NHS Richmond Clinical Commissioning Group (CCG) Governing Body. Tuesday 6 March :30 12:10

Transcription

1 NHS Richmond Clinical Commissioning Group (CCG) Governing Body 33 rd Meeting in Public Tuesday 6 March :30 12:10 The Salon, York House Richmond Road Twickenham TW1 3AA

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3 33 rd MEETING IN PUBLIC OF THE NHS RICHMOND CLINICAL COMMISSIONING GROUP (CCG) GOVERNING BODY TUESDAY 6 MARCH :30 12:10 in the Salon, York House, Twickenham PART 1 AGENDA No Time Item Executive Lead Attachment 1 Standing items :30 Welcome and introductions Chair Apologies for absence and confirmation of meeting quoracy (see quorum at end of agenda) Reminder to members to put mobile phones on silent or switch them off during the meeting 1.2 Declaration of interests in matters covered on the agenda GP members: Richmond General Practice Alliance participant Note 1.3 Minutes of the CCG governing body meeting on 9 January 2018 Approval Chair & GB Members Chair A (to follow) 1.4 Matters arising Note Chair Verbal 1.5 Items taken in private on 9 January 2018: Mental Health o South West London and St George s Mental Health NHS Trust - Estate Modernisation Programme Full Business Case o Mental health commissioning function Recommendations from SWLA Remuneration Committee - Very Senior Manager (VSM) Remuneration Note Chair Verbal :40 Managing director s report Note Managing Director B :50 CCG chair s report Note Chair Verbal

4 No Time Item Executive Lead Attachment 2 Governance/Business :00 Kingston & Richmond transformation Musculoskeletal model and pathway Information Director of Commissioning C :10 Urgent treatment centre and primary care centre update Discussion :20 Update on progress on refreshing the primary care strategy for Richmond 3 Quality, Performance & Finance :25 Quality, safety and performance: SWL Performance report Discussion & information Quality, safety and performance committee summary Information Local Director of Primary Care & Planning Local Director of Primary Care & Planning GP Lead for Quality D E F :35 Finance committee summary Information Local Director of Finance G :40 Month 10 finance report Information Local Director of Finance H 4 For information :50 Primary care commissioning committee notes of meeting of December 2017 Information Lay Member for Finance, Remuneration, PC & Governance I :55 Any other business Chair 4.3 Date of next meeting: Tuesday 1 May 2018, 10:30-12:30, in the Salon, York House, Twickenham 5 Public Question Time :00 Members of the public present are invited to ask questions of the CCG Governing Body relating to the business being conducted. Priority will be given to written questions that have been received in advance of the meeting. Quorum: No business shall be transacted at the meeting unless at least one-third of the whole number of the Chair and members (including at least one lay member and three GP members and either the Accountable (Chief) Officer or Chief Finance Officer are present. Representatives of members will count towards the quorum where the representative either has formal acting up status or has been agreed with the Chair as the member s representative in advance of the meeting.

5 Attachment A 32 ND MEETING IN PUBLIC OF THE RICHMOND CLINICAL COMMISSIONING GROUP S GOVERNING BODY HELD ON TUESDAY 9 JANUARY 2018, 10:30 12:30 IN THE SALON, YORK HOUSE MINUTES Attendance Log: Voting members: Dr Graham Lewis Chair A A A SA A (GL) Sarah Blow (SB) Accountable Officer SWL A A A SA A Alliance James Murray (JM) Chief Finance Officer SWL A A A A A Alliance Tonia Michaelides (TM) Managing Director, Kingston & Richmond A A A A A Charles Humphry (CH) Bob Armitage (BA) CCGs Vice chair and lay member for audit, remuneration and governance Lay Member for finance, remuneration, primary care and governance A A A SA SA A A A A A Susan Smith (SS) Lay Member, Patient & A A SA A A Public Involvement Dr Kate Moore (KM) Vice Clinical Chair (VCC) SA SA A A A Dr Branko Momic GP A SA A A A (BM) Dr Nicola Bignell GP A A SA A SA (NB) Dr Stavroula Lees GP A A A A A (SL) Dr Zehra Rashid GP A SA SA A A (ZR) Dr Alireza GP - A A A A Salehzadeh (AS) Liz Bruce (LB) Director of Adult Social SA SA SA SA SA Services, LBRuT Dr Anne Dornhorst Secondary Care Doctor A A A SA A (AD) Fergus Keegan (FK) Registered Nurse & Local Director of Quality A A A SA SA Non-voting members: Houda Al-Sharifi Director of Public Health A SD A A A (HAS) Richmond and Wandsworth Councils John Thompson (JT) Healthwatch Member A A A A A In attendance on : Yarlini Roberts Local Director of Finance Vicki Harvey-Piper Jo Dandridge Sue Lear (SL) Local Director of Corporate Affairs & Governance Governance & Business Lead (notes) Deputy Local Director of Commissioning Page 1 of 13

6 KEY: A = Attended, DNA = Did not attend, SA = Sent Apology, SD = Sent Deputy 1 STANDING ITEMS 1.1 Welcome, apologies for absence and quoracy ACTION The Chair welcomed all members present to the 32 nd meeting in public of the Richmond Clinical Commissioning Group s governing body. Apologies for absence were received as per the attendance table. It was confirmed that the meeting was quorate. 1.2 Declaration of interests in respect of items on the agenda The standard declaration of interest from GP members was noted: o Participant of the Richmond General Practice Alliance 1.3 Minutes of the CCG governing body meeting on 7 th November 2017 The minutes were agreed as a correct record. Attachment A 1.4 Items taken in private on 7 th November 2017: Integration 111 & Out of Hours SWL Effective Commissioning Initiative Lay Member Remuneration SWL Performance Report Remuneration Committee Recommendations 1.5 Chair s report Dr Graham Lewis provided a verbal report to the Governing Body on the following matters: Following a request for video recording of Governing Body meetings, members were advised that functionality across South West London was currently being explored. A meeting between Richmond CCG and the Richmond GP Alliance had been held in December to discuss provider commissioner roles, working together more collaboratively and refreshing the primary care strategy. The Rt Hon Jeremy Hunt, MP had been appointed Secretary of State for Health and Social Care on 8 January The Governing Body NOTED the Chair s report. 1.6 Managing Director s report Attachment B The governing body received Attachment B, the managing director s report and particular attention was drawn to the following points: Patient and public involvement rating - good Members noted that Richmond CCG had been rated good for patient and public involvement against the new NHS England patient and public engagement indicator. The guidance introduced earlier this year sets out 10 key actions for CCGs in England on how to embed involvement in the daily work of the CCG. NHS England complemented Richmond CCG for its section on the website Page 2 of 13

7 have your say and the annual report which included some positive examples of public involvement activity. There was also some feedback for improvement around making more information available about how the public are, and can be, involved and how the CCG promotes and supports this involvement. ACTION Stay well this winter Members were advised that the CCG s communications and engagement team had been working together with health and social care partner organisations to support the national Stay Well this Winter campaign. Prescribing over the counter medicines Members noted that NHS England had released new national guidance on prescribing over the counter medicines. Richmond s Safeguarding Adults Board Members were informed that Richmond and Wandsworth s safeguarding adults boards will joining together in the coming year. An independent chair will be appointed who will be accountable to an executive, comprising the statutory partners. A transitions working group, including the key statutory partners will be set up to plan the new joint safeguarding board, its governance and strategic priorities. The last safeguarding adult board meeting for Richmond took place in December 2017 and for Wandsworth in January It is anticipated that the first joint meeting will take place in April Kingston Hospital dementia friendly ward Kingston Hospital has been recognised in the Alzheimer s Society Dementia Friendly Awards They were nominated for the work they did to transform an elderly care ward to enhance the wellbeing of patients with dementia. They were one of three finalists and eventual runner up in the large organisations category. Healthy London Partnership Healthy London Partnership (HLP) had published a document outlining their work undertaken during 2016/17. Some of which included: Published London s section 136 pathway and Health based Place of Safety specification and now working with others to implement this new model of care; Worked with partners to deliver Thrive LDN, the Mayor of London s new citywide movement to improve mental health and wellbeing in the capital Funding secured to support implementation of online GP services Worked with others to help reduce the number of patients conveyed by ambulance to hospital Evaluated a GP-led service in Croydon for men with prostate cancer Clinical network GP lead role (Hampton, Twickenham and Teddington) Dr Heather Bryan, a GP from Hampton Wick Surgery has been appointed as chair of the Hampton, Twickenham and Teddington Clinical Network. Page 3 of 13

8 Mental health transformation programme Over 100 people attended a public event in November 2017 as part of Richmond CCG s engagement on mental health transformation. The event was hosted by Healthwatch Richmond who led discussion on the improvements, the challenges people face and the road to better mental health care. The event was in addition to engagement by local mental health providers. Attendees were from a range of backgrounds including people who use services, carers, interested members of the public and professionals from NHS / social care and the voluntary sector. The outputs of this event will be used to inform our mental health transformation programme. ACTION The Governing Body NOTED the Managing Directors report. 1.7 Audit Committee Chair s Report Verbal The Governing Body received a verbal report from the Audit Committee Chair who provided a summary of the reports presented to the last Audit Committee meeting. Internal Audit progress report Locally Commissioned Service Report had been issued a reasonable assurance opinion. LCFS now renamed NHS Protect lack of referrals being reported External Audit progress report interim audit of annual accounts would commence at the beginning of February Conflicts of Interest register kept updated and available for the auditors QIPP data presented range quite severe across all CCGs Discussion followed on the ethical challenges faced by clinicians in relation to potential cases of fraud when immigration issues arise and patients are not entitled to treatment. The Governing Body NOTED the Audit Committee Chair s Report. 2 GOVERNANCE/BUSINESS /17 Safeguarding Adults Annual Report Attachment C The Governing Body received Attachment C, a report demonstrating how Richmond CCG has continued to improve outcomes for Adults at Risk through governance and assurance processes and by engaging service users in all issues related to adult safeguarding. Sarah Loades, Safeguarding Adults Lead Nurse advised members that the report also illustrates the priorities for and moving forward, how Richmond CCG will fulfil its statutory duty to promote the wellbeing principle through its safeguarding arrangements. Members noted that the Mental Capacity Act and Deprivation of Liberty Safeguards are two sections that the CCG require evidence of compliance from commissioned services for those providing care to adults (aged 16 years and over) who lack capacity to consent to care and treatment. Members noted a PREVENT conference was being held in collaboration with Kingston CCG, Richmond CCG and Kingston Hospital and NHS England. The Page 4 of 13

9 purpose of the conference was to raise awareness about PREVENT, and ensure that all sections of health are aware and know how to identify and refer those people at particular risk of radicalisation or showing signs of being radicalised. ACTION Members were also advised on the joint working across safeguarding children and safeguarding adults in relation to those children transitioning into adulthood and of the training being provided for professionals on this matter. The Governing Body NOTED the Safeguarding Adults Annual Report and supported the areas of priorities presented within the report for /17 Safeguarding Children Annual Report The Governing Body received Attachment D, a report which provided an overview of the safeguarding activity across Richmond CCG for 2016/17. It is a mandatory requirement for Governing Bodies to receive the annual report for information. Attachment D Sian Thomas, Designated Nurse for Richmond CCG highlighted the key sections for particular note as follows: The Wood Review there will be changes to local safeguarding arrangements with CCGs in 2018 with CCGs expected to take a central role alongside social care and police colleagues. Inspections Richmond CCG will have a CQC safeguarding children s inspection in The CCG is expected to lead this inspection across the entire health economy Child Protection Information Service this remains outstanding due to Achieving for Children s electronic system, this has been escalated to the Local Safeguarding Children s Board Members were informed that Ofsted were due to carry out a health inspection at some point this year and the CCG would only be given two days notice. Due to the short inspection notice period, members sought how assurance would be sought from the third sector. There was a need for partnership working and sharing of intelligence to enable the working together on common issues. Following discussion, it was agreed that the Designated Nurse would familiarise herself with all third sector contracts and have oversight of all contracts that the CCG commissions and would also liaise closely with Heather Matthew the third sector safeguarding lead. Members questioned the timing for when the Governing Body would receive the Safeguarding Children Annual Report for 2017/18 and it was noted that it would be a joint report with Kingston CCG next year and taken to the Quality, Safety & Performance Committee for consideration in June 2018 and would then be presented to the Governing Body in the early Autumn. Members highlighted the challenges with GP attendance at case conferences and agreed there was room for improvement. The narrative within the reports was very important and needed to be meaningful to ensure the best use of a GPs time and resources. The Governing Body NOTED the 2016/17 Safeguarding Children Annual Report. 2.3 South West London Health and Care Partnership one year on Members received Attachment E, an update from Sarah Blow, Accountable Officer on the South West London Health & Care Partnership. Attachment E Page 5 of 13

10 ACTION Members were advised that in the autumn of 2017, the newly appointed Accountable Officer directed a refresh of the STP to ensure that transformation actions and programmes addressed patient needs, clinical and financial issues within South West London and that delivery actions were clear so that South West London continued to improve services and care for patients. The paper outlined the two stage approach to refreshing the SWL Strategy for Health and Care. Stage one being the publication of a discussion document in November 2017 which outlined the commitments and priorities for the next two years; and Stage two is the development of local health and care plans between December 2017 and June The document also highlighted that in October 2017, the South West London Clinical Senate agreed a set of clinical standards for six clinical services in hospitals: Emergency department Acute medicine Paediatrics Emergency general surgery Obstetrics Intensive care Members noted that the next step was to develop the locally focussed health and care plans showing the Local Transformation Board s joint vision; their model for Health and Care; the local context and challenges to be faced including financial and clinical sustainability; their priority focus for the next 2 years to meet the health and care needs of their local populations. These plans will be produced initially for discussion with final plans being published no later than September Tonia Michaelides, provided members with a verbal update advising that discussions had commenced through the Richmond Health & Well Being Board and the beginnings of an approach for how to take forward the health and care plans had been initiated. The Governing Body ENDORSED the South West London Health and Care Partnership: one year on paper and the two step approach to refreshing the South West London Strategy for Health and Care as described. 2.4 Update on physical outcome based commissioning (OBC) in Richmond Attachment F Members received Attachment F, a report which provided an update on the physical outcome based commissioning programme. Sue Lear, Deputy Director of Commissioners advised members that in 2016, Richmond CCG had entered into a five year outcomes based commissioning contract (OBC) with Hounslow and Richmond Community Health (HRCH) who have formed a joint venture with the Richmond GP Alliance and work in partnership with them as Richmond Community Health in Partnership (RCHiP). Investment has been made through the OBC contract to date to develop the following five pathways: Diabetes Page 6 of 13

11 Respiratory Cardiology End of life Frail elderly ACTION Members noted the progress to date on cardiology, respiratory and diabetes community services. Members also noted the significant financial challenge that requires a wholescale change in the model of care to put patients at the centre and to wrap services around them in the place where they live. Work is being progressed alongside HRCH to design and develop a locality model of care including care homes, end of life care and the frail elderly. Members commented that there had been a considerable length of time since the OBC board had met and there was now the need to ensure the right governance level on the board and to expand the terms of reference to meet the needs identified through the STP and local planning work. Action: It was agreed that a review of the terms of reference would be undertaken and OBC would become a standing agenda item for Governing Body meetings going forward to ensure members are kept up to date. VHP, BA, TM The Governing Body NOTED the update on the physical outcome based commissioning in Richmond. 2.5 Proposal for a refreshed primary care strategy for Richmond Attachment G Members received Attachment G, a proposal for a refreshed primary care strategy for Richmond. The aim is to co-produce the refreshed primary care strategy with the Richmond GP Alliance. Members noted that the current Joint Primary Care Strategy between Richmond CCG and Richmond Council sets out strategic objectives over a five year period with year one being 2016/17. Members were being asked to consider proposed changes to the following sections: 03 Current services 04 Why do we need a primary care strategy? 05 Enablers 06 Priority objectives 07 Stakeholder engagement 08 Benefits and outcomes 09 Road map for change Members were also being asked to approve the following new sections: Locally commissioned services The intention to invest in Richmond general practice a Richmond local contract Commitment to supporting RGPA deliver primary care at scale Equality and diversity Page 7 of 13

