As the designated system leader for cancer transformation, the UCLH Cancer Collaborative has been playing a central role in shaping the local programmes to deliver against these desired improvement outcomes. The cancer work programmes across NCL are describes in this report under the following broad headings: Prevention: This is largely managed at local CCG level with commissioners working with local authority partners to deliver smoking cessation services and reducing obesity in both children and adults. Early Detection: The STP is working closely with Public Health England and NHS England to ensure local areas are prepared for the proposed changes to some (bowel and cervical) screening programmes and to explore options for 148

149 increasing uptake and plan for the resulting increase in demand for endoscopy and cystoscopy. Early Diagnosis: Efforts to ensure compliance with NICE guidance in respect of urgent GP direct access to diagnostics and diagnostic optimisation exercise led by Transforming Cancer Services Teams are examples of work programmes aimed at delivering faster diagnosis of patients. The importance of early diagnosis is being reinforced by the introduction of the Faster Diagnosis Standard (diagnosis by day 28 of referral) in Waiting time to Treatment The waiting time to treatment national operational standard remains a top priority in 2018/19 and a precondition for accessing the Cancer Transformation Fund. Although NCL has made significant improvements in the last few months, recovery on a sustainable basis remains a challenge that is being closely managed under significant scrutiny from regulators. NCL plans to recover in June Survivorship: With the partial release of the 2018/19 Cancer Transformation Funding to London, it is expected that plans to implement stratified follow-up in the community and recovery packages will commence in the new few weeks. These programmes will directly contribute to patients experience of care before, during and after treatment another key priority for the STP. The roles of key partners are also highlighted in this report to show the alignment of priorities across the system and the respective contributions to the National Cancer Strategy. Purpose (tick one only) Information Approval To note Decision Recommendation Conflicts of Interest Strategic Direction Identified risks and risk management actions Resource implications Engagement Equality impact analysis The NCL Joint Commissioning Committee is asked to: NOTE and COMMENT ON the Cancer Programme being developed for NCL Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy. The report is aligned to the 2017/18 and 2018/19 CCG Planning Guidance, the National Cancer Strategy and North Central and East London Cancer Alliance priorities. The key risks to the delivery of the NCL cancer programme are: Delivery of the 62-day cancer waiting time standard. Lack of capacity and resources within acute trusts and the commissioning system to manage increasing demand for services and commissioning work programmes, respectively. These are being mitigated through the development of recovery plans and regular reviews of demand and capacity. The programmes are resourced by various NHS organisations and the charitable sector. Resource requirements will be reviewed in light of increasing scale of the work programmes. Key stakeholders have been engaged in the development of the various programmes. This report was written in accordance with the provisions of the Equality Act

150 Report history Next steps Appendices This is first detailed report to the Committee that is focused on the wider cancer programme. Updates on cancer performance are provided in the monthly performance and quality report presented to the Committee. Work with the various stakeholders will continue and the Committee will receive regular progress updates. None 150

151 North Central London Cancer Programme Update March 2018 Ed Nkrumah Charlotte Stone 151

152 Table of Contents 1. Strategic Context & Overview /19 Planning Guidance - Deliverables 3. Early Detection: Screening Uptake & Projects 4. Early Diagnosis: Projects, GP Direct Access to Diagnostic Services & qfit 5. Cancer Waiting Times to Treatment: Performance, Improvement Actions, Harm & Risks 6. Living with and Beyond Cancer 7. Patient Experience 8. UCLH Cancer Collaborative (NCEL Cancer Alliance or Vanguard) 9. Transformation Funding: 2017/18 and 2018/ Transforming Cancer Services Team (TCST) 11. Charitable Sector 12. Governance 13. Key Issues & Risks 14. Recommendations 152 1

