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1 Haringey Clinical Commissioning Group Governing Body Meeting Thursday, 13 September pm 4.30pm Cypriot Centre Earlham Grove London N22 5HJ Item Title Lead Action Papers Page No. 1. INTRODUCTION 1.1 Welcome and Apologies Chair To note Oral Declarations of Interest Register Chair To note Declarations of Gifts and Hospitality Chair To note Oral l Draft minutes of previous Governing Body meetings on 12 July 2018 Chair For approval Action Log Chair For approval 1.6 Questions from the public Chair Oral - 2. OVERVIEW REPORTS 2.1 Accountable Officer s Report Accountable Officer 3. DISCUSSION 3.1 Whittington Health Community Services Chief Executive, Whittington Health 4. CORPORATE BUSINESS AND BUSINESS CASES To note For discussion Presentation System Intentions for 2019/20: Haringey CCG NCL Director of Strategy For discussion NCL and Haringey Systems Intentions 5. FINANCE AND PERFORMANCE NCL Director of Performance, Planning and Primary Care 5.1 Finance Report Chief Finance Officer For discussion For discussion

2 5.2 Performance Report Director of Planning, Performance and Delivery 6. GOVERNANCE Board Assurance Framework Haringey BAF Risks available here Director of Planning, Performance and Delivery For discussion For discussion To note NCL Risk Register (August 2018) available here NCL Primary Care Committee in Common Risk Register (August 2018) available here To note To note NCL Joint Commissioning Committee Risk Register (August 2018) available here 7. ITEMS FOR INFORMATION AND ASSURANCE 7.1 Minutes of the Haringey and Islington CCGs Quality and Performance Committee in Common Meeting on 25 July 2018 available here 7.2 Minutes of the Haringey & Islington CCGs Strategy & Finance Committee in Common meeting on 28 June 2018 available here 7.3 Minutes of the Haringey CCG Clinical Cabinet meeting on 5 July available here 7.4 Minutes of the NCL Joint Commissioning Committee Meeting on 7 June 2018 available here 7.5 Minutes of the NCL Primary Care Commissioning Committee Meeting on 21 June 2018 available here 8. ANY OTHER BUSINESS Chair of Haringey and Islington CCGs Quality and Performance Committee in Common Chair of Haringey and Islington CCGs Strategy and Finance Committee in Common Chair of Haringey CCG Clinical Cabinet Chair of NCL Joint Commissioning Committee Chair of NCL Primary Care Commissioning Committee To note To note To note To note To note To note 9. DATE OF NEXT MEETING - Thursday 15 November 2018 REGISTER OF INTERESTS A register of members interests is available for viewing by the public. The register will be available at the meeting or during working hours within the Haringey CCG Office, River Park House, 225 High Rd, Wood Green, London N22 8HQ. 2

3 Haringey Clinical Commissioning Group Governing Body Meeting 13 September 2018 Report Title Declaration of Interest Register Date of report 6 September 2018 Agenda Item 1.2 Lead Director / Manager GB Member Sponsor Peter Christian Chair, Haringey CCG Peter Christian Chair, Haringey CCG Tel/ Report Author Steve Beeho, Board Secretary Tel/ s.beeho@nhs.net Report Summary Governing Body Members and attendees are asked to review the agenda and consider whether any of the topics might present a conflict of interest, whether those interests are already included within the Register of Interest, or need to be considered for the first time due to the specific subject matter of the agenda item. A conflict of interest would arise if decisions or recommendations made by the Governing Body or its Committees could be perceived to advantage the individual holding the interest, their family, or their workplace or business interests. Such advantage might be financial or in another form, such as the ability to exert undue influence. Any such interests should be declared either before or during the meeting so that they can be managed appropriately. Effective handling of conflicts of interest is crucial to give confidence to patients, tax payers, healthcare providers and Parliament that CCG commissioning decisions are robust, fair and transparent and offer value for money. If attendees are unsure of whether or not individual interests represent a conflict, they should be declared anyway. Recommendation The Governing Body is asked to NOTE the Register of Interests and advise the meeting / Board Secretary of any changes. Identified Risks and Risk Management Actions The risk of failing to declare an interest may affect the validity of a decision / discussion made at this meeting and could potentially result in reputational and financial costs against the CCG. Conflicts of Interest The purpose of the Register is to list interests, perceived and actual, of members that may relate to the meeting. 3

4 Resource Implications Engagement Equality Impact Analysis Report History and Key Decisions Next Steps Appendices Not applicable. Not applicable. Not applicable. The Register of Interests is a standing item presented to every Governing Body Meeting. The Register of Interests is reviewed monthly. The Register of Interests. 4

5 Haringey CCG Governing Body Declarations Name Declared Interest- (Name of the organisation and nature of business) Current position (s) heldi.e. Governing Body, Member practice, Employee or other Financial Interests Type of Interest Non-Financial Professional Interests Non-Financial Personal Interests Is the interest direct or indirect? Nature of Interest Date of Interest From To Updated Action taken to mitigate risk Morris House Group Practice X Direct Practice Partner GP Partner, Morris House Group Practice North East GP Member, Governing Body Member, Governing Body The Morris House Group Practice is a member of Federated4Health, the pan-haringey federation of GP practices. X Direct Practice Partner Gino Amato Member, Clinical Cabinet Planned Care Lead, Governing Body Member, NMUH Clinical Quality Review Group The Morris House Group Practice provides anticoagulant care to Haringey residents under a contract with the CCG. X Direct Practice Partner The Morris House Group Practice premises are also used for the provision of physiotherapy services by Premier X Direct Practice Partner Medical, who are charged a nominal amount to cover electricity and gas etc. Local Medical Committee (LMC) X Direct GP representative NHS England Italian Medical Charity X Direct GP Trainer X Direct Trustee Fernlea Surgery X Direct Practice Partner Simon Caplan GP Partner, Fernlea Surgery North East GP Member, Governing Body Member, Clinical Cabinet Chair, A&E Delivery Board (advised this had ceased on ) Chair, Medicines Management Committee Fernlea Surgery is a member of Federated4Health, the pan-haringey federation of GP practices. Fernlea Surgery premises are also used for the provision of MSK services by Premier Health and Sport Therapy Ltd, who are charged a nominal amount to cover electricity and gas etc. Direct X Practice Partner X Practice Partner Talawa Fostering X Direct Medical adviser Jewish Care Direct clinical governance committee member New North London synagogue NHS England (London) Central London Community Healthcare NHS Trust. X X Direct Organiser of doctors' rota Direct Indirect (wife) Senior clinical adviser Community paediatric physiotherapist

6 Muswell Hill Practice X Direct Practice Partner CCG Chair, West GP Lead GP Partner, Muswell Hill Practice Peter Christian Member, Strategy and Finance Committee Member, Clinical Cabinet Member, Health and Wellbeing Board Member, Collaboration Board Member, Remuneration Committee Member, STP Clinical Cabinet and Transformation Board Muswell Hill Practice is a member of Federated4Health, the pan-haringey federation of GP practices. Muswell Hill Practice is a member of WISH - Urgent Care Centre provider at Whittington Hospital. Muswell Hill Practice provides anticoagulant care to Haringey residents under a contract with the CCG. The Hospital Saturday Fund - a charity which gives money to health related issues. 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. Federated4Health, the pan-haringey federation of GP Practices Haringey Health Connected, the federation of west Haringey GP practices X Direct Practice Partner X Direct Practice Partner X Direct Practice Partner X Direct Member Indirect (wife) Patron Indirect (wife) Patron Indirect (Practice manager ) Indirect (Practice manager ) Chair Finance Manager Vale Practice X Direct Practice Partner Dina Dhorajiwala GP Partner, Vale Practice West GP Member, Governing Body Member, Strategy and Finance Committee Member, Clinical Cabinet Primary Care Lead, Governing Body Haringey Primary Care Lead, Co-Commissioning Committee, NCL NHS Vale Practice is a member of Federated4Health, the pan-haringey federation of GP practices. X Direct Practice Partner Member, Primary Care Steering Group Member, Primary Care Transformation Group Member, Health and Wellbeing Board The Vale Practice is a member of WISH, the Urgent Care Centre X Direct Provider at Whittington Health. WISH, the Urgent Care Centre Provider at X Director Whittington Health. Direct NHS England X Direct GP appraiser Frater Clinic (a private clinic) X Direct Appraisal lead and appraiser Vale Practice X Indirect Husband is a practice partner

7 Simon Goodwin Chief Finance Officer East London Foundation Trust X Indirect Wife is Senior Manager at the Trust Lay Member, Governing Body Chair, Primary Care Co- Commissioning Committee, NCL NHS Chair, Investment Committee Chair, Communications and Engagement Sub- Committee Member, Remuneration Committee Catherine Herman Member, Audit Committee Member, Quality and Performance Committee Member, Health and Wellbeing Board Member, Primary Care Transformation Group Member, Organisational Development Group Chair, Engagement Network No interests to declare Chief Operating Officer Islington CCG X Member, Governing Body Tony Hoolaghan Chief Operating Officer Member, Governing Body Member, Finance and Performance Committee Member, Strategy and Finance Committee Sidney Estates Tenants and Residents Association, Tower Hamlets X Chair Will Maimaris Interim Director of Public Health, Haringey Council No interests to declare Queenswood Practice X Direct Practice Partner Queenswood Practice is a member of WISH, the Urgent Care Provider at Whittington Hospital. X Direct Practice Partner David Masters GP Partner, Queenswood Practice West Member, Governing Body Clinical Lead for Children (including CAMHS and child safeguarding) Member, Investment Committee Chair, Safeguarding Queenswood Medical Practice takes part in various funded research projects, including PANDA, Kare and North Thames CRN Primary Care Team X Direct Practice Partner

8 Chair, Safeguarding Assurance meeting Member, Clinical Cabinet Queenswood Practice is a member of Federated4Health, the pan-haringey federation of GP practices. X Direct Practice Partner Queenswood Practice arranges education activities with our local hospital teams, including the Whittinghton Hospital and Highgate Hospital X Direct Practice Partner Tavistock Clinic X Direct NHS England (Whittington Health scheme) Hornsey Heath Care Ltd that holds the lease at Hornsey Central Health Care Systemic Therapist (one day a week) X Direct GP trainer X Direct Director GP Partner, Arcadian Gardens Surgery Clinical Director, Central Haringey, Governing Body Member, Governing Body Arcadian Gardens X Direct Practice Partner Sheena Patel Member, Clinical Cabinet Women s Health Lead, Governing Body Member, QIPP Delivery Group Member, Primary Care Steering Group Arcadian Gardens is a member of Federated4Health, the X Direct Practice Partner pan-haringey federation of GP practices. Central Haringey CHIN X Direct Joint Clinical Lead Muswell Hill Practice (CCG member practice) X Direct Registered patient Helen Pettersen Accountable Officer Royal Borough of Kensington and Chelsea Local Authority X Indirect Husband is Programme Manager for Partners in Practice, a social work training programme Lawrence House Surgery X Direct Practice Partner John Rohan CCG Deputy Clinical Chair North East GP Lead, CCG Governing Body GP Partner, Lawrence House Surgery Member, Governing Body Chair, Strategy and Finance Committee Chair, Clinical Cabinet Member, Primary Care Steering Group Member, QIPP Delivery Group Finance, Estates and QIPP Lead, Governing Body Lawrence House Surgery is a member of Federated4Health, the pan-haringey federation of GP practices. Lawrence House Surgery has merged with Dowsett Rd Surgery and Broadwater Farm Health Centre. Lawrence House Surgery also runs the Tottenham Hale practice. X Direct Practice Partner X Direct Practice Partner X Direct Practice Partner NHS England X Direct GP Trainer: Enfield and Haringey GP Scheme NHS England X Direct GP appraiser Whittington Health Indirect (wife) Consultant (based at St Ann's Hospital)

9 Primary Care Health Professional Member, South East, Governing Body Advanced Nurse Practitioner, JS Medical Practice JS Medical Practice X Direct Advanced Nurse Practitioner Sharon Seber Member, Quality and Performance Committee Member, Clinical Cabinet Nurse Member, NCL Joint Commissioning Committee Healthy Life Expectancy Clinical Lead, Governing Body Chair, Increasing Healthy Life Expectancy Group Member, Primary Care Steering Group JS Medical Practice is a member of Federated4Health, the pan-haringey federation of GP practices. Islington COPD Steering Group Camden, Islington and Haringey Responsible Prescribing Group X Direct Advanced Nurse Practitioner X Direct Attending Member X Direct Attending Member Adam Sharples Lay Member, Governing Body Chair, Audit Committee Chair, Remuneration Committee Member, Strategy and Finance Committee Member, Finance and Performance Partnership Board Chair, IFR Panel Member, NCL Joint Commissioning Committee Money Advice Trust (a national debt advice charity) X Direct Chair Enfield CCG X Direct Member, Audit Committee Lionel Sherman GP Partner, Bounds Green Practice Member, Governing Body Member, Clinical Cabinet Chair, CCG CHC Funding Panel POLCE lead, CCG Bounds Green Group Practice X Direct Practice Partner Learning Disabilities Lead, CCG Member, QIPP Delivery Group Bounds Green Group Practice is a member of the pan-haringey GP Federation X Direct Practice Partner

10 Dowsett Rd Surgery X Direct Practice Partner Dai Tan Sessional GP Member, Governing Body Salaried GP, Lawrence House Surgery Practice Partner, Dowsett Rd Surgery Member, Clinical Cabinet Member, Primary Care Steering Group Chair, CEPN Steering Group Lawrence House Surgery and Dowsett Rd Surgery are both members of Federated4Health, the pan-haringey federation of GP practices. X Direct Practice Partner Member, Organisational Development Group Education and Workforce Lead, Governing Body Whittington Health X Indirect Husband is currently on a Fixed Term Contract as a Locum Consultant in Endocrinology Clinical Lead for Diabetes Nurse Member, Governing Body Chair, Quality and Performance Committee Member, Clinical Cabinet Sarah Timms Member, Investment Committee Member, Remuneration Committee Sarah Timms Consultancy Ltd X Direct Sole Director Member, Organisational Development Group Member, NMUH Clinical Quality Review Group Member, Eligibility Panel Chair, Primary Care Transformation Group Member, QIPP Delivery Group Non-voting Governing Body attendees Vale Practice X Direct Registered patient Whittington Health X Indirect Daughter is employed in an administrative role. Public Voice CIC (a Community Interest Company) X Direct Chair of the Board Healthwatch Haringey X Direct Chair, Steering Committee Sharon Grant Chair, Healthwatch Haringey Haringey CCG Governing Bernie Grant Arts Centre Partnership X Direct Director

11 Sharon Grant Haringey CCG Governing Body Observer (With Speaking Rights) Independent Advisory Group, Metropolitan Police Haringey X Direct Member Parliamentary researcher X Direct Part-time-employment as a Parliamentary Researcher on Health issues for backbench Labour MP Consumers Association (Which?) X Direct Trustee and Director (Unremunerated) Attendee of CCG Governing Body No interests declared Clare Henderson Director of Commissioning Member, Strategy and Finance Committee Member, Clinical Cabinet N/A Will Huxter NCL Director of Strategy Attend any of the five CCGs in NCL Group N/A Director, Wellbeing Partnership Vale School Rachel Lissauer Attendee of CCG Governing Body X Direct Co-opted Governor Sarah Mcilwaine Programme Director, Care Closer to Home, North London Partners Non-Voting GB Member Hillside (Islington-based mental health charity) X Direct Trustee NCL Director of Performance and Acute Commissioning No interests to declare. Paul Sinden Attend NCL Primary Care Commissioning in Common Attend any of the five CCGs in NCL Group Director of Performance, Planning and Delivery No interests declared Alex Smith Non-Voting GB member Member of Strategy and Finance Committee N/A Jennie Williams Director of Quality and Nursing Non-voting member, Governing Body Member, Quality and Performance Committee Islington CCG X Direct Central and North West London NHS Foundation Trust X Indirect Husband is Director of Nursing Son is working in administrative post via Temp Bank. Whittington Health X Indirect

12 Draft Minutes of the Meeting of the Haringey Clinical Commissioning Group Governing Body Thursday 12 July 2018 at 1.30pm Cypriot Centre, Earlham Grove Dr Peter Christian Helen Pettersen Dr Gino Amato Dr Simon Caplan Dr Dina Dhorajiwala Dr David Masters Dr Sheena Patel Dr John Rohan Dr Lionel Sherman Dr Daijun Tan Sharon Seber Catherine Herman Adam Sharples Sarah Timms Tony Hoolaghan Simon Goodwin In attendance: Anthony Browne Clare Henderson Alex Smith Sharon Grant Will Maimaris Steve Beeho Chair of Haringey CCG, West Lead Accountable Officer, North Central London CCGs GP Governing Body Member, North East GP Governing Body Member, North East GP Governing Body Member, West GP Governing Body Member, West GP Governing Body Member, Central Lead GP Governing Body Member, North East Lead GP Governing Body Member, Central GP Governing Body Member, Sessional GP Governing Body Primary Care Health Professional Member, South East Lay Member, Haringey CCG Lay Member, Haringey CCG Nurse Member, Haringey CCG Chief Operating Officer, Haringey CCG Chief Finance Officer, North Central London CCGs Deputy Chief Finance Officer, Haringey CCG Director of Commissioning, Haringey CCG Director of Planning, Performance and Delivery, Haringey CCG Chair, Healthwatch Haringey (Observer with speaking rights) Consultant in Public Health, Haringey Council Board Secretary, Haringey CCG (minutes) 1. INTRODUCTION 1.1 Apologies for Absence Apologies were received from Jeanelle De Gruchy. Will Maimaris was attending on her behalf. As Jeanelle would shortly be beginning her secondment in Manchester, the Chair thanked her in her absence for her contribution to the achievements of the CCG. 1.2 Declarations of Interest There were no additional declarations of interest. 1.3 Declarations of Gifts and Hospitality There were no additional declarations of gifts or hospitality. 12

13 1.4 Chair s Introduction and Opening Remarks The Chair formally welcomed all present to the meeting. In addition he welcomed Chantelle Fatania (Consultant in Medicine, Haringey Public Heath) and Lorraine Wiener (Head of Quality, Islington CCG), who were both attending the meeting as observers. 1.5 Minutes of the Previous Meeting The Governing Body agreed the minutes of the Governing Body meeting held on 10 May 2018 as an accurate record, subject to section being amended to state that Adam Sharples will be the Chair of the NCL Audit Committee in Common, rather than the Vice Chair. 1.6 Matters Arising The Governing Body discussed the progress against the actions from the last meeting Alex Smith confirmed that an update on the Health Information Exchange would be brought to the Governing Body Seminar in October Alex Smith noted that in addition to the update on the Memory Clinic included in the Performance and Quality Report, further details would also be presented at the next meeting of the Joint Commissioning Committee Adam Sharples observed that the breakdown of the charges incurred by the CCG for each private provider and the corresponding budget allocation highlighted the scale of the overspend at Highgate Hospital Assurance was given that the CCG is taking steps to control this. The CCG will be attending Clinical Quality Review Group (CQRG) meetings for this provider It was also hoped that the MSK work would help to obviate the situation Sharon Grant confirmed that she had now received a response to the concerns raised by the Reference Groups at the last Joint Partnership Board meeting, which she would now relay to the next meeting Jennie Williams noted the she had met with CCG colleagues to clarify the governance processes which other early e-referral adopters have in place, following on from the earlier concerns expressed about what happens when a patient referral is rejected. It was agreed that Jennie Williams would speak to Sheena Patel outside the meeting about assurances the CCG has received regarding the volume of rejected referrals The Governing Body NOTED the action log ACTION 12/7-1: Jennie Williams to speak to Sheena Patel outside the meeting about assurances the CCG has received regarding the volume of rejected referrals. 1.7 Questions From the Public Ten questions had been submitted in advance from members of the public. The responses are appended to these minutes. 2 13