12 Members noted that the delivery plan is key to development of the refreshed strategy and an iterative process would be followed that will include the membership forum, clinical networks, clinical executive team, the primary care commissioning committee, the primary care operational group, the patient participation group network, practice managers forum and other appropriate groups. ACTION Members commented the primary care strategy needed to be more specific in its iteration and narrative of the following areas: Extended access to be listed as an enabler Link strategy further with outcomes based commissioning Describe more clearly the intention for investment to be made in Richmond Members requested that the refresh elaborated on how engagement with the membership had been established throughout. It was noted that the London Delivery Board was likely to have recommendations for the strategy. The Primary Care Commissioning Committee would have oversight of the strategy and the Governing Body would be kept updated. Discussion followed on the areas of dentistry, optometry and pharmacists that were all part of primary care and it was agreed to widen the strategic intent within the strategy to include how these could be included recognising that they were not directly commissioned by the CCG. Action: It was agreed that the Primary Care Commissioning Committee would have oversight on development of the strategy and for the final version to be completed by end of March The Governing Body APPROVED the changes being proposed to the Joint Primary Care Strategy including the additional sections presented within the report. 2.6 Public sector equality duty report Attachment H Members received Attachment H, a copy of the Public Sector Equality Duty (PSED) Compliance Report covering the period January to December The Equality Act 2010 (specific duties) Regulations 2011 require the CCG to publish relevant, proportionate information demonstrating their compliance with the Equality Duty imposed by section 149(1) of the Equality Act 2010 at intervals of not greater than one year from the date of the last publication. Members attention was drawn to the following key sections within the report: Equality objectives Workforce data in relation to equalities Engagement and consultation activities reaching groups with protected characteristics Equalities information in relation to key work areas including commissioning, safeguarding and primary care Members noted that Richmond CCG had carried out an EDS audit in 2016 and going forward would be exploring a joint approach for equalities work across the Kingston and Richmond local health and care partnership to include working with key NHS, council and voluntary sector partners from 2018 onwards. Page 8 of 13

13 Caroline O Neill, Engagement Manager was thanked for her valued contribution with the comprehensive list of engagement activities. Members requested that more analysis of this activity should be reflected year on year to ensure that improvements were being captured. ACTION The Governing Body APPROVED the annual Public Sector Equality Duty report for the period January to December 2017 and AGREED the equality objectives for the CCG for QUALITY, PERFORMANCE & FINANCE 3.1 SWL Performance Report Attachment I1 Members received Attachment I1, the SWL Performance report and noted the following: Richmond CCG did not achieve the RTT performance standard in September with an outcome of 90%, driven by non-achievement of the standard for Richmond CCG patients at Chelsea and Westminster and Imperial Healthcare Trusts. The 2WW Cancer performance standard continues to be achieved for Cancer since July. Whilst performance in Diagnostics continues to improve month on month, the standard was not achieved in September with performance of 98.91% (28 breaches out of 2,569 pathways) missing the target by 3 patients. 9 breaches occurred at Chelsea and Westminster Hospital and 7 at St George's Hospital. Breaches were spread across a range of procedures. Chelsea and Westminster Hospital achieved the target in September and SGH has recovery plans in place to achieve the diagnostics performance standard. The 2WW cancer performance standard continues to be achieved since recovery in July with performance of 95.07% for September The new London Ambulance Response Programme went live on 1 st November 2017 with the aim of treating the sickest patients soonest. Richmond has slipped below the dementia diagnosis rate national performance standard for the first time this year in September at 66.2%. Patient lists from the Memory Clinic at St Georges are shared with General Practice every month however feedback from GP s suggest that these patients are often already on their own QOF Registers and there may be issues with internal dissemination. The recipients of dementia lists are being reviewed, and with HRCH to feedback dementia diagnosis to practices is continuing. Patient lists from SWL & StGH being sent out to practices. Richmond had a total of 482 acute delayed transfers of care days (DTOC) in September 2017 compared to 753 days for the same period last year. The majority of DTOCs were related to Further non acute NHS care, Care homes, Patient choice or Completion of assessments in almost equal measure. The London Borough of Richmond is ahead of the NHS England winter 2017 DToC trajectory, Richmond CCG is above planned levels. Members noted the challenges faced with meeting the A&E standard and of the actions taken to address the recover as part of the emergency care programme plan which is monitored by the Kingston, Richmond and Surrey A&E Delivery Board. Members valued the comparison of performance data across south west London Page 9 of 13

14 and requested that it would also be of benefit to include the whole London and national level data. ACTION The Governing Body NOTED the SWL Performance Report 3.2 Quality, Safety & Performance committee summary Attachment I2 The governing body received Attachment I2, a report from the Governing Body GP Lead for Quality, Dr Zehra Rashid who provided a summary of the discussions at the Quality, Safety & Performance Committee meeting held in November Members noted that the Quality, Safety & Performance Committee had received a copy of the dementia diagnosis detailed action plan to seek to address nonachievement of the standard. Members noted from the SWL Performance report that Richmond were doing fairly well on the 111 data when benchmarked against others. Discussion followed on ways to transfer this data into intelligence that can be shared with the membership. Action: It was agreed that Dr Rashid could present the constitutional standards overview and include areas of performance that were doing well to a future membership meeting and to seek feedback on how they wished to be kept updated on a regular basis. The Governing Body NOTED the Quality, Safety & Performance report. 3.3 Finance committee summary Attachment J The governing body received and noted attachment J, which provided a summary of discussions at the Finance Committee on 19 th December Yarlini Roberts, Local Director of Finance took the GB through the report, with the following areas of note: The committee had received a report from the CSU on the financial performance of the CCG acute contracts showing overspend overall against the acute contracts ( 5.1m forecast) with significant over performance seen at Chelsea & Westminster ( 3.5m forecast). The CCG was forecasting to meet its planned in year deficit of 5m. Overall the position in Month 7 had held steady in comparison to the position reported at Month 6, with a worsening in the acute over performance forecast outturn of 0.6m being offset by the release of unrequired prior year accruals on the balance sheet of 0.6m. The achievement of the planned deficit remains challenging with all reserves held being used to balance the position and a run rate position improvement of 1.5m is required in respect of higher QIPP performance during the rest of the year. The risk adjusted position has stabilised from Month 7 at 7.8m with further potential balance sheet releases identified offsetting the 600k released into the position that were previously badged under mitigations. Significant work would be required to close the gap between identified schemes and QIPP savings required to bring the CCG back into financial balance in 2018/19. The Governing Body NOTED the Finance Committee summary. 3.4 Month 8 Finance Report Attachment K Page 10 of 13

15 ACTION The governing body received attachment K and during discussion the following points were highlighted: The final 2017/18 financial plan submitted in March 2017 included a planned deficit of 5m which aligned to the CCG s financial recover plan, this included QIPP schemes of 13.1m. Following formation of the Kingston and Richmond Local Delivery Unit, details reviews of the 2071/18 budgets were carried out; this raised some concerns with some baseline assumptions and the scale of some QIPP schemes. These have not been re-assessed in terms of impact on financial outturn. The risk adjusted position had stabilised from Month 7 at 7.8m with future potential balance sheet releases identified offsetting the 600k released into the position that were previously badged under mitigation. The main drivers of over performance are acute, in particular Chelsea and Westminster, adult continuing care and delegated primary care. Work continues with the CSU to ensure challenges are played into the acute position. Continuing Healthcare Forecast outturn for adult CHC remains unchanged and is to report an adverse forecast variance of 0.6m by year end based on list of patients on local authority database after adjusting for errors identified and savings identified not yet reflected in the database. QIPP Performance Members were informed that Richmond CCG had achieved 4.9m year to date savings against a plan of 5.8m. Transactional delivery remains very strong, whilst the transformation programme remains weak. The forecast outturn position assumes that mitigations on transformational schemes are successful. Sarah Blow expressed appreciation to the finance team for their line by line budgeting process as it was recognised how onerous this task was but a very positive way to get a grip on finances. The Governing Body NOTED the financial position at Month 7 and the challenges required to achieve the planned deficit at the end of the financial year. 3.5 Board Assurance Framework Attachment L The governing body received Attachment L, an overview of the risks, controls, assurances and actions currently identified on the CCG s Corporate Risk Register and Board Assurance Framework as at 3 rd January Members noted that an Internal Audit of risk management to inform work plans for the remainder of this year and for was currently underway and as part of the audit there would be a review of the CCG s current Risk Management Policy. Risk registers are reviewed regularly at various CCG sub committees. Members were advised of the 35 risks identified on the risk register categorised as follows: 2 very high risks 20 high risks Page 11 of 13

16 11 moderate risks 2 low risks ACTION The BAF details the controls, assurance and gaps for all the high and very high risks. Discussion had been held on two areas where it was felt the risks were not rated highly enough. These were in relation to delivery of the constitutional standards. Therefore some of the detail of the risks may need to be separated out. Discussion followed on the inherent risks which are listed but not reported on and the residual risks. It was recognised that the matrix scoring determines the colour rating but it was agreed that further distinction of the colouring needed to be explored. Action: it was agreed to use a heat map to present the high risks as visually it would be easier to understand. VHP A request was made for volunteers from within the governing body membership to sit alongside the Managing Director and Director of Corporate Affairs and Governance to review the corporate risks on a regular basis and to standardise across Richmond and Kingston CCGs. The Governing Body NOTED the Corporate Risk Register and Board Assurance Framework. 4 COMMISSIONING 4.1 Primary care commissioning committee Attachment M The governing body received attachment M, the minutes of the Primary Care Commissioning Committee meeting held on 3 rd October 2017 for information. The Governing Body NOTED the minutes of the Primary Care Commissioning Committee meeting held on 3 rd October FOR INFORMATION 5.1 Any Other Business None. 5.2 Date of next meeting Tuesday 6 th March 2018, 10:30-1:00, in the Salon, York House, Twickenham 5.3 Policies Approved Attachment N Organisational Change Policy The Governing Body received a copy of Attachment N, the Organisational Change Policy for information. Page 12 of 13

17 6 PUBLIC QUESTION TIME 6.1 None. ACTION A comment was made by a member of the public on the earlier discussion around the mental health Outline Business Case (OBC). There had been no mention of social prescribing, experts by experience, or medicalisation of stress. The meeting finished at 12:25. Page 13 of 13

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19 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing Body in public Date 6 March 2018 Report Title Managing Director s Report Agenda Item 1.6 Attachment B Purpose (please indicate with X) Approval/ Ratification Discussion / Comment Information X Report Author: (name & job title) Tonia Michaelides Managing Director, Kingston & Richmond CCGs Presented by: (name & job title) Tonia Michaelides, Managing Director, Kingston & Richmond CCGs Managing Director s Report The following report highlights items of interest to governing body members and the public which are not discussed in detail in the rest of the agenda. Richmond governing body update Charles Humphry, Vice Chair and Lay Member for Audit, Remuneration & Governance at Richmond Clinical Commissioning Group (CCG) has retired from his role on the grounds of ill health. I would like to extend my thanks to Charles from all at NHS Richmond CCG. He has been a key member of the CCG s governing body and previously Richmond & Twickenham Primary Care Trust s board for the past eleven years bringing with him a wealth of experience. During this time he has provided strategic, impartial advice and insight to both organisations and overseen many changes and improvements in healthcare within the borough. As vice chair he played an integral role in establishing the CCG in Revised constitution Following discussion at the governing body meeting in September 2017, a request to NHS England to amend the CCG s constitution has been approved - to include the introduction of the South West London Alliance and to adhere to new conflicts of interest regulations. Legal advice was taken and we consulted with the Good Governance Institute before the application was submitted. While the five CCGs in south west London remain separate statutory bodies, it was necessary to update the underpinning corporate governance documents to enable collaborative decision making. Page 1 of 4 Working together a healthier Richmond for everyone

20 There are two key changes: The ability for the CCG to make collaborative decisions with other CCGs at a governing body level and The creation of a managing director to assist the accountable officer in giving leadership and control for the CCG. The key changes to the constitution which have been agreed are: a) Governing body lay membership increased to 3 individuals (conflict of interest guidance) b) Addition of the managing director as a member of the governing body c) Adjustment where necessary to the quorum for decision making d) Nomination of a governing body member as the conflict of interest guardian e) Addition of a primary care commissioning committee f) Addition of a committee for collaborative decision making g) Enabling of all governing body committees to use the committees in common arrangement. Operating plan guidance NHS England has shared operating plan guidance with CCGs and providers We are now working through the guidance to agree our operating plan for and will bring an update to the next governing body meeting. Update on Cedars Bed Move to Teddington Memorial Hospital In January 2018 commissioners met with Your Healthcare and Hounslow and Richmond Community Healthcare to receive assurance in relation to the plans for the transfer of the in-patient beds from the Tolworth Hospital site to Teddington Memorial Hospital. The providers are planning for the transfer to be made by 31 March and have plans in place to be able to phase the transfer to accommodate any need for double running. Medical cover for the beds will continue to be provided by Central Surgery Kingston and this will include as currently; a daily ward round and an on-call service. The pharmacy service will continue from Kingston Hospital and there will be a satellite stock available on the site. There will also be in-reach by the community physiotherapy service to Teddington. There have been fortnightly meetings with the staff involved and the move has been met positively by the staff. There is recognition of joint training opportunities and the potential to provide cover in times of staff shortages. Page 2 of 4 Working together a healthier Richmond for everyone

21 The other services that are currently provided from Tolworth will move into Your Healthcare premises at Hollyfield Road in Surbiton. The bus routes to Teddington have been mapped and information on this will be made available to the public. The new service will be known as The Cedars at Grace Anderson. An open morning to view the new site will be arranged for members of the public prior to the opening of the ward. Letter from Department of Health diagnostic performance Richmond CCG has received a letter of congratulations from the Secretary of State for Health and Social Care, congratulating the team on recent improvement in diagnostic performance. The monthly diagnostics collection looks at data on waiting times and activity for 15 key diagnostic tests and procedures, and Richmond CCG s performance improved between November and December The letter states: Moving from 4.1% to 2% is a real achievement. In this sense, the CCG is a real example to others, demonstrating how to improve performance in a short space of time and ensure that your patients get the care they deserve. Whilst it is encouraging that you have made progress in respect of your diagnostic performance, you are not yet meeting the 1% standard and I look forward to seeing continued performance. This refers to the fact that less than 1% of patients should wait 6 weeks or longer for a diagnostic test - and we continue to work towards meeting this. Stay Well Pharmacy campaign The CCG has been working with health and social care partner organisations in Richmond and Kingston to support the NHS England Stay Well Pharmacy campaign, which urges parents to consult a pharmacist first for minor illness, instead of GP or A&E. In working together with partners, it is hoped that we have maximised the impact of the national messaging across our local transformation board areas (Richmond and Kingston). The campaign reminds people that local pharmacy teams offer fast and convenient clinical support with no appointment needed and has it has been supported with extensive TV advertising and social media work. More information can be found at Breast cancer in women over 70 campaign The CCG is also supporting the Public Health England campaign which seeks to raise awareness in women over 70 of the symptoms of breast cancer. The key message being promoted is 1 in 3 women who get breast cancer are over 70, so Page 3 of 4 Working together a healthier Richmond for everyone

22 don t assume you re past it. The campaign also reinforces the message that finding it early makes it more treatable. Hounslow and Richmond Community Health win award for wound care app Hounslow and Richmond Community Healthcare has won an Outstanding Practice in Wound Care Award (Journal of Community Nursing) for its wound care buddy app which helps district nurses treat patients wounds in their own homes You can read a media article about it here: The app was introduced in response to NHS England s policy for improving wound assessments. It gives frontline teams immediate access to specialist information. Before the app was introduced, district nurses had to call a specialist tissue viability nurse and leave a telephone message. Sometimes they were called back after they had left the patient s house. Patients wound care has improved due to instant access to the right information at the right time through the app. Tonia Michaelides Managing Director of Kingston and Richmond CCGs Page 4 of 4 Working together a healthier Richmond for everyone

23 Attachment C Kingston & Richmond Transformation Integrated Musculoskeletal Model and Pathways Right Care, Right Place, Right Time Richmond Governing Body 6 March 2018 peogopleathe right care, in the right place at the right time

24 SWL MSK Strategy: Implementing NHS England s Integrated MSK national specification SWL Clinical Senate and Senior Management Team have committed to the development of an integrated MSK service across SWL. This includes every area jointly developing: Common specification and governance for all Single Point of Triage(SPT) Integrated pain pathway including active links to mental health Integrated rheumatology pathway and MDT in each SPT Integrated orthopaedic pathway Standardised referral documentation and protocols Single patient outcome and quality measures which will allow us to proactively manage the SPTs A single self-management resource across SWL Developing alternative care pathways and services

25 Benefits More people accessing the right care, in the right place at the right time Improved patient experience and outcomes Providers working together to deliver standardised care pathways Improved referral management via Electronic Referral System All routine GP MSK referrals managed by the Single Point of Triage(SPT) Improved equity of access and reduce variation More appropriate utilisation of diagnostic capacity

26 South West London MSK MSK conditions account for up to 30% of GP consultations nationally (DH, 2016) MSK referrals make up approximately 10% of all GP referrals (NHSE, 2017) The SPT ensures people are seen in the right place, by the right person, first time. Registered population of Kingston 210,000 and Richmond 215,000 Referral information for 2016/17 Kingston/Richmond GP s Orthopaedics KCCG 2, 900, RCCG 2,700 Pain Management KCCG 800, RCCG 700 Rheumatology KCCG 850, RCCG 950 Physiotherapy/ESP KCCG 7,000, RCCG 10,000 MSK MRI Diagnostics KCCG 1,700, RCCG 4,500

27 Kingston and Richmond MSK Integrated Service NHS Kingston and Richmond CCGs are working together to establish a Single Point of Triage (SPT) and the appropriate range of alternative pathways. This has included partnership working and co-design of service models and approach between: Kingston Hospital NHS Foundation Trust Hounslow & Richmond Community Healthcare NHS Trust Your Healthcare Chelsea and Westminster Trust GPs Karina Knights, Andrea Davis, Naz Jivani Kingston and Richmond CCGs The introduction of the Single Point of Triage, is the first stage in this journey.