153 1. Strategic Context (1/2) The NHS 5 Year Forward View published in October 2014 prioritises improvements in cancer services because; Cancer remains the leading cause of mortality across England 1 in 2 people born after 1960 in the UK will be diagnosed with some form of cancer during their lifetime 50% of those with cancer will live for at least 10 years. People living with and beyond cancer typical suffer from other long term conditions and require proactive management to live normal lives. This is below the European average especially for over 75s. 30,000 people were living with cancer in NCL at the end of March % annual increase since March in 10 people who have cancer have at least one other long term condition 1 in 5 cancers are diagnosed through emergency presentations the majority being stage 3 or 4 (late stage diagnosis) Volume of urgent GP referrals for suspected cancers (2-week waits) continues to increase in line with demographic (age and lifestyle) changes and NICE guidelines. Currently 1 in 5 GP referrals to a consultant-led clinics is for suspected cancer. Suspected cancer referrals and treatments have increased by more than 10% in the last year. 15 months after diagnosis, people with cancer had 60% more A&E attendances, 97% emergency admissions, four times as many outpatient attendances and nearly six times more elective admissions than would be expected in a population of the same age/gender, according to a Nuffield Trust study

154 1. Strategic Context (2/2) The National Cancer Strategy therefore focuses on improving outcomes (prevention, survival, patient experience and quality of life of cancer survivors) through; - prevention, - faster diagnosis, and - better treatment and care for people diagnosed with cancer. Priority for 2017/18 has been the recovery and sustainable delivery of 62 cancer waiting time standards. Recent guidance on refreshing 2018/19 NHS operating plans reiterates the national commitment to deliver cancer waiting times standards amongst other improvement priorities. These are also aligned to the 5 Year Forward View ambitions and reinforced in the CCG Improvement and Assessment Framework, Annual Operational Plans, Quality Premium Schemes

155 1. Strategic Overview Interventions to improve outcomes fall under one of the stages of the pathway depicted below, with patient experience as the overarching goal. Improving Patient Experience (delivering person-centred care across the entire cancer pathway) Prevention (Working with local authority partners on smoking cessation and obesity reduction programmes) Early Detection (working with PHE and NHSE on cervical, Breast and Bowel Screening programmes) Early Diagnosis (Access to diagnostics supported by the Faster (28 Days) Diagnosis Standard from 2020) Waiting Time to Treatment Standards (Treatment within 62 days of GP referral) Survivorship (Living with and Beyond Cancer Recovery package, stratified followup services) Further work is required to ensure NCL STP initiatives on cancer prevention is integral to the outcomes improvement agenda

156 /19 Planning Guidance - Deliverables 156 5

157 3. Early Detection - Screening Uptake Bowel screening Uptake: Breast screening Uptake: Cervical screening Uptake: 157 6

158 3. Early Detection - Screening Projects (1/2) Screening programmes are commissioned by NHSE and PHE, however, CCGs are required to commission and fund the diagnostics component (e.g. cystoscopy for cervical screening and endoscopy for bowel screening). Project Increasing Cervical Screening coverage through alternative provision and digital (pilot mobile app and text messaging) Safety netting: Negotiated for NCL GP practices to attend NEL/UCLH CC safety netting workshops in March 2018 Expected Outcome Increase in proportion of cases diagnosed at Stage 1 and 2. Increased awareness in primary care Progress to date Next Steps Risks NHSE has been developing SMS text message reminders which is due to go live in April 2018 NHSE working with Barnet and Jo Cervical Cancer Trust are rolling out targeted campaigns for women aged between Working with Cancer Research UK and TCST to develop safety netting GP practice check list/implementation plan Development of implementation plans for Primary HPV Screening in the NHS Cervical Screening Programme by December 2019 Further efforts to be made following the release of 2018/19 Cancer Transformation Funding HPV Screening is likely to increase demand for colposcopy by between 40 and 60% Lack of engagement from primary care 158 7

159 3. Early Detection Screening Projects (2/2) Project Expected Outcome Progress to date Next Steps Risks Increasing participation in Bowel Screening through engagement nonresponders, replacement of gfobt test with FIT Increasing breast screening uptake through effective contract management by NHSE Increase in proportion of cases diagnosed at Stage 1 and 2. Increase in proportion of cases diagnosed at Stage 1 and 2. Roll out of bowel scope being offered in GP practice population within Haringey and Camden CCG Barts Health service is transferring to RFL with ongoing discussions to concerns relating to capacity and performance. Roll out of bowel scope being offered to Barnet and Islington patient s Ensure a safe transfer of screening services from Bart s Health to RFL Delay in implementation due to national delay in procurement of approx. 11 months FIT likely to increase demand for endoscopy beyond existing capacity. Capacity constraints may not improve in the short to medium term