14 1.7.2 In response to a follow-up comment about the lack of notice concerning a recent consultation, it was agreed that the CCG would look into how consultations can be promoted more effectively ACTION 12/7-2: Tony Hoolaghan to arrange for consultations to be promoted more effectively. 2. Overview Reports 2.1 Accountable Officer s Report Helen Pettersen introduced the Accountable Officer s Report, highlighting a number of specific items Haringey CCG s achievement of a Green rating for its patient and local community engagement under a new national assessment was welcomed, although it was recognised at the same time that further progress still needs to be made. Helen Pettersen thanked in particular the contribution made by the CCG s partners (Public Voice, Healthwatch Haringey and the Bridge Renewal Trust) and the CCG s Communications and Engagement Team The CCG is currently awaiting NHS England s approval of the business case to take back in-house the contracting support function from NEL Commissioning Support Unit but in the meantime the necessary planning work was continuing Following feedback from the engagement on the draft Primary Care Strategy, the engagement period had been extended and the final version of the strategy would now be brought to the November Governing Body meeting for approval There was then a brief discussion of the recent meeting of the STP Advisory Committee. Peter Christian observed that it had highlighted tensions between different parties which he was optimistic would be worked through In response to potential concerns about accountability in the context of the STP, Helen Pettersen said that it was important to remember that no statutory bodies had delegated authority to the STP and it therefore does not have a formal decision-making forum. She confirmed that it had been agreed that future agenda-setting needed to allow for more discussion of strategic issues and that future meetings of the Advisory Committee would be minuted and ultimately published on the North London Partners in Health and Care website In response to a query from Adam Sharples, Tony Hoolaghan noted that the membership of the two newly-created Committees in Common had initially been established on a lift and shift basis, prior to further recalibration The Governing Body NOTED the Accountable Officer s Report. 3. Business, Quality and Integrated Performance 3.1 Finance Report 3 14

15 3.1.1 Anthony Browne provided an overview of the Finance Report, highlighting the following points: At month 2 the CCG is reporting a 14k year to date deficit and forecasting to plan at year end. Month 3 reporting, which had just closed, did not show a significant variance from the Month 2 figures. The CCG is already reporting significant pressure against its Continuing Care spend a more detailed report will be brought to a future meeting The NMUH contract is projecting a material overspend these figures will require further examination across the patch The 2018/19 QIPP target ( 19.5m) is particularly challenging compared to previous years, with the focus on avoiding admissions. There is currently a financial risk around closing the 7.6m QIPP gap A breakdown of the other financial risks and the mitigations identified to date were set out in section Simon Goodwin then provided an overview of the summary of CCG financial variances across NCL which would now be presented at future meetings. The summary showed 36m- 40m financial risk across NCL, with the level of Haringey risk sitting in the middle of the five CCGs He also noted that the increased NHS funding announced recently by Jeremy Hunt would be available from 2019/20, rather than the current financial year. He further cautioned that it was unclear at this stage how much of the increased funding would be directed to CCGs and how the recent NHS staff pay awards will be funded The Governing Body then noted that Becky Booker, Director of Finance, Camden CCG is leading on a piece of work to benchmark Continuing Care expenditure across NCL and a progress report will be brought to the Strategy and Finance Committee in due course John Rohan suggested that it would be helpful if the Governing Body could be provided with an outline of how the CCG will meet its QIPP targets in-year, in order to avoid a repetition of the pressures incurred in the previous financial year Anthony Browne confirmed that the CCG would be adopting the style of reporting modelled by Camden CCG with effect from the QIPP Delivery Group Meeting in early August, followed by the Strategy and Finance Committee meeting later that month. The new format, combined with acute reporting data, will help the CCG to assess the level of financial risk better Adam Sharples highlighted that the CCG s projected running costs were actually increasing, despite the recent organisational changes. Anthony Browne clarified that this was a function of the NHS reporting process and acknowledged that this ought to be made clearer in future. More detail would be provided at the next meeting of the Strategy and Finance Committee. It was noted that the CCG is not permitted to spend its running cost budget on other areas of work Gino Amato suggested that if it would be helpful if the CCG could be notified of its financial allocation for the following financial year earlier than at present, to facilitate more effective planning. 4 15

16 3.1.9 The Governing Body NOTED the financial position at Month Performance and Quality Report Alex Smith provided an overview of the Performance and Quality Report, highlighting the following key points from the performance section: The overall Referral to Treatment 18 Week Target was not met in April 2018, although the CCG has been assured that that NMUH will soon be back on track as their summer elective catch-up continues apace. A contract notice had been issued to RFH as a result of their failure to meet this target since August 2017 Five of the eight targets for cancer had been met in April In light of regional concern about NMUH s achievement of the 62 day standard, the Cancer Intensive Support Team has made recommendations which are to be addressed in the Trust s refreshed improvement plan Urology and gastroenterology performance at NMUH remains challenging, with endoscopy capacity a particular issue as a result, NHS England and NHS Improvement have asked commissioners to participate in a demand/capacity review The recent A&E performance at NMUH continues to improve and the provisional figures for June place it 3% ahead of its improvement trajectory Bed occupancy rates at NMUH remain high and are the single highest cause of the trust s performance breaches The CCG will need to work closely with local trusts, Haringey Council and Community Health Services to meet the target set by NHS England and NHS Improvement to reduce stranded patients The Community Health dashboard presented a mixed picture, with a significant improvement in Child and Adolescent Mental Health Services (CAMHS) performance off-set by a decrease in the percentage of Podiatry patients seen within six weeks Performance at the Memory Clinic has deteriorated, falling to 6.7% in April The fact that the trust largely attributed this to workplace changes has led to the CCG requesting a demand and capacity review. A new clinic specification is being proposed by commissioners and GPs are being sought to strengthen the clinical input to this Jennie Williams then provided a further update to the quality section of the report. A rapid review is being carried out following NMUH s recent declaration of a new Never Event, concerning the insertion of an incorrect intraocular lens. A paper on the LUTS (Lower Urinary Tract Symptoms) service will be presented at the Joint Overview and Scrutiny Committee meeting on 20 July The Governing Body then discussed the report. 5 16

17 3.2.4 Simon Caplan welcomed the improvements being made in Community Services but sought assurance that these were not being achieved at the expense of patients who are already in the system. Rachel Lissauer also noted the concern that follow-up appointments are being spaced out to accommodate the introduction of additional clinics for first appointments. Alex Smith welcomed this feedback and said that he would raise this at the next meeting of the Transformation Group Adam Sharples welcomed the establishment of an agreed basis for assessing performance and hoped that this would form the basis for improvements going forward. However, he observed that the general level of Community Services performance was significantly below where it ought to be and the lack of timely data undermined the value of the dashboard. The fact that the majority of urgent targets are not being met was a particular matter of concern The Governing Body then discussed potential steps that could be taken to improve the performance of the Memory Clinic, including the use of interim staff. Simon Goodwin cautioned that the CCG needs to be clear whether the number of referrals is actually increasing, as it may be the case that the resource is not keeping up with the level of activity. It was agreed that Alex Smith would provide an update to the Governing Body Catherine Herman queried whether there had been any data to inform the Trust and the CCG on patient satisfaction with the call centre used by Community Services for booking appointments. Jennie Williams confirmed that this issue would be raised at the next meeting of the Whittington Health Clinical Quality Review Group. She suggested that it would also be worth tracking the average length of time it takes for patients to get through to a receptionist. Rachel Lissauer noted that the Trust had acknowledged at the Improvement Working Group that more needs to be done to improve communications with the public Simon Caplan highlighted that Community Services are currently not accessible on the e-referral System (ers) and suggested that the CCG should address this in the next round of Commissioning Intentions Sharon Grant expressed concern about the backlog of radiology reporting, (predominantly x-rays), which was currently being reviewed by Whittington Health. Gino Amato clarified that these x-rays would have been reviewed by a doctor at the trust who would have drawn their own conclusions about any action that might need to be taken, but it was nevertheless unsatisfactory that the results not been reported further Jennie Williams confirmed that the trust had reviewed the backlog and had not identified any incidents of patient harm. An internal root cause analysis had been undertaken and a report will be taken shortly to the next Trust Board meeting, after which it will be presented to the Clinical Quality Review Group It was agreed that Jennie Williams would update Sharon Grant outside the meeting about the action being taken by BEHMHT to improve the timeliness of its complaints management The Governing Body NOTED the Performance and Quality Report ACTION 12/7-3: Clare Henderson to provide an update on the Memory Clinic. 6 17

18 ACTION 12/7-4: Jennie Williams to update Sharon Grant outside the meeting about the action being taken by BEHMHT to improve the timeliness of its complaints management. 4. Strategy and Development 4.1 Strategic Risk Report Alex Smith provided an overview of the report, highlighting the changes over the past two months to the CCG, NCL Joint Commissioning Committee and NCL-wide Risk Registers. The CCG currently had five open risks rated at 12 and above It was noted that a new risk around diagnostic endoscopy capacity would be opened during the next review period The Governing Body NOTED the Strategic Risk Report. 5. Governing Body Committee Minutes 5.1 The Governing Body NOTED the minutes of the Audit Committee meeting held on 27 February 2018, the Clinical Cabinet meeting held on 3 May 2018, the Finance and Performance Committee meeting held on 27 April 2018, the NCL Joint Commissioning Committee meeting held on 5 April 2018 and the NCL Primary Care Committee in Common meeting held on 19 April Any Other Business 6.1 Adam Sharples informed the Governing Body that Catherine Herman had agreed to be the third member of the Haringey CCG Audit Committee. As a consequence, Catherine Herman would be stepping down as the CCG s lay member representative on the Joint Commissioning Committee with effect from September 2018 and Adam Sharples would be taking over this role. 7. Date of Next Meeting 7.1 Thursday, 13 September

19 Draft Minutes of the Part II Meeting of the Haringey Clinical Commissioning Group Governing Body Thursday 12 July 2018 at 1.30pm Cypriot Centre, Earlham Grove Present: Dr Peter Christian PC Chair of Haringey CCG, West Lead Helen Pettersen HP Accountable Officer, North Central London CCGs Dr Gino Amato GA GP Governing Body Member, North East Dr Simon Caplan SC GP Governing Body Member, North East Dr Dina Dhorajiwala DD GP Governing Body Member, West Dr David Masters DM GP Governing Body Member, West Dr Sheena Patel SP GP Governing Body Member, Central Lead Dr John Rohan JR GP Governing Body Member, North East Lead Dr Lionel Sherman LS GP Governing Body Member, Central Dr Daijun Tan DT GP Governing Body Member, Sessional Sharon Seber SS GP Governing Body Primary Care Health Professional Member, South East Catherine Herman CHr Lay Member, Haringey CCG Adam Sharples ASh Lay Member, Haringey CCG Sarah Timms ST Nurse Member, Haringey CCG Tony Hoolaghan TH Chief Operating Officer, Haringey CCG Simon Goodwin SGo Chief Finance Officer, North Central London CCGs In attendance: Anthony Browne AB Deputy Chief Finance Officer, Haringey CCG Clare Henderson CHn Director of Commissioning, Haringey CCG Alex Smith ASm Director of Planning, Performance and Delivery, Haringey CCG Will Maimaris WM Consultant in Public Health, Haringey Council Steve Beeho SB Board Secretary, Haringey CCG (minutes) 1. INTRODUCTION Action 1.1 Apologies for Absence Apologies were received from Jeanelle De Gruchy. Will Maimaris was attending on her behalf. 1.2 Declarations of Interest There were no additional declarations of interest. 2. Minutes of the Previous Meeting 2.1 The Governing Body agreed the minutes of the Governing Body meeting held on 10 May 2018 as an accurate record. 19

20 3. Matters Arising 3.1 There were no matters arising. 4. Any Other Business 4.1 Tony Hoolaghan noted that the CCG would be undertaking a refresh of clinical lead responsibilities using a similar approach to the one which Dominic Roberts had used in Islington. 5. Date of Next Meeting 5.1 Thursday, 13 September

21 Haringey CCG Governing Body meeting Thursday 12 July 2018 Questions from the public (received in advance of the meeting) Question 1-3 from Rod Wells, Haringey Keep Our NHS Public Question 1 relates to Item 2.1 Accountable Officer s report, section 2 Engagement assessment rating. 1. HKONP note that the CCG believe Patient and community engagement is vital when it comes to improving health services within Haringey. However the recent consultation on draft policy for primary hip and knee arthroplasty (replacement) run by London Choosing Wisely-who London CCGs I understand contracted- was a dire failure to engage with the public in Haringey. Ref Haringey residents were given 4 days to respond to a long and technical consultation (by 4/6/18) which most would not be aware of. We understand that up to 30 May no notification was received by Haringey Healthwatch of this. These proposed changes in the way patients may expect to receive surgical treatments would affect people for years. HKONP believe the rushed way the consultation was done and manner it was carried out fails any community engagement test HKONP want any future consultation on changes in people s health to be carried out properly, in good time, and in clear and plain language and ask what steps Haringey CCG are taking to ensure this happens in future. Answer: The London Choosing Widely engagement was a London wide exercise led by the Healthy London Partnership. Response provided by the London Choosing Wisely programme From the patient perspective, the London Choosing Wisely programme has had support from Healthwatch England in cascading information to London s Healthwatch networks, whom the programme has also been contacting directly. The Steering Group has two patient representatives and each Task and Finish Group also has a patient representative supporting the development of each draft London policy. The programme is engaging directly with patient-facing groups for the relevant treatment areas too. There have been some concerns raised about 21

22 the short timeline of the programme s sense check phase and wider engagement with local patient groups. These concerns are being reviewed by the London Choosing Wisely Steering Group and Programme Board. Questions 2-3 relates to Item 3.1 Finance Report 2. I understand that the CCG has a financial plan to deliver a surplus of 19k in 2018/19 from a deficit of 14 m and that this means delivering net efficiencies of 19.5m. Any efficiencies could mean a reduction in health services Then the finance report states that the net risk is 7.1m, (and ) the CCG does not have any reserves or mitigations set aside if these risks materialise If so why is the CCG considering putting itself in this position? Is there pressure from NHSE or the STP North London Partners- to produce a surplus of this size? If not should the CCG reduce the surplus and keep more money for health services in Haringey? Answer: The statutory requirement is to breakeven. CCGs typically budget slightly better than breakeven, hence 19k in Haringey. 3. Given the above can the CCG explain in plain language what are the STP Interventions and how do you stretch them? Can the CCG point me to how the QIPP will deliver the net savings of 11.8m. as per para and will this involve cuts to services? Answer: STP interventions refer to the larger areas of QIPP (Quality, Innovation, Productivity and Prevention) taking place across all Trusts in North Central London. Stretch is a term used to increase the level of efficiency where a scheme has the opportunity to exceed original savings targets. We will ensure language is clearer in future. Focus on QIPP savings plans will be presented at future meetings. The CCG has no plans to make cuts to services. Question 4 from Liz Ciokajlo Question 4 relates to Item 2.1 Accountable Officer s Report - section 8 Osborne Grove Nursing Home 4. I am a daughter of a long standing resident of the home. We welcome Haringey Council's reverse decision to keep the home open and the seven remaining residents will stay before, during and after which future option is decided upon. My question is the CCG planning to protect the 22

23 residents and raise the standards to CQC 'good' standard now in all areas by employing Pamela Edam to advise improvement and implement this advice, officially raising the CQC standard to 'good'? Also how is the CCG planning to protect the residents in the event of building works and expansion, given in the past at OGNH residents health has been significantly impacted when moved from one wing to another? Answer: As a Local Authority owned residential nursing home the responsibility for employing staff at Osbourne Grove and ensuring that residents and patients are kept safe sits with Haringey Local Authority. The CCG s care homes team is supporting the Local Authority and staff within the home to ensure continuous improvement of the care delivered. With regard to the protection of residents in the event of building works, the CCG has been advised by the Director of Adult Social Services that all decisions made by the council will be made in the best interests of the residents. There will be a risk assessment made prior to building works and the CQC in their regulatory role will make a decision about whether it is appropriate for regulated activities to be delivered. Question 5 from Gordon Peters, Older Persons Group Question 5 relates to Item 2.1 Accountable Officer s Report - section 8 Osborne Grove Nursing Home 5. What does the CCG see its role as in keeping Osborne Grove as a nursing home, now that Haringey Council has agreed to do that? Answer: Haringey CCG is keen to take part in the co-design of new or expanded facilities at Osborne Grove. The Council has set up a steering group and the CCG will take an active role in this. Questions 6-7 from Anne Gray Question 6 relates to Item 1.5 Minutes from previous meeting, section a) if assessment of continuing care needs is done at home, what steps are taken to carry out a pre-assessment to ensure before they are discharged that the patient will have someone to provide meals, shopping, basic housework, medical, washing and toileting needs? What are patients advised to do if these arrangements break down (e.g. if a friend/relative who does not normally reside with them breaks their commitment to be available, perhaps for some unavoidable reason to do with employer demands or other car-ees, or goes sick themselves?) 23

24 b) How is continuing care coordinated with local authority domiciliary care? c) Has the CCG evaluated the adequacy of the Home from Hospital service and are members aware of the misgivings of at least one local pensioners group about its adequacy? Answer: a) The assessment of a patient s needs prior to discharge is not undertaken by the continuing healthcare team so we cannot comment on the nature of that assessment. We are advised by the acute setting of the appropriate care package to meet the health and social care needs of the patient and commission a package accordingly. It is rarely, if ever, reliant on the ability of family members to provide care. Patients (and sometimes appropriately authorised family members) can decline CCG services if they wish to manage care themselves. In those circumstances a new application would have to be made to be re-referred for CHC assessment. If there is any breakdown in care arrangements for a funded care package the first point of call would be to the provider organisation for that care who would contact the appropriate commissioner of that care for advice, support or increased care provision. b) Continuing healthcare does not involve local authority domiciliary care. In the event that a person is in receipt of local authority commissioned care, the funding responsibility for that care package is taken over by the CCG at the point the person is deemed eligible for continuing healthcare, which can only happen after a full assessment for eligibility. In those circumstances it has usually been an increase in care needs so the package of care is often recommissioned. c) The Home from Hospital is commissioned by the London Borough of Haringey. The Council evaluates the service via quarterly monitoring meetings which are informed by performance reporting from the provider (Bridge Renewal Trust). We evaluate patient satisfaction levels (surveyed by Bridge Renewal Trust after receiving a service), referral levels and outcomes against the terms of the contract, and we supplement this with wider stakeholder feedback. Any complaints would be shared with the commissioners during the quarterly evaluation or they may be received directly by the Council. Where we receive any complaints about the service, these are investigated, and followed up with a quality assurance visit if required. We have not received any complaints regarding the service. In order to investigate the point raised in the question we would need further details which may be provided by ing HARCCG.Complaints@nhs.net Question 7 relates to Item 3.2 Performance and Quality summary, section 3.3 and page 9 of the Performance and Quality summary report. 24

25 7. Will the senior CHC nurses overseeing discharge routinely communicate discharge information to GPs, or whose responsibility will it be? What proportion of people discharged have no GP registration? (may be common given low GP registration rate of recent arrivals in Haringey). Answer: The responsibility to ensure GPs receive discharge summaries within 24 hours of the patient being transferred or discharged lies with Trusts. CHC teams do not have a role in overseeing discharge information to GPs. It is very unlikely that patients with CHC needs do not have a GP because they often have a long history of complex care needs. In situations where people are unregistered, Trusts take an active role in encouraging registration. Questions 8-10 from Joanna Bornat, Haringey Keep Our NHS Public Question 8 relates to Item 5.2 Clinical Cabinet Minutes, section Update on BEHMT Haringey Mental Health Services 8. Is the CCG satisfied with the current situation relating to the provision of community based mental health services, their staffing and coordination between primary and secondary care, and might the CCG press BEHMT Mental Health Services to consider whether the future role of the St Ann s site might be used to improve community mental health service provision given that, at present, plans appear to be for adult acute services only? Answer: The CCG works continuously with BEHMHT, and our other partners including the Council, to improve community mental health services. For example, we are pleased to be launching the Primary Care Link Workers in the Central area of Haringey over the summer, bringing mental health nurses into general practice to advise GPs and patients, and to liaise between primary and secondary care. We are also facilitating discussion between primary and secondary care to explore opportunities for joint working in the new primary care buildings that will be opening over the coming years in Haringey. The St Ann s site redevelopment is focused on improving the mental health inpatient wards, and this has been identified as a priority. However, we note that the Trust is also seeking to improve the other facilities on the site that will be under their management in future, to ensure their community teams have appropriate facilities to operate from. Question 9 relates to Item 5.4 Joint Commissioning minutes, section 3.1 Whittington Health Lower Urinary Tract service 9. Could the CCG provide an update on the situation with the Lower Urinary Trace Service at the Whittington Hospital, given that this service 25