28 Kingston and Richmond MSK Integrated Service Existing Triage Arrangements A single point of triage does not currently exists for all MSK conditions. KCCG have commissioned KHFT to provide a robust ESP triage and assessment for orthopedics as well as a treatment service. RCCG have commissioned HRCH to provide ESPs triage this manages circa 30% of all physio and orthopedic referrals. HRCH also provides a treatment service. Phase 1 ( by April 2018) Establish a more integrated Single Point of Triage (SPT) for orthopedics, pain, rheumatology and physiotherapy which will: Review referrals Refer to the most appropriate service Provide advice and guidance from ESPs To optimise the use of advice & guidance for general practice via Kinesis To optimise the use of DXS to reduce variation in referrals Phase 2 (by April 2019) Development of pathways for rheumatology, Pain and orthopedics across primary, community and secondary care Direct Listing, supported by guidelines with pre and post-operative work up and rehabilitation, utilising the principles of enhanced recovery and utilising local information on co-morbidity factors to ensure patients are fit for surgery An emphasis on improving public health outcomes and supporting preventative measures

29 Integrated MSK Single Point of Triage Pathway Access to self-management portal/ information CLINICAL TRIAGE Triage via Specialist Physiotherapy for: APPOINTMENT VIA BOOKING FUNCTION Pain Management Self Care Pain management Or as appropriate Patient Rheumatology Orthopaedics Community Physiotherapy Rheumatology Orthopaedics Follow Up Appts Booked by Specialties A&E GP Diagnostic Requirements Community Physiotherapy Joint Injections Advice via Kinesis Referral Utilising Standard referral form via e- referral/ DXS Using referral protocols to direct patients into the most appropriate clinic ESP Links to Podiatry, Joint Injections & Neurosurgery

30 Single Point of Triage The aims and objectives of the SPT are to: Ensure MSK patients from Kingston and Richmond CCGs are seen by the right person, in the right place first time Provide a patient focused service, enhancing patient choice and the patient experience Standardise appropriate GP referral pathways whilst appropriately managing demand in primary care Reduce the number of inappropriate referrals into secondary care Develop a service that dovetails with and compliments existing local services Promote self-management with information and advice given at the point of access and reinforced throughout the pathway

31 Single Point of Triage (SPT): Key Pillars Delivery by a team of MSK Extended Scope Practitioner(ESP) and Physiotherapists Triage of all routine GP referrals within 48 hours (Red flags and 2week wait (cancer) separate urgent pathway) Liaison with other components of the MSK service to ensure a seamless pathway ensuring the patient sees the right person, at the right time An emphasis on appropriate self-management and shared decision making to empower people and prevent the unnecessary use of unscheduled care supported by a SWL Collaborative aim to introduce a patient selfmanagement portal Reductions in clinically avoidable MRIs, as patients will be triaged and MSK MRIs will be requested where deemed appropriate (in line with the Royal College of Radiologists guidelines) Supported by a robust clinical governance processes 9

32 Progress to Date Well established Kingston and Richmond MSK Working Group, chaired by GP Programme includes managers and clinicians from from HRCH, KHFT, ChelWest(West Middx), Your Healthcare Redesign of single point of access pathway is underway including use of e-referral Routes from SPT to Radiology SPT specification drafted and is being reviewed Routes for advice and guidance via Kinesis (GP to Consultant e- communications system) under review Clinical governance protocols for the SPT providers has been developed is being finalised.

33 Next Steps/Timeline February 18 March 18 April 18 October 18 Oct 18 Mar 19 Apr 19 Finalise SPT service specification Deliver Pain training Deliver Rheumatology filter training ERS front end trial period begins Begin HRCH/YHC ESP cross training includes shadowing Continue Physio Review across LDU to inform Phase 2+ development Continue SH engagement ERS front end trial & implementation period begins Finalise all ESP cross training Establish MSK Working Group as Steering Group Establish evaluation process Phase 2+ BC development continues Continue Physio Review across LDU to inform Phase 2+ development Agree the outcomes data to be collected SPT Go Live! SPT Evaluation period begins Review of existing pathways and development of alternative pathways to support Phase 2 of the work. This will include: Physiotherapy Pain management Rheumatology Orthopaedics Stakeholder discussions around MSK diagnostics Mobilisation for Phase 2 Submission of Phase 2+ BCs processes established Phase 2 go live! Stakeholder discussions around MSK diagnostics Ongoing links to SWL Collaborative MSK work programme

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35 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing Body in public Date 6 March 2018 Report Title Urgent Treatment Centre and Primary Care Centre update Agenda Item 2.2 Attachment D Purpose (please indicate with X) Approval/ Ratification Discussion / Comment X Information Report Author: (name & job title) Kathryn MacDermott, Director Primary Care & Planning Presented by: (name & job title) Kathryn MacDermott, Director Primary Care & Planning Summary and purpose of report The report provides an update on the commissioning discussions with Houslow & Richmond Community Health (HRCH) and Richmond GP Alliance (RGPA) on the development of an Urgent Treatment Centre at Teddington Memorial Hospital and the establishment of a Primary Care Centre in the East of the borough. Key sections for particular note Slide 4 sets out the service model for Teddington Memorial Hospital. The proposed Urgent Treatment Centre will bring together the currently co-located but separate services of the nurse led walk in centre and the GP hub into one new integrated service that will offer both booked appointments and the ability to walk in. Appointments will be with GPs, nurses and healthcare care assistants. The proposed UTC will operate 8am to 8pm, 7 days a week including all bank holidays. Slides 6 and 7 set out our commitment to provide extended primary care services in the east of the borough. These will be booked GP and nurse appointments. This service will operate for 8 hours, 6 days a week. Slides 9 and 10 provide a summary of the additional services that will be provided at TMH Urgent Treatment Centre (UTC). Report recommendation The Governing Body is asked to approve the proposed service model of an Urgent Treatment Centre at TMH and a Primary Care Centre in the east of the borough. Financial and / or resource implications The finance model is to be considered in part 2 and the March Finance Committee. Key risks identified & mitigation None identified at this stage. Version: Final D - 1 Date:

36 Equality and / or privacy impact analysis No PID will be included therefore a privacy impact analysis is n/a. An equality impact assessment will be completed in the early stages of roll out and any necessary amendments to the service model will be identified and considered by the Primary Care Commissioning Committee. Committees that have previously discussed / agreed the report and outcomes Clinical Executive Team Primary Care Commissioning Committee Previous Governing Body meetings Communication plan / stakeholder involvement / patient engagement RCCG and RCHiP have a joint communications plan in place. The detail of this plan is to be considered at the March Patient Participation Group network meeting. All key stakeholders, including Richmond Healthwatch are a member of the joint working group that is developing and implementing these new services. The Richmond Patient Participation Group network has received regular updates on the progress of this work and activity participating in shaping the operational model. Assurance Does the report need to be taken to any additional meetings for further assurance or ratification? Yes. RCCG Finance Committee CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final D - 2 Date:

37 Urgent Treatment Centre & Primary Care Centre Update for RCCG Governing Body March 2018 Kathryn MacDermott Director Primary Care & Planning

38 Extended primary care services: one integrated service Richmond Community Health in Partnership (RCHiP) and Richmond Clinical Commissioning Group are working together to improve healthcare for the people of Richmond We plan to combine a range of primary and urgent care services run by GPs, nurses and other healthcare professionals at Teddington Memorial Hospital, starting from 9 th April 2018 called an urgent treatment centre (UTC) A primary care centre will follow in the east of the borough once we have confirmed the site The expected start date for the east is the 9 th April

39 Urgent Treatment Centre in Teddington The Urgent Treatment Centre will be run, managed and commissioned as a single service rather than the current separate but co-located Walk in Centre and GP Hub. The integrated service will meet all the requirements set out in the NHS Urgent Treatment Centre (UTC) Principles and Standards document. Walk in Centre GP Hub Urgent Treatment Centre 3

40 TMH Urgent Treatment Centre The Urgent Treatment Centre will offer GP and Nursing services for 12 hours per day, 7 days per week, including Bank Holidays. The plan is to include dedicated paediatric nursing within the service. The UTC will offer both bookable and non-bookable appointments. Staff General Practitioner (GP) Qualified nurse and Emergency care practitioner (ECP) Nurse prescriber Specialist paediatric nurse Healthcare assistant Examples of appropriate care More complex illness, ailments and diagnostics, Pregnancy related conditions, PV bleeding All minor injuries and routine illness and ailment e.g. UTIs, ENT conditions, simple anti-biotic prescriptions, bites and stings As nurse but including emergency prescription renewal and medications review/advice All children 0-15 ailments Simple minor injuries, wound dressings 4

41 Bookable appointments Walk in appointments Some urgent same-day appointments will be reserved for people who just walk in. Patients will be offered a time slot and choose to wait or come back. Gradual move to booking The proportion of advanced bookings to same-day appointments could be similar to the following: 1. By April 2019, 40% will be available as walk-ins 2. By April 2020, 30% will be available as walk-ins 3. By April 2021, 20% will be available as walk-ins 5

42 East Richmond Primary Care Centre We also plan to offer extended primary care on the east side of the borough. Setting up a PCC in the east of the borough will help rebalance provision across the borough. This service will operate for 8 hours a day, 6 days a week. We are currently confirming the site. UTC PCC This service will include booked appointments with GPs and nurses We are also looking to include paediatric nursing services in this service Patients will continue to have access to Queen Mary s for minor injuries 6

43 Positive primary care centre model Some capacity could potentially transfer from TMH to eastern PCC, rather than seek funding for completely new service Eastern PCC could be co-located at a practice site or existing centre This would be an improvement to residents services, rather than a reduction We would aim for a viable site to be open by 9 th April

44 The proposed model Better use of non-medical staffing time will free up GP time Better use of GP time will free up hospital time Freed up acute time will release costs savings More nursing & other non-medical capacity used more efficiently Less pressure on GPs, who offer more appointments and spend more time with LTC patients Better care of long term conditions (LTCs)and easier access to GPs for medical diagnosis's means less visits to A&E and less use of hospital outpatients GPs send more generally well and routine patients to nurses & others Patient choose GP over A&E Holistic GP care reduces hospital admission 8

45 Accessible diagnostic facilities To provide a credible alternative to A&E, the UTC will have fast access to diagnostics, either onsite or commissioned On-site facilities X-Ray Commissioned Urinalysis Blood work 9

46 Access to specialist community service Educating nurses and GPs in UTC and PCC, and improving referral pathways, can help patients access services they need before a crisis develops Community UTC/PCC Mental Health Respiratory Tissue Viability Paediatric ANP Specialist Community services 10

47 Access to specialist community service Case study A diabetic patient is directed to UTC with a lesion Nurse recognises a potential problem and links with tissue viability and diabetes service Through early action, the patient s limb is saved and significant acute and pharmaceutical costs are avoided 11

48 Managing acute demand via behaviour change in primary care By advertising trusted and available primary care support, with medical and nursing care, patients can be tempted away from use of A&E Trusted position of GPs and nurses in community can help inform and motivate patients to use alternatives to A&E UTC/PCC 12

49 Managing acute demand via behaviour change in primary care Offering bookable appointments with sufficient capacity to tempt away from A&E Screens in A&E waiting room showing available UTC/PCC appointment slots 111 access to bookings avoid redirection to A&E GP reception and pharmacy counter redirect demand as per Whitton & Twickenham PCH pilot Accept redirections from local urgent care centres Education and behaviour change for primary care referrers on use of UTC/PCC Patient induction programme on available care for new registrants into GP practices 13

50 Promoting self care The UTC will give patients the support, resources & motivation to care for themselves in future Ways UTC can promote self care Information about other care, eg, pharmacy Referral to navigation services for voluntary care Social prescriptions re healthy lifestyle & exercise Information prescriptions about self-care and what is available in the community Giving out/directing to resources people need (such as medication or equipment) to care for themselves or loved ones at home in future 14

51 Promoting self care As well as treating people, the new services will provide patients with the support, resources and motivation to care for themselves in future Ways PCC can promote self care Informing patients of other places they could have gone for care i.e. pharmacies Referral to Care Navigation services for better access of voluntary services Providing social prescriptions around healthy lifestyle and exercise Providing information prescriptions about how to self care and what is available in the community? Giving out or directing to the resources people need, such as medications or equipment, to care for themselves or their loved ones at home in future Non-recurrent cost An appointment where self care promotion takes place reduces the chances of a repeat interaction Standard care Living well in community Need Self care Living well in community 15

52 Key contacts Tom Penman Urgent Care and Rehabilitation Divisional Manager HRCH Subir Bali GP and RCHiP Board member RGPA Kathryn MacDermott Director of Primary Care and Planning RCCG

53 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing Body in public Date 6 th March 2018 Report Title Update on progress on refreshing the primary care strategy for Richmond Agenda Item 2.3 Attachment E Purpose (please indicate with X) Approval/ Ratification Discussion / Comment X Information X Report Author: (name & job title) Kathryn MacDermott, Director Primary Care & Planning Presented by: (name & job title) Kathryn MacDermott, Director Primary Care & Planning Summary and purpose of report The January 2018 Governing Body agreed to refresh its primary care strategy. Since that meeting the draft strategy has been considered at: Membership forum on 24 th January Patient participation group network on 30 th January Primary care commissioning committee on 6 th February Clinical executive team on 13 th February This paper provides a summary of the suggestions made to-date Key sections for particular note Slide 4 lists the proposed changes to the principles set out in the current strategy. The GB is asked to consider rewording the listed principles. Slide 5 suggests including two new enablers of communications and workforce and suggests that extended access is not listed as an enabler, but an outcome. Slide 6 suggests new priority objectives that match across to the CQC objectives. Slide 7 sets out new inclusions suggested to date. The GB is asked to consider these proposals. Slide 8 sets out a challenge for the CCG. The Primary Care Commissioning Committee has had a 1 st discussion on this and has agreed to establish a Primary Care Commissioning Committee seminar to provide the opportunity for a fuller conversation. Report recommendation The GB is asked to consider rewording the listed principles, the proposed new priority objectives, and proposed new inclusions. The GB is asked to note that the PCCC has asked for a seminar to discuss the model of sustainable primary care for Richmond. Financial and / or resource implications The refreshed primary care strategy will include a section on primary care investment. Version: Final E - 1 Date:

54 Key risks identified & mitigation None identified at this stage. Equality and / or privacy impact analysis No PID will be included therefore a privacy impact analysis is n/a. An equality impact assessment will be completed as the draft primary care strategy is nearing the final draft. Committees that have previously discussed / agreed the report and outcomes January 30 th Governing Body meeting Membership forum on 24 th January Patient Participation Group network on 30 th January Primary Care Commissioning Committee on 6 th February Clinical Executive Team on 13 th February Communication plan / stakeholder involvement / patient engagement RCCG is currently carrying out a Quality in Primary Care engagement programme of events. The outcomes of this engagement will inform the development of the primary care strategy. The development of the strategy will follow an iterative process that will include the membership forum, clinic networks, clinical executive team, the primary care commissioning committee, the primary care operational group, the patient participation group network, practice managers forum and any other appropriate groups. The aim is to co-produce this strategy with RGPA. Assurance Does the report need to be taken to any additional meetings for further assurance or ratification? Yes. Governing Body Membership forum Clinic networks Clinical executive team Primary care commissioning committee Primary care operational group Patient participation group network. CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final E - 2 Date:

55 Richmond CCG Governing Body March 2018 Update on Refreshing the Primary Care Strategy Kathryn MacDermott Director Primary Care & Planning Richmond & Kingston CCGs

56 Purpose of the update January 2018 Governing Body meeting agreed to update its Primary Care Strategy. Since that meeting the draft strategy has been considered at: Membership forum on 24 th January Patient participation group network on 30 th January Primary care commissioning committee on 6 th February Clinical executive team on 13 th February This paper provides a summary of the suggestions made to-date 2

57 Richmond Clinical Commissioning Group Joint Primary Care Strategy The Membership Forum discussed the need for and purpose of a Primary Care Strategy. It was agreed that the aim of the strategy would be to set a high level description of what we wished to achieve in primary care locally. This would be complemented by annually, updated implementation plans. This would enable all stakeholders the membership, partners, patient & public to be clear on what we aim to achieve and how. 3

58 Principles The Membership Forum and the Patient Participation Group suggested included additional, new principles: Setting out patient responsibilities Promoting self help and self care Promoting and enabling ownership of one s own health and well being Taking a collaborative approach These will be added to the existing principles of: Safe Improving the patient experience, including accessibility Effective in delivering key outcomes Providing value for money Working to reduce health inequalities Monitored regularly to ensure all the above 4

59 Enablers The feed back to-date includes the suggestion that extended access is better described as an outcome rather than an enabler. The Patient Participation Group network made a number of suggestions for new enablers these focussed on improved communications about services in general and better communications in practices. A specific suggestion included practices listing their GP interests on their websites. Training was raised by both the Membership Forum and the Patient Participation Group network, both recognised the importance of the right workforce with the right skill mix and training. 5