160 4. Early Diagnosis: Projects (1/2) Project Expected Outcome Progress to date Next Steps Risks Diagnostic Optimisation Urgent direct access to diagnostics in line with NICE Guidelines Multidisciplinary Diagnostic Centre (MDC) Address anticipated demand and capacity imbalance for key modalities (endoscopy, MRI, CT) Increase in proportion of cases diagnosed at Stage 1 and 2. Early diagnosis of patient having suspected cancer with vague symptoms Baseline work completed by providers with support from TCST. NCL providers fully engaged and working towards full compliance. MDC being piloted at UCLH and NMUH. RFL pilot commenced in January Governance arrangement of the programme under review to ensure alignment with other STP programmes Communication with GPs about available services. Monitoring to ensure full compliance Promotion of the services at RFL, UCLH and NMUH. Lack of engagement from providers and commissioner ownership due to competing priorities Over ordering resulting in a net increase in demand Lack of capacity to extend pilot and lack of clarity around protocols for onward referral

161 4. Early Diagnosis: Projects (2/2) Project Expected Outcome Progress to date Next Steps Risks Introduction of the national faster diagnosis standard and information system Population awareness qfit Increase in proportion of cases diagnosed at Stage 1 and 2. Increase diagnosis via population awareness of cancer symptoms Quick and easy tool to rule out cancer, which prevent patient s going to hospital for unnecessary colonoscopy NCL providers attended national roadshows to keep updated on requirements and implications Promotion of ovarian and bowl cancer in March & April UCLH CC QFIT high risk patient pilot has collected 550 samples have been analysed, data collection on matched colonoscopies is ongoing 161 CWT guidance to be released in March TCST will attend NCL Performance Leadership Group to support members through the change Development of the low risk symptomatic qfit NCL implementation group to be established National guidance and test portal delayed, resulting in a risk of local implementation. There is a risk of capacity not being increased to accommodate extra referrals generated by campaigns Recommendation from NHSE to stop local implementation of qfit for high risk patients until results of national pilots have been analysed 10

162 4. Early Diagnosis: Overview of GP Direct Access in NCL NCL Cancer Commissioning Board under the direction of NHS England has been working with NCL providers to ensure full compliance with NICE Guidelines for cancer including access to urgent direct access for some suspected cancer cases. The first phase of the of the exercise was to confirm the current state of service provision across NCL shown of the next slide. Phase two encompasses further work with providers and commissioners, with support from TCST to agree timescales for providers to deliver modalities not currently available: Gastroscopy for upper cancer GI symptoms Non-obstetric ultrasound for low risk, not no risk of cancer Same day chest x-ray and x ray for high suspicion of cancer CT scan of the abdomen in order to support early diagnosis of pancreatic cancers MRI scanning for GPs for a specific group of patients in order to improve the early detection of brain cancer The board will be communicating with primary care clinicians on current services and plans to deliver compliance at all trusts. It is important to note that in the absence of urgent GP direct access for some modalities in some provider organisations GP are making 2 week wait referrals and using up outpatient appointment slots which could otherwise be avoided. The introduction of these services entails the use existing diagnostic capacity in different way. Providers do not need to secure additional capacity to implement this