26 has yet to be restored after a very long period of closure and request dates for the phased re-opening ( see minute 3.19) of this service? Answer: Following a meeting of the Joint Commissioning Committee (JCC) of North Central London CCGs and the Whittington Health NHS Trust Board, the LUTS clinic has re-opened to new patients. In order to re-open the clinic the Islington Clinical Commissioning Group (CCG) and Whittington Health Trust Board has approved a Commissioning Service Specification, which meets the recommendations set out in the report from the Royal College of Physicians (RCP) Invited Review. The RCP report says: Based on all of the information considered by the review team it was concluded that significant changes need to be made to ensure the safety of patients currently being treated by the LUTS clinic. The Royal College of Physicians (RCP) Invited Service Review Panel recommended that until the future of the service has been determined by the Trust and commissioners, no new patient referrals should be accepted into the LUTS clinic. In line with this recommendation the clinic has remained open to existing patients, but the Trust has not accepted any new referrals since October Any clinician who wrote to make a referral during that time was advised that the referral would not be accepted and that they should refer their patient elsewhere. There is therefore no waiting list or backlog of patients for the Whittington Health LUTS clinic. A more detailed update on the LUTS clinic is available on Whittington Health s website. Question 10 relates to Item 5.3 Finance and Performance Committee Minutes, section Reference is made to the possibility of cutting down on contracts in order to prevent overspend. Could the CCG provide reassurance that this will not mean loss of provision of services or to any reduction in plans for service development for local people? And could the CCG also note that much of this important paper is not written in a way that is easily understood by members of the public? Answer: Haringey CCG will be facing very difficult choices over the coming year as we have a large savings programme to deliver, however, we do not have plans in place to reduce current provision. Our focus will be on continuing to transform services that will provide care closer to home and better value for 26

27 money. This includes continuing to focus on areas such as reducing variation in primary care, supporting people at home, introducing new ways of working such as tele-dermatology and working with partners to take cost out of the system. Your second point has been noted. 27

28 Haringey CCG Governing Body: Action Log Item 1.6 Meeting No. Action Description Lead Action Taken Date Action Log Jennie Williams To speak to Sheena Patel outside the meeting regarding assurances about the volume of rejected e- referrals Matters Arising To arrange for consultations to be promoted more effectively. Tony Hoolaghan Jennie Williams has liaised with Sheena Patel and Denise Pettit outside the meeting. There have been no formal escalations regarding rejections but will be kept under review. The CCG Communications Team is looking into ways of raising awareness of consultations via the CCG website Performance and Quality Summary Report To provide an update to the Governing Body on the Memory Clinic Performance and Quality Summary Report To provide Sharon Grant with more detail about the action being taken by BEH MHT regarding its failure Clare Henderson Jennie Williams Page 1 of 2 An update is included in section four of the Performance Report. Healthwatch and other carer representatives have been invited to be core members of the Dementia Strategy Group. The group is multi-agency and works together to create effective partnership-working, with an emphasis on improving the experience for people with Dementia and their carers via a dementia care delivery plan. The membership of the group has been extended in order to ensure wider engagement and support of the delivery plan. An summarising the action taken by the Trust was sent to Sharon Grant on

29 to meet its complaints management performance target. Page 2 of 2 29

30 Haringey Clinical Commissioning Group Governing Body Meeting 13 September 2018 Report Title Accountable Officer s Report Date of report 27 August 2018 Agenda Item 2.1 Lead Director / Manager GB Member Sponsor Helen Pettersen Tel/ h.pettersen@nhs.net Not applicable. Report Author Tony Hoolaghan Chief Operating Officer Tel/ t.hoolaghan@nhs.net Report Summary Recommendation This report updates the Governing Body on developments in the local NHS and wider policy issues. The Governing Body is asked to NOTE the Accountable Officer s Report. Identified Risks Not applicable. and Risk Management Actions Conflicts of Interest Not applicable. Resource Implications Engagement Equality Impact Analysis Report History and Key Decisions Next Steps Appendices Not applicable. Not applicable. Not applicable. Not applicable. Not applicable. Not applicable. 30

31 Accountable Officer s Report 1 Introduction 1.1 This report focuses on the key activities that the senior team and I have been involved in since the last Governing Body meeting and work progressed. 2 Haringey and Islington Wellbeing Partnership Expression of Interest to Healthy London Partnership 2.1 In June, London areas were invited by the Healthy London Partnership (HLP) to put forward expressions of interest to set out the ways how they might use the flexibilities of devolution in London to progress with integration. These flexibilities include more joint regulation to support joint working or support to enable people to work across transitional health and social care boundaries. Haringey and Islington Wellbeing Partnership submitted a bid in which we set out an ambition to test an expansion of our Care and Health Integrated Network (CHIN) work within two geographical areas, one in Haringey and one in Islington. We would develop these as 'prototypes' of a holistic approach towards improving health and wellbeing within an area, drawing on all assets and the full range of services available. Within the Welllbeing Partnership there is an agreement that this work will be progressed locally and would be supported by, but is not dependent on, additional resource through Healthy London Partnership. 3. Wellbeing Week 3.1 To mark our annual Health and Wellbeing week for our staff, we are hosting a range of activities taking place from September for all staff at Haringey CCG. The week is an opportunity to promote the importance of staff wellbeing in the workplace. Our staff involvement group are also taking a lead on the preparation for the week by hosting a range of activities. The week was a huge success last year. We will also be applying for the London Workplace Charter to highlight the work we do to support our staff wellbeing. 4. Draft Strategy for General Practice 4.1 NCL Clinical Commissioning Groups are developing a refreshed strategy focusing on general practice and which builds on previous collaborative strategies for NCL. A draft strategy has been developed through a dedicated task and finish group, which also included representation from CCGs, Healthwatch, nursing and the NCL GP federations. This group met six times between March and June We are now in the process of engaging on this draft. The timeline has been lengthened until October and November 2018, for the Primary Care Committee in Common and CCG Governing Bodies respective approvals. 4.2 Engagement is being clinically and locally led by each CCG through patient and public forums, GP locality meetings, LMC meetings, primary care development meetings and letters to local councillors. Where it is appropriate, some engagement is being done once across NCL e.g. Joint Health Overview and Scrutiny Committee (JHOSC) and the Primary Care Committee in Common. 4.3 Feedback to date has indicated that stakeholders would like to see greater clarity on what our key priorities are (less is more), clearer examples of what will be different for patients, what investment is available, stronger messages on prevention and self-care and a clearer message on our vision for the workforce and new ways of working (e.g. using pharmacists in general practice, portfolio working for GPs). All feedback is being considered as part of the development of the final draft of the strategy. 31

32 5. GP Patient Survey 5.1 The results of the national GP survey have been published this month by NHS England. This year s survey has been extensively redesigned - the aim is to help better understand and shape areas for improvement in people s experiences of general practice and evolving approaches to delivering GP services. This means the majority of questions are not comparable with pr evious years, and that no comparable data will be published by NHS England. CCGs in NCL will be reviewing their data packs to consider the findings and identify the actions needed to deliver improvement particularly in relation to what patients have said about access. 5.2 Haringey CCG noted the slight overall improvement in overall satisfaction, from 79% to 80%, so closer to the national average which dropped from 85% to 84%. There is significant variation between practices, and our focus is on working with the practices that are at the low end of patient satisfaction. Low patient satisfaction is a potential indicator of other performance issues. 6. Haringey CCG: Maternity and Cancer CCG assessments 6.1 In August, Haringey received its 2017/18 CCG assessments for cancer and maternity. The assessments are based on performance against the indicators in the Integrated Assurance Framework (IAF) for CCGs for these clinical areas. Haringey received a rating of good for maternity and requires improvement for cancer. 6.2 Although the cancer IAF indicator for early stage diagnosis was achieved, patient experience, one year survival rates and the 62 day urgent referral to treatment standard were not at the level required. The focus that is being given in primary care regarding early diagnosis will ultimately support improvements in survival rates and there is an improvement plan in place supported by the cancer collaborative, CCG and NHSI regarding 62 day performance. A plan to improve patient experience of cancer services at NMUH is also in place. 6.3 Contributing to the successful maternity rating has been progress between partners to improve women s experience of maternity services. We would like to thank all staff from across the system involved in delivering these improvements and will continue to work with partners to improve cancer services and outcomes across out system. 7. St Ann s Hospital update 7.1 Barnet, Enfield and Haringey Mental Health Trust is rapidly progressing the plans for the brand new mental health inpatient wards and other improvements at St Ann s Hospital in Haringey. Plans will see the proceeds from the surplus land no longer needed for healthcare, which was sold to the GLA in March 2018, reinvested into the building of the new wards and other improvements. 7.2 The Trust expects to receive final approval from NHS Improvement in September this year. It has already received final planning approval from Haringey Council in March Initial building work is due to begin around November 2018, with completion of the new inpatient building by late 2020 and the other improvements by late The plans have widespread support, with backing from Haringey Council, Haringey CCG and wider stakeholders following two extensive public consultations and on-going stakeholder engagement. The project is affordable and will bear no additional costs to the Trust or NHS commissioners with the new facilities being fully funded from the sale of the surplus land. 32

33 Haringey Clinical Commissioning Group Governing Body Meeting Thursday 12 September 2018 Report Title STP Programme Update Agenda Item 4.1 Governing Body Sponsor Helen Pettersen Accountable Officer Lead Director / Manager Will Huxter NCL Director of Strategy will.huxter@nhs.net Report Author Will Huxter NCL Director of Strategy will.huxter@nhs.net Report Summary The report provides an update on the work of the Sustainability and Transformation Partnership (STP) since April The aim is to ensure that Governing Body members are aware of the current and planned work being undertaken as part of the STP. Recommendation The Governing Body is asked to NOTE the report. Identified Risks and Risk Management Actions Not Applicable Conflicts of Interest Not Applicable Resource Implications Engagement Equality Impact Analysis Report History and Key Decisions Next Steps Appendices There are no direct resource implications arising from this report. Not Applicable Not Applicable This report is a follow-up to previous STP update reports. Not Applicable Six Monthly Report 33

34 STP Programme update Haringey CCG Governing Body 13 September 2018 Will Huxter, Director of Strategy Barnet, Camden, Enfield, Haringey & Islington CCGs 34

35 Ambitions of the STP Improve the health and wellbeing of the local population Ambition for the STP is built on existing CCG, Local Authority and Provider values and strategy Maximise out of hospital care and build resilient well supported communities 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. 35

36 NLP Governance Structure The Adult Social Care Programme runs alongside the STP workstreams 36

37 Key points about STP governance The STP has no formal decision-making authority, beyond management of the agreed programme, and the delegated budget for the STP central team. Statutory bodies retain responsibility for decisions on funding commitments and endorsement of the STP priorities. Increasingly, the STP is being asked by NHS England and NHS Improvement to co-ordinate and submit NCL-wide bids for funding e.g. for Wave 4 capital, and for digital revenue and capital. These are formally signed off by Helen Pettersen as STP Convenor, on recommendation from the relevant STP workstream. The Joint Commissioning Committee has delegated authority for acute commissioning on behalf of the 5 CCGs. The Primary Care Committee in Common has delegated authority for primary care commissioning on behalf of the 5 CCGs. 4 37

38 Summary: Clincal and care workstream objectives Workstream High level objectives Urgent and Emergency Care A consistent and reliable UEC service by 2021 that is accessible to the public, easy to navigate, inspires confidence, promotes consistent standards in clinical practice and leads to a reduction in variation of patient outcomes. Work focussing on Admissions avoidance, ambulatory care, end of life and discharge to assess. Health and care closer to home A place-based population health system of care base around neighbourhoods of 50-80k which draws together social, community, primary and specialist services underpinned by a systematic focus on prevention and supported self-care. Mental Health Working to address inequalities for those with SMI and provide consistent care. Deliver services closer to home, reducing demand on the acute sector and mitigating the need for additional MH inpatient beds. Adult Social Care Working to address care inequalities in provision and improving longer term strategic approach to workforce and care market. Maternity Delivery of the National Maternity Transformation programme through improved continuity and safety of perinatal care for women, working across professional and organisational boundaries to drive better patient experience and integrated care. Children and Young people Delivery of Health and social care services which are equitable, accessible, responsive and efficient, delivered locally wherever possible. Working closely with social care and council services to increase focus on promoting wellbeing, reducing health inequalities and improving social outcomes such as school readiness. Cancer Focus on the delivery of improved survival, reduced variation, improved patient experience, efficiency of service delivery including services closer to home, and, reduced costs and financial sustainability. Planned Care Deliver better value planned care, delivering efficiency savings and reducing unwarranted variation in planned care across providers. Review of orthopaedic services across providers. Prevention Driving system-wide approach to prevention and population health working to enable success in the overall STP strategy for care. 5 38

39 Tangible benefits and delivery to date: UEC One of the first areas nationally to launch the new integrated urgent care model. This means that more people in NCL ringing 111 now speak directly with a clinician to try to resolve their issue. Star divert numbers enable clinical staff to get through to a clinical expert for urgent advice and support by dialling the appropriate number. For 2017/18 star line activity increased 42%, from 751 calls in May 2017 to 1068 calls in April 2018 with a total of 11,929 calls recorded across the period. Mental health patients can now ring 111, and be directly transfer to crisis team for advice and support. 16 people in April who rang 111 with mental health issues were successfully transferred to a mental health team. Successful bid for enhanced mental health liaison services in A&E at University College Hospital in 2017/18, and North Middle sex University Hospital in 2018/19. This will enable us to place more mental health staff in hospitals so patients physical and mental health needs are cared for holistically. We have made it faster and safer for patients to get home from hospital by agreeing standard ways of working and working more effectively with social care. Use of the new discharge to assess pathways has increased by 50% over the past six months. Planned Care Clinical advice & guidance now live across providers in NCL in 8 specialities with further specialties going live in November Tele-dermatology service to go live in 2018/19 to improve patient experience and performance for waiting times. Review of adult elective orthopaedic care commenced in March Our ambition is to create a comprehensive adult elective orthopaedic service for NCL, which will be seen as a centre for excellence with an international reputation for patient outco mes and experience, education and research. Health and Care Close to Home Since April 2018 it has been possible for residents to access GP services 8am-8pm across the whole of NCL through extended access. Established the first NCL Care and Health Integrated Networks and Quality Improvement Support Teams, focusing on improving quality and reducing unnecessary variation. Mental Health Our perinatal mental health service operates across the five boroughs. Our community specialist perinatal mental health service s aw an additional 400 women in 2017/18 and plans to reach an additional 600 women in 2018/19. A new women s psychiatric intensive care unit at Camden and Islington NHS Foundation Trust service opened in November All women who require intensive care services can now be treated close to where they live. All women have been repatriated back f rom out of area placements (OAPs) and we currently have zero women in OAPs. 39

40 Major finance and activity impact for 18/19 Overview of programmes impact and leadership Workstream and leads Programme Primary impact Major Independencies UEC SRO: Sarah Mansuralli C CCG Clinical leads: Chris Laing Shakil Alam Integrated urgent care, Quality & Performance Digital Admission avoidance, Quality & Performance Digital, Workforce Simplified discharge, Quality & Performance Digital, Social Care Last Phase of life, Quality & Performance Digital, Social Care Planned Care SRO: Marcel Levi Clinical leads: Debbie Frost Richard Jennings Health and Care Closer to Home SRO: Tony Hoolaghan H&I CCG Clinical lead: Katie Coleman Mental Health SRO: Paul Jenkins Clinical leads: Vincent Kirchner Jonathan Bindman Alex Warner Using NHS money wisely (POLCE), Q, Learning: Enactment of policy - Clinical Advice and Navigation, Q, Learning: working across acute & primary care Digital Dermatology, Q, Perf & Learning: Use of digital pathway Digital Urology & Learning: upskill primary care HCCH Orthopaedic review Proposed reduction in variation Q and - CHIN/Neighbourhood development Population health and wellbeing Workforce, Estates, Digital Quality Improvement & Reduction in primary care variation Workforce Social Prescribing Reduction in primary care variation Workforce Improve the acute care pathway Reduction in bed requirement in future HCCH, Social Care Improvement to CAMHS Quality improvements CYP Mental Health Liaison services Quality and and perf UEC Primary Care mental health (Inc. IAPT) Q & and Perf HCCH Mental Health Workforce Future workforce development Quality and safety Quality Digital Maternity Donald Peebles Mai Buckley Improving personalisation and choice Quality Digital Single point of access and Quality Digital, Workforce Community services development Quality & NHS E recommendation HCCH NCL collaborative working and Quality Workforce 40

41 Overview of programmes impact and leadership Prevention SRO: Julie Billett Cancer SRO: Kathy Pritchard-Jones Children and Young People SRO: Charlotte Pomery Workforce for prevention Referrals to preventative services (inc MH) Workforce Healthier environment Employee health and wellbeing and sickness rates Workforce Healthier choices (maternity and Frailty) Child health outcomes, independent living Maternity, UEC Sustained delivery of cancer waits Quality & Performance Diagnostics capacity Early diagnosis Quality (lives saved) HCCH, Prevention Living with and beyond cancer Quality HCCH, Planned Paediatric surgery Quality UEC Asthma Quality Prevention, HCCH School readiness by 5 Child outcomes - Paediatric admissions avoidance, Quality and Performance UEC Estates SRO: Simon Goodwin Develop NCL estates strategy Strategic priority,, Quality improvement All St Pancras development C&I FT, Quality improvement Mental Health St Ann s development - BEH, Quality improvement All Project Oriel Quality Improvement - Digital SRO: David Sloman Reducing void spaces, quality improvement All Health Information Exchange Enabler for and Quality improvements Clinical Workstreams Population Health Management Enabler for and Quality improvements Clinical Workstreams UEC preparation winter 2019 Performance and quality UEC, HCCH, Social Workforce SRO: Siobhan Harrington Portability (including passports, MAST) Performance and UEC, Maternity, Cancer Temporary Staffing Provider productivity Social & Primary care/community/place based Long term quality HCCH, Social Care Analytics (workforce planning) enabler for new clinical models Digital 41

42 Overview of programmes impact and leadership Social Care SRO: Dawn Wakeling Provider Productivity SRO: Tim Jaggard Independent Care Sector Workforce Capacity and Quality HCCH, UEC, Workforce Social Care Markets Increased Capacity & Quality; ; HCCH, UEC, MH, Workforce Workforce Workforce Procurement - Facilities management - Diagnostics and Quality Planned Care 42

43 Capacity to facilitate change Dedicated capacity now in place across majority of workstreams to facilitate working across partner organisations to deliver agreed STP initiatives. Workstream Programme lead Address Adult Social Care Richard Elphick Cancer Nasar Turabi Children and Young People Sam Rostom Digital Interim to start in September Estates Dianne MacDonald Health and Care Closer to Home Sarah McIlwaine Maternity Julie Juliff Mental Health Chris Dzikiti Planned Care Donal Markey Prevention Mubasshir Ajaz Productivity Shahbaz Bhutta Orthopaedic review Anna Stewart Urgent and Emergency Care Alex Faulkes Workforce Sarah Young (interim) 43

44 Digital: plan to deliver by 2020 Enable information to flow between all NHS providers and local authorities within NLP Optimise spend on health and care information sharing across NLP Enable population health management capability for NLP Implement international IT standards to enable interoperability and support integrated care Activate person held records (PHR) for NLP residents 11 44