60 Priority objectives The existing priority objectives are considered to be fundamentally business as usual and the Membership Forum suggested instead priority objectives that linked to the CQC objectives: Ensuring our services are safe Effective Caring That we are responsive to people s needs Well led Additional priorities suggested include: Establish sustainable primary care services Develop primary care at scale (past of sustainability) Effective patient engagement 6

61 Suggested inclusions Themes from the Clinical Network workshops: More co-ordinated / cohesive working Sharing clinical and back office staff Sharing IMT staff Sharing prescribing management, referral management processes Skill mix within and across practices Looking at new roles physicians assistant, clinical pharmacists etc Training Moral GP IT Description on how we engage with patients and how we feedback Link to the OBC physical and mental health programme of work 7

62 The questions coming up Is the current model of sustainable primary care for Richmond? How do we support smaller practices - should we talk about integrated primary care networks? 8

63 Engagement still to happen Clinic networks on 28 th February, 28 th March Clinical Executive Team on 13 th March, 10 th April Primary care operational group on 20 th March Primary Care Commissioning committee on 3 rd April Patient participation group network on 27 th March LCS Steering Group on 27 th March Executive Management Team on 22 nd March Governing Body on 6 th March The aim is to co-produce this strategy with RGPA. RCCG/RGPA meetings on 14 th March Sign off Governing Body 1 st May

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65 Richmond Clinical Commissioning Groups Report Summary Meeting Title Governing Body in Public Date 6 March 2018 Report Title Quality, Safety & Performance Agenda Item 3.1 Attachment F Purpose (please indicate with X) Approval/ Ratification Discussion / Comment Information X Report Author: (name & job title) Ruth Harkness Clinical Quality Manager Presented by: (name & job title) Dr Zehra Rashid, Governing Body General Practitioner Lead for Quality Summary and purpose of report The purpose of this summary report is to provide an overview of the assurance given in January 2018 by the South West London performance report and the Richmond Quality, Safety & Performance (QSP) Committee. Key sections for particular note All key points of note included in narrative. Report recommendation The Governing Body is asked to note the contents of these reports Financial and / or resource implications Not required as summary report. Key risks identified & mitigation South West London performance report (Richmond) Diagnostics performance continued the recent downward trend in November driven primarily by 91 Non-Obstetric Ultrasound breaches occurring at Chelsea and Westminster Trust. Richmond Quality Safety and Performance Committee Vacancy Rates Equality and / or privacy impact analysis Not required as summary report Committees that have previously discussed / agreed the report and outcomes Richmond Quality, Safety & Performance Committee. Communication plan / stakeholder involvement / patient engagement Not required as summary report. Assurance Not required as summary report. CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final F - 1 Date:

66 Version: Final F - 2 Date:

67 Highlight Constitutional Standards South West London Performance Highlight Report Month 8 page 2 A&E -4 hour standard page 3 Referral to Treatment (RTT) 18 week Incomplete page 4 Cancer Waiting Times Two week wait (2WW) & 62 Day page 5 Diagnostics waits For: South West London Senior Management Team page 6 Ambulance Handovers- London Ambulance Service (LAS) page 7 NHS 111 service page 8 Improving Access to Psychological Therapies (IAPT) page 9 Dementia and Mental Health Sponsor: Director of Commissioning Operations, South West London Alliance Author: NELCSU / SW London Performance Management & Pressure Surge Team Version: FINAL /02/2018 page 10 Delayed Transfers of Care (DTOCs) page 11 Glossary page 12

68 Highlight Constitutional Standards (By CCG) A&E- All Type (4 hour standard By CCG) CCG Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Croydon 87.53% 84.86% 84.96% 85.25% 86.58% 88.57% 90.83% 90.48% 88.57% 90.07% 90.64% 93.57% 91.93% 88.60% Kingston 89.33% 87.22% 84.31% 88.25% 91.19% 91.10% 89.90% 91.01% 93.11% 91.75% 92.10% 92.60% 90.04% 87.05% Merton 93.31% 90.06% 88.34% 91.30% 90.93% 91.69% 91.33% 92.67% 91.54% 91.24% 91.69% 90.41% 89.62% 86.95% Richmond 91.78% 89.87% 88.01% 91.13% 92.56% 93.55% 92.39% 93.87% 94.77% 94.11% 93.60% 94.12% 93.08% 91.39% Sutton 95.22% 93.47% 93.73% 94.56% 95.52% 94.59% 94.97% 94.67% 94.56% 93.50% 94.68% 93.29% 93.28% 89.87% Wandsworth 91.57% 88.36% 86.34% 89.99% 89.33% 91.01% 90.10% 92.38% 91.02% 91.30% 90.96% 90.02% 89.24% 87.39% Data has been mapped from providers to CCGs using a mapping derived from Hospital Episode Statistics figures. This calculates what proportion of each provider can be attributed to a given CCG. Cancer- 62 day GP referral CCG Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Croydon 77.27% 88.68% 80.33% 84.00% 90.80% 86.79% 81.58% 89.04% 82.56% 84.62% 79.45% 78.67% 90.41% Plan 85.92% 85.92% 85.92% 85.92% 85.92% 86.44% 85.51% 86.11% 85.51% 86.11% 85.51% 86.11% 86.11% Kingston 87.10% 87.88% 85.71% 88.24% 91.30% 92.31% 100% 86.84% 92.59% 85.29% 87.50% 86.11% 82.93% Plan 88.00% 87.50% 88.46% 87.50% 88.46% 88.46% 86.67% 87.10% 86.67% 87.10% 86.67% 87.10% 87.10% Merton 86.67% 79.31% 83.33% 80.00% 92.00% 95.24% 82.14% 88.89% 75.86% 85.71% 89.66% 83.87% 93.55% Plan 85.71% 85.19% 87.10% 87.50% 87.88% 88.46% 86.67% 87.50% 86.67% 87.50% 86.67% 87.50% 87.50% Richmond 100% 96.97% 96.30% 90.00% 83.33% 92.31% 90.91% 92.59% 87.80% 82.86% 92.86% 91.18% 93.75% Plan 85.71% 85.71% 85.71% 85.71% 85.71% 86.21% 85.29% 85.71% 85.29% 85.71% 85.29% 85.71% 85.71% Sutton 86.49% 85.71% 80.00% 88.89% 90.91% 90.00% 91.18% 84.85% 89.13% 74.19% 86.11% 85.71% 89.74% Plan 87.18% 87.18% 87.18% 87.18% 87.18% 86.67% 85.71% 86.49% 85.71% 86.49% 85.71% 86.49% 86.49% Wandsworth 80.56% 85.00% 82.35% 88.57% 81.25% 87.10% 75.56% 82.35% 75.00% 82.76% 83.33% 91.18% 84.38% Plan 85.00% 86.36% 85.71% 86.36% 86.84% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% Period: M8 2017/18 Report: Date: 30/01/ Week Referral to Treatment (RTT) - Incomplete Pathways Diagnostics- Waits over 6 Weeks CCG Level Narrative CCG level narratives have been provided for the four Constitutional Standards that receive the most focus. Further detail is provided in subsequent pages about Trust level performance and any associated key actions. Croydon CCG: The CCG continues to achieve RTT standard. The diagnostics standard has been achieved, both at CCG and CHS, for the third, consecutive month. The national A&E performance standard was not achieved at CHS with performance of 89.4% in December, below the operating plan trajectory of 94.8% for the month. Performance on Type 1 A&E attendance has declined. The CCG achieved all cancer performance standards in November, which included the recovery of the Cancer 62 day GP referral standard which had previously been achieved in June. CCG Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Croydon 91.70% 90.81% 90.93% 90.91% 91.46% 91.22% 91.70% 91.91% 92.19% 92.06% 92.18% 92.80% 92.87% Plan 92.00% 92.00% 92.01% 92.00% 92.00% 90.75% 90.76% 90.78% 90.79% 90.78% 90.81% 90.82% 90.82% Kingston 93.89% 94.18% 94.03% 94.35% 94.52% 94.21% 94.18% 93.84% 93.74% 93.30% 92.97% 93.03% 93.71% Plan 93.01% 93.01% 93.00% 93.00% 93.01% 92.01% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% Merton 92.59% 91.55% 91.89% 92.26% 92.56% 91.74% 91.97% 91.39% 91.16% 90.26% 90.08% 89.85% 89.79% Plan 91.88% 92.00% 92.04% 92.15% 92.41% 91.97% 91.97% 92.06% 92.07% 91.96% 92.09% 92.08% 92.08% Richmond 92.84% 92.83% 92.97% 92.93% 93.14% 92.42% 93.53% 93.77% 93.48% 92.44% 90.90% 91.39% 92.37% Plan 94.87% 94.87% 94.87% 94.87% 94.87% 92.03% 92.03% 92.02% 92.03% 92.02% 92.03% 92.02% 92.02% Sutton 92.82% 92.48% 92.54% 93.13% 93.30% 92.91% 92.99% 92.05% 91.98% 90.96% 90.69% 90.41% 91.33% Plan 92.15% 92.15% 92.15% 92.15% 92.15% 91.87% 91.88% 92.16% 92.16% 91.82% 92.24% 92.24% 92.24% Wandsworth 90.21% 89.31% 90.72% 91.36% 90.67% 89.90% 90.36% 90.08% 89.58% 89.02% 88.72% 88.71% 88.78% Plan 91.81% 91.96% 91.95% 92.08% 92.39% 92.04% 92.01% 92.00% 92.00% 92.01% 92.00% 92.00% 92.01% CCG Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Croydon 0.33% 0.68% 0.91% 2.42% 3.81% 5.74% 5.40% 4.10% 2.93% 1.60% 0.34% 0.44% 0.83% Plan 0.99% 1.00% 0.99% 0.99% 0.99% 0.94% 0.97% 0.98% 0.97% 0.98% 0.97% 0.98% 0.98% Kingston 0.36% 1.16% 1.27% 0.96% 0.81% 1.32% 1.51% 0.57% 0.84% 1.16% 0.67% 0.59% 0.95% Plan 0.87% 0.87% 0.89% 0.88% 0.87% 0.99% 0.98% 0.98% 0.97% 0.97% 0.99% 0.99% 0.97% Merton 0.64% 3.38% 2.83% 1.74% 1.59% 2.03% 1.68% 1.08% 1.05% 0.68% 1.05% 0.38% 1.14% Plan 0.99% 0.99% 0.99% 0.99% 0.99% 0.92% 0.86% 0.88% 0.86% 0.88% 0.86% 0.88% 0.88% Richmond 0.57% 0.76% 0.89% 0.63% 1.28% 2.23% 1.49% 1.48% 1.43% 1.21% 1.09% 3.70% 4.09% Plan 0.92% 0.92% 0.92% 0.92% 0.92% 0.86% 0.86% 0.86% 0.86% 0.86% 0.86% 0.86% 0.86% Sutton 0.57% 7.05% 0.77% 0.45% 0.30% 0.52% 0.58% 0.39% 0.64% 0.54% 0.77% 0.58% 1.12% Plan 0.98% 0.98% 0.98% 0.98% 0.98% 0.89% 0.90% 0.93% 0.90% 0.93% 0.90% 0.93% 0.93% Wandsworth 0.60% 1.69% 3.33% 1.93% 2.42% 3.50% 2.70% 2.48% 2.77% 2.17% 1.31% 0.48% 1.25% Plan 1.00% 0.99% 1.00% 0.99% 1.00% 1.00% 1.00% 0.99% 0.99% 0.99% 0.99% 0.99% 0.99% Richmond CCG: Achieved the RTT performance standard in November with an outcome of 92.37% after two months of nonachievement. The CCG achieved all Cancer performance standards in November. Diagnostics performance continued the recent downward trend in November driven primarily by 91 Non-Obstetric Ultrasound breaches occurring at Chelsea and Westminster Trust. The Trust has a Recovery Plan in place with performance modelled to recover in January Kingston CCG: The performance standards for Diagnostics and RTT were achieved in December 2017, with the diagnostic standard being met every month year to date. However the 62 Day GP referral standard was not achieved with performance of 82.93% (7 patients breaching out of 41 patients.) in November 2017, which were related to patients with complex needs and late onward referrals. A&E performance at Kingston Hospital was 87.05% in December 2017, below the 88.0% operating plan trajectory for the month. Merton CCG: The 2 week wait / 2ww (See Page 5) and the 62 day GP referral standards were achieved in November. This was the fourth consecutive month for both 2WW cancer standards. RTT performance, which does not include SGH figures, has declined slightly compared to previous months with performance of 89.79% delivered. Reported under-performance is due to non-achievement at Epsom & St Helier and Moorfields for the CCG. Epsom & St Helier, a large provider to the CCG also did not achieve the standard, delivering performance of 89.30%. The Trust is developing a recovery plan for RTT based on a comprehensive demand and capacity analysis, however this is having to be reviewed by the Trust to take account of any impact on the plan from following national guidance to cancel non-urgent surgery until the end of January The CCG did not achieve the diagnostics standard in November with performance of 98.86% (37 breaches out of 3,240 patients waiting, narrowly missing the target by 5 patients). Sutton CCG: Continues to achieve the 2WW and 62 day GP referral Cancer performance standards. The A&E 4-hour standard was not achieved at ESTH for All Type attendances in December with performance of 90.3% down from 93.8% in November. This is the third consecutive month that performance has not been achieved at the Trust. The RTT standard, while not achieved by the CCG in November with performance of 91.33% is a slight improvement on the 90.4% in October. Overall this is driven mainly by performance at ESTH, which also did not achieve the performance standard, with. performance of 89.30%. The Trust is developing a recovery plan for RTT based on a comprehensive demand and capacity analysis. This is being reviewed by the Trust in view of the impact on the plan following the national guidance to cancel nonurgent surgery until end-january. Wandsworth CCG: With SGH not reporting, RTT performance is mainly affected by outcomes at Imperial, Chelsea and Westminster, Moorfields and GSTT Hospitals where performance for CCG patients was not achieved. Diagnostics performance was not achieved in November with an outcome of 98.75% (66 breaches out of 5,270 waits, missing the target by 13 breaches). All cancer standards with the exception of the 62 day GP referral cancer standard were achieved in November. The 62 day GP referral cancer standard had 5 patients breaching out of a total of 32 accountable patients, narrowly missing the 85% standard with an outcome of 84.38%. A&E performance of 85.0% was delivered at SGH in December, down from 87.17% the previous month against an operating plan trajectory of 92.9% for December. 2