163 4. Early Diagnosis: Urgent GP Direct Access to Diagnostics Table below shows urgent GP direct access diagnostic services that are recommended by NICE Guidance for some cases of suspected cancer (NG12), and current provision within NCL in waiting times in January Modalities University College London Hospitals Royal Free North Middlesex University Hospital The Whittington In Health** GP direct access to gastroscopy tests for the investigation of specific upper GI symptoms. Provided within 2 weeks* Provided from Barnet & Chase Farm Hospitals 4 weeks* (working towards 2 weeks) Not provided - Implementation plan being developed for Summer 2018 Provided 2 weeks N/A All GPs to have direct access to diagnostic services - non-obstetric ultrasound for low risk, not no risk of cancer Not Provided Capacity and demand modelling being developed All Provided -2 weeks* Provided Within 2 weeks Provided Within 2 weeks* Barnet, Camden, Enfield, Islington All GPs to have direct access to same day chest x-ray and x ray for high suspicion of cancer Provided - Walk in service, seen on the same day Provided - Walk in service, seen on the same day Provided- Walk-in service, seen on the same day Provided - Monday-Friday Barnet, Enfield, Haringey Direct access to CT scan of the abdomen in order to support early diagnosis of pancreatic cancers Provided Within 2 weeks Not provided. Multi Diagnostic Centre option available To be provided from April 18 Provided - Within 2 weeks N/A Direct Access MRI scanning for GPs for a specific group of patients in order to improve the early detection of brain cancer Start date to be confirmed. To be monitored at UCLH/Camden CCG CQRG Provided from Barnet & Chase Farm Hospitals 2 weeks* Provided - Within 2 weeks Provided -- Within 2 weeks Barnet, Enfield * Waiting times in December 2017 ** Service provision being validated

164 4. Early Diagnosis: NICE Guidance (DG30) qfit Implementation Quantitative faecal immunochemical test (qfit or FIT) is a highly accurate and non-invasive stool test that detects hidden blood in stool that is indicative of colorectal cancer. There is growing evidence that a negative FIT test could rule out colorectal cancer with matching efficiency of a colonoscopy. UCLHCC is leading on the largest pilot to date in terms of participating organisations to evaluate the process and accuracy of the test in high risk patients. NICE Guidance published DG30 published in July 2017 also recommends the use of qfit for patients with low risk symptoms of colorectal cancer. The introduction of this test in NCL has the potential of significantly reducing endoscopy investigations, with capacity and cost benefits (approx. 10 for a qfit test compared to approx. 600 for an endoscopy). NCL cancer commissioners are working with TCST and UCLH CC to establish a steering group to develop a robust business and clinical case for consideration by CCGs. Progress is being impacted partly by a lack of project management resource

165 5. Cancer Waiting Times: NCL Performance NCL Providers on aggregate achieved the 62 day cancer waiting time standard in December 2017, the first time in over 3 years. NCL CCGs also achieved the standard on aggregate November and December These improvements have occurred within the context of a 12% increase in treatments between 2016 and Detailed analyses of breach reasons is being undertaken to fully understand the drop in performance in January The findings will inform recovery action plans required to recover and sustain performance against the 85% standard by June Key recurring avoidable breach reasons are: Prostate, Renal, Upper & Lower GI delays with diagnostics and treatment capacity Inter Trust Transfer (ITT) delays, also relating to urology pathways Patients not attending appointments

166 5. Cancer Waiting Times: Key Improvement Actions Access to diagnostics delaying pathways/low volumes via STT Optimising & implementing STT/Optimal Pathway such as STT LGI at NMUH & optimising RFL STT Improving Access to GP Direct Access to diagnostics via NCL GP Direct Access Working Group Working with TCST on optimising diagnostics in NCL UCLH & RFL identified as having high PTL backlogs Improved patient tracking including increase in tracking resource NCL backlog currently below backlog target Reduction LGI PTL across UCLH Deep dives in PTL backlogs for all providers at Cancer Performance Leadership Group (PLG) 30.5 breaches in December 2017 and 62.5 in January, highest number of breaches in Urology Inter Trust Transfer (ITT) delays Non compliance of 38 day onward referrals and treatment in 24 days Top 10 breaching pathways have been identified across NCEL Bi-lateral Pathway Meetings have taken place with action plans agreed Action plans being reviewed and monitored via Cancer PLG ITT weekly call now chaired by NCL STP and will concentrate on Urology Breaches being reviewed with NCL trusts Escalation meeting held with NMUH to agree steps to recover and sustain performance Signed off 38 and 24 day performance trajectories for troubled ITT pathways Detailed breach analysis including referral in 38 and treatment in 24 days as standard item on PLG Follow up bi-lateral beings are being arranged to monitor progress Inter Trust Transfer Standard Operating Procedure being developed to support patient transfers between providers