45 Adult elective orthopaedic services review We think there may be opportunities to improve adult elective orthopaedic surgery in north central London by consolidating services onto fewer sites We are undertaking a review of these services to see if these improvements can be achieved The review has been established by North London Partners in Health and Care A review group led by local clinicians is coordinating the development of how this kind of care could be delivered in the future Clinical commissioners will make decisions on where and how this happens The review covers services in Barnet, Camden, Enfield, Haringey and Islington 12 45

46 Stages of the review Stage 1 Engage to get feedback on the draft case for change Propose a service model describing how services might be delivered in Stage future, 2 informed by feedback Clinical commissioners consider the feedback from the engagement, agree a service model Produce a pre-consultation business case Patients & residents Providers Clinicians Clinical Commissioners engagement 13 46

47 Principles underpinning this review Co-production (everyone working collaboratively) Evidence based service model (using evidence from trusted sources) Clinically led collaborative approach which enables meaningful engagement with all stakeholders, particularly front line clinical staff and the public (people involved in delivering and receiving care) Independent experts to provide challenge and advice Sharing what we learn Clear separation of decision-making functions Flexible timelines to ensure we are properly engaging with stakeholders and the public 14 47

48 Leadership and Review Group Chair: Professor Fares Haddad (UCLH) CEO Sponsor and Project SRO: Rob Hurd (RNOH) Review Group Members: Clinical representatives from each of the five largest providers of adult orthopaedic services Two clinical commissioning representatives from NCL CCGs NHS England Specialised Commissioning Two patient and public representatives (recruited by Healthwatch) NHS England Strategy and Reconfiguration In attendance: Trust management leads from each of the five largest providers of adult orthopaedic services Programme Director and Programme Manager Other workstream leads as required 15 48

49 Adult elective orthopaedic services review We think there may be opportunities to improve adult elective orthopaedic surgery in north central London by consolidating services onto fewer sites We are undertaking a review of these services to see if these improvements can be achieved The review has been established by North London Partners in Health and Care A review group led by local clinicians is coordinating the development of how this kind of care could be delivered in the future Clinical commissioners will make decisions on where and how this happens The review covers services in Barnet, Camden, Enfield, Haringey and Islington 16 49

50 Ways to feed back Seeking feed back by 19 October 2018 Read the full case for change on our website: us: Complete our online questionnaire Write to us: North London Partners in Health and Care, 5th Floor, 5 Pancras Square, London N1C 4AG *Additional time will be allowed to hear more views if required 17 50

51 Breakdown of STP financial benefits (NCL-wide) Financial benefits 2018/19: 35m worth of QIPP plans aligned to STP workstreams Successful with bid for 2 grants with Department of Health for Beyond Places of Safety worth 1.0 m and 0.8m 500k grant awarded from Health Education England 100k funding for engagement 100k awarded via RightCare to take forward work on Cardio Vascular Disease prevention NHS E funded dementia project manager 51

52 Supporting local QIPP plans and focus on delivery at scale Urgent and Emergency Care, Planned Care and Health and Care Close to Home workstreams aligned to CCG QIPP plans to support in year financial delivery. This aligns to approximately 35m of acute QIPP schemes across NCL. Across the STP there has been close working with local CCG teams to align plans across the NCL CCGs, spread good practice and support CCGs to add to their pipeline opportunities. This work has resulted in a shared set of priorities across acute contracts (next slide). This will allow the opportunity for greater collaboration and implementation at pace and scale. STP and local teams are working through local delivery teams at each acute site to drive changes and unblock issues. This includes directly supporting implementation of new ways of working and acceleration of local work. Work is underway to quantify new pipeline schemes that can feed into individual CCG QIPP plans

53 NCL wide priorities delivery at scale: Across NCL, the top schemes by value are shared across the four main acute providers. These are summarised below: Number of times scheme appears within top 15 Royal Workstream Free NMUH UCLH Whitt Total Planned Care POLCE Planned Care Diagnostics - Pathology UEC Adult Admission Avoidance - Rapid Response Services UEC Ambulatory Care UEC Simplified Discharge UEC IUC UEC Last Phase of Life Health and Care Closer to Home CHIN & QIST initiatives combined Planned Care MSK UEC Reducing NEL Admissions for Children UEC ED Front Door Streaming & Redirection Planned Care Gastroenterology & Colorectal Surgery Planned Care Clinical Advice and Navigation (CAN) Planned Care Gynaecology 2 2 Planned Care Camden Clinical Assessment Service (CCAS) 1 1 Planned Care Urology 1 1 Health and Care Closer to Home Universal Offer Review 1 1 Planned Care Teledermatology UEC HIU / LAS - Frequent Attenders 1 1 Planned Care Dermatology - minor skin lesions 1 1 UEC Stroke Prevention 1 1 Planned Care STT Cancer Pathway

54 Haringey Clinical Commissioning Group Governing Body Meeting Thursday, 13 September 2018 Report Title System Intentions for 2019/20: Haringey CCG Date of report 30 August 2018 Agenda Item 4.2 Lead Director / Manager Paul Sinden, Director of Performance, Planning and Primary Care Tel/ p.sinden@nhs.net alexander.smith1@nhs.net clare.henderson4@nhs.net Alex Smith, Director of Planning, Performance and Delivery GB Member Sponsor Clare Henderson, Director of Commissioning Not Applicable Report Author Seonaid Henderson, Head of Performance and Planning Tel/ seonaid.henderson1@nhs.net Report Summary This report sets out system intentions and provisional commissioning intentions for 2019/20, and the backdrop to the development of North Central London (NCL) System Intentions for 2019/20. It should be noted that these are provisional system/commissioning intentions and are subject to change as the financial impact of them is assessed. Recommendation The Governing Body is asked to: NOTE the report; and COMMENT on this iteration of System Intentions and local Commissioning Intentions for 2019/20. Identified Risks and Risk Management Actions Conflicts of Interest The main risks to delivering system intentions for 2019/20 are: The need to align CCG and provider operating plans to support a reduction in system costs; and The need to better align system incentives to support delivery of System and Transformation Plan (NCL) priorities and reduce system costs. The report was prepared in accordance with conflict of interest guidance Resource Implications Plans for 2019/20 will need to be developed within CCG resource envelopes and encompass run-rates from 2018/19 adjusted for demographic growth, the impact of the NCL Sustainability and Transformation Plan (STP), local QIPP interventions, and the impact of national planning guidance. 54

55 Engagement Intentions 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. Haringey CCG strives to engage with patients, partners and residents throughout the commissioning cycle to ensure that local people have a voice. We have a strategic approach which is set out in our engagement strategy to demonstrate how we involve patients and wider stakeholders in services we commission. In 2018, the CCG was rated Green as part of a national assessment undertaken by NHS England. Haringey CCG wants to make real and sustainable improvements to the health and wellbeing of the people living in the borough. Effective engagement will help us to improve health outcomes and make the best use of public resources. We will continue to work with patients, carers, and the public to listen to their views, and we will continue to involve them in decisions about commissioning, developing, and improving health services. Equality Impact Analysis Report History and Key Decisions Next Steps The report was written in accordance with the provisions of the Equality Act System Intentions for 2019/20 were considered by the Joint Commissioning Committee Seminar held on 5 July 2018 and by the Joint Commissioning Committee held on 2 August The System Intentions for 2019/20 were considered at the Strategy and Finance Committee on 30 August System intentions and commissioning intentions for 2019/20 will be further developed with feedback from: CCG Strategy and Finance Committees; The five NCL CCG Governing Bodies in September 2018; The NCL Sustainability and Transformation Plan Chief Executives Group (commissioners and providers) in September 2018; The outcome of the NCL STP Integrated Care Systems workshop to be held in October 2018; Priorities set out in the NHS Ten-Year Plan to be published in autumn Before 30 September 2018 all providers in North Central London will have been sent intentions and supporting technical guidance (with notice where required) for 2019/20. Appendices 1. Haringey CCG Notices 55

56 1. Introduction This report sets out system intentions and provisional commissioning intentions for 2019/20, and the backdrop to the development of North Central London System Intentions for 2019/20. Any service changes described in this report are also subject to scrutiny via a business case at the relevant committee or board, during the course of the commissioning cycle, which evaluate the quality, safety, financial viability and strategic fit of any proposal. Commissioning intentions therefore do not represent formal commitments to act, but do ensure commissioners have legally given notice on the pipeline of activities they would like to work jointly with providers on, as notice needs to legally be given to exit contracts or change service configurations in alignment with a strict planning timetable. Intentions for 2019/20 will consist of the following: 1. System intentions - Following on from the after action review of the 2018/19, contract round system intentions for 2019/20 seek to identify a few high-level priorities, agreed by all parties to the STP that will then be translated into operating plans and provider contracts for the year; 2. Commissioning intentions that provide a more detailed view of how system intentions will be delivered locally, plus any local intentions for CCGs that sit outside of the STP; and 3. Supporting technical guidance identifying any areas requiring formal contract notice to providers for 2019/20 System intentions and commissioning intentions for 2019/20 will be further developed in response to feedback from: CCG Strategy and Finance Committees; The five NCL CCG Governing Bodies in September 2018; The NCL STP Chief Executives Group (commissioners and providers) in September 2018; The outcome of the NCL STP Care Systems workshop to be held in October 2018; and Priorities set out in the NHS Ten-Year Plan to be published in autumn Before 30 September 2018 all providers in North Central London will have been sent intentions and supporting technical guidance (with notice where required) for 2019/ System Intentions The high-level priorities for 2019/20 seek to focus on what is best required to meet the needs of the local population, rather than taking an institutional approach. NCL will seek support for the collective commitment to reduce system costs and to ensure that any unintended consequences of that for individual organisations is mitigated. To take this forward there will need to be a single local delivery plan for the year for both commissioners and providers, with the plan developed and signed-off by combined clinical and executive leadership to assure inclusion in operating plans and delivery during the year. Local Delivery Groups, aligned to each provider, will lead in-year delivery. The high-level system priorities for 2019/20 to address the strategic challenges faced by NCL are identified below: A focus on prevention to tackle the broader determinants of health and reduce health inequalities, and to deliver this, extend the scope of work with the third sector and utilisation of community assets; Further developing integrated care systems across health and care services as part of our move to population based health models and to better tackle the broader determinants of health; 56

57 To support our move to population based health models this means redefining community services contracts to an outcomes based approach for future years, allowing greater flexibility in service redesign to support the development of Care and Health Integrated Networks (CHINs), and establishing integrated services across health and care for admission avoidance and discharge from hospital; Building resilience in general practice including developing primary care at scale alongside the emerging GP Federations; The redesign of outpatient pathways building on service models developed in 2018/19 including Clinical Advice and Navigation; Continuing to deliver value and reduce variations in care, building on the work to date in both primary care and secondary care to reduce unwarranted variations in care; Delivering investment in prevention and primary care will require historic growth in acute contract baselines to be halted. Aligned to this, system intentions are designed to deliver off-setted cost reductions for acute providers. This will be supported by: Joint work on provider cost improvement plans and CCG QIPP programmes to help providers reduce their costs; and Joint development of system incentives as below; Trialling new system incentives and contract forms to promote a reduction in system costs and better align incentives to the service models being developed through the NCL STP: In 2019/20 to support STP service developments a focus on outpatient and elective pathways, community services outcomes, and streaming in emergency departments to support urgent treatment centre designations and winter resilience are proposed; CCGs will also work with providers on opportunities for whole contract form changes for adoption in 2019/20 or future years; and In preparation for contracts for 2019/20 and onwards, CCGs would therefore like to shadow-run alternative contract forms in 2018/19 to ensure that any changes support delivery of the STP and balance risk equitably across the system. The delivery of enablers for the above, including: Roll-out of the Health Information Exchange across North Central London; Provider collaboration initiatives including opportunities for common procurement, repatriation of activity, and exploring further opportunities for mutual aid across providers to support delivery of NHS Constitution targets for cancer, referral-to-treatment times, and A&E; Delivery of the estates strategy for NCL based on the one-public estate approach to support the development of a place-based approach to our community estate and increase operational efficiency; and Workforce, including the work by Community Education Provider Networks (CEPN), to develop the workforce to support our strategic service changes with a focus on skill-mix, recruitment and retention, collaboration across providers including passporting, and portfolio careers. 3. Commissioning Intentions The information below sets out how Haringey CCG intends to achieve the priorities within the 2019/20 system intentions and any other local intentions it is required to issue. These intentions are provisional at this stage and have been developed through the following process: Commissioning managers in each commissioning area have collated intentions based on their work programme, giving due to regard to the Joint Strategic Needs Assessment (JSNA), relevant national or regional guidance/policy, patient and public feedback, contract and outcome monitoring, value for money analysis and any available assessments of quality and safety. 57

58 The Executive Management Team (EMT) and Heads of Planning and Performance from Haringey and Islington CCGs have undertaken a joint review taking into account fit with NCL STP strategy and local business plans. EMT and Heads of Planning and Performance have determined which commissioning intentions require a formal notice (see Appendix 1) and which of those are already part of a n existing workplan which might lead to future transformation, for example, joint work to develop a new MSK clinical model. The next steps are for feedback to be collated on both the system intentions (Joint Commissioning Committee (JCC), all five CCG Governing Bodies and Strategy and Finance Committees) and commissioning intentions (Haringey and Islington CCG Governing Bodies and Strategy and Finance Committee). This will allow intentions to be further refined ahead of formal notice being given on 30 September 2018 to all providers in NCL. It should be noted that further intentions are likely to be added as work to agree consistent QIPP initiatives across the STP continues. Community and Acute Commissioning Intentions: Haringey CCG intends to achieve the priorities within the 2019/20 system intentions through the following community health and acute intentions: As part of the Wellbeing Partnership, commissioners and providers have agreed to collaborate in the development of a new MSK clinical model for Haringey and Islington which will include, a single point of clinical triage, increased community provision and a programme of provider led improvements to existing services. This pathway redesign is aligned to national best practice and aims to ensure more people are treated in community based care. As part of the Well Being Partnership programme of work to improve intermediate care, Haringey CCG intends to review and re-specify the Community Rehabilitation Teams service to deliver improvements for Haringey service users. As part of the Wellbeing Partnership programme of work to improve services for Children and Young People within Haringey, a joint review of Specialist Therapies will take place with the London Borough of Haringey which aims to agree new specifications being agreed for all therapies. This will deliver earlier intervention and prevention of speech and language issues. As part of the Wellbeing Programme, Islington and Haringey CCGs will review against best practice all elements of our frailty services in order to consider the current provision and identify any gaps or priority needs. This will be done in a way that is aligned to guidance contained in NHS England s Frail older people Safe, compassionate care practical guide for commissioners and will ultimately aim to support people in community settings better and reduce unnecessary hospital admissions. Haringey CCG intends to draft a new service specification and model for children's community nursing provided by North Middlesex University Hospital. The new model will aim to ensure more children can be cared for in community settings, without the need for hospital attendance/admission. As part of NCL wide work to develop primary care at scale and strengthen care closer to home, wound management and leg ulcer treatment services will be procured at CHIN level. This work aims to ensure better outcomes for patients, ensuring community services are proactive and high quality, in a way that reduces the need for hospital attendance. As part of NCL wide work to improve Urgent and Emergency Care, Haringey CCG and Islington CCG will be exploring opportunities to align and integrate our stroke and neuro-rehab pathways and community and inpatient rehabilitation services in order to improve and expand access to Early Supported Discharge (ESD). This will improve outcomes for patients and enhance their recovery. Aligning and integrating pathways will also improve value for money. 58

59 In alignment with NCL wide work, Haringey CCG will seek to develop revised payment mechanisms that incentivise providers to focus on overall pathway outcomes, and to shift care from acute to primary and community settings. This is likely to be a staged process, with shadow tariffs in place first. Haringey CCG s acute intentions support the redesign of pathways that build upon service models developed in 2018/19. As part of the London Five Point Cancer Improvement Plan, Haringey CCG will require North Middlesex University Hospital to sustainably implement Straight to Test for upper and lower gastro intestinal 2-week wait referrals. This will improve outcomes for patients with cancer, contribute to improving survival rates and help enable this important constitutional target to be delivered. As part of NCL wide work to improve planned care pathways, new pathways will be implemented for planned urology care, ear nose and throat, gynaecology, ophthalmology, chronic kidney disease and physiotherapy for women s bowel services. This will improve the effectiveness and efficiency of pathways in line with recognised good practice. As part of NCL wide work the recommendations from the orthopaedics planned care review will be implemented across NCL and the pain management pathways reviewed. The aim of this work is to improve outcomes for patients and the effectiveness of the pathway, in line with recognised good practice. Taking into account the outcomes of the National Consultation on Evidence-Based Interventions, July 2018, the new sector wide Procedures of Limited Clinical Effectiveness (POLCE) policy will be implemented by all providers. Mental Health Commissioning Intentions Haringey CCG intends to, subject to a positive evaluation, extend the primary care mental health service for the whole of Haringey. The mental health link worker service, nurses and occupational therapists, work in collaboration with secondary mental health services and primary care to deliver a range of interventions including clinical advice and guidance and access to services to prevent emergency admissions. Haringey CCG will continue to support Barnet, Enfield and Haringey Mental Health Trust (BEH MHT) to introduce mental health link workers in the Central CHIN. Haringey CCG intends to review and re-specify the Crisis Response and Home Treatment Teams to strengthen the crisis and acute intervention pathways and models delivering improvements for Haringey service users. Haringey CCG intends to work closely with BEH MHT to improve the dementia pathway including the memory clinic. This work aims to improve patient experience, reduce waiting times, improve post diagnosis-support, and implement the requirements of the NICE guidelines on Dementia: assessment, management and support for people living with dementia and their carers, June As part of NCL wide work, and subject to a successful evaluation, Haringey CCG intends to extend Improving Access to Psychological Therapies (IAPT) for people with long term conditions introducing more long term physical health condition pathways, potentially in cardiology and chronic pain. This work aims to support people to better manage their long term condition, improving outcomes and ultimately reducing costs to the health and care system. Haringey CCG intends to increase the non-long term conditions (LTC) psychological therapies to meet NHS England access target requirements towards 21%. This will be achieved through the expansion of the outreach functions providing a preventative approach to the identification and management of mild to moderate mental health issues. Enhanced provision will also be 59

60 implemented in priority areas, which may include behavioural therapy for couples and specialist support for year olds not suited to Cognitive Behavioural Therapy (CBT). In order to better support recovery and in line with NHS England policy, Haringey CCG intends to implement improvements to the rehabilitation and accommodation pathway in-line with the BEH MHT Out of Area Treatment reduction plan. These improvements may include step down models such as discharge to assess or intermediate care support and treatment options for people with complex needs requiring further assessment for safe discharge home or to a new setting. Haringey CCG intends to recommission Tier 2 CAHMS services to further improve alignment with national policy published in the Department of Health/NHS England: Future in Mind: Promoting, protecting and improving our children and young people s mental health and wellbeing, 2015 and in line with NHS England s Model Specification for Child and Adolescent Mental Health Services: Targeted and Specialist levels (Tiers 2/3). In line with NCL STP strategy, Haringey CCG will work with partners to develop sustainable mental health liaison services that are compliant with national Core 24 requirements (those services that need nationally to be delivered 24/7). This will support all main emergency departments and acute hospitals and aims to improve the responsiveness of services to people experiencing an acute mental health crisis. Haringey CCG intends to commission an evening crisis café service, to work with the psychiatric liaison service and the crisis response and home treatment team service. Haringey CCG intends to reduce the number of people with severe mental illness who are in residential care, supported living or who are homeless by strengthening their community and at - home care and support, using personal health budgets to personalise support across NHS and Social Care services. This is in alignment with the NHS England s National Expansion Plan for Personal Health Budgets, June 2017 and will support people in primary and secondary care to be more physically active and improve wellbeing. This initiative is informed by the good practice developed regionally by Islington CCG, which is an NHSE Personalisation Demonstrator site. As part of delivering the new NICE guidelines for Attention Deficit Hyperactivity Disorder (ADHD), March 2018, mental health commissioners are working together to scope out the service model for a specialist ADHD and Autism Spectral Disorder (ASD) neurodevelopmental disorders (NDD) service that would cover Camden, Islington and Haringey CCGs. Processes are underway to scope a procurement and contracting model for the three CCGs and if this goes ahead then a procurement process will be initiated in December 2018, which could potentially identify a new service provider by autumn The new service model will improve post diagnosis support and include voluntary and community sector engagement. 4. Technical guidance Acute Contracts for 2019/20 and 2020/21 (early indications point to a minimum two-year contract process) will be consistent with national planning guidance, and an indicative timetable is set out below that mirrors the timetable for the 2018/19 planning round. This will be updated once national planning guidance is published in autumn