69 CHS ESTH KHFT SGH Trust Provider A&E Type Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 A&E Performance -v- Attendance A&E Performance By Type A&E - 4 Hour Standard Croydon UH - T1 77.4% 78.3% 76.1% 80.1% 79.9% 85.0% 80.6% 75.3% 77.5% 79.4% 87.7% 83.0% 74.3% Croydon Health T2/T3 Urgent Care Centre % 98.0% 99.3% 96.4% 96.6% 96.7% 98.5% 97.7% 99.6% 99.5% 99.8% 99.7% 99.4% Services NHS Trust Provider All Type 84.9% 85.0% 84.4% 86.1% 88.4% 91.2% 90.6% 88.3% 90.1% 90.9% 94.8% 93.0% 89.4% Epsom And St Helier University Hospitals NHS Trust Kingston Hospital NHS FT St George's University Hospitals NHS FT Lead LDU:Sutton Period M9 2017/18 Named Lead:Sean Morgan Report: Date: 30/01/2018 A&E Performance Epsom - T1 94.9% 94.7% 93.7% 97.3% 96.3% 95.6% 96.1% 94.8% 95.5% 94.9% 92.7% 94.0% 88.7% St Helier - T1 93.2% 94.0% 95.9% 95.5% 94.3% 95.5% 94.0% 95.2% 92.5% 95.2% 93.5% 92.4% 88.2% Sutton - T2/T3 100% 100% 99.6% 99.1% 98.2% 99.8% 100% 100% 100% 100% 99.8% 100% 100% Provider All Type 94.1% 94.6% 95.2% 96.4% 95.2% 95.6% 95.0% 95.2% 94.0% 95.2% 93.7% 93.8% 90.3% Kingston - T1 84.6% 80.9% 85.4% 89.5% 89.4% 87.8% 89.0% 92.1% 90.2% 90.7% 91.8% 88.3% 85.0% Kingston REU - T2/T3 100% 100% 100% 99.7% 100% 100% 99.9% 100% 100% 100% 100% 100% 100% Provider All Type 85.9% 82.6% 87.0% 90.7% 90.4% 89.0% 90.2% 92.9% 91.3% 91.7% 92.6% 89.5% 86.3% St George's - T1 88.0% 85.2% 89.7% 87.6% 89.5% 88.6% 91.3% 88.9% 89.1% 89.0% 86.7% 85.9% 83.5% Q Mary Roe'ton - T2/T3 100% 100% 100% 100% 100% 100% 100% 99.4% 99.8% 99.9% 100% 100% 99.8% Provider All Type 89.1% 86.6% 90.6% 88.6% 90.5% 89.7% 92.1% 89.8% 90.0% 90.0% 88.0% 87.2% 85.0% South West London Total All Type 88.9% 87.6% 89.7% 90.6% 91.1% 91.5% 92.1% 91.3% 91.3% 91.9% 92.3% 91.0% 87.9% N.B. ALL DATA IS NHSE PUBLISHED DATA EXCEPT ESTH AT SITE LEVEL, WHICH IS BASED ON DAILY RETURNS AND NOT MONTHLY RETURN. A&E Attendance by Type Key Actions Actions Narrative Owner Due SW London Narrative SWL Overall performance has significantly deteriorated in December with aggregate All Type performance across the 4 SWL providers at 87.9% down from 91.0% in November. The operating plan December trajectory for the 4 main SWL providers was 93.05%. CHS Performance was 89.4% for 'all types' attendances in December, which was below the operating plan trajectory of 94.8%. Type 1 performance declined from 83.0% in November to 74.3% in December. This deterioration in Type 1 performance has continued with UNVALIDATED Type 1 performance of 65.4% for the period 1 st -17 th January, ranging between 82.4% to 52.2%. An Improvement Plan agreed at the A&E Delivery Board is being implemented. Further diagnostic work is being undertaken to inform key actions. Progress is monitored by the A&E Delivery Board. The CCG holds daily calls with the Trust to discuss performance and to support resolution of any issues impacting on its ability to deliver the agreed trajectory. The completion of the new ED at CHS has slipped from February 2018 to June ESTH Did not achieve the performance standard in December with performance of 90.3%, down from November s performance of 93.8%. The operating plan trajectory was 95% for the month. Additional escalation beds have been opened, funded from the national Winter monies, and community services capacity is also to be expanded. KHFT Delivered performance of 86.3% in December, down from 89.5% in November The operating plan trajectory for December 2017 was 88.0%. The main reasons for breaches were responses within the ED and from specialties, with minimal breaches relating to bed availability. An Emergency Care Programme Plan is in place. The Kingston, Richmond and Surrey A&E Delivery Board has been reviewed with the appointment of a new Chair and the Board has refreshed the work programme of work using the 8 pillars for improvement in Urgent & Emergency Care with progress achieved with the support to the 8 pillar leads from a new PMO. St. SGH - performance was 85.0% in December, down from 87.2% in November. The operating plan trajectory for December was 92.9%. At the January performance meeting the Trust reported challenges with inpatient flow, DTAs most mornings and red and black escalations along with issues with patient repatriations to neighbouring trusts. A paper supporting the Repatriation of Tertiary Patients from St. George s Hospital had been discussed at Merton and Wandsworth AEDB and then supported at the SWL UEC Board for roll out to other Providers / AEDBs In terms of staffing the Trust reported fewer unfilled locum shifts after changing pay rates. There is an improved focus on use of the discharge lounge and a prescribing pharmacist has been allocated to the discharge lounge to help improve flow. The recovery plan identifies high impact changes with greatest improvement expected from 1) Full scale review of patient flow and discharge processes utilising SAFER (SAFER patient flow bundle) and Multi Agency Discharge Event (MADE) initiatives to give greater focus and granularity of data, 2) The introduction of high impact changes for discharges, 3 ) Recruitment, retention and retraining of staff across ED. The action plan is monitored by the A&E Delivery Board. An ambulance turnaround group has been established to improve the efficiency of patients being handed over and to explore alternative appropriate care pathways, with improvements expected when the trust return to their ED from the decant. Staffing levels are being continually reviewed to ensure that all key posts are covered. The completion of the new ED at CHS has slipped from February 2018 to June John Goulston CEO, CHS and Chair of the Croydon A&EDB Additional capacity funded from Winter monies with the expectation of delivering a two percentage COO, Epsom & point improvement in performance. System-specific triggers are in development and actions within St Helier Sutton Director the OPEL framework to have prescribed actions for all parties at each trigger point - ideally of invoking a pre-agreed response. Focus on flow, discharges and stranded patients, with a deepdive into the super-stranded patient group (>21 days) with NHSI collaboration in progress. This will Commissioning help expedite recovery actions. Actions to address the recovery are part of the Emergency Care programme plan monitored via the Kingston and Richmond A&E Delivery board. The hospital to home work stream through Kingston Co-ordinated Care is being rolled out throughout Q , with a similar locality team model planned in Richmond. Update reports on the 8 pillars of the ECP are scrutinised at the K&R A&E Delivery board, although recruitment of staff is the predominant risk to delivery, which is borne out by the local breach reports. GP hubs are working well and utilisation has increased through the winter period, which has meant that the numbers into A&E are stable. The Trust continues to implement its Unplanned and Admitted Patient Care programme, (U&APC Programme) a Trust wide approach to improving flow for non-elective and admitted patients. The Trust reported at the January performance meeting while the performance target has not been achieved, unplanned care flow has improved. As well as redesigning the front door process, there has been an increase in rapid assessment leading to improvements in flow for patients likely to be admitted, in addition to hosting MADE events to focus on the collaborative discharge approach. LAS activity has been relatively stable and the AAA expansion building work is likely to complete on There are good demand and capacity plans and escalation plans in place, which have received positive feedback from NHSI. ECIST has visited the Trust recently and is to provide a detailed report on Patient flow. Chair, A&EDB COO St. George s Hospital 95% in Mar 18 June-18 Jan 18 95% in Mar 18 Current trajectory shows 95.0% Feb 18 3

70 Referral to Treatment (RTT) 18 week Incomplete RTT- By Trust Provider Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 KHFT 95.20% 95.02% 94.80% 95.04% 95.11% 94.63% 94.67% 94.55% 94.36% 94.47% 93.69% 94.00% 94.63% CHS 92.80% 92.06% 92.03% 92.04% 92.14% 92.01% 92.24% 92.24% 92.01% 92.05% 91.60% 92.03% 92.01% ESTH 91.45% 90.52% 90.94% 91.40% 92.01% 91.24% 91.51% 91.01% 90.71% 89.54% 89.06% 89.05% 89.30% SGH RMH 96.76% 96.51% 96.82% 97.01% 96.58% 95.83% 96.73% 96.77% 96.75% 96.78% 97.22% 97.30% 97.15% Total 92.96% 92.34% 92.47% 92.71% 92.96% 92.48% 92.70% 92.44% 92.17% 91.74% 91.26% 91.44% 91.65% RTT By Specialty - (Commissioners) Treatment Function Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 November CCG Pass Rate Lead LDU: Merton and Wandsworth Period M8 2017/18 Named Lead: John Atherton Report: Date: 30/01/2018 SW London Narrative At CCG level in SW London: At 91.7% RTT performance was not achieved for November in SWL, however this is a slight improvement on the 91.3% in October. SGH activity continues to not be reported and therefore is not included in the SWL figures. Croydon, Kingston and Richmond CCGs achieved the performance standard in November. At provider level in SW London: Aggregate RTT Performance of 91.65%. for the 4 main SWL providers did not achieve the performance standard, for the fourth consecutive month. However November was a slight improvement on performance of 91.44% in October. The RTT performance standard was not achieved at ESTH for the 8th consecutive month, November's outcome of 89.30% is a slight improvement on October s outcome of 89.05%. SGH continues not to report RTT performance. However, it is worth noting that if RTT performance for the independent sector is included, SW London achieved the target with an outcome of 92.04%. CHS: Performance was maintained in November with an outcome of 92.01%. At Trust level ENT, Oral Surgery and T&O remain significantly below 92% largely due to reported capacity issues. Cardiology 95.3% 94.4% 95.5% 94.8% 94.6% 93.8% 93.6% 93.3% 93.1% 92.5% 91.7% 92.7% 92.7% 4/6 Cardiothoracic Surgery 85.5% 84.8% 91.1% 92.4% 86.6% 77.2% 75.0% 76.7% 80.0% 84.2% 82.1% 82.9% 79.7% 2/6 Dermatology 93.9% 92.3% 92.7% 94.4% 94.6% 94.3% 95.7% 95.6% 95.0% 93.7% 91.9% 91.7% 92.1% 4/6 ENT 87.7% 86.7% 87.8% 87.1% 87.4% 88.5% 89.1% 89.4% 88.8% 86.4% 85.4% 86.1% 86.7% 0/6 Gastroenterology 94.6% 94.3% 94.6% 94.8% 95.4% 94.1% 94.6% 94.3% 94.5% 93.4% 93.0% 93.3% 93.0% 3/6 General Medicine 97.3% 96.9% 97.6% 96.5% 96.1% 95.3% 97.1% 96.4% 95.2% 93.8% 92.7% 93.4% 95.4% 5/6 General Surgery 90.2% 90.0% 90.2% 90.0% 89.1% 89.0% 89.7% 89.5% 88.9% 89.1% 89.8% 89.2% 89.1% 0/6 Geriatric Medicine 97.2% 97.0% 97.2% 97.5% 98.8% 97.1% 98.9% 98.9% 97.1% 98.7% 97.8% 96.8% 94.3% 4/6 Gynaecology 90.6% 89.9% 89.7% 90.5% 90.0% 89.0% 89.2% 89.1% 89.7% 89.2% 88.8% 89.5% 90.7% 1/6 Neurology 91.5% 92.6% 92.7% 93.4% 94.4% 92.8% 92.5% 91.8% 92.0% 90.6% 90.0% 89.5% 90.2% 2/6 Neurosurgery 81.4% 81.0% 83.8% 80.4% 83.2% 84.1% 85.0% 87.1% 85.9% 82.2% 81.2% 85.9% 84.3% 1/6 Ophthalmology 95.6% 95.5% 95.9% 95.5% 95.6% 94.2% 94.0% 93.9% 93.0% 92.1% 91.2% 90.4% 90.6% 2/6 Oral Surgery % % 100.0% 100.0% % 100.0% 100.0% 100.0% - 0/0 Other 92.5% 92.1% 92.3% 92.8% 93.7% 93.2% 93.5% 93.1% 93.5% 93.6% 94.3% 94.6% 94.9% 6/6 Plastic Surgery 91.8% 91.0% 90.5% 90.2% 88.3% 88.0% 88.7% 88.9% 87.6% 87.8% 88.1% 86.5% 86.6% 0/6 Rheumatology 97.1% 96.5% 96.5% 96.1% 96.4% 96.3% 96.0% 96.3% 95.9% 95.6% 94.9% 95.9% 95.5% 5/6 Thoracic Medicine 97.0% 97.3% 97.1% 97.5% 97.6% 97.1% 97.6% 96.9% 97.0% 96.8% 95.1% 94.4% 92.6% 5/6 Trauma & Orthopaedics 88.0% 86.6% 86.6% 87.1% 86.7% 87.4% 87.7% 87.6% 87.9% 86.9% 87.5% 88.1% 89.1% 2/6 Urology 90.3% 90.1% 91.1% 91.7% 91.2% 90.8% 92.1% 91.6% 91.3% 91.8% 90.7% 90.6% 91.0% 3/6 Total 92.2% 91.6% 91.9% 92.2% 92.4% 91.9% 92.3% 92.1% 92.0% 91.4% 91.1% 91.3% 91.7% 3/6 RTT Incomplete Pathways ESTH: Performance was 89.30% in November. The Trust has undertaken a demand and capacity analysis for each specialty, using the IMAS Tool. This analysis suggests there is a significant capacity gap in a number of specialties. The Trust has re-profiled its elective work following the national guidance to cancel non-urgent surgery until end-january. SGH: The CCG and the Trust continue to attend fortnightly meetings with NHSI/E looking at RTT performance and recovery. The Trust have written out to 18,500 phase 1 patients where further information is required from the patient to validate / close their pathway. The Trust has also implemented a web based Pathway Management Module (PMM) for Out Patient first appointments, Continuing patients and Admitted patients. This Incomplete PTL will be reconciled with the current PTL. This system will allow validation comments in real time and will allow for the production of a daily PTL. The final validated position of Cohorts A&B will feed into current trajectories and will allow the Trust to finalise the exact volume of patients and the capacity needed to treat them. Outpatient caps (set at 30 weeks) and ers functionality are also being actioned. The plan remains principally focused on improving operational processes, validation and waiting list management. The Trust are continuing with their Cohort strategy and the associated trajectories. As at 05/01/2018 from Cohort A there were 28 patients from the original 1,803 patients waiting 40+ weeks and 2 patients from the original 212 waiting 52+ weeks, 52 Week Waits: At SWL CCG level there were 7 patients reported on UNIFY waiting over 52 weeks in November, (down from 15 patients in October). Of the 7 patients reported in November, 3 were at Imperial, 2 of which were Richmond CCG patients. One has a TCI in January and the other was treated/ removed. The other patient was from Croydon CCG with a TCI date in January. There were 2 patients waiting over 52 Weeks at ESTH one was a Merton CCG patient and the other was Sutton CCG patient. In addition there was 1 patient at GSTT and 1 patient at Kings College Hospital waiting over 52 weeks, both were Croydon CCG patients. The GSTT patient had a TCI in December and the Kings College Hospital patient was treated in December. At SGH validation continues. RTT Incomplete Pathways > 52 weeks by SW London Commissioners SWL CCGs Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 NHS CROYDON CCG NHS KINGSTON CCG NHS MERTON CCG NHS RICHMOND CCG NHS SUTTON CCG NHS WANDSWORTH CCG SWL Total Action Actions Narrative Owner Due CHS Reporting of Oral Surgery RTT data ESTH Recovery plan SGH RTT Reporting and recovery plan Key Actions The administrative issue within Oral Surgery reporting has been raised as a Serious Incident with NHS Improvement and the Trust is conducting an investigation. The Trust has undertaken an initial clinical harm review and not identified any harm as yet. NELCSU has requested an update from Croydon Healthcare Services on progress with the Report In addition efforts were being made to put on extra theatres and clinics. The Trust is producing a new RTT Recovery Plan, which will need to be discussed with commissioners and with NHS Improvement. The Trust has included activity for RTT backlog clearance in its 2018/19 contract proposal, which is anticipated to be funded from the additional funding announced in the Autumn Budget The Trust has split the Trust PTL into Cohorts. Cohort A includes all patients waiting over 40 weeks and aims to reduce this group from 2,015 patients in to 100 patients by 29/12/17. The Trust achieved this trajectory with 45 people waiting. Cohort B includes patients on the 3 RTT PTL's (First, Continuing and Admitted) with a 52 week breach date between 25/11/17 and 31/03/18. (Currently ahead of plan) The Trust reported at the January performance meeting that, as a result of the ongoing validation, it has written to 18,500 patients where further information is required to complete validation. Waiting time caps have been introduced and the Trust is not booking beyond 30 weeks Cerner will be implemented on the QMH site from September CHS / GM Cancer & RTT Performance Jan-18 ESTH / Feb-18 Director of Planned Care SGH/ Dec-17 Elective Care Recovery Board Mar-18 Dec-17 Feb-18 Sep-18 4