167 5. Cancer Waiting Times: Key Improvements Actions 1. Compliance of 38 day onward referrals & compliance of treatment in 24 days Follow up bi-lateral meetings being arranged with the help from UCLH CC: Gynaecology between RFL & UCLH Head and Neck between RFL & UCLH Urology between RFL & UCLH, and NMUH & UCLH New bi-lateral meetings are being arranged : Upper GI between RFL & UCLH Breast between NMUH & UCLH Renal between UCLH and RFL The introduction of new and fairer breach allocation rules from July 2018 is serving as additional incentive for late referring providers to improve waiting times 2. Reduction of breaches Sector approach to Root Cause Analysis (RCA) has been developed for 62 day breaches and due to be signed off in March 2018 Lower GI STT implemented at Barnet hospital on 22 nd January Head and Neck pathway re-design has reduced waits by 7-14 days Working with UCLH CC on reduction of prostate breaches via Q4 prostate pathway improvement transformation funding 3. Reduction in backlog NCL backlog for the 2 nd consecutive week is below sustainable backlog target an early indication system-wide improvements Tracking resources for Lower GI in RFL has been increased temporarily to support implementation of STT 4. Access to diagnostics Breast and LGI tracking diagnostic support at ULCH commenced 5 th March 2018 Working with NMUH to implement GP Direct Access for gastroscopies and CT scans in Summer 2018 Whittington had reduced their GP Direct Access waiting times to under 14 days for all tests

168 5. Cancer Waiting Times: Clinical Harm NCL providers routinely review for clinical harm purposes, patients who waited for 104 days or longer to start treatment for cancer. The Root Cause Analyses (RCAs) for these patients are also shared with commissioners and NEL CSU for quality assurance purposes. These analyses and findings are discussed at Clinical Quality Review (CQRG) meetings with providers on a quarterly basis. CCG Committees responsible for quality, patient safety and risk also maintain oversight of any issues and provides assurance to respective Governing Bodies on the process, issues and remedial actions where required. The NCL Joint Commissioning Committee Performance and Quality Reports also provides an overview for the committees assurance The RCA process is being extended to all breach patients (over 62 day waiters)

169 5. Cancer Waiting Times: Funding for Rapid Recovery Funding Tranche Wave 1 (Late Summer 2017) Wave 2 (December 2017) Projects Outcomes Funding Impact MRI Optimisation Project Expansion of STT at RFL for LGI Reduce repeat scans being carried out by UCLH For NCEL Now Increased volumes via STT 44,000 March 2018 NMUH STT nurse for LGI Implementation of STT at NMUH 44,000 March 2018 Radiologist to attend H&N SMDT Dermatology to 95% at RFL UCLH & BHRUT joint CNS Patient tracking capacity at UCLH UCLH imagining administration Reduced duplication of image reporting & outcomes reduces delays Consistently achieving 95% to ensure achievement on the 62 day standard Improve patient flows between the two organisations Improved tracking of patients therefore reduction in avoidable breaches Reduction in patient s not attending their appointments 12,000 Now 49,000 March ,000 for NCEL April ,168 March ,000 March 2018 RFL patient tracker for LGI Reduction in LGI backlog 10,000 Completed

170 5. Cancer Waiting Times: Key Risks Org. Risk Rating Mitigation NMUH Sector wide Sector wide Sector wide Lack of clarity on future of the NMUH dermatology service currently outsourced to Concordia. Contract is due be transferred to CCGs from July 2018 Demand exceeding capacity (GP referrals for suspected cancer increased by approx. 10% across NCL in 2017 compared to previous year) could result in extended waiting times. Providers are reporting a sharp rise in breast symptomatic referrals in recent months, for instance. Cancer Waiting Times Information System is changing from April Early indications are that data access may be limited which will impact on data analyses to support performance improvement work. GPs not routinely informing patients they are being referred on a suspected cancer pathway, resulting in patients not attending appointments which adversely impacts performance as well as patient experience. E.g. A UCLH survey demonstrated only 10% of patient s received patient information leaflet from their GP at the point of a suspected cancer referral. High Medium Medium High Ongoing discussions with RFL to explore contract transfer Ongoing focus on improvement action plans to optimise and increase capacity, and develop innovate pathways via the transformation programme. NHS Digital has been contacted for clarification. NCL is also engaging with TCST who have the expertise in this area. CCGs are being encouraged to develop plans to support GPs. UCLH CC and sector providers have offered to support for education sessions