61 The contract round will have to account for the following: Lessons learned from the 2018/19 contracting and planning round. Agreement of operational planning and contracting principles to ensure a consistent approach for planning and setting contract baselines; Agreement of key planning assumptions for growth, the impact of QIPP and 2018/19 run -rate for baseline setting; The publication of tariffs for 2019/21 tariffs, following an engagement process in autumn The report sets out early indications for 2019/21 tariffs with potential material changes to outpatient and non-elective tariffs; Any changes to the revised standard acute contract including any new mandated contract forms; The approach for setting contract baselines for each individual year as part of any multi-year contract; The approach to setting non-acute baselines; Identification of local variations to the Standard Contract: Local tariffs to support delivery of Sustainability and Transformation Plan (STP) initiatives; Marginal rates; Claims and challenges; Penalties/sanctions; Timetable and approach to generating 2019/20 STP and QIPP schemes and including them in 2019/20 contract baselines; and Local escalation process where progress is slipping against the timetable above, and to avo id the need to refer contracts to NHS England and NHS Improvement for resolution. 61

62 Appendix 1 - Haringey CCG Notices Reference number Programme Area Commissioning purpose and rationale Lead commissioner Coverage Commissioning Lead (name) inc. contact details System Intention detail Providers impacted on H&ICCG2 c/f for 19/20 Children and Young People: Autism Diagnostic Pathw ay Recommissioning of the service to improve quality of care including post-diagnostic support in line w ith the new NICE guidelines on ADHD (March 2018) and Autism Spectrum Disorder (2011) Haringey CCG Multiple CCGs and Kathryn.collin1@n hs.net As part of delivering the new NICE guidelines for Attention Deficit Hyperactivity Disorder (ADHD), March 2018, mental health commissioners are w orking together to scope out the service model for a specialist ADHD and Autism Spectral Disorder (ASD) neurodevelopmental disorders (NDD) service that w ould cover Camden, Islington and Haringey CCG. Processes are underw ay to scope a procurement and contracting model for the three CCGs and if this goes ahead then a procurement process w ill be initiated in December 2018, w hich could potentially identify a new service provider by autumn The new service model w ill improve post discharge support and include voluntary and community sector engagement. All acute providers HCCG 39 Children and Young People (CAMHS) Recommissioning service in line w ith NHS England s Model Specification for CAMHS: Targeted and Specialist levels (Tiers 2/3). NHS Haringey CCG NHS Haringey CCG Dependent on the outcomes of public consultation/engagement requirements, Haringey CCG intends to recommission Tier 2 CAMHS services to further improve alignment w ith national policy published in the Department of Health/NHS England: Future in Mind: Promoting, improving and protecting our children and young people s mental health and w ellbeing (2015) and in line w ith NHS England s Model Specification for Child and Adolescent Mental Health Services: Targeted and Specialist levels (Tiers 2/3). NMUH WH RFL H&ICCG3 Intermediate care Recommissioning service to better support people to be cared for outside of acute hospital settings Islington CCG Multiple CCGs Jacob Wheeler (jacob.w heeler@ islington.gov.uk) and Marco Inzani (marco.inzani@ nhs.net) The intermediate care system across Haringey and Islington w ill be redesigned in collaboration w ith users and providers in order to improve outcomes for patients and services users. This w ork w ill affect all elements of Intermediate Care, and w ill be operationally led in order to determine impact on existing contracts. UCLH WH CNWLFT NMUH 62

63 Haringey Clinical Commissioning Group Governing Body Meeting 13 September 2018 Report Title Haringey CCG Finance Report as at 31 July 2018 Date of report 29 August 2018 Agenda Item 5.1 Lead Director / Manager GB Member Sponsor Report Author Anthony Browne Deputy Chief Finance Officer Simon Goodwin Chief Finance Officer Scott Hunn Head of Finance (HCCG) Tel/ Anthony.Browne@nhs.net Tel/ Scott.Hunn@nhs.net Report Summary This paper sets out for the Governing Body, the Haringey CCG financial position at the end of July 2018 (month 4). The 2018/19 financial plan for the CCG is to deliver an in year surplus of 19k at the year-end. At month 4 the CCG is reporting a 514k year to date deficit and forecasting to plan at year end. Based on April to June activity and an estimate for July the financial position of the CCG s acute contracts reports forecast over-performance of 14.0m at month 4, this has been mitigated by the release of the acute demand reserves, contingency and the impact of QIPP in the latter part of the year. In order to deliver the control target of a 19k surplus the CCG are required to deliver net efficiencies of 19.5m. The CCG has developed 15.8m of schemes and set aside investment of 3.9m to support their delivery. Work is on-going to identify additional efficiencies in-year to cover the 7.6m of unidentified efficiencies. The delivery of our planned in-year surplus of 19k is subject to a number of risks, particularly in year acute over performance, delivery of the STP Interventions & QIPP programme and increased continuing healthcare activity. The net risk is 8.1m, the CCG does not have any reserves or mitigations set aside if these risks materialise. This financial position has been reported to NHS England as part of the monthly monitoring process. Recommendation The Governing Body is asked to NOTE the financial position at month 4. 63

64 Identified Risks and Risk Management Actions Conflicts of Interest Resource Implications Engagement Equality Impact Analysis This report is one element used to monitor the Clinical Commissioning Group s financial performance in terms of adherence to core statutory duties. Not applicable. There are no direct resource implications for this paper, as it is not a project proposal for additional internal resourcing, nor is it assuming additional external resourcing. Not applicable. No Equality Impact Assessment is planned or has been undertaken for the finance report itself, though individual QIPP schemes undergo the assessment. Report History and Key Decisions Next Steps Appendices Not applicable. Updates to be provided at all Governing Body meetings. Financial position of all five NCL CCGs. 64

65 HARINGEY CLINICAL COMMISSIONING GROUP Finance Report for the period to 31 May Introduction 1.1 This paper sets out for the Governing Body, the financial position at the end of May 2018 (month 2). 2 Executive Summary 2.1 The 2018/19 financial plan for the CCG is to deliver an in year surplus of 19k at the yearend. 2.2 At month 2 the CCG is reporting a 14k year to date deficit and forecasting to plan at year end. It should be noted that the position is largely based on one month s data, therefore it is too early in the financial year for any activity trends to emerge. 2.3 In order to deliver the control target of a 19k surplus the CCG are required to deliver net efficiencies of 19.5m. The CCG has developed 15.8m of schemes and set aside investment of 3.9m to support their delivery. Work is on-going to identify additional efficiencies in-year to cover the 7.6m of unidentified efficiencies. 2.4 The delivery of our planned in-year surplus of 19k is subject to a number of risks, particularly in year acute over performance, delivery of the STP Interventions & QIPP programme and increased continuing healthcare activity. The net risk is 7.1m, the CCG does not have any reserves or mitigations set aside if these risks materialise. 2.5 This financial position has been reported to NHS England as part of the monthly monitoring process. 3 Financial Position at Month Financial performance can be summarised as follows: 65

66 Budget YTD Actual Variance FOT Variance '000 '000 '000 '000 '000 Resource Allocation - 70,823-70, ,519 - Acute Contracts (In and Out of Sector) 39,620 39, ,502 - Other Acute 3,092 3, ,554 - Acute Commissioning 42,712 42, ,057 - Mental Health 6,909 6,909-41,457-0 Continuing Care 3,658 3, ,946 - Community Services 3,130 3,130-18,777-0 Primary Care Prescribing 4,849 4,849-29,096-0 Primary Care ,195-0 PRC Delegated Co-Commissioning 6,776 6, ,231-0 Primary Care 111 & OOH Integrated Care ,450-0 Programme Corporate Cost ,882 - Non-Acute Commissioning 26,743 26, ,033-0 Running Costs 1,056 1, , % Contingency ,858 - Demand Reserve ,846 - (Surplus) / Deficit The 2018/19 financial plan for the CCG is to deliver an in-year surplus of 19k at the yearend. 3.3 At month 2 the CCG is reporting a year to date deficit of 14k and forecasting to plan at year end. 3.4 The most significant points to note include: The position is based on one month s data and therefore it is too early in the financial year for any activity trends to emerge. Activity data provided by the main providers is reasonable however contract plans still require correct point of delivery apportionment from Trusts ahead of Month 3 reporting. Out of Sector provider data varies. Not all providers have submitted data and in some instances the data is incomplete. On this basis acute contracts have been reported to plan. The Continuing Healthcare budget is over-performing by 109k at month 2 but is forecast to be in line with plan at year-end. Running cost budget of 6,398k is forecast to plan at month 2. 66

67 4 QIPP Delivery 4.1 The 2018/19 QIPP plan for the CCG is a net 19.5m. The CCG has QIPP identified which are expected to delivery net savings of 11.8m. This includes 12.3m of acute schemes and 3.5m of Non Acute schemes offset by investments of 3.9m to support delivery of the QIPP schemes. 7.6m of unidentified QIPP remains in the plan. 4.2 In order to bridge the gap a repository of QIPP work in progress is maintained and used to support scheme generation. Governance and assurance is provided at Strategy and Finance Committee with the QIPP Delivery Group (QDG) responsible for operational and detailed monitoring of each scheme. 4.3 In addition QDG is focussing on stretch STP interventions and alignment of provider CIPs with commissioner QIPPs to achieve greater savings. The CCG is continuing to work closely with the Right Care delivery team to identify further opportunities from variation analysis. The current work in progress has a value of 3m and is in the process of being validated clinically and financially. 5 Financial Risks 5.1 The delivery of our planned in-year surplus of 19k is subject to a number of risks, particularly in year acute over performance, delivery of the STP Interventions & QIPP programme and increased continuing healthcare activity. 5.2 The CCG on a monthly basis makes an assessment of its key financial risks and mitigations. This is also a key element of the monthly financial report submitted to NHS England. These risks and mitigations represent the level of net risk from delivering a surplus of 7.1m. 6.3 The current assessment of financial risks and mitigations is set out below: Assessment of Risks & Mitigations /19 Adjusted Full Value Probability Value Risks m % m Acute Contract over-performance of 3% at a marginal rate of 50% % Under delivery of QIPP/STP interventions % Increased in year CHC activity % Increased in year Prescibing activity % Increased activity at private providers and out of area mental health providers % Pay 3% % Total Risk Mitigations Contingency (1.9) 100% (1.9) Delay/reduce STP investment (3.9) 20% (0.8) Total Mitigations (5.8) (2.6) Net Risk/(Mitigation) As highlighted above, the current assessment of net financial risk is around 7.1m. This position reflects an assessment of acute over-performance, under-delivery of QIPP/STP interventions and increased non-acute activity. It is evident from the above that the CCG does 67

68 not have any significant mitigations if these risks materialise. The CCG will continue to monitor these and any emerging risks closely looking to identify further mitigations where possible. 6 Recommendation The Governing Body is asked to NOTE the financial position at month 2. Scott Hunn June

69 Finance Report Month 4 (July 2018) Lead Director: Anthony Browne Author: Scott Hunn 69

70 NCL CCG Summary Financial Position at Month 4 Bottom line QIPP Net risks Net risks Net risks Underlying position Annual Plan YTD Var. FOT Var. YTD Var. YTD Var. FOT Var.FOT Var. previous month current month Movement 18/19 Plan M4 Forecast m m m m % m % m m m m m Barnet (0.15) 96% (1.35) 93% (3.55) (6.42) (2.87) Camden (0.00) (1.41) 79% (3.34) 87% (9.82) (9.63) (9.60) Enfield 0.00 (3.33) (0.00) (1.75) 74% % (15.77) (15.77) (3.99) Haringey 0.02 (0.51) (0.00) % (4.82) 75% (7.87) (8.11) (0.23) Islington 0.00 (0.16) (0.00) (0.27) 92% (3.90) 75% (2.02) (2.20) (0.18) 7.50 (0.00) Total 0.22 (3.77) 0.00 (3.58) 84% (13.41) 87% (39.03) (42.13) (3.09) (11.65) This table sets out the aggregate position across the five NCL CCGs. There is an annual plan to deliver a 0.22m surplus. There is a YTD adverse variance at M4 of ( 3.77m) mostly at Enfield ( 3.3m). Each CCG is reporting a FOT on plan. There is an adverse YTD QIPP variance ( 3.58m). The FOT QIPP variance is ( 13.41m) There is an overall Net risk of ( 42.13m) to the achievement of NCL CCG financial plans, a net deterioration in the risk position by 3.1m since M3. The 18/19 target underlying position was for a 14.2m surplus. At M4 the forecast is for a 11.65m deficit, a net deterioration of 3.4m since M3 (mostly at Barnet). 70

71 Executive Summary Summary financial position ( m) YTD Full Year Bud Actual Var Bud FOT Var Revenue Resource Limit Acute Non-Acute (0.9) Corporate & Running Costs Total Operational Total Non Operational (0.6) 1.9 (0.0) (1.9) Total Expenditure Surplus / (Deficit) 0.0 (0.5) (0.5) (0.0) Acute performance ( m) Trust / Service YTD Full Year Bud Actual Var Bud FOT Var North Mid Whittington Other Acute (0.8) (7.0) Total Acute Prior month /19 QIPP programme ( 'm) YTD Full Year Bud Actual Var Bud FOT Var Planned care CC2H (0.2) UEC Other Acute Other Schemes (0.6) (0.6) (6.8) Net QIPP (4.8) Summary Financial Position: The 2018/19 financial plan for the CCG is to deliver a surplus of 19k at the year-end. At month 4, the CCG is reporting a 514k year to date over-performance and forecast to plan at year end. There continue to be significant levels of risks that may impact on the CCGs financial position further, these relate to QIPP, acute activity and CHC. Acute: Based on April to June activity the financial position of the CCG s acute contracts reports forecast over-performance of 14.0m at month 4, this has been mitigated by the release of the acute demand reserves, contingency and the impact of QIPP in the latter part of the year. Non Acute: The CHC budget is seeing increased levels of activity and costs in the first four months of the year and is currently under review. QIPP: The QIPP Programme is forecast to deliver 14.7m (75%) of the 19.5m plan. Additional schemes are being worked through to mitigate the current under delivery and to provide cover against any future deterioration in the financial position. 71

72 Financial Bridge Plan to Forecast Outturn The forecast outturn at month 4 is a surplus of 19k which is in line with the agreed NHSE control total. 4.0 (1.0) Driven By: 4.5m Whittington Health 5.4m North Middlesex 1.6m Royal Free London 2.8m UCLH 0.8m Out of Sector m Private Providers 0.0 (6.0) (11.0) (16.0) (4.8) (10.9) Applied at: 0.5m Whittington Health 1.0m Royal Free London 0.2m UCLH 1.6 Applied at: 5.0m Acute Demand Reserve 6.7m QIPP Delivery 2.0m Delay/Reduce Investment (21.0) 17/18 Plan QIPP slippage Acute performance Marginal rate Prior year items Mitigations Other FOT M2 M3 M4 Var Plan (0.1) QIPP Slippage (4.8) (4.8) Acute performance - (7.4) (10.9) (3.5) Marginal rate Prior year items Mitigations Other (1.0) FOT - (0.0) Material Changes from the prior month FOT are: QIPP slippage of 4.8m. Deterioration in acute performance of 3.5m, partially offset by the application of the marginal rate ( 1.6m). Phasing of QIPP plan adjusted to reflect forecast delivery of 6.7m in latter part of the year. Investment reduction of 1m withheld to offset QIPP under delivery. 72

73 Risk and Mitigations An assessment of risks and opportunities that may impact on the CCGs financial position further has been estimated at 8.1m over and above the forecast position. Risk and mitigations ( m) Last Current Change Best Worst FOT Acute Services (6.9) (6.8) (6.8) Mental Health Community Health (0.0) 0.6 (0.0) Continuing Care (1.0) (0.8) (0.8) Primary Care Services (0.5) (0.3) (0.3) PC Co-Commissioning Other Programmes - (0.7) (0.7) - (0.7) Running Costs (0.1) (0.0) (0.0) Total (7.9) (8.1) (0.2) 0.6 (8.7) Haringey CCG is reporting breakeven but has identified 8.7m of Risk with 0.6m of Mitigations. This position has been reported to NHSE. The Acute Risk consists of 4.8m QIPP slippage and 2.0m of over performance on agreed contracts. Community Services mitigation relates to the potential delayed investments supporting QIPP. Continuing Health Care risk consists of 0.2m QIPP slippage and 0.6m increased activity and package of care prices. Primary Care Services risk of 0.3m relates to QIPP slippage. 73

74 NCLsummary Financial Position All CCGs are forecasting to hit plan. However, there is 42.13m overall net risk to the achievement of the plan, which means delivery will be challenging. Table 1 - NCL CCG Summary Financial Position - Month 4 18/19 Annual Plan Bottom line QIPP Net risks Net risks Net risks Underlying position YTD Var. FOT Var. YTD Var. YTD Var. FOT Var. FOT Var. previous month current month Movement 18/19 Plan M4 Forecast m m m m % m % m m m m m Barnet (0.15) 96% (1.35) 93% (3.55) (6.42) (2.87) Camden (1.41) 79% (3.34) 87% (9.82) (9.63) (9.60) Enfield 0.00 (3.33) 0.00 (1.75) 74% % (15.77) (15.77) (3.99) Haringey 0.02 (0.51) % (4.82) 75% (7.87) (8.11) (0.23) Islington 0.00 (0.16) 0.00 (0.27) 92% (3.90) 75% (2.02) (2.20) (0.18) 7.50 (0.00) Total 0.22 (3.77) 0.00 (3.58) 84% (13.41) 87% (39.03) (42.13) (3.09) (11.65) Source: Non-ISFE return This table sets out the aggregate position across the five NCL CCGs. There is a annual plan to deliver a 0.22m surplus. There is a YTD adverse variance at M4 of ( 3.77m) mostly at Enfield ( 3.3m). Each CCG is reporting a FOT on plan. There is an adverse YTD QIPP variance ( 3.58m). The FOT QIPP variance is ( 13.41m) There is an overall Net risk of ( 42.13m) to the achievement of NCL CCG financial plans, a net deterioration in the risk position by 3.1m since M3. The 18/19 target underlying position w as for a 14.2m surplus. At M4 the forecast is for a 11.65m deficit, a net deterioration of 3.4m since M3 (mostly at Barnet). 9 74