71 Cancer -Two week wait (2WW) & 62 Day 2 Week Wait (Provider) Lead LDU:SWL Alliance Period M8 2017/18 Named Lead:Maggie Lam Report: Date: 30/01/ Day Wait (CCG) Provider Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 CHS 98.40% 95.73% 93.74% 97.33% 98.66% 98.15% 97.08% 96.46% 96.87% 95.51% 95.10% 97.71% 96.82% ESTH 96.72% 97.97% 96.15% 97.85% 95.95% 93.33% 94.74% 95.50% 95.45% 96.44% 96.61% 96.10% 96.70% KHFT 98.51% 99.11% 98.54% 97.96% 99.35% 99.05% 99.41% 98.22% 98.96% 97.89% 98.88% 97.72% 98.50% SGH 85.71% 93.27% 87.90% 87.94% 86.00% 75.44% 76.64% 67.39% 80.27% 89.71% 93.98% 96.05% 97.35% RMH 98.70% 99.16% 97.74% 97.36% 98.03% 97.77% 96.55% 97.99% 97.47% 97.32% 96.20% 97.88% 95.74% Total 94.62% 96.62% 93.84% 95.11% 94.86% 90.84% 91.09% 88.86% 92.16% 94.88% 95.95% 96.95% 97.16% 2 Week Wait by Tumour Site (CCG) Tumour Site Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Brain/Central Nervous System 95.8% 100.0% 92.9% 100.0% 99.1% 90.9% 96.3% 95.0% 90.9% 91.7% 93.3% 96.0% 100.0% 4/4 Breast 97.7% 97.1% 97.6% 96.0% 96.5% 94.8% 92.9% 88.2% 90.3% 97.6% 97.5% 98.8% 98.3% 6/6 Childrens 84.6% 100.0% 100.0% 100.0% 98.6% 87.5% 96.0% 86.4% 96.8% 91.7% 100.0% 96.3% 96.3% 5/6 Gynaecological 96.8% 98.4% 91.7% 93.7% 96.4% 89.4% 89.9% 90.3% 96.9% 96.3% 95.7% 94.4% 97.1% 5/6 Haematological 95.1% 100.0% 100.0% 98.3% 97.9% 88.0% 98.6% 93.9% 98.4% 100.0% 100.0% 98.6% 100.0% 6/6 Head & Neck 97.8% 97.3% 98.7% 98.5% 97.4% 94.2% 93.5% 93.1% 93.5% 91.1% 95.9% 96.1% 98.9% 6/6 Lower Gastrointestinal 94.6% 92.7% 87.6% 94.1% 94.4% 89.6% 91.8% 81.9% 87.2% 87.9% 93.9% 96.3% 94.9% 4/6 Lung 99.1% 99.0% 99.2% 100.0% 99.0% 98.4% 94.4% 93.9% 95.8% 95.5% 98.0% 98.4% 99.2% 6/6 Other 100.0% 100.0% 100.0% % 100.0% 100.0% % 100.0% 100.0% % 1/1 Sarcoma 100.0% 100.0% 96.8% 92.3% 96.0% 100.0% 97.3% 84.0% 88.9% 96.2% 89.5% 96.8% 96.0% 5/6 Skin 85.0% 92.6% 87.7% 88.1% 85.2% 79.7% 80.7% 85.7% 88.4% 95.7% 96.7% 97.4% 96.0% 6/6 Testicular 100.0% 100.0% 94.7% 100.0% 96.3% 83.3% 95.0% 100.0% 100.0% 95.0% 95.2% 96.0% 100.0% 5/5 Upper Gastrointestinal 94.9% 94.7% 91.1% 97.8% 95.4% 92.8% 95.1% 94.2% 97.3% 94.0% 89.8% 94.1% 96.4% 6/6 Urological (exc. testicular) 99.0% 97.5% 97.5% 98.1% 97.8% 97.7% 95.2% 92.8% 98.0% 97.4% 96.5% 96.2% 98.7% 6/6 Total 94.2% 95.7% 93.1% 94.7% 94.3% 90.4% 90.4% 88.5% 91.6% 94.1% 95.8% 96.6% 97.2% 6/6 SW London Narrative The 2WW Performance Standard: At SW London CCG level: The performance standard was achieved at 97.2%. All CCGs achieved both 2WW performance standards. At SW London provider level: The performance standard was achieved for the fourth consecutive month with 97.16% in November. The Breast Symptomatic standard was also achieved in all SW London providers in November at 98.3% against the National performance of 95.6% and above a London performance of 96.7%. The 62day Performance Standard: At SW London CCG level: The performance standard was achieved at 89.1% (27 breaches out of 248 patients). Both Kingston and Wandsworth CCGs did not achieve the performance standard. For Kingston CCG there were 7 breaches against 41 pathways with complex diagnostics and late referrals for treatment. Wandsworth CCG had 5 breaches against 32 pathways with the main breach reason being delay in clinical work-up. Croydon CCG achieved performance in November with 90.4%, the first time the CCG has achieved performance since June 17. At SW London Provider level: The performance standard was achieved in November at 86.1% (43 breaches out of 309 patients). This is above London's performance of 83.4% and a National performance of 82.3%. St George s did not achieve the standard with 80.6% along with The Royal Marsden 78.6%. Both The Royal Marsden and St Georges delivered performance internally with St Georges at 90% and The Royal Marsden 97%. Performance at Royal Marsden was 87.2% on reallocation and St Georges was 82.0% on reallocation. Looking forward, there are a number of challenges that present a risk to delivering compliance for 62 days, these are: Administration and clinical vacancies at Croydon Health Services Lower GI capacity Epsom & St Helier Sustainability of performance at St George s Shared patient pathways across SWL. Early sight of week 2 data for December shows that the SW London sector is non-compliant with the 62 day standard. However this will be subject to change and validation as more data becomes available. November CCG Pass Rate 62 Day Wait by Tumour Site (CCG) Key Actions Action Narrative Owner Due Compliance against 62 day Standard Improved performance against 38 day trajectories within SWL Recruitment to staff vacancies at CHS Prostate pathway at ESTH Lung Pathway at ESTH Tumour Site Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Brain/Central Nervous System % % % 2/2 Breast 100.0% 97.5% 100.0% 100.0% 97.6% 96.8% 100.0% 100.0% 97.6% 97.4% 95.3% 95.2% 90.6% 5/6 Childrens % % 100.0% 0.0% /0 Gynaecological 91.7% 88.9% 75.0% 88.9% 62.5% 86.7% 76.9% 81.3% 53.8% 81.8% 80.0% 92.3% 86.7% 3/5 Haematological (inc. acute leukaemia) 94.7% 81.8% 87.5% 85.7% 100.0% 100.0% 71.4% 88.9% 93.3% 81.8% 85.7% 76.9% 100.0% 3/3 Head & Neck 42.9% 80.0% 58.3% 41.7% 71.4% 55.6% 61.5% 33.3% 65.0% 71.4% 75.0% 73.3% 78.6% 3/6 Lower Gastrointestinal 78.3% 85.0% 81.3% 75.0% 75.0% 86.7% 92.3% 78.3% 93.8% 96.3% 84.2% 100.0% 96.4% 5/6 Lung 75.0% 83.3% 69.2% 86.7% 61.5% 91.7% 73.3% 61.5% 64.7% 60.0% 78.6% 52.6% 65.4% 1/6 Other 25.0% 50.0% 100.0% 100.0% % 0.0% 100.0% 100.0% - 0.0% 100.0% - 0/0 Sarcoma 0.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 60.0% 50.0% 100.0% 1/1 Skin 93.0% 100.0% 100.0% 95.7% 96.2% 97.7% 98.0% 100.0% 96.7% 90.0% 92.5% 92.6% 95.5% 5/6 Upper Gastrointestinal 58.8% 81.8% 30.8% 83.3% 92.9% 81.3% 66.7% 92.3% 80.0% 58.8% 50.0% 90.0% 90.0% 3/4 Urological (inc. testicular) 83.0% 79.7% 83.6% 84.1% 88.1% 88.4% 80.6% 85.4% 79.2% 81.5% 85.4% 81.7% 90.5% 4/6 Total 83.8% 87.4% 83.8% 86.4% 88.7% 90.0% 85.3% 87.5% 83.6% 83.1% 85.0% 84.9% 89.1% 4/6 All providers have been asked to provide details for recovery of the standard and what additional support is required. Data is being reported monthly for compliance against 38 day ITT and treatment within 24 days. SWL are focusing on 3 challenged tumour groups Urology, Lung and Head & Neck. CHS have advertised administrative vacancies and an internal plan has been developed to backfill whilst these posts are recruited to. The Trust introduced a new prostate pathway on 6 November, which is expected to be compliant with the 62- day standard however some patients starting their pathway before that date will have breached the standard in November and December. Agreed at the SLF meeting on 10th Jan 18 for RMH to discuss potential support with prostate with ESTH. RMP to support ESTH with clinical engagement for the lung optimal pathway. (November performance was 64.3%) Cancer General Manager s Cancer General Managers, CSU, Cancer General Manager CHS Jan 18 Jan 18 Feb 18 Jan - 18 Cancer General Impact from Jan 18 manager, ESTH End Jan 18 Cancer General End-Feb 18 manager, ESTH November CCG Pass Rate 5

72 SW London Diagnostic Performance (By CCG) SWL CCG Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 NHS CROYDON CCG 99.7% 99.3% 99.1% 97.6% 96.2% 94.3% 94.6% 95.9% 97.1% 98.4% 99.7% 99.6% 99.2% NHS KINGSTON CCG 99.6% 98.8% 98.7% 99.0% 99.2% 98.7% 98.5% 99.4% 99.2% 98.8% 99.3% 99.4% 99.0% NHS MERTON CCG 99.4% 96.6% 97.2% 98.3% 98.4% 98.0% 98.3% 98.9% 99.0% 99.3% 98.9% 99.6% 98.9% NHS RICHMOND CCG 99.4% 99.2% 99.1% 99.4% 98.7% 97.8% 98.5% 98.5% 98.6% 98.8% 98.9% 96.3% 95.9% NHS SUTTON CCG 99.4% 93.0% 99.2% 99.5% 99.7% 99.5% 99.4% 99.6% 99.4% 99.5% 99.2% 99.4% 98.9% NHS WANDSWORTH CCG 99.4% 98.3% 96.7% 98.1% 97.6% 96.5% 97.3% 97.5% 97.2% 97.8% 98.7% 99.5% 98.7% Total 99.5% 97.7% 98.3% 98.4% 97.9% 96.9% 97.2% 97.9% 98.1% 98.6% 99.2% 99.2% 98.6% SW London Diagnostic Waiting List and Performance Diagnostic waits Lead LDU:Merton and Wandsworth Period M8 2017/18 Named Lead:John Atherton Report: Date: 30/01/2018 SW London Diagnostics Waits < 6 Weeks (By Test) Diagnostic Test Name Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Audiology Assessments 99.8% 99.7% 98.1% 98.1% 98.6% 96.1% 95.1% 97.5% 97.8% 96.8% 97.7% 98.9% 99.9% 5/6 Barium Enema 100.0% % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% % 100.0% 2/2 Colonoscopy 99.2% 96.9% 93.8% 96.9% 96.4% 97.3% 97.4% 97.8% 97.2% 98.1% 98.0% 98.0% 99.0% 3/6 CT 99.9% 99.6% 99.5% 99.9% 99.7% 99.6% 99.6% 99.9% 99.8% 99.7% 99.2% 99.6% 99.7% 6/6 Cystoscopy 92.7% 87.1% 91.9% 93.3% 93.2% 87.9% 90.9% 83.8% 91.0% 91.8% 88.4% 94.4% 95.1% 0/6 DEXA Scan 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 6/6 Echocardiography 99.9% 99.9% 99.9% 93.3% 90.1% 83.4% 79.6% 89.0% 91.2% 95.7% 99.7% 99.7% 99.2% 3/6 Electrophysiology 100.0% 100.0% 100.0% 90.9% 77.8% 100.0% 87.5% 62.5% 75.0% 55.6% 75.0% 100.0% 100.0% 1/1 Flexi Sigmoidoscopy 99.0% 93.4% 89.5% 94.5% 96.9% 97.9% 99.5% 98.4% 96.5% 98.6% 98.1% 98.8% 99.0% 3/6 Gastroscopy 98.8% 96.7% 97.0% 98.6% 98.1% 94.2% 95.3% 95.4% 95.3% 96.4% 98.0% 98.2% 97.9% 1/6 MRI 99.3% 99.3% 97.2% 98.5% 98.9% 98.9% 99.4% 99.3% 99.4% 99.6% 99.6% 99.3% 99.3% 4/6 Non Obstetric Ultrasound 99.8% 96.6% 99.2% 99.5% 99.1% 98.8% 99.2% 99.8% 99.6% 99.6% 99.9% 99.3% 99.1% 5/6 Peripheral Neurophys 99.6% 100.0% 99.5% 100.0% 100.0% 99.2% 98.3% 99.3% 98.0% 98.9% 98.8% 99.4% 99.8% 6/6 Sleep Studies 100.0% 97.1% 94.3% 100.0% 98.4% 98.1% 97.4% 100.0% 94.6% 98.5% 98.6% 96.8% 73.6% 0/6 Urodynamics 96.6% 96.2% 94.6% 91.6% 88.3% 86.5% 77.1% 77.9% 82.0% 80.1% 84.8% 93.8% 95.5% 3/6 Total 99.5% 97.7% 98.3% 98.4% 97.9% 96.9% 97.2% 97.9% 98.1% 98.6% 99.2% 99.2% 98.6% 2/6 SW London Diagnostic Waiting List and Performance (By Provider) Provider Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 KHFT 99.54% 99.27% 99.68% 99.73% 99.79% 99.27% 99.27% 99.45% 99.18% 99.06% 99.53% 99.27% 99.21% CHS 99.93% 99.62% 99.79% 97.50% 96.01% 93.79% 94.37% 95.67% 97.08% 98.40% 99.89% 99.88% 99.78% ESTH 99.63% 94.65% 99.29% 99.78% 99.87% 99.73% 99.72% 99.82% 99.67% 99.69% 99.33% 99.54% 99.58% SGH 99.29% 97.81% 94.83% 97.22% 97.10% 95.87% 96.67% 97.79% 97.28% 98.01% 98.64% 99.69% 98.11% Total 99.59% 97.53% 98.00% 98.46% 98.12% 97.05% 97.39% 98.14% 98.25% 98.73% 99.30% 99.62% 99.11% November CCG Pass Rate SW London Narrative At CCG Level in SW London: Performance was not achieved at aggregate level across SW London CCGs with an outcome of 98.6%. This decline in performance comes after two consecutive months where performance has been achieved at sector level. Performance was achieved at both Croydon and Kingston CCGs. Non achievement of the target at SGH in November has impacted on performance at the other CCGs with the exception of Richmond which was affected by performance at Chelsea and Westminster Hospital Trust (C&W). Merton, Sutton and Wandsworth CCGs narrowly missed the target in November. Richmond CCG: The diagnostic standard has not been achieved at the CCG since March 17. In November 17, there were 111 breaches out of 2,654 waits (97 breaches occurred at C&W, 91 of which were in Non Obstetric Ultrasound). Richmond and Kingston LDU colleagues have been reviewing the Richmond CCG M8 Diagnostics position of 95.9% along with CSU BI colleagues. Richmond CCG performance is primarily affected by performance at C&W and Imperial for the CCG s patients. The main issue is non-obstetric ultrasound, predominately at West Middlesex site, which is having a significant impact on Richmond patients compared to other SW London CCGs. Workforce issues are the main reason for the decline in performance and the Trust have an action plan in place to address and are planning to return to compliance during January Key Actions Objective Actions Narrative Owner Due SGH - Performance Recovery SGH are providing additional Urodynamics clinics to clear the backlog and provide on-going capacity and additional endoscopy capacity through waiting list initiatives. Recruitment is on-going to staff 2 additional rooms. There is recentralisation of management at the QMH site and SGH Tooting site is being offered capacity to help recover the position. At the Commissioners & Provider Performance Meeting held in January, the Trust reported that it had introduced weekly meetings to support and challenge service managers, implementing a zero tolerance policy for breaches. The Trust also previously reported that it was internally focusing on breaches at 4 weeks against the 6 week standard. St George's Hospital / Lead Director for Diagnostics / COO SGH expects to achieve the diagnostics target by 31/12/17 At Provider level in SW London: Performance was achieved at SWL provider level in November for the third consecutive month with an outcome of 99.11%. SGH: The Trust did not achieve the diagnostic target in November. The Trust had already highlighted this outcome following the identification of some previously unreported tests that should have been included in the DM01 return (i.e. sleep studies and stress echo). A plan has been developed to address this. The Trust reported at the January performance meeting that they will be reporting a compliant position for December as outlined in the recovery trajectory. The Trust have introduced weekly challenge meetings and are confident that performance will be achieved on a sustainable basis going forward. CHS: The Trust highlighted recently that they were planning to replace one of their two CT scanners. In order to mitigate against a material lengthening in CT scan waits during the 8-12 weeks of the replacement programme, Croydon Healthcare Services increased CT activity, so that currently CT waits are around one week, providing a buffer to protect performance during the reduction in capacity. An enhanced maintenance contract has been put in place on the remaining operational CT scanner to protect that capacity whilst CHS has only one CT scanner operating.. Richmond CCG Performance Recovery CHS - CT Delivering Diagnostics whilst Replacing one of two CT Scanners Ongoing work with host commissioners for C&W to review and improve current performance. A Recovery Plan is in place which has the Trust recovering performance for January 2018 CHS have commenced replacement of one of their two CT scanners. Waits have been reduced to protect performance and an enhanced maintenance and support contract is in place to protect the remaining capacity provided by the remaining one operational CT scanner. Progress with the replacement as well as with CT waits will be monitored at each of the two monthly meetings with Croydon Healthcare Services. Richmond & Kingston LDU & NW London CCGs. CHS General Manager Cancer and RTT / Diagnostic /Radiology Manager Feb 18 Jan March 18 Trust Performance Meetings 6