171 6. Living with and Beyond Cancer 80.00% 1 year Survival Rate (2014) by CCGs - All Cancers 75.00% 70.00% 65.00% NHS Barnet NHS Camden NHS Enfield NHS Haringey NHS Islington 1 Yr Survival National 2020 Ambition Programme Recovery Package: Embed the 4 components of the Nation Cancer Survivorship Initiative recovery package across all tumour sites Self-Administration of Denosumab : Patients in NCL are offered self-administration as an option for the delivery of denosumab. This is intended to increase clinic capacity and improve patient experience by reducing visits to hospital. Stratified Follow-Up: Improved patient experience and release of limited acute capacity. 171 Progress to date Extra support provided to support NCL providers with implementation via cancer transformation funding The model was agreed by the NCL Cancer Commissioning Board and financial arrangements agreed. Patient information and policy are in the final stages of sign off. With support from TCST prostate stratified follow up went live in quarter 3 (2017/18). Steering to be strengthened to improve uptake. Colorectal stratified pathway guidance awaited. 20

172 7. Patient Experience The National Cancer Patient Experience Survey 2016 was presented by TCST at the NCL Cancer Commissioning Board (CCB) in November 2016 The average scores for NCL STP are broadly similar to the national averages. The NCL STP average for the one indicator on the CCG Improvement and Assessment Framework (Q59: Overall how would you rate your care) was 8.5. National average was 8.7 out of a maximum score of 10. Next Steps Area of Concern Working with UCLH CC and Macmillan Integrated Cancer Programme are implementing the following which will help to resolve the areas of concern: Roll out and promotion of the recovery care package Trail of quality of life tool at ULCH Stratified follow up Review of patient information on the pathways that have been reconfigured Establishing an Improving Quality and Patient Experience community which brings together heads of strategy, patient experience and patient information, CNS s and lead cancer nurses from all 8 NCEL Trusts plus Macmillan and TCST stakeholders. Development of standardised real-time feedback questions across our geography Real-time patient feedback is valuable in facilitating rapid learning for services where patient satisfaction and experience is high to share best practice, or low to improve and assess initiatives rapidly Patients understanding their diagnosis and receiving understandable information 34% of patients did not completely understand what was wrong with them. Referrals - across NCL STP 27% of patients saw their GP more than twice before being referred. Patients being given a care plan very poor for all cancer types Support from health and social services - poor scores for all questions in this section in all STPs. Patients receiving information on getting financial help was poor Hospital staff giving family all information to help with care at home Local CCG Cancer Working Groups are working with providers to produce local aligned plans, which will be presented in NCL CCB in May 2018 Information regarding side effects of treatment both short and long term - poor scores across all STPs in London

173 8. UCLH Cancer Collaborative UCLH Cancer Collaborative (UCLH CC) brings together healthcare organisations across north central and north east London, and west Essex to improve early cancer diagnosis, outcomes and care for patients. The collaborative is also part of the national Cancer Vanguard a partnership between UCLH Cancer Collaborative, Greater Manchester Cancer Vanguard Innovation and RM Partners - tasked with working collectively to change the way cancer care is provided through NHS England s new care models programme. London Cancer - the NCEL and West Essex Alliance of health professionals and patients - was transferred to the UCLH Cancer Collaborative in September 2016 to become one of the 6 pillars for the collaborative. Across England, Alliances have been tasked with delivering the national cancer programme for the geography they represent. The collaborative has developed a number of options for securing funding on a sustainable basis to support the work needed over the current lifecycle of cancer alliances (up to 2021). NCL and NEL STPs have been asked to consider the business model options. This will be presented to the NCL executive team in the coming weeks

174 8. UCLH Cancer Collaborative: Programmes