75 Executive Summary The CCG is forecasting to deliver the plan, although there is significant risk in relation to QIPP delivery and acute activity Summary financial position ( m) YTD Full Year Bud Actual Var Bud FOT Var Revenue Resource Limit Acute Non-Acute Programme Corporate Costs (0.1) (0.1) Corporate & running costs Total Operational Total Non Operational - (2.1) (2.1) (4.4) Total Expenditure Surplus / (Deficit) - (0.2) (0.2) - (0.0) (0.0) Acute performance ( m) YTD Trust / Service Full Year Bud Actual Var Bud FOT Var m m m m m m Whittington UCLH Other Acute Total In Sector Prior month /19 QIPP programme Gross ( '000) YTD Full Year Bud Actual Var Bud FOT Var m m m m m m CC2H (0.22) (0.60) Planned Care (0.20) UEC (0.05) Other Schemes (0.36) (3.04) QIPP Programme (0.28) (3.89) Summary position o o o o o o Year to date the CCG is showing a 0.2m adverse variance against plan, however maintains a breakeven forecast outturn (FOT) whilst further analysis of QIPP and performance levels are completed. Acute Data - To date the CCG has only received Month 3 (flex) data and are mindful of the risk of using a small sample to draw full year conclusions. The adverse variance of 2.3m is based on QIPP slippage and the effect of this is offset with non recurrent items within the Acute Demand Reserve. The Acute Demand Reserve is fully utilised to achieve the FOT position. Non Acute - The majority of Mental Health and Community contracts are block arrangements but there has been notification of a 0.2m FOT cost pressure on the Learning Disabilities pooled budget. Continuing Healthcare has a reported 0.1m overspend YTD but this is expected to reduce as the work for the agreed CHC QIPP has started. Prescribing data has only been received for April and May and as yet, as in all years, the full year forecast is not available until August. Contracts There is a large element of QIPP that is not included within Whittington, UCLH and RFL contracts and this represents a significant risk to delivery of the CCG control total. 1 75

76 Bridge The forecast outturn is breakeven QIPP slippage and acute performance have been offset by reserves (Acute Demand and Contingency) (1.0) Total acute variance is split between QIPP slippage 0.3m and over performance 0.4m Release of contingency Driven by: Prescribing of 0.8m; partially offset by CHC overspend of 0.7m (above QIPP slippage of 0.8m) (2.0) (3.0) (4.0) (3.9) (0.5) 4.4 (5.0) 18/19 Plan QIPP slippage Acute performance Mitigations Other FOT Bridging items ( m) M2 M3 M4 Var Plan QIPP Slippage - (0.0) (1.3) (1.3) Acute performance - (0.4) (1.5) (1.1) Mitigations Other - (0.9) Movement Material changes from the prior month FOT are: QIPP slippage of ( 1.3m); Acute performance has deteriorated by ( 1.1m); Prescribing now forecasting an underspend of 0.8m; and Remaining contingency of 1.5m held at M3 has been released 2 76

77 Risk & Mitigations There is a 2.2m net risk for Islington CCG reported to NHSE. This Risk not reported in position & should it materialise will be a pressure to CCG bottom line Table 8 - Risk & Mitigations Risk and mitigations ( m) Emergent risk Last Current month month Change Mitigations Best Case Med Case Worst Case FOT (0.0) (0.0) (0.0) Acute Services (4.0) (4.2) (0.1) (0.2) (4.2) Mental Health (0.0) Community Health (0.2) (0.2) (0.2) Continuing Care (0.2) (0.1) (0.1) (0.1) Primary Care Services (0.5) (0.5) (0.0) (0.5) PC Co- Commissioning Unidentified QIPP (2.3) (2.3) (2.0) (2.3) Running Costs (0.1) Total (7.2) (7.3) (0.1) 5.1 (0.0) (2.2) (7.3) o o o o o o o This is the basis of the month 4 return to NHSE. Islington CCG is reporting breakeven but has identified 7.3m of Risk with 5.1m of Mitigations The Acute Risk consists of 1.6m QIPP slippage and 2.6m of over performance on agreed contracts. For the Acute Mitigations the continued levels of over performance are being challenged and data is being further analysed to ensure over performance is not linked to QIPP slippage. Mental health services has some over performance in Pooled budgets but this is being managed within other areas. Continuing Health Care Services risk relates to the delay is patient assessments that are behind the QIPP target Primary Care Services relates to risk on Prescribing charges (NCSO and Category M). These may be offset by underspends elsewhere in Primary Care, predominantly CCG staffing. Islington CCG has a Stretch QIPP target of 3.3m. QIPP shemes are being identified but due to the time taken to initiate there is a risk that 2.3m will not be achieved in 18/

78 Haringey Clinical Commissioning Group Governing Body Meeting Thursday, 13 September 2018 Report Title Performance Report Date of report: 29 August 2018 Agenda Item 5.2 Lead Director / Manager Alex Smith, Director of Planning, Performance and Delivery, Haringey and Islington CCGs Tel/ alexander.smith1@nhs.net GB Member Sponsor Report Author Not applicable. Seonaid Henderson, Head of Planning and Performance, Haringey CCG Tel/ seonaid.henderson1@nhs.net Report Summary This report provides an overview of the performance of Mental Health, Community Health Services, Ambulance services and other key non-acute standards Acute Performance information is reported at the Joint Commissioning Committee (JCC) and the papers for JCC have been made available to the Governing Body. As the Governing Body will be aware (due to reporting timetable differences) the performance report contain different months activity. This is stated within the relevant sections of the P&Q summary. Recommendation The Governing Body is asked to NOTE the contents of this report. Identified Risks Not applicable. and Risk Management Actions Conflicts of Interest Not applicable. Resource Implications Engagement Equality Impact Analysis Report History and Key Decisions Next Steps Appendices Not applicable. Not applicable. Not applicable. Not applicable. Not applicable. Performance & Quality Report - Governing Body Summary 78

79 1. Executive Summary The Performance and Quality Summary (P&Q) and this report provide an overview of the performance of Mental Health, Community Health Services, Ambulance services and other key non-acute standards in Haringey. Acute Performance information is reported at the Joint Commissioning Committee (JCC) and the papers for JCC have been made available to the Governing Body. As it is widely seen as a system target, dependent on multiple agencies to deliver, this paper also provides an overview on A&E performance. As the performance of acute services is already reported to the Governing Body via the Joint Commissioning Committee report reporting on acute services had been removed from this report to avoid duplication. The Performance and Quality Summary produced by North East London Commissioning Support Unit (NEL CSU) will report performance of A&E (including the London Ambulance Service performance), Mental Health and Community Services. It should be noted that sections of the report contain different months activity, due to the reporting timetable. This is stated as clearly as possible within the report and near-time local intelligence is also included, where relevant. 2. Accident & Emergency (A&E) The provider level performance for the A&E four hour waiting standard for June 18 is shown below Main provider A&E performance for the A&E four hour waiting standard: Provider Performance June 18 Lead commissioner North Middlesex University Hospital 89.7% Haringey CCG Whittington Health NHS Trust 90.6% Islington CCG Our main provider, NMUH, achieved the standard expected within the NHS Operating Plan trajectory for NMUH for 2018/19. The target was 86% while performance for June 2018 was 89.7%. NMUH Performance Update The A&E standard is dependent on multi-agency working to delivery, including through nonacute providers and social care. A&E performance has continued to stablilise for the six weeks leading up to 19 August This is largely due to the implementation of the new Emergency Department (ED) operating model: Week Provisional Performance Target (improvement trajectory) w/e 19 th August % 89% w/c 12 th August % 89% w/e 5 th August % 89% w/e 29 th July % 86% 79

80 w/e 22 nd July % 86% w/c 15 th July % 86% Under NHS Operating Plan guidance, NMUH is planning to achieve 90% by September 2018 and 95% by March Making the step changes necessary to consistently achieve these targets continues to require collaborative and system wide efforts across all partner agencies, managed via the Safer, Faster, Better Programme and overseen by the A&E Delivery Board. NMUH has exceeded trajectory targets in three of the last six weeks, against a number of challenges including an unprecedented heatwave and CPE infection outbreak. The Safer, Faster, Better Programme (overseen by A&E Delivery Board) has developed a number of High Impact Initiatives which aim to further support ED improvements, including through a breaches in minors reduction plan and a multi-agency plan to tackle LOS challenges which impact on flow. The weekly breach analyses continues to show bed management (i.e. lack of available beds) to be the main reason for breaches, accounting for approximately 40% of all breaches over the above six week period. This emphasises the importance of LOS work both within NMUH and between multi-agency partners. Delayed Transfers of Care (DToC) Performance DToCs at NMUH have been an increasing issue in recent weeks. One of the reasons for this increase has been challenges associated with care home provision. Work is also being undertaken in partnership with Haringey Local Authority to understand reasons behind apparent increases in social care DTOCs. Weekly multi-agency platinum command meetings attended by Executive level sponsors from NMUH and Haringey/Enfield CCGs have been established to understand and unblock internal and external reasons for delay amongst patients who have the longest delayed discharges (21 days +). Learning from these meetings is being incorporated into system improvement plans. This approach is in line with good practice mandated within the National Length of Stay initiative, whereby all systems must reduce the number of patients who experience the longest delays significantly by December This is because of the safety issues concerned with deconditioning and resultant impact on flow. Continuing Healthcare (CHC) in the acute setting Haringey CCG continues to perform well with 0% of assessments taking place in an acute setting and 98%+ eligibility decisions on cases with a positive NHS CHC Checklist, being made within 28 days of the receipt of the checklist (target 80%) in May Whittington Health (WH) Community Health Services (CHS) The full report showing the performance for each service against the maximum and average waiting time for urgent and routine appointments is shown in main performance pack. The number of patients seen in the latest month is also indicated. The community services report shows that in June, for Haringey CCG, eight community services at Whittington Health achieved performance of 95% or above for routine appointments. This compares to ten in May

81 A number of areas that did not achieved their service target did however demonstrate significant improvements in performance in June 2018: Physiotherapy (from 50% to 77.8%); MSK CATS (from 75.2% to 88%); and Podiatry (from 62.9% to 74.8%) The Community Services improvement work stream has focused mainly on podiatry, bladder and bowel, nutrition and dietetics and lymphoedema. Whittington Health and the Wellbeing Partnership identified these services for improvement based on their high waiting times, service throughput and recruitment and retention issues. The service improvement work s focus is on workforce, efficiency, estates and improving patient satisfaction. Each of these services have observed improvement in performance since improvement work started. The table below summarises when the reduction in waiting times is expected to be achieved by. Service improvement delivery timeline: Service Agreed date for achievement of target Podiatry Oct 18 Bladder and Bowel Adults Dec 18 Nutrition and Dietetics Oct 18 Lymphoedema Sept 18 Now that these work streams are well-established further areas are being added to the scope of the improvement work which are summarised in table below. Service improvement delivery timeline for extended scope Service Improvement objective Agreed date for achievement of target Intermediate Diabetes Service Respiratory Service Intermediate Care Community Reablement Team (CRT) Integrated Community Therapy Team (ICTT) Bladder and Bowel (Children and Adults) School Nursing Patients are able to expect and receive prompt and accurate assessment and care to enable them to live healthy and independent lives. Reduce the number of inappropriate referrals and support GP/Practice education of Type 2 diabetes. The service will reduce the waiting times for Pulmonary Rehabilitation, in the longer term, the impact of earlier interventions will contribute to a reduction in hospital admissions. The service will continue to ensure patients are seen on time according to clinical need(s) and are offered a rehab programme where necessary. The service will continue to ensure patients are seen on time according to clinical need(s) and are offered a rehab programme where necessary. The service aims to improve access rates and see clients in a timely manner, preserve independence for clients living in their own home for longer and reduce the number of cancellations by the team. The work will address capacity issues with recruitment scheduled. Performance improvement plans include a first point of access, senior team organisational development work and a focus on operational efficiencies. The work will address capacity issues and an increase in number of referrals, particularly with safeguarding. Recruitment is planned for Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Feb 19 Sept 18 81

82 Parents & Infants Psychological Services (PIPS) nurses. A review of Emergency Department and Multi-Agency Safeguarding Hub referrals is underway by the safeguarding team. Improvements are expected by September Address capacity issues (new trainee starting in October 2018) Dec Barnet, Enfield & Haringey Mental Health Trust (BEH MHT) Out of area placements This relates to people being admitted to an adult acute bed out of the Barnet, Enfield and Haringey area, and is an area of particular focus with NHS England. It also has significant impact on North Central London s Sustainability and Transformation Partnerships (NCL s STP) aim of staying within the current mental health acute bed base, and for Haringey CCG and BEH MHT in terms of quality and sustainability. Haringey s monthly figure for June 2018 was 200 days; a reduction from an average of 325 per month over the previous six months. BEH MHT led a Perfect Week exercise in August 2018 which has led to the agreement of a significant number of actions and changes, including opening a new acute ward in Barnet to support the trust wide position on this performance. Delayed Transfer of Care (DToC)/Length of stay on acute wards Haringey Mental Health Delayed Transfer of Care (DToCs) were increased to 5.3% of bed days in June 2018 against a target of 2.5%. A Trust-wide DToC reduction plan has been approved and is being implemented by the tri-borough System Resilience Lead. Memory Clinic Service (MCS) Haringey CCG is reassured that the service meets the Memory Service National Accreditation Programme (MSNAP) standard of 12 weeks for people who require complex investigations to determine a diagnosis, standards which have been published by the Royal College of Psychiatrists. However, the service has continued to not provide referral to diagnosis within six weeks and significant collaborative work is being undertaken between commissioners and BEH operational and clinical leads to improve the pathway. As part of the wider tri-borough and NCL commissioning arrangements, we have engaged the NCL performance and improvement manager who has undertaken an initial demand and capacity review of the service. This will help to identify issues in relation to the future SLA and to understand current pressures. Recommendations from the demand and capacity review of the service are being shared with Haringey CCG in mid-september. Haringey CCG officers have been meeting with the memory clinic service and The Haynes dementia hub service, launched in June this year, to create opportunities for people to be referred to post diagnostic support quicker and reduce the need for the memory clinic to offer follow on appointments routinely. This has released some capacity to offer appointments to reduce the waiting list. Haringey CCG is also actively supporting the development of a memory clinic service Service Level Agreement for all three memory service clinics within Barnet, Enfield & Haringey Mental Health Trust that will ensure equitable standards across BEH for services from

83 We have agreed with our local authority colleagues and the wider dementia care strategy group to develop a co-produced action plan to ensure that all services within Haringey are working towards the recent NICE guidance on dementia care Dementia: assessment, management and support for people living with dementia and their carers. This has significant guidance on assessment and diagnosis tools and will support more efficient approaches that will ultimately reduce waiting times and improve quality of post diagnostic support. Membership for the dementia care strategy group includes carer representatives, NMUH, LBH and BEHMT. Membership will be extended from September this year to include increased carer representation. We will also extend an invitation to Healthwatch colleagues to ensure that we are engaging the widest audience possible to influence the development of the pathway for both patients and their families and carers. An additional invitation has been sent to NHS England regional dementia care leads. The demand and capacity review will offer a view on whether the current service has the resource to meet the current six week target in all cases. However, the service is MSNAP accredited and has additionally been rated as outstanding by CQC and therefore the general offer is deemed to be of a high standard. The results of the demand and capacity review will support the consideration of a sustainable approach and it is recommended that a business case will be developed to incorporate reducing the current waits, improve the 6 week target to all applicable cases and to consider the impact of improved pathways both into the service and earlier discharge into post diagnostic support services. The business case will highlight where efficiencies can be made and what further resource may be required. It is important to note that 32% of people require more than one assessment or diagnostic meeting something that will require significantly longer than six weeks (dependent on complexity). However, waiting times from referral to diagnosis for those patients with particularly complex presentations still fall within good practice guidelines. As a result of the need for a second or third appointment, which will apply to one third of all available appointment slots, the number of slots available for the initial assessment and diagnosis appointments has reduced. The recent NICE guidance on dementia will support more efficient and timelier diagnosis times for dementia potentially reducing the number of second and third appointments. As part of the Dementia Care Strategy, we are working closely with clinical and operational leads to ensure the service is supported, particularly post diagnosis, to be able to signpost both clients and their families to support services. This will reduce the number of follow on appointments that people may need following their diagnosis and ensure people are supported in the optimal care setting. Haringey CCG are seeking Healthwatch involvement in the dementia care strategy group. The dementia strategy group met in July and is chaired jointly by HCCG and Haringey social services and has further membership from colleagues from BEH, NMUH, carer representation, social services and the independent sector. This is where the collaborative work of commissioners comes together with wider stakeholders. It has been working to support the wider dementia care pathway and particularly the flows following diagnosis from the memory clinic service. With Dr Gino Amato offering to support the work of the group, we are hoping to increase the focus on supporting the referrals into the service even more. Since July the Group has: Re-drafted dementia care protocols and these will be signed off for wider circulation to primary and secondary care colleagues following the next strategy meeting in September Linked the dementia care navigators (1.5WTE) with the Haynes dementia care hub that was launched earlier this year 83

84 Agreed to update its overall action plan and focus on the ensuring a multi-agency plan to support the recently published NICE guidance. Early Intervention Psychosis (EIP) The Haringey service continues to meet the two-week RTT target of 50%, with performance of 75% in June Increasing Access to Psychological Therapies (IAPT) Local June 2018 data showed the IAPT recovery rate was 58.2% (target 50%) and Haringey s IAPT service continues to improve and exceed all targets. Both the IAPT six weeks and 18 weeks waiting time standards were achieved in June 2018 (93.4% and 100% respectively). Children and Young People Mental Health (CYPMH) Quarter four 2017/2018 national data is now available. Prior to the data release there was a one-off special data collection by NHS Digital/NHS England for all the providers to contribute. Local data has previously shown that performance is better than the information NHS England formally publish. This is because it captures activity from our local voluntary sector providers who were not yet able to upload their activity to the national reporting toolkit in a way that is compliant with recent information governance legislation. Therefore the non-submitting local providers were able to submit their activity and the CCGs signed these off. Haringey CCG achieved 27.3% (2017/18) with the Mental Health Services Data Set (MHSDS) data. Once all local providers manual updates were included, Haringey CCG achieved 31.8% against the 30% standard. There is a local action plan in place at BEH MHT to increase access. Commissioners have been working with NHS England/CSU representatives to develop a local way of uploading the voluntary sector activity sustainably on Haringey CCG s behalf in accordance with General Data Protection Regulation (GDPR) standards to the NHS Bureau Service. 5. Quality Premium (QP) The QP award is based on measures that cover a combination of national and local priorities and reflect the quality of the health services commissioned. Quality Premium 2017/18 The total value of the Quality Premium in 2017/18 was 1,434,000. Payments are usually made in month nine (December 2018) of the financial year. The Quality Premium due in month nine 2018/19 is based on the performance for 2017/18. There were five national measures (early cancer diagnosis, GP access and experience, continuing healthcare, bloodstream infections and mental health) and two local measures (one of which is the mental health measure and the other is the expected prevalence of people with atrial fibrillation). The indicators for these measures were: 1. For CCGs to show an improvement in early cancer diagnosis (increase proportion diagnosed at stages 1 or 2); 84

85 2. That the GP survey indicates 85% of respondents said that they had a good experience of making an appointment or that there was a 3 percent increase (between July 2017 and July 2018 survey results); 3. For CCGs to ensure that in more than 80% of cases with a positive NHS Continuing Health Care (CHC), assessments took place within 28 days, and that less than 15% of all NHS Continuing Health Care assessments take place in an acute hospital; 4. For CCGs to demonstrate they are reducing Gram Negative Bloodstream Infections (GNBSIs) and inappropriate antibiotic prescribing in at risk groups; and 5. For CCGs to demonstrate a reduction in the number of out of area mental health placements. The final data has not yet been confirmed for 2017/18. However, early indications are that at least four of the national improvement measures have not been met (early cancer diagnosis, overall experience of making a GP appointment, CHC assessments and Out of Area Placements) and reductions in gram negative bloodstream infections and inappropriate antibiotic prescribing will be met. The value of the quality premium paid will be reduced by 25% for each of the constitutional measures which are not met. Of the four constitutional measures, the latest data for 2017/18 shows that at least three of these standards were not met. These were A&E 4 hour waits, Cancer 62 day waits (GP referral to first definitive treatment and Category A RED 1 ambulance calls). The constitutional standard of referral to treatment within 18 weeks (92% of patients) was met. This means that the payment any of the national or local measures which were met will be reduced by 75%. The current estimate of the likely Quality Premium payment based on the performance for 2017/18 is 93,250. Quality Premium 2018/19 The 2018/19 Quality Premium scheme guidance published by NHS England in April 2018 has been restructured to include an incentive on non-elective demand management. In keeping with the 2017/18 Quality Premium, the maximum payment for a CCG is expressed as 5 per head of population, calculated in the same methodology as for CCG running costs, and made as a programme allocation (this is in addition to a CCG s main financial allocation and its running costs allowance). Emergency Demand Management Indicators ( 210M national allocation): 85