73 Ambulance Handovers - London Ambulance Service (LAS) Lead LDU: Croydon Period M9 2017/18 Named Lead:Elaine Clancy Report: Date: 30/01/2018 LAS Conveyances by Provider LAS patient handover within 15 minutes Data is not validated LAS 30 Minute Breaches By Provider Data is post validation LAS 60 Minute Breaches By Provider Data is post validation This section reports upon and considers London Ambulance Service (LAS) conveyances only. Some Hospital sites will also have conveyances from SECAMB and/or others, however these are not included in the above data. SW London Narrative December saw LAS handover breaches (30 and 60 minutes) increase across all sites in South West London. This corresponds with the drop in 4 hour A&E performance in the same month. 15 minute handovers in SWL dropped from 46.3% in November to 40.2% in December. 30 minute breaches increased from 255 in November to 440 in December. 60 minute handover breaches totalled 72 in December, in SWL, 61 of which were at St Helier. St Helier experienced capacity issues in the ED from higher acuity conveyances due to a reported rise in acuity as winter took hold. Volumes, whilst high on some days were not up sharply overall, but the increases in LOS and ITU use reflect the a shift in acuity. SWL Urgent & Emergency Care Transformation Delivery Board has requested greater visibility of South East Coast Ambulance (SECAM) Service data in SWL. Whilst the SWL Surge hub have sight of this on a daily basis to support A&E calls, the local data set on handover delays does not include this. Whilst SGH are likely to receive the majority of SECAMB conveyances, this has been raised by ESH and KCH also. There is a SW London demand management plan aimed at reducing demand for LAS and therefore, conveyances to ED. This contains measures such as use of Rapid Response and frailty in-reach teams, in addition to appropriate care pathways with patients transported directly to services, bypassing EDs. The SWL LAS Working Group are seeking to validate all Appropriate Care Pathways (ACP) in SWL to ensure the Directory of Services (DoS) contains accurate information to support the roll-out of electronic devices to crews. Increases in 'Hear and Treat' and 'See and Treat' also contribute to demand management. In Month 9 'Hear & Treat' rates for LAS were 9% compared with the 7% national average. The proportion of face to face calls managed without the need to transport a patient to a type 1 or 2 A&E department was 26% compared to 30% national average. From the new ambulance system indicators time series data for December Trust Actions Narrative Owner Due Croydon Health Services Kingston Hospital St Helier St George's Key Actions CHS has an improvement plan via optimised ED layout, standardising core processes, managing queue situations effectively. Care Homes use of 111 has reduced conveyances 20%. Temporary location of the ED is causing issues. Jayne Black Chief Operating Officer Handovers are monitored via daily information provided by KHFT, Tracey Moore including conveyances, % handover within 15mins, >30 minutes, AD Emergency >60 minutes and data completeness. The Trust wishes to work more Care closely with SECAMB on delays. Work on a frailty in-reach and rapid response / re-ablement model is in development to improve the flow in the ED. Modifications to the estate will also reduce pressure on ED. Actions to release capacity in ED for ambulance arrivals include, increasing ambulatory care capacity, using consultant rapid assessment on the front door, and transfers to AMU for patients requiring a medical specialty assessment. The Trust are reviewing ambulance handover processes to reduce delays. There is a capital project to provide additional capacity for ambulatory care away from the ED to reduce pressure and ensure sufficient capacity for urgent patients. Dan Bradbury Chief Operating Officer James Friend Director of Delivery Completion of ED layout improvements is now expected June 2018 Mar-18 Mar-18 Mar-18 7

74 NHS 111 percentage Clinical Contact NHS 111 service Lead LDU: Sutton CCG Period M9 2017/18 Named Lead: Sean Morgan Report: Date: 30/01/2018 SW London Narrative Overall: The Integrated Urgent Care Service for South West London includes 111/Clinical Assessment Service (CAS) and GP OOHs and is provided by SELDOC and Vocare, with Vocare as the prime contractor. The relationship with the Provider is constructive with collaborative and effective working to deliver the Improvement Plan, which has a trajectory to compliance with the calls answered within 60 seconds performance standard by the end of March % 93.4% 94.5% 93.7% 94.5% 94.7% 89.1% Calls Answered Within 60 Seconds & Calls Abandoned After 30 Seconds 94.0% London- Answered in 60 seconds SWL- Answered in 60 seconds Target- Answered (95%) 89.2% 88.1% 87.2% 92.6% 92.1% 91.7% 92.5% 84.2% 85.2% 88.0% 87.8% 88.5% 90.7% 89.5% 70.8% 7.2% 2.2% 2.8% 3.0% 2.8% 2.0% 1.9% 2.0% 2.2% 1.9% 2.4% 2.7% 4.0% 1.2% 2.5% 1.4% 1.1% 1.2% 1.1% 1.2% 1.3% 1.3% 1.4% 1.3% 1.7% 1.8% Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 London Abandoned after 30 seconds SWL - Abandoned after 30 seconds Target- Abandoned (5%) Volume of Calls 86.9% 85.5% 84.6% 95% 81.5% Dec-17 Answered in 60 seconds NEL 93.2% SEL 89.3% NCL 77.4% NWL 73.3% SWL 70.8% London 81.5% Dec-17 Abandoned after 30 seconds SEL 1.0% NEL 2.2% NCL 3.7% NWL 6.3% SWL 7.2% London 4.0% Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 London- Calls Offered 173, , , , , , , , , , , , ,031 London- Calls Answered 169, , , , , , , , , , , , ,051 London- Ambulance Dispatches 16,579 16,316 12,404 13,237 13,168 13,852 12,509 13,227 12,412 12,762 14,586 14,644 17,786 SWL- Calls Offered 32,250 30,129 25,067 26,963 30,957 29,913 26,795 28,267 26,038 25,853 27,598 27,866 35,425 SWL- Calls Answered 30,929 29,209 23,984 25,719 29,416 28,369 25,410 27,110 25,024 24,876 26,448 26,601 32,398 SWL- Ambulance Dispatches 3,222 2,924 2,107 2,279 2,402 2,524 2,173 2,454 2,304 2,380 2,646 2,827 3,423 SWL- Recommended to attend A&E 2,212 2,338 1,910 2,127 2,307 2,451 2,302 2,517 2,180 2,257 2,418 2,352 2,460 SWL- Recommended to attend Primary Care 14,242 13,088 10,922 11,428 13,710 13,014 11,453 12,549 11,528 11,639 12,795 12,581 16, Dispositions (Outcomes)- Top 3 At Month 9: % Calls transferred to Clinical Contact: 40.9% of calls were transferred in December / M9 2017/18. SW London is currently achieving the required performance of 40% by the end of Q3 2017/18. % Calls Abandoned after 30 seconds: 7.2% of calls were abandoned after 30 seconds. SW London has consistently achieved the required performance standard, better (i.e. a lower %) than the required 5% up to November. December s underperformance is seen as a blip reflecting unexpected surge in activity together with rota challenges. Performance appears to be back on track and the latest data for w/e 14 th Jan sets abandonment rate back below 5% at 2.18% % Calls Answered within 60 seconds. 70.8% of calls were answered within 60 seconds in November. This compares to 81.5% across London overall. An improvement plan is in place with Vocare to achieve the required 95% performance standard by the end of March Improvement Plan: A robust Improvement Plan is in place with Vocare which prioritises actions that will have the most impact on performance. Elements include: 1. Improved forward modeling informed by an accurate activity forecast coupled with the number and skill mix of staff required to deliver the required and contracted performance and KPIs. 2. Improved recruitment and retention of the required number and skill mix of staff in the face of London-wide competition for staff. 3. Reducing levels of staff sickness and staff absence. 4. Reviewing and refreshing the format of performance management and performance reporting to better reflect the contract, the KPIs and the needs of the commissioners. (This has advanced with draft proposals to be shared with commissioners shortly) 5. A robust trajectory to compliance / achievement of the required performance standards by the end of March Vocare is working collaboratively and effectively on delivering the Improvement Plan with the commissioners and contracting staff. % Calls Transferred to Clinician & % Calls Leading to Ambulance Call Out: Both indicators have become closely aligned with the wider London performance, due in part to the new contract settling and the service becoming less risk-averse. Dispositions: Month 9 is likely to show expected rises in Ambulance disposition and Emergency Department attendances during winter. This is in line with other sectors. Looking ahead: The Senior Commissioning Manager - SWL Integrated Urgent Care is in post and working with the Senior Contract Manager and colleagues at NELSCU and the Director of Commissioning Operations - SWL Alliance on confirming: 1. Business as usual activity. 2. Priorities for Q4 2017/ Developing leaner, smarter commissioning, contracting and performance reporting processes, with effective governance arrangements. 3. Developing performance, quality and outcome priorities for 2018/19, including transformation where appropriate. Key Actions Action Action narrative Owner Due CPN issued in relation to a number of performance issues. Response is to address identified issues collaboratively through the Improvement Plan. No further action at his time, but performance and the outcomes of the Improvement Plan will be monitored monthly and further action under the CPN will be taken if no improvement is seen. Monitored at monthly Contract Management Meeting. Commissioners Jan-18 At Contract Management Meeting Reformat Monthly Performance Reports Performance Reports required reformatting to better present and narrate current and predicted future performance. Meetings have been held between NELCSU and Vocare Regional Director and information team to develop new model. Commissioners will be presented with new model for review at Contract Management Meeting January Vocare Regional Director Jan-18 Implementation and Outcomes of Improvement Plan Improvement Plan continues to be refined in the light of additional information to inform actions and in response to changes in performance as a result of the actions taken. NELCSU / Senior Contract Manager engaged with Vocare Regional Director. Monitored at monthly Contract Management Meeting Vocare Region al Director & Commissioners Mar-18 8

75 IAPT (By CCG) Lead LDU: Kingston and Richmond Period M6 2017/18 Named Lead: Fergus Keegan Report: Date: 30/01/2018 % Waited Less than 6 Weeks for Treatment (75% threshold) % Waited Less than 18 Weeks for Treatment (95% threshold) Waiting Times (6 weeks) Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 NHS CROYDON CCG 93.3% 94.0% 94.3% 92.5% 97.7% 95.0% 98.0% 92.7% 93.6% 93.6% 95.0% 90.9% 95.6% NHS KINGSTON CCG 92.3% 94.3% 95.2% 92.6% 96.7% 96.4% 96.3% 100% 96.7% 94.3% 90.6% 90.6% 97.1% NHS MERTON CCG 95.7% 92.3% 85.7% 89.2% 85.7% 89.2% 90.3% 87.9% 81.0% 80.0% 71.4% 69.3% 74.7% NHS RICHMOND CCG 100% 96.3% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99.4% 100% NHS SUTTON CCG 95.7% 96.3% 95.5% 97.0% 92.9% 100% 94.6% 96.2% 96.2% 100% 96.2% 98.0% 100% NHS WANDSWORTH CCG 93.4% 95.3% 93.8% 93.7% 94.2% 92.6% 89.6% 81.6% 80.5% 76.6% 81.9% 90.1% 93.4% South West London 100% 99.5% 99.0% 98.8% 100% 99.1% 100% 100% 99.5% 99.1% 99.8% 99.5% 99.8% Waiting times (18 weeks) Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 NHS CROYDON CCG 100% 100% 100% 100% 100% 97.5% 100% 100% 100% 100% 100% 100% 100% NHS KINGSTON CCG 100% 100% 100% 96.3% 100% 100% 100% 100% 96.7% 97.1% 99.2% 97.4% 99.3% NHS MERTON CCG 100% 100% 96.4% 100% 100% 97.3% 100% 100% 100% 100% 99.0% 100% 100% NHS RICHMOND CCG 100% 96.3% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99.4% 100% NHS SUTTON CCG 100% 100% 100% 97.0% 100% 100% 100% 100% 100% 100% 100% 100% 100% NHS WANDSWORTH CCG 100% 100% 97.9% 98.4% 100% 100% 100% 100% 100% 97.9% 100% 99.6% 99.5% South West London 100% 99.5% 99.0% 98.8% 100% 99.1% 100% 100% 99.5% 99.1% 99.8% 99.5% 99.8% Recovery Rate (50% threshold) IAPT Recovery Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 NHS CROYDON CCG 45.2% 45.5% 43.8% 45.0% 48.7% 40.5% 50.0% 50.0% 53.5% 46.3% 50.7% 43.3% 51.7% NHS KINGSTON CCG 47.8% 45.2% 44.4% 52.2% 50.0% 50.0% 46.2% 42.1% 44.8% 45.5% 44.1% 45.9% 49.6% NHS MERTON CCG 50.0% 50.0% 48.0% 57.6% 45.0% 45.5% 46.7% 43.3% 50.0% 47.4% 48.0% 50.6% 51.8% NHS RICHMOND CCG 45.5% 56.0% 50.0% 60.9% 70.0% 57.7% 50.0% 58.8% 56.3% 56.4% 51.3% 61.7% 57.9% NHS SUTTON CCG 45.0% 48.0% 47.4% 45.2% 53.8% 52.0% 57.6% 45.8% 52.2% 46.9% 48.8% 48.9% 45.9% NHS WANDSWORTH CCG 38.9% 39.5% 39.5% 41.5% 42.2% 39.3% 31.7% 34.4% 34.3% 36.6% 46.5% 47.6% 51.8% South West London 44.3% 46.5% 44.5% 48.4% 50.0% 45.7% 46.4% 46.6% 47.6% 46.3% 48.3% 49.6% 51.3% IAPT DATA FOR OCT-DEC 2017 IS FROM LOCAL UNVALIDATED DATA RETURNS TO NHS ENGLAND SW London Narrative Key Actions Kingston CCG: Kingston CCG has agreed additional funding for staffing with the Kingston service, enabling increased access to the with the expectation of reducing waiting times. Staff have been recruited, bringing waiting list numbers down, as well beginning to increase access rates. The service is reducing the waiting list backlog, which is adversely affecting recovery. Recovery has increased in December 2017, where the access target was missed by 1 person. While access for December was below target, it is the highest access rate seen for a December in Kingston since the service began. Croydon CCG: Croydon CCG / Provider met with the NHS Intensive Support Team (21st September 2017) to look at the service and identify action points and improvements to the service. The provider has developed an action plan which will support an increase in activity throughout Qtr. 4. This aims to achieve the compliant run rate of 4.2% in Qtr. 4, and is approved by the CCG. The final annualised position is expected to be increased to 12.52%. The action plan requires inputs from both commissioner and provider to achieve the Qtr. 4 increased run rate. These include; staff recruitment, supporting practices to increase referrals, promoting increased capacity within the service and the provider looking at their other services where attrition rates between referral and treatment is much lower. The use of 300k from NHSE to increase performance to 4.2% in Q4 2017/18, has been agreed with SLAM. The CCG has budgeted to maintain this level of performance from Q1 Q3 of 2018/19, at which point, the national performance standard changes to 19%. Performance in September was impacted by staff leaving the service. One Psychological Wellbeing Practitioner (PWP) and four trainees left for alternative employment Merton CCG: The Merton IAPT provider submitted a backlog clearance plan at the beginning of September. The aim of the plan is to clear a backlog of first appointment and follow up appointments and improve performance against the access standard with a Q4 exit rate of 4.1%. The Q3 plan to achieve 3.2% access has been achieved (based on monthly provider data). Sutton CCG: There has been an increase in drop-out rates which has contributed to the reduction in recovery target. There has also been an issue with recruitment because of 2 vacancies, which are being covered by locums. An audit is planned to look at reasons for drop-outs. Rolling Quarterly Access Rate (3.75% for , 4.20% for ) CCG Action Actions Narrative Owner Due IST Action plan and reduction of waiting list (Kingston) Increasing Access Rate for Q4 (Croydon) Service Mobilisation post-re-procurement (Wandsworth) Increased capacity through two provider model (Merton) Increased workforce/ capacity (Sutton) IAPT Access Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 NHS CROYDON CCG 2.60% 2.94% 2.70% 2.44% 2.00% 1.92% 2.31% 2.60% 2.69% 2.41% 2.50% 2.44% 2.40% NHS KINGSTON CCG 4.04% 3.75% 3.75% 4.10% 3.70% 3.60% 3.81% 4.28% 4.33% 3.94% 4.06% 4.11% 3.93% NHS MERTON CCG 1.98% 2.50% 2.70% 2.87% 2.44% 2.02% 1.69% 2.08% 2.19% 2.58% 2.87% 3.33% 3.55% NHS RICHMOND CCG 3.41% 3.57% 3.64% 4.05% 4.35% 4.60% 4.76% 4.46% 4.58% 4.42% 4.75% 4.76% 4.51% NHS SUTTON CCG 2.27% 2.22% 2.57% 3.82% 4.70% 5.21% 5.11% 5.23% 5.44% 5.60% 5.41% 5.30% 4.73% NHS WANDSWORTH CCG 2.83% 2.85% 2.70% 3.04% 2.77% 2.94% 2.90% 3.34% 3.62% 3.89% 3.87% 3.75% 3.52% South West London 2.79% 2.93% 2.91% 3.20% 3.06% 3.11% 3.18% 3.45% 3.61% 3.63% 3.72% 3.73% 3.56% An action plan has been agreed with the Kingston provider from the IST review. Staffing has been increased to bring down the waiting list, as well as to increase the access rate. The Croydon IAPT Service have recruited additional therapists using the 300k from NHSE. The CCG is working to ensure that demand is increased in line with additional capacity. The service is being promoted with GPs, Voluntary Sector Groups, including SLaM issuing leaflets to Croydon residents. Progress against, recruitment, referrals and a weekly trajectory is monitored via regular conference calls. The new provider (SWL & St Georges) is continuing to mobilise the service following the recent re-procurement, and plans to only be compliant in quarter , as per the Operating Plan Submission. The Merton IAPT provider has recently agreed to commission an online IAPT provider to increase capacity and access from November 17 to March 18. They have committed to delivering 3.75% in Q4 under this new two provider arrangement. Additional funding for the increased IAPT access target for 17/18, will increase capacity and reduce waiting times, which should improve recovery. Additional workforce capacity is expected to be in place in early Feb 18 with an impact on performance expected from early March 18 which is being managed through the contract management process. The CCG has issued a formal Contract Query Notice requesting an action to recover performance for Q4. Sylvie Ford Head of Mental Health Commissioning Complete Leo Ongoing Whittaker- Head of (Mar-18) Performance, Assurance and Emergency Planning Mark Robertson Commissioning Redesign Lead Mental Health John Atherton Director of Performance Improvement Wandsworth CCG and Merton CCG Clare Wilson Director of Commissioning Sutton CCG Jan-18 On-going Feb-18 9