86 Indicator Rationale Weighting Type 1 A&E Attendances Total number of type 1 A&E attendances for 2018/19 is no greater than their total planned number of type 1 A&E attendances in 2018/19. These will be measured as simply the difference between actual and plan e.g. [2018/19 actual attendances] - [2018/19 planned attendances] 50% Non-Elective admissions with zero length of stay Total number of actual non-elective admissions with LOS =0 days in 2018/19 is no greater than their total planned number of non-elective admissions with LOS = 0 days in 2018/19. These will be measured as simply the difference between actual and plan e.g. [2018/19 actual attendances] - [2018/19 planned attendances] Non-Elective admissions with length of stay of 1 day or more Total number of actual non-elective admissions with LOS >=1 days in 2018/19 is no greater than their total planned number of non-elective admissions with LOS >=1 days in 2018/19. This will be measured as simply the difference between actual and plan i.e. [2018/19 actual admissions] - [2018/19 planned admissions]. 50% 86

87 Quality Indicators ( 68M national allocation): No. Simple QP Inidcator name Target Baseline YTD Performance Weighting 1 Cancer diagnosed at early stage. 60% 56% 56% (2016 Q4) 17.00% 2 GP Survey - patients experienceing a good service when making an appointment. 68% In July % (August 2018) 65% (August 2018) 17.00% NHS CHC Checklist decicsion made within 28 days. Above 80% To be Compliant 83% - Q1 2018/ % Less than 15% of NHS CHC Checklists take place in acute hospital setting Below 15% To be Compliant 11% - Q1 2018/19 4 Improved Access to Children & Young People s Mental Health Services: The increase in activity to enable children and young people aged under 18 with a diagnosable Mental Health condition to receive treatment in NHS funded community services. Above 32% 27.3% (2017/18) 27.3% (2017/18) 17.00% The reduction target in all E coli BSI reported at CCG level below March March % Collection and reporting of a core primary care data set for all E coli cases No Target No Target Ongoing 2.55% 5 A 30% reduction in the number of Trimethoprim items prescribed to patients aged 70 years or greater 30% below the June 2015-May 2016 baseline (May 2018) 3.40% (STAR-PU) must be equal to or below England 2013/14 mean performance value of items per STAR-PU Below (March 2018) (May 2018) 1.70% (STAR-PU) equal to or below items per STAR-PU (A STAR-PU (or Specific Therapeutic group Age-sex Related Prescribing Unit) is a value calculated to reflect not only the number of patients in a practice, but also the age and sex mix of that group) Below (March 2018) (May 2018) 4.25% 6 Improvement in the proportion of people with atrial fibrillation with CHADSVASC2 score> % (Oct 2017) 72.53% (Oct 2017) Next data due Nov % *CCGs can select one local indicator which will be worth 15% of the QP for the Quality Indicators. In 2017 Haringey CCG chose expected prevalence of people with atrial fibrillation as its local indicator for the 2017/2019 quality premium and this has been retained for the 2018/19 scheme. Quality, Financial and Constitutional Gateways will again be core requirements for payment in 2018/19. However, given the introduction of an emergency demand management element and to remain aligned with Operating Plan guidance, NHS England have suspended the operation of the tests relating to Ambulance response times and 4 Hour A&E. 87

88 NHS constitution gateway indicators are therefore: Indicator March 2018 (Baseline) % Reduction of QP The number of patients on an incomplete pathway not to be higher in March 2019 than in March ,250 50% Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 81.13% 50% Some of the measures can be reported on monthly, some quarterly and others annually (as performance is derived from national surveys). A summary of performance for indicators, which are available to be reported on, will be included within the next Performance report. 6. London Ambulance Service (LAS) The new national ambulance response time standards were established under the Ambulance Response Programme Initiative (ARP) led by NHS England. The aim of the ARP is to ensure that: The sickest patients receive the fastest response All patients get the best response allocated to them No one is left waiting for an unacceptably long time for an ambulance to arrive The new ambulance response time standards are summarised below. Category Basic definition Response time standard Category 1 Category 2 Category 3 Category 4 Life threatening injuries and illness (e.g. anaphylactic shock or bee sting) Emergency calls (e.g. stroke) Urgent calls (e.g. uncomplicated diabetes some of these may be treated in patient s own home) Less urgent likely requiring transport or hear and treat Response time with an average of 7 minutes Response before 15 minutes for 9 out of 10 calls (90 th centile) Response time with an average of 18 minutes Response before 40 minutes for 9 out of 10 calls (90 th centile) Response before 120 minutes for 9 out of 10 calls (90 th centile) Response before 180 minutes for 9 out of 10 calls (90 th centile) The four new patient categories are: Category One Life Threatening Category Three Urgent Category Two Emergencies Category Four Less Urgent 88

89 The LAS performance for June 2018 against the national standards is shown in the table below: National Category Measure April May June Standard 1 Mean response time 7 minutes 00:06:52 00:06:54 00:07:17 90 th centile 15 minutes 00:11:15 00:11:21 00:11:46 2 Mean response time 18 minutes 00:16:54 00:18:41 00:20:02 90 th centile 40 minutes 00:33:16 00:38:11 00:40:52 Mean response time 60 minutes n/a 00:55:50 01:01: th centile 120 minutes 01:49:47 02:12:40 02:22: th centile 180 minutes 02:05:05 02:24:33 02:28:17 In June 2018, LAS achieved four out of the seven measures against the national standards when evaluating city-wide performance. The table below shows the LAS Performance by STP for June 2018: NCL achieved the C1 90 th Centile target and the C4 90 th Centile target. The LAS C4 90 th centile has been well within the 3 hour standard for the eight months since ARP was implemented The table below shows a further breakdown for Haringey CCG in June 2018: C1 Mean C1 90 th Centile C2 Mean C2 90 th Centile C2 Mean C3 90 th Centile C4 90 th Centile National Standard Haringey CCG 7 minutes (00:07:00) 15 minutes (00:15:00) 18 minutes (00:18:00) 40 minutes (00:40:00) 60 minutes (01:00:00) 120 minutes (02:00:00) 180 minutes (03:00:00) 00:07:33 00:11:27 00:22:43 00:48:08 01:27:35 03:15:29 01:50:38 Haringey CCG achieved C1 90 th Centile and C4 90 th Centile. Most other CCGs had similar performance. Drivers of underperformance included delays with handovers by Acute Trusts and increased demand for Category 1. Hospital handovers have a direct impact on performance, particularly across non-life threatening categories as ambulances are less available for conveyances. It has been recognised by regulators nationally that Ambulance services will not be in a position to meet ARP standards straight away and performance management against these standards comes into effect in September

90 Haringey CCG Governing Body Performance and Quality Report August

91 Contents Item Page Haringey CCG A&E Summary 3 Whittington Health NHS Trust Community Services Dashboards 4 Haringey CCG Mental Health Performance Dashboards 8 NMUH A&E Performance Summary 11 NMUH Quality Summary 13 Barnet, Enfield and Haringey MH Trust Dashboards and Summary London Ambulance Service

92 Haringey CCG A&E Summary Key Messages A&E From April 2018 CCG level A&E Performance is no longer measured as a quality premium indicator. As with CCG Operating Plans performance is measured at provider level with CCGs responsible for the performance of the providers for which they are lead commissioners. The main providers for Haringey CCG patients performed as below for June 2018 against the four hour waiting standard: North Middlesex University Hospital 89.7% Whittington Health NHS Trust 90.6% (Lead Commissioner Islington CCG) At North Middlesex University Hospital, the local improvement trajectory of 86% was achieved. The key issues were; Lower than anticipated streaming of patients via the Urgent Care Centre (approximately 46% through June 2018, against a trajectory of 50%), though this is strong performance in comparison to other NCL Trusts. A training plan is place, which will run through until the end of August 2018, with the intention of reducing minors breaches. Longer than expected waiting times in ambulatory care for triage, though this has been reducing since early May 2018, from highs of 50 minutes, to 28 minutes at the end of June Insufficient discharges, particularly, earlier in the day and lower than expected number of patients utilising the Discharge to Assess pathways. This causes flow pressures from ED, resulting in bed management issues accounting for the majority of breaches. The Whittington Health NHS Trust/Islington CCG System revised the Accident and Emergency Improvement Plans in May 2018 with an improvement trajectory to achieve and sustain 95% from September 2018 onwards. A Rapid Improvement Plan to support this was agreed in May 2018 and is reviewed and updated monthly at the Accident and Emergency Delivery Board. 92 3

93 Whittington Health NHS Trust Community Services Dashboard Whittington Health - NELCSU CCGs KPI Measure Target threshold Mar-18 Apr-18 May-18 Haringey HV reviews Islington HV reviews DNA rate% <10% Face to Face contacts FFT% Positive (all CCGs) >90% FFT responses (all CCGs) > % 8.00% 8.30% % 96.20% 95.90% New birth visits % within 2 weeks 95% 90.50% 89.40% 92.70% 8 week review % within 8 weeks 40.10% 38.00% 48.20% HR1 % within 15 months 64.50% 65.30% 74.50% HR2 % within 30 months 60.50% 56.90% 63.60% New birth visits % within 2 weeks 95% 96.40% 94.40% 93.00% 8 week review % within 8 weeks 66.10% 68.10% 73.50% HR1 % within 15 months 81.50% 69.40% 80.00% HR2 % within 30 months 76.50% 77.80% 76.70% District nursing - 48 hour response time (all CCGs) 95% in 2 days 86.70% 83.20% 91.00% District nursing - 2 hour response time (all CCGs) 80% in 2 hours 92.50% 86.70% 88.90% Routine Referral Urgency Urgent Referral Urgency Routine Referral Urgency Urgent Referral Urgency % Target Avg Wait No of Pts % Target Avg Wait No of Pts ICSU Service Name Target Apr-18 May-18 Jun-18 Avg Wait No of Pts % Target Apr-18 May-18 Jun-18 Avg Wait No of Pts ICSU Service Name Threshold Weeks Mar-18 Apr-18 May-18 (June-18) Seen Threshold Weeks Mar-18 Apr-18 May-18 (June-18) Seen Threshold Weeks (May-18) Seen Threshold Weeks (May-18) Seen CYP CYP CAMHS CAMHS >95% >95% % 70.10% 67.10% 66.20% 60.90% 67.80% >95% >95% % % % % 0 0 CYP CYP Child Child Development Development Services Services >95% >95% % 66.70% 62.30% 44.20% 62.30% 56.50% >95% >95% CYP CYP Community Community Children's Children's Nursing Nursing >95% >95% % 78.70% 85.20% 84.10% 85.70% 83.30% >95% >95% % % % % % % CYP Community Paediatrics Services >95% >95% % 80.60% 84.20% 59.10% 86.50% 83.30% >95% >95% % 46.30% 44.20% 36.40% 31.00% 43.10% CYP Haematology Service >95% % % % >95% >95% CYP Looked After Children >95% % 55.60% 78.60% 80.00% 79.20% 77.30% >95% >95% CYP Occupational Therapy >95% % 46.40% 30.40% 19.20% 30.40% 31.80% >95% >95% CYP Physiotherapy >95% % 54.70% 47.30% 55.70% 47.80% 54.30% >95% >95% CYP PIPS >95% % % % 70.00% >95% >95% 0 0 CYP School Nursing >95% % 81.70% 86.50% 90.80% 88.00% 76.80% >95% >95% 0 0 CYP Speech and Language Therapy >95% % 33.70% 35.90% 34.60% 42.20% >95% >95% % 0.00% 33.30% 0.00% 5 4 <5 <5 IM Bladder and Bowel - Children >95% % 57.10% 37.50% 28.60% 37.50% 26.70% >95% >95% 0 0 EUC Community Matron >95% % % 95.70% % 95.70% >95% >95% IM Adult Wheelchair Service >95% % 87.10% 97.80% 87.10% 97.80% 85.70% >95% >95% % 0 0 IM Cardiology Service >95% >95% % 93.10% % % >95% >95% % 0.00% % 0.00% 81.80% % IM IM Community Community Rehabilitation Rehabilitation (CRT) (CRT) >95% >95% % 94.40% 95.50% 97.70% 95.40% 92.60% >95% >95% % 62.10% 56.50% 62.90% 68.80% 56.50% IM IM Community Rehabilitation (ICTT) Community Rehabilitation (ICTT) >95% >95% % 78.10% 78.10% 84.90% 84.80% 89.20% >95% >95% % 29.30% 29.30% 37.50% 37.90% 43.40% IM IM Diabetes Service Diabetes Service >95% >95% % 65.70% 65.70% 71.60% 72.20% 67.10% >95% >95% % % % % % 50.00% <5 <5 IM IM Intermediate Care (REACH) Intermediate Care (REACH) >95% >95% % 86.30% 86.30% 80.60% 80.60% 73.30% >95% >95% % 60.70% 60.70% 41.40% 41.40% 45.80% IM Paediatric Wheelchair Service >95% 83.30% 80.00% % 5.6 <5 >95% 2 0 IM Paediatric Wheelchair Service >95% % % 66.70% 6.6 <5 >95% 2 0 IM Respiratory Service >95% % 53.20% 36.40% >95% % 6.50% 0.00% IM Respiratory Service >95% % 36.40% 63.60% >95% % 0.00% % 1.4 <5 PPP Bladder and Bowel - Adult >95% % 44.30% 50.40% >95% % 0.00% 0 PPP Bladder and Bowel - Adult >95% % 50.00% 60.80% >95% % 0 PPP Musculoskeletal Service - CATS >95% % 81.60% 76.00% >95% % 0.00% 75.00% 2 <5 PPP Musculoskeletal Service - CATS >95% % 76.00% 89.60% >95% % 75.00% % 1.3 <5 PPP Musculoskeletal Service - Routine >95% 83.90% 89.50% 92.10% >95% PPP PPP Musculoskeletal Service - Routine Nutrition and Dietetics >95% >95% % 72.50% 92.10% 74.60% 92.60% 83.90% >95% >95% % 72.50% 73.30% 74.60% 42.90% 83.90% PPP PPP Nutrition and Dietetics Podiatry (Foot Health) >95% >95% % 58.20% 83.90% 38.20% 89.70% 59.70% >95% >95% % 38.20% 59.70% PPP PPP Podiatry (Foot Health) Lymphodema Care >95% >95% % 83.30% 59.70% 73.30% 72.80% 95.20% >95% >95% % 59.70% 72.80% PPP PPP Tissue Lymphodema Viability Service Care >95% >95% % 95.20% 95.00% >95% >95% % 74.70% 69.40% PPP Tissue Viability Service >95% % 93.90% 99.00% >95% % 0.4 <5 4 93

94 Whittington Health NHS Trust Community Services Dashboard Whittington Health - Haringey CCG KPI Measure Target threshold Mar-18 Apr-18 May-18 Haringey HV reviews DNA rate% <10% Face to Face contacts FFT% Positive (all CCGs) >90% FFT responses (all CCGs) > % 8.80% 9.00% % 96.20% 95.90% New birth visits % within 2 weeks >95% 90.50% 89.40% 92.70% 8 week review % within 8 weeks 40.10% 38.00% 48.20% HR1 % within 15 months 64.50% 65.30% 74.50% HR1 % within 30 months 60.50% 56.90% 63.60% District nursing - 48 hour response time (all CCGs) 95% in 2 days 86.70% 83.20% 91.00% District nursing - 2 hour response time (all CCGs) 80% in 2 hours 92.50% 86.70% 88.90% Routine Referral Urgency Urgent Referral Urgency Routine Referral Urgency Urgent Referral Urgency % Target Avg Wait No of Pts % Target Avg Wait No of Pts ICSU Service Name % Target Apr-18 May-18 Jun-18 Avg Wait No of Pts % Target Apr-18 May-18 Jun-18 Avg Wait No of Pts ICSU Service Name Threshold Weeks Mar-18 Apr-18 May-18(June-18) Seen Threshold Weeks Mar-18 Apr-18 May-18 (June-18) Seen Threshold Weeks (May-18) Seen Threshold Weeks (May-18) Seen CYP CAMHS >95% % 75.00% 66.70% 6.6 <5 >95% 2 0 CYP CAMHS >95% % % 75.00% 4.6 <5 >95% 2 0 CYP Child Development Services >95% % % % >95% 2 0 CYP Child Development Services >95% % 80.00% % >95% 2 0 CYP Community Children's Nursing >95% % 83.30% % >95% 1 0 CYP Community Children's Nursing >95% % 70.00% 83.30% >95% 1 0 CYP Community Paediatrics Services >95% % 93.30% 90.50% >95% % 35.00% 16.70% CYP Community Paediatrics Services >95% % 50.00% 93.30% >95% % 25.70% 35.00% CYP Haematology Service >95% % % 0.6 <5 >95% 2 0 CYP Haematology Service >95% % % 1 6 >95% 2 0 CYP Looked CYP Looked After After Children Children >95% >95% % % 84.60% % % 84.60% >95% >95% CYP CYP Occupational Occupational Therapy Therapy >95% >95% % 50.00% 0.00% 0.00% 11.10% 0.00% >95% >95% CYP Physiotherapy Physiotherapy >95% >95% % 44.90% 50.00% 42.90% 77.80% 50.00% >95% >95% CYP PIPS PIPS >95% >95% % % % % 62.50% % >95% 0 0 CYP School School Nursing Nursing >95% >95% % 73.20% 75.00% 85.70% 75.90% 74.30% >95% 0 0 CYP Speech and and Language Therapy >95% >95% % 29.10% 31.50% 28.10% 28.20% 31.50% >95% % 0.00% 50.00% 5 4 <5 <5 IM Bladder and and Bowel - Children - >95% >95% >95% 0 0 EUC Community Matron >95% >95% % % 92.00% % % 92.00% >95% IM Adult Wheelchair Service >95% >95% % % 97.80% 87.10% 88.90% 97.80% >95% % 0 0 IM Cardiology Service >95% >95% % 95.00% % % % % >95% % 0.00% % <5 <5 IM Community Rehabilitation (CRT) (CRT) >95% >95% % 83.30% % % % % <5 <5 >95% % % <5 <5 IM Community Rehabilitation (ICTT) (ICTT) >95% >95% % 84.30% 83.90% 78.30% 88.30% 83.90% >95% % 42.70% 37.20% 27.50% 43.60% 37.20% IM Diabetes Service >95% >95% % 59.10% 65.50% 60.30% 63.00% 65.50% >95% % % 0.00% % <5 <5 IM Intermediate Care Care (REACH) (REACH) >95% >95% % % % 0.00% 0.00% % <5 <5 >95% % % % 0.9 <5 IM Paediatric Paediatric Wheelchair Wheelchair Service Service >95% >95% % 83.30% % 80.00% 66.70% % <5 <5 >95% >95% 2 0 IM Respiratory Respiratory Service Service >95% >95% % 68.40% 26.90% 33.30% 54.70% 26.90% >95% >95% % 7.10% 0.00% 6.50% 0.00% PPP Bladder and Bowel - Adult >95% % 55.30% 66.00% >95% % 0 PPP Bladder and Bowel - Adult >95% % 66.00% 59.30% >95% 2 PPP Musculoskeletal Service - CATS >95% % 79.20% 75.20% >95% % 0.00% 50.00% 2.4 <5 PPP Musculoskeletal Service - CATS >95% % 75.20% 88.00% >95% % 50.00% PPP Musculoskeletal Service - Routine >95% % 88.00% 90.80% >95% PPP Musculoskeletal Service - Routine >95% % 90.80% 92.20% >95% % 71.40% 33.30% 2.8 <5 PPP Nutrition and Dietetics >95% % 79.00% 90.30% >95% 2 0 PPP Nutrition and Dietetics >95% % 90.30% 91.90% >95% 2 0 PPP Podiatry (Foot Health) >95% % 34.70% 62.90% >95% % 34.70% 62.90% 2.2 <5 PPP Podiatry (Foot Health) >95% % 62.90% 74.80% >95% % 62.90% 74.80% 1.1 <5 PPP Lymphodema Care >95% % 81.80% % >95% 2 0 PPP Lymphodema Care >95% % % 91.70% 3 12 >95% 2 0 PPP Tissue Viability Service >95% 6 0 >95% % 95.70% 66.70% PPP Tissue Viability Service >95% % 95.80% % >95%

95 95 6 Haringey CCG Community Services Summary Key Messages Community Services The main areas of concern within the Community Services are, Bladder and bowel, nutrition and dietetics, podiatry and lymphedema. Whilst all four areas are underperforming, there has been improvement across each over the past three months. Whittington Health NHS Trust has provided a detailed breakdown of those services not meeting current access standards, the reasons for the performance, actions to address it and anticipated dates for recovery at a service level. Anticipated dates for recovery of the waiting time positions for services range from August 2018 to March On July 24 th 2018 Islington CCG issued a contract performance notice to Whittington Health to formally raise concerns regarding on-going under performance in regards to waiting times into the CAMHs emotional health and behaviour pathways. Discussions around a recovery plan to return the service to a reasonable waiting time position will take place in August 2018.

96 Whittington Health NHS Trust Performance & Quality Summary Key issue Community Access and Waiting Times At the July 2018 meeting of the Community Service Improvement Group it was noted that although many waiting time indicators on the community performance dashboard were red, there was an upward trajectory in terms of improvement, for each of the specific areas identified for improvement by the group: Bladder and bowel April 50.7%, May: 57.3%, June: 68.3%. Nutrition and dietetics April 74.1%, May: 83.2%, June: 87.9%. Podiatry April 37.9%, May: 59.8%, June: 69.3%. Lymphedema April 73.3%, May: 95.2%, June: 94.1%. Whittington Health have provided a detailed breakdown of those services not meeting current access standards, the reasons for the performance, actions to address it and anticipated dates for recovery at a service level. Anticipated dates for recovery of the waiting time positions for services range from August 2018 to March Priority actions Update following Community Service Improvement Group in July 2018 Formal notes from the meeting were not available at the time of writing however: It was agreed that children and young people services were a priority and future meetings of the Community Service Improvement Group would be split to allow distinctive time allocations for discussion of adult services and discussion of children and young people services. Themes from the discussion around children and young people services were: Data Quality for children and young people services is not as good as for adult services particularly around urgent and routine definitions The need to look at the overall paediatric workforce and workload Assess how staff can be best utilised to support provision across services rather than based on historical departmental boundaries A strategic plan for community services for children and young people, based on analysis of demand and capacity, to be brought to the Community Service Improvement Group by the end of August

97 Haringey CCG Mental Health Performance Dashboard Theme KPI/Measure Source Reporting Period Actual Standard Current Month and Previous Month's Trend Blue = Actual Red = Target Dementia Diagnosis Rate (Age 65+) NHS Digital Jun % 66.7% 68.60% 68.50% 67.67% 67.20% 67.82% 68.27% 67.80% 67.61% 68.50% 67.90% 67.70% 67.76% 67.43% Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 HARINGEY CCG MENTAL HEALTH The percentage of RTT First Episode Psychosis (FEP) periods within 2 weeks of referral. * Proportion of patients on CPA who were followed up within 7 days after discharge from psychiatric inpatient care Proportion of admissions to acute wards that were gate kept by the CRHT teams NHS Digital Jun % 50% NHS Digital Q % 95% NHS Digital Q % 95% Proportion of Children and Young people with eating disorders (routine cases) that wait 4 weeks or NHS Digital Q % 95% less from referral to start of NICEapproved treatment Proportion of Children and Young people with eating disorders (urgent cases) that wait 1 week or less from NHS Digital Q % 95% referral to start of NICE-approved treatment 50.00% 62.50% 75.00% 80.00% 77.78% 62.50% % 75.00% 60.00% 57.14% 87.50% 92.86% 75.00% Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun % 99.33% % 98.77% Q Q Q Q Q % % 96.12% 97.37% Q Q Q Q Q % 92.86% 91.67% Q Q Q Q Q % % 50.00% Q Q Q Q Q1 *Latest data is provisional and unpublished NHS Digital data published by NHS Digital Local data derived from Provider reports to NHS England 8 97

98 Haringey CCG Improving Access to Psychological Therapies Performance Dashboard Theme KPI/Measure Source Reporting Period Actual Standard Current Month and Previous Month's Trend Blue = Actual Red = Target % Waited less than 6 weeks for a course of treatment (for those finishing a course of treatment) % Waited less than 18 weeks for a course of treatment (for those finishing a course of treatment) NHS Digital Apr % 75% NHS Digital Apr % 95% 96.00% 94.00% 93.00% 97.00% 98.00% 95.00% 93.00% 94.00% 92.00% 92.00% 94.00% 93.00% May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr % 99.00% 99.00% % % % 96.00% 98.00% 98.00% 99.00% 98.00% 99.00% May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr % 52.00% 47.00% 50.00% 53.00% 49.00% 49.00% 45.00% 47.00% 45.00% 57.00% 53.00% Reliable Recovery Rate NHS Digital Apr % HARINGEY CCG IAPT Recovery Rate NHS Digital Apr % 50% Recovery Rate - QUARTERLY NHS Digital Q % 50.00% May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr % 55.00% 50.00% 54.00% 56.00% 51.00% 52.00% 51.00% 48.00% 50.00% 60.00% 54.00% May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr % 53.00% 52.00% 53.00% Access Rate NHS Digital Apr % 1.40% Q Q Q Q4 1.70% 1.57% 1.56% 1.54% 1.49% 1.13% 1.24% 1.39% 1.41% 0.94% 0.87% 1.81% Access Rate - QUARTERLY NHS Digital Q4 4.29% 4.20% May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr % 3.94% 4.29% 3.34% BME % of Numbers Entering Treatment - QUARTERLY NHS Digital Q % Q Q Q Q % 53.99% 54.27% 56.33% Q Q Q Q4 NHS Digital data published by NHS Digital Local data derived from Provider reports to NHSE 9 98

99 Haringey CCG Mental Health Summary Key Messages Barnet Enfield and Haringey Mental Health Trust Crisis Resolution and Home Treatment Team In April 2018 the performance reporting changed to 95% having a Face to face assessment within 4 hours for those triaged as Urgent - clinically appropriate following referral to Crisis Resolution and Home Treatment Team. This has been monitored for three months and in June 2018 Barnet Enfield and Haringey Mental Health Trust reported 26.1% (161 out of a total of 617 referrals) were assessed within four hou rs, if the clinically triaged figures are used 36.9% were assessed (82 out of 222 referrals). A three month review is required on the impact of the new clinically triaged as appropriate including a commentary on change in service outcomes as the services are seeing / assessing less clients within four hours since the changes were implemented. Early Intervention in Psychosis Commissioners are working with Barnet Enfield and Haringey Mental Health Trust to finalise the evidence required from the Ear ly Intervention in Psychosis services in terms of the National Institute for Health and Care Excellence compliant treatments and timely access. The Early Intervention in Psychosis Network Report on the recent audit of all EIP teams in England have been received with a Trust overview and Essential Standards included in the report. It is recommended that in addition to the audit evidence a plan with traject ory on the move to using structured clinical coded recording (SNOMED CT) and outcome measures is required. Children and Adolescent Mental Health Services There are two main priorities firstly the time waiting to first appointment (standard 13 weeks) and the Access to Treatment (second appointment). The overall waiting list for Children and Young People increased by 25 to 866 in June 2018 with 212 in June 2018 waiting over 13 weeks. The Children and Young People seen within 13 week waiting time for first appointment decreased in June 2018 to 73.8% The number of children and young people seen who waited over 13 weeks improved to 98 in June Barnet Enfield and Haringey Mental Health Trust are reporting staff shortages within the Barnet and Enfield Child and Adolescent Mental Health Services which has led to an increase in long waits. Reporting against the Five Year Forward View Improving Access Rate to Children and Young People Mental has increased to 32% for 2018 / 2019 for the proportion of children and young people aged 0-18 with a diagnosable mental health condition who have received treatment (two attendances). Barnet Enfield and Haringey Mental Health Trust contributed cumulatively April - June treatment (second) contacts to the 2018 /2019 standard, therefore achieving 14.2% against the expected 8%. The Haringey Services are showing a contribution below expected at 5.1% against 8% expected

100 North Middlesex University Hospital A&E Performance Key issue A&E Performance at North Middlesex University Hospital showed further improvement, from 85.16% in May 2018 to 89.67% in June Whilst the national standard has not been achieved, the local improvement trajectory of 86% was achieved. The key factors impacting performance are: Insufficient streaming of patients via the Urgent Care Centre, though performance is strong in comparison to other NCL Trusts Longer than expected waiting times in ambulatory care Slow discharges from the wards, with insufficient patients home before lunch and lower than expected number of patients utilising the Discharge to Assess pathways. This causes flow pressures from ED, resulting in bed management issues accounting for the majority of breaches. Priority actions There is a recovery plan in place to help improve the 4 hour A&E performance. The main areas of focus remain the same as the previous month, namely, improving streaming, streamlining the ambulatory care pathway and greater focus on early discharge planning and admission avoidance. Emergency Department Flow Continue to embed the new Emergency Departmentflow model, focussing on changes on the Fit2Sit space and optimising processes within the model and is expected to be embedded by mid July Specialty visits to build relationships between specialties and the Emergency Department planned and completion on-going. Visits to be completed by mid July 2018, followed by time to test and embed the new ways of working with specialties. The training plan continues as part of the embedding period of the flow model; this is anticipated to continue until end of August 2018, to support a reduction in minors breaches. Wards Regular reviews of Red2Green are undertaken, to identify the key delays and devise specific actions to address these. An enhanced stranded patients review commenced on 02 July 2018 to address top delay reasons. There is greater focus on reducing length of stay, by implementing several initiatives: Optimising the number of patients utilising Discharge to Assess pathways, by undertaking a ward by ward engagement plan with clear communications. A home first focus Embedding a trusted assessor initiative Increasing the use of NM@Home to complete acute care at home; a meeting is scheduled for 29 July 2018 between the Trust and the community teams, to identify gaps in provision and agree appropriate use of all services

101 North Middlesex University Hospital A&E Performance

102 North Middlesex University Hospital Quality Summary Key issue Serious Incidents (SI) North Middlesex University Hospital reported three Serious Incidences in June Incidents were reported in the following categories: One Suboptimal Care Diagnostics Falls At the end of June 2018 there were 20 reports overdue for submission and eight Further Information Requests made. Governance and Risk Improvement Process The June 2018 Trust Board mandated the establishment of a Trust wide Governance and Risk Improvement Process. The process gives direction to existing risk and governance initiatives to ensure delivery of the Trust strategic objectives. Priority actions Haringey CCG and North Middlesex University Hospital continue to meet to support timely submission and closure of Serious Incident investigation reports and good progress is being made. North Middlesex University Hospital has revised its Serious Incident investigation process and has introduced dedicated Serious Incident investigators for a trial period to improve the quality and timeliness of investigation reports. The revised Serious Incident process was shared with the July 2018 Clinical Quality Review Group meeting. The Trust has recruited additional staff to the Governance Team to ensure a more robust process is in place The July 2018 Clinical Quality Review Group meeting received assurance that the Trust Serious Incident and Learning Group identify any immediate actions required in response to an Serious Incident, and ensures that the service or team is aware and addresses the issues raised. The overdue status of a report investigation is not affecting immediate action implementation. Commissioners are continuing to work with North Middlesex University Hospital to ensure only essential further information requests require a response. Additional comments and recommendations will be submitted to the Trust but a response is not required in order to close the investigation report. The Governance and Risk Improvement Process Steering Group has met twice since the June 2018 Board. Meetings are now bi monthly to ensure momentum is maintained. Six additional Governance Team members have been recruited. The Serious Incident and Duty of Candour processes have been reviewed and revised. Audit plans have been aligned with Governance and Risk Improvement Process deliverables. Nine staff have been trained in to undertake Structured Judgement Reviews. NHS Improvement has agreed to support the Trust in key areas of the process

103 North Middlesex Barnet Barnet, Enfield and Haringey MH Trust Mental Health Performance Dashboard Theme KPI/Measure Source Reporting Period Actual Standard Current Month and Previous Months' Trend Blue = NHS Digital Green = Local Data Red = Target The percentage of RTT First Episode Psychosis (FEP) periods within 2 weeks of referral. * Proportion of patients on CPA who were followed up within 7 days after discharge from psychiatric inpatient care Proportion of admissions to acute wards that were gate kept by the CRHT teams NHS Digital May % 50% NHS Digital Q % 95% NHS Digital Q % 95% 90.91% 78.57% 64.29% 73.68% 66.67% 76.47% 90.48% 84.62% 81.25% 87.50% 77.78% 85.71% 85.71% 62.50% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May % 99.76% 99.76% 99.52% Q Q Q Q % 99.45% 98.64% 97.86% Q Q Q Q4 BEH MENTAL HEALTH TRUST % Assessments begun within 1 hour in A&E % Assessments begun within 4 hours in AMU Local Data Jun % 95% Local Data Jun % 95% 85.0% 82.0% 76.0% 73.0% 67.0% 76.0% 72.0% 82.0% 88.0% 89.0% 92.0% 86.0% 81.0% 72.0% 70.0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun % 56.0% 52.0% 68.0% 72.0% 77.0% 61.0% 85.0% 71.0% 81.0% 91.0% 81.0% 64.0% 63.0% 60.0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 % Assessments begun within 24 hours on wards Local Data Jun % 95% 90.0% 93.0% 89.0% 92.0% 77.0% 92.0% 87.0% 91.0% 91.0% 95.0% 97.0% 94.0% 88.0% 75.0% 84.0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 % Assessments begun within 1 hour in A&E Local Data Jun % 95% 95.0% 95.0% 89.0% 93.0% 94.0% 92.0% 92.0% 98.0% 95.0% 95.0% 95.0% 94.0% 95.0% 86.0% 89.0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 % Assessments begun within 24 hours on wards *Latest data is provisional and unpublished NHS Digital data published by NHS Digital Local data derived from Provider reports to NHSE Local Data Jun % 95% 100.0% 100.0% 100.0% 100.0% 100.0% 98.0% 100.0% 98.0% 98.0% 98.0% 98.0% 90.0% 93.0% 94.0% 96.0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun

104 Barnet, Enfield and Haringey Mental Health Quality and Performance Summary Key issue Care Quality Commission Barnet Enfield and Haringey Mental Health Trust was subject to a comprehensive Care Quality Commission inspection in September 2017 following which the Trust was awarded an overall rating of Requires Improvement. Two of the Trust s mental health services were awarded a rating of Outstanding, three were rated as Good and three were rated as Requires Improvement. Barnet, Enfield and Haringey Mental Health Trust was subject to an unannounced inspection of two additional services in quarter four 2017/18.Recommendations were made in relation to nutrition and hydration, care planning, medicines management, physical health care and consultant cover. Priority actions Barnet Enfield and Haringey Mental Health Trust has shared the Trust wide action plan addressing the Must Do and Should Do recommendations. All actions arising from Care Quality Commission inspections are being incorporated into the single Trust wide plan. Barnet, Enfield and Haringey Mental Health Trust is holding bi-monthly meetings to review service area evidence and update the plan. The full updated plan was shared with the July 2018 Clinical Quality Review Group meeting; the Trust is reporting good progress with implementing and completing actions. In addition commissioners received an exception report outlining the closed actions and those that are behind schedule. Commissioners received actions plans for the two wards visited during the March 2018 unannounced inspections. Progress with implementing actions is being monitored on a quarterly basis together with the Trust wide plan

105 Barnet, Enfield and Haringey Mental Health Quality and Performance Summary Key issue Early Intervention in Psychosis - Performance There are concerns about Barnet Enfield and Haringey Mental Health Trust evidencing compliance with the NICE Standards for Early Intervention in Psychosis. In June 2018 all three teams achieved the standard for starting NICE compliant treatments within two weeks of referrals with suspected first episode of psychosis. Early Intervention in Psychosis - Data Quality and Recording There have been issues with the assurance about reporting of the Barnet Enfield and Haringey Mental Health Trust data related to Early Intervention in Psychosis performance standards when comparing data sources i.e. Mental Health Services Data Set, Unify submissions and local data. The submissions are via SDCS from April The EIP Network Report on the recent audit of all EIP teams in England have been received with a Trust overview and Essential Standards included in the report. It is recommended that in addition to the audit evidence a plan with trajectory on the move to using structured clinical coded recording (SNOMED CT) and outcome measures is required Priority actions Commissioners continue to invest an additional 800k for Early Intervention in Psychosis Services. Implement agreed Cluster 10 Service Specification when approved within CCG Governance processes. Develop and implement a Child and Adolescent Mental Health Service specification to include the Early Intervention in Psychosis standard. Commissioners to agree the measures for assessing the impact on access and National Institute for Health and Care Excellence compliance of the additional 800k investment. A revised Data Quality Improvement Plan is being discussed for 2018/19. It is recommended that in addition to the audit evidence a plan with trajectory on the move to using structured clinical coded recording (SNOMED CT) and outcome measures is required DIALOG (quality of life and treatment satisfaction questionnaire) and Questionnaire on the Process of Recovery (QPR)

106 London Wide Ambulance Service Performance (LAS) With the introduction of the new Ambulance Response Programme performance reporting is being reviewed by London Ambulance Service and commissioners. London Ambulance Service have provided both CCG and pan-london summary reports for June This gives a summary of performance against the new standards for the whole of London. Data Source: LAS Monthly Performance Report The four new patient categories are: Category One Life Threatening Category Three Urgent Category Two Emergencies Category Four Less Urgent

107 London Wide Ambulance Service Performance (LAS) The table below shows the seven key ambulance performance measures profiled by the Sustainability Performance Programme Areas. Two areas performance achieved two out of seven ambulance measures, North Central London and North West London. North Central London performance was lower across all the unmet standards across the areas and London overall. Category One mean standard has a safety standard of nine minutes and all areas where within this. Data Source: London Ambulance Service Performance Report The four new patient categories are: Category One Life Threatening Category Three Urgent Category Two Emergencies Category Four Less Urgent

108 London North Central London Ambulance Service Performance The four new patient categories are: Category One Life Threatening Category Three Urgent Data Source: London Ambulance Service Performance Report Category Two Emergencies Category Four Less Urgent

109 London North Central London Ambulance Service Performance London Ambulance Service previously noted the North Central London performance (which has consecutively achieved only two of the seven standards since month one) and have investigated the Category Four (less urgent) activity in Enfield specifically. Two Sustainability and Transformation Planning areas achieved two out of the seven ambulance standards the other areas achieved four out of seven ambulance standards. In month two, six calls were made by Acute trusts to book ambulances the evening before they were required for morning conveyances, triggering six hour dispatch waits each time. London Ambulance Service have since brought this issue to the attention of those Trusts and in month three the Category Four performance has improved accordingly. Within the North Central London CCGs three out of five CCG areas did not achieve four out of seven ambulance standards; Enfield CCG area achieved one (Category One 90 th Centile Emergencies), Barnet CCG area achieved two (Category One 90 th Centile Emergencies and Category Four 90 th Centile Less Urgent) and Islington CCG area achieved two (Category One 90 th Centile Emergencies and Category Four 90 th Centile Less Urgent). Within the North Central London CCG areas two out of five CCGs achieve four or more ambulance standards, Haringey CCG four out of seven and Camden CCG six out of seven A monthly Ambulance Acute Transformation meeting was established in July 2018 to oversee the implementation of the improvement plans, patient flow process mapping and suggested improvement. The group includes representative from each site (Barnet and Royal Free), London Ambulance Services, East of England Ambulance Services, NEL Commissioning Support Unit and Barnet CCG

110 London NCL Ambulance Service Performance NHS Haringey CCG Area

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