76 Estimated Dementia Diagnosis Rate (66.7% threshold) Dementia and Mental Health Lead LDU: Kingston and Richmond Period M6 2017/18 Named Lead: Fergus Keegan Report: Date: 30/01/2018 Care Programme Approach (CPA) 7 Day IAPT ACCESS NHS CROYDON CCG Q Q Q Q Q % 97.73% 98.91% 97.78% 95.88% Q % NHS KINGSTON CCG 94.05% 94.81% 95.35% 96.92% 96.00% 97.44% NHS MERTON CCG 97.47% 96.91% 96.70% 96.88% 95.65% 98.81% NHS RICHMOND CCG 98.67% 97.44% 96.05% 93.98% 97.85% 95.16% NHS SUTTON CCG 94.44% 95.83% 96.61% 100% 98.46% 98.46% NHS WANDSWORTH CCG 95.65% 95.10% 94.87% 95.81% 94.42% 95.95% SWL New Referrals Received (Mental Health Service Data Set) SWL Total 96.09% 96.22% 96.25% 96.69% 95.97% 96.77% Early Intervention in Psychosis (50% of people start treatment within 2 weeks) Dementia: SW London Narrative Key Actions Action Actions Narrative Owner Due Kingston: The Kingston dementia nurse is in post, and has reviewed potential dementia patients in all Kingston GP Practices. The nurse has also liaised with Kingston Memory Assessment Service, provided by SWL & St Georges. A practice Mental Health KPI has been developed and implemented in GP Practices which includes a dementia KPI in order to raise rates. A dedicated GP is assessing the cognition of patients in nursing homes and will notify their GP of the diagnosis if found to have dementia. The dementia diagnosis rate has dropped slightly for December 2017 compared to November 2017, which is as a result of a small reduction in those on the register, but a larger increase of the estimated dementia list size (the denominator), provided by NHS Digital. CPA 7 Day Access: Wandsworth CCG missed the CPA 7 day standard in Quarter by one person. CPA follow up is a standing agenda item on the monthly South West London and St Georges performance meeting, with a report on each breach and actions shared with commissioners at that point. Review of patients in Care Homes. (Kingston) Employment of dedicated Dementia nurse. (Kingston) Dedicated GP resources are assessing patients in care and nursing homes to ensure that they are correctly recorded as having dementia. Kingston CCG Has employed a dementia nurse to increase diagnosis rate by: 1. Liaising with stroke rehab team, falls service and Parkinson s clinic to discuss if cognitive function is reviewed and communicated back to GP 2. Working with substance misuse teams/services and consider joint working with CMHT as cognitive impairment in patients with alcohol misuse is often missed. Head of Mental Health Commissioning - Sylvie Ford Head of Mental Health Commissioning - Sylvie Ford Continuing Completed: Nurse in post All CCGs achieved the 7 day standard for Information sharing from HRCH and SWL & St Georges. (Richmond) Devising a standard template for HRCH to use to feedback dementia diagnosis confirmation to surgeries to enable them to update their QOF registers. Continue to send out the patient lists from SW London St. George's MHT Memory Clinics on a monthly basis and to include those with mild cognitive impairment for follow up assessment. Senior Commissioning Manager - Amanda McGlennon Dec-17 10

77 DTOCs - KHFT DTOCs - SGH FT DTOCs ESTH DTOCs - CHS Delayed Transfers of Care Lead LDU: Sutton CCG Period M8 2017/18 Named Lead: Sean Morgan Report: Date: 30/01/2018 Key Actions CCG Action Narrative Owner Due Establish multiagency working group Croydon: Awaiting social care placement responsible for 172 days (acute). Patients not covered by NHS and Community Care Act (NHS) for 120 days.(acute) 183 patients were awaiting completion of assessment (NHS non-acute). CCG/ESTH Task and Finish group has been set up Sutton CCG: Waiting for further NHS nonacute care for 41 days and patient or family choice (NHS acute)) responsible for 44 days. Awaiting care package in own home (Social Care acute) 60 days. Non-acute DToCs were 8 days all attributable to Social Care. Implement refreshed Joint Delivery Plan Richmond CCG: The majority of DTOCs were related to Further non acute NHS care, Care homes, Patient choice or Completion of assessments in almost equal measure. Richmond Council is ahead of the NHS England winter 2017 DToC trajectory, Richmond CCG is above planned levels. 1. Mental health patients processes being reviewed, to reduce waits and evaluate potential for weekend admissions. 2. ADASS supporting Croydon bid for funding for a social worker for the hospital discharge team leading on out of area patients 3. The new DOO at CHS is the lead for the High Impact Changes Program (HICP) which incorporates all the DToC actions. 4. Regular MADE events to expedite DTOCs with long LoS. CCG and LA providing on-site support. 5. Discharge to Assess pathway 2 rolled out on all wards, design work on pathway 3 underway. 1. High Impact Change Model implementation is in progress/action plan developed. 2. Improve communication/unblock process issues twice weekly multi agency, MDT discharge meeting at St Helier Hospital 3. Weekly Director level escalation meetings commenced (super stranded reviews) 4. LBS and SCCG have agreed to place without prejudice based on checklist outcome with the use of the shorter DST form 5. Work with community and social care providers to ensure robust recruitment /retention procedures in place. LBS is implementing a new Adult Social Care commissioning strategy to improve homecare capacity 1. Support the developments against the High Impact Change Model to improve services to support people ready for discharge from hospital, including developing the Discharge to Assess model, Better at Home and enhance equipment provision to support earlier discharges. 2. This includes additional social work posts in the RRR Team to increase capacity to support improvements in transfers of care from hospital, reduce waiting times for assessment and reduction in DToCs. 3. Actions in progress on-going & being closely monitored by AEDB Increase in enablement capacity 1. Increase in enablement capacity to support hospital discharges Wandsworth CCG: Awaiting care package including a plan to facilitate weekend discharges into Enablement Service in own home responsible for 79 days (acute) Mitigate by step-down beds and 24-hour enablement packages / care of which NHS for 47 and Social Care for 32, packages in own home investment from the ibcf to increase staff / Patient or family choice (NHS) for 59 days and waiting further NHS non-acute for 48 number of PoC. days. NHS responsible for 63 non-acute 2. Daily calls and weekly escalation call in place (mostly awaiting residential placement, 59) and Social Care for 80 days Awaiting nursing home placement for 42). Reduce DToCs Merton CCG: Waiting for further NHS nonacute care responsible for 66 (acute) and awaiting care package in own home (Social Care) for 60 (acute). Non-acute DToCs was 66 days of which NHS was responsible for 8, Social Care for 28, and awaiting care package in own home (Social Care) for 15 days. Review of DToC information Kingston CCG: The majority of DToCs were related to non-acute NHS care, the vast majority of these were waits for Neurorehabilitation bed, or waits for CHC. Kingston CCG and The Royal Borough of Kingston are ahead of the NHSE DToC trajectory. CCGs average daily rate (as per the London expectation) is 5.1, compared to the trajectory of 8.5 for Nov The RBK average is 0.8 compared to the 1.5 target 1. Improve communication / unblock process issues A daily conference call between CLCH, CHC and LB Merton to discuss patient discharges. 2. Daily call and weekly escalation meeting CLCH and LB Merton and Merton CCG. 3. LB Merton and Merton CCG have agreed to place without prejudice based on checklist outcome with the use of the shorter DST form. 4. Reablement capacity LB Merton increased by 100 hours W/C 20 December 17 Kingston DToC information is sent from Kingston Hospital and is reviewed by community teams and adult social care for response. Director of Operations, Croydon Health Services, Sam Goldberg Chair, Sutton A&EDB Chair, Richmond Accident and Emergenc y Delivery Board Chair, Wandswort h and Merton A&EDB 1. On-going 2. Feb On-going 4. On-going 5. Mar 18 Reviewed at the Sutton A&EDB April 2018 Reviewed monthly at the Richmon d A&EDB 1. Reviewed monthly at the AEDB Completed Nov 17 2.On-going Chair, 1.On-going Wandswort 2.On-going h and 3.On-going Merton 4.Done A&EDB Chair, Kingston A&EDB Reviewed monthly at the Kingston A&EDB 11

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

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

80 Richmond Quality Safety and Performance Committee Summary Monthly Performance Reporting The headline performance issues and risk relate to the following: Acute/Constitutional Standards: 52 week + Referral to Treatment waiters Diagnostic 6 week waits Cancer 31 Day Standard 1st Treatment Cancer 31 Day Standard Subsequent Drug Treatment Surgery A&E waiting time >4 hours 52 Week At SWL CCG level there were 7 patients reported on UNIFY waiting over 52 weeks in November, (down from 15 patients in October). Of the 7 patients reported in November, 3 were at Imperial, 2 of which were Richmond CCG patients. One has a TCI in January and the other was treated/ removed. The other patient was from Croydon CCG with a TCI date in January. There were 2 patients waiting over 52 Weeks at ESTH one was a Merton CCG patient and the other was Sutton CCG patient. In addition there was 1 patient at GSTT and 1 patient at Kings College Hospital waiting over 52 weeks, both were Croydon CCG patients. The GSTT patient had a TCI in December and the Kings College Hospital patient was treated in December. At SGH validation continues. Referral to Treatment Richmond CCG narrowly missed the RTT performance standard in December with an outcome of 91.7%. The YTD position is one of compliance at 92.4%. YTD Performance remains strong at the CCGs two largest providers, Kingston and Chelsea & Westminster, with continued significant pressure Imperial. Imperial continues the work on its waiting list improvement programme (WLIP) and action plan to address RTT challenges and return to delivering the RTT standard sustainably. The WLIP also oversees the management of the clinical review process which provides assurance that patients who wait over 52 weeks are not coming to harm. The trust reports progress has been made on all of the aspects of the programme, including the data clean-up of the waiting lists, improved waiting list management, systematic clinical review, and additional clinical activity and theatre capacity and performance recovery trajectories for 18 week and long waiters. Performance against the 6 week diagnostic standard is showing signs of recovery; December s position is 98 %. Under performance is being largely driven by non-compliance at West Middlesex Hospital for non-obstetric ultrasound. The loss of scanning capacity (staffing issues) experienced in October has had a knock on effect into November and this will continue until the end of the calendar year. However, several actions have been taken to address the issue including: Recruitment of temporary staff Introduction of additional evening and weekend lists Closer and more regular monitoring of backlog Addition of extra patients onto existing lists; beginning and end so as not to impact upon existing appointments Equipment and staff loaned from Chelsea site Certain examinations have been redirected to the Chelsea site The Trust is anticipating a return to compliance during January Cancer Standards The preliminary cancer waiting times summary shows Richmond CCG has met 6 of the 8 CWT Standards for December (M9) 2017/18. The CCG failed to meet the Cancer 1st treatment within 31 days and subsequent Version: Final F3-1 Date:

81 treatment for surgery. The breach reasons are under investigation and will be confirmed when the final performance report is published. The 2WW Cancer performance standard continues to be achieved since July and all CWT Standards are now compliant year to date. Issues and Actions: To address late referrals/ ITTs, SLF are monitoring trusts referrals to the treating trust by day 38. Weekly calls between trusts to agree referral/itt dates are being undertaken and 38 day performance is being monitored on weekly performance calls with the CSU. Trusts are also developing reports to show 38 day breach reasons. SWL Trusts have been asked to develop trajectories to achieve the 38Day ITT to RMH by RMH is developing a trajectory to improve performance on 62 Day pathway for all internal patients. (3TP) 3 trust pathways are being monitored through SLF and NHSE London are collating data on 3TP s Head & Neck pathway for SW London is being reviewed by TCST. Accident and Emergency Waiting Times Performance has shown a slight improvement on the December position at both KHFT and Chelsea & Westminster, with KHFT achieving 87.3% of patients seen within 4 hours and Chelsea & Westminster narrowly missing the 95% target at 94.6%. Dementia Diagnosis Following January Quality Safety and Performance committee (QSPC) it was noted that December s dementia diagnosis rate is 66.7% and therefore exactly meeting the national standard. It was noted that improvements were continuing. Further work would be undertaken on improving diagnosis rates. NHS Continuing Healthcare The lead for Continuing Healthcare has developed the improvement action plan requested by NHSE and the SWL Alliance for Kingston and Richmond, and had identified a range of actions which will be implemented over the next quarter to achieve the required trajectory. This will remain an area of challenging performance given the scale of improvement required across the winter period. DST s completed in an acute setting has met the target in January. Reporting from Clinical Quality Review Groups (CQRGs) Chelsea and Westminster Trust; Trust wide vacancy rate is high WM site at 16%; The higher use of trust bank staff has decreased the use of agency staff. There will be 6 monthly reporting the next review in July CQRG. CQC report due in March. No immediate actions required, informal feedback positive. The NHS Improvement Resource Assessment was completed and received a score of 1, the outcome will form part of the final CQC report. Four breaches of #NOF pathway: 3 due to theatre admin/logistics awaiting list space, 1 was due to unavailability of Anaesthetist; operation took place 1 hour outside the 36 hour target. White board solution as interim until IT issue resolved. Across trust inpatient recommendation rate is just below 90% target for FFT A&E response rate is below the target of 30% sitting across the trust at 16.9%. Mobile phone text responses are low due invalid or no mobile phone number recorded. Now using Volunteer support with Hand held devices and confirmation of telephone numbers and administrative checks at registration Kingston Hospital Foundation Trust Complaints response rate: recognition that process wasn t working, undertook consultation new process implemented. Complaints responded to within 25 days or by agreed date with complainant: 65% (as of January meeting a response rate of 87% has been achieved in December) Vacancy rate just below 10% target of 5% Pressure Ulcers 3 out of the 5 pressure ulcers (grades 3/4) were unavoidable. The data for December and Version: Final F3-2 Date:

82 particularly January indicates there has been more pressure damage arriving and sustained, largely due to frailty and elderly patients. There were 5 reported serious incidents in November. The Serious Incident Review Group provides scrutiny of all the investigation reports and obtains assurance from the Divisional Directors that actions to mitigate recurrence are delivered. The inpatient response rate to FFT is approximately 40% with a 95.3% would recommend rate, Outpatient response is not documented the recommend rate is at approximately 90%. The new system is in place and is currently being embedded. Winter pressures; good partnership working this year and now need to embed the learning for 2018 St Georges Hospital Trust SI s showed non-compliance with NICE guidance for patients presenting with acute cholecystitis; surgery was not being performed within 7 days. Insitgation of a hot list for semi urgent patients to ensure compliance with NICE guidance will be implements by April 18 and actions in place to mitigate risks until then. Child and Adult Safeguarding 6 monthly reports not submitted Concerns about lack of assurance provided in relation to safeguarding. New Head of safeguarding appointed, risks being address through staff training and support to increase moral and closer working with clinicians and administrative staff. Hounslow and Richmond Community Healthcare There continues to be high vacancy rates in community nursing: This is being continuously supported and safety maintained, there is continuous monitoring via e-rostering and appropriate measures are taken as required. Slips, trips & falls incidence TMH - April November 2017 The number has increased since April but patients that have repeated falls is low and controlled falls have increased accounting for 1/3, TMH has quite aggressive rehabilitation, feel that controlled falls are more likely to be recorded. There appears to be no correlation to occupancy or cognitive status but a potential correlation for those patients with a dependency Actions to have Regular Audits, spot checks, call bell audit, falls training for HCA s and porters, computers on wheels in bays for staff to be more present, increase in low level beds, GP with special interest fall and medication training, Ensure learning from falls is shared. There will be an unannounced CQC visit in March, focus groups planned in February. Serious Incident Quarter 3 The report highlighted the serious incidents for healthcare trusts used by the SW London population and by incident type; each trust follows a serious incident review process and root cause analyses are undertaken and reviewed by the lead CCG. Oversight of RCA s related to Kingston or Richmond patients from Trusts where we are not the lead commissioner are not consistent, meetings have or are being arranged with relevant CCG safety leads. Version: Final F3-3 Date:

83 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing Body in public Date 6 th March 2018 Report Title Finance Committee Summary Agenda Item 3.2 Attachment G Purpose (please indicate with X) Approval/ Ratification Discussion / Comment Information x Report Author: (name & job title) Liam Bayly, Head of Finance Presented by: (name & job title) Yarlini Roberts, Local Director of Finance Summary and purpose of report This paper provides a summary of the Finance Committee that took place on the 23 rd January. The following areas were covered: Acute Trust Update The committee received a report from the CSU on the financial performance of the CCG acute contracts. There is overspend overall against the acute contracts ( 5.8m forecast) with significant over performance seen at Chelsea & Westminster ( 3.6m forecast). The main issues on the Kingston Hospital and Chelsea & Westminster contracts were discussed, as well an update on potential year end contract settlements. Month 9 Finance Report The month 9 report was reviewed by the committee: At Month 9 the CCG is reporting that it will meet it s planned in year deficit of 5.0m. Overall the position has improved slightly in comparison to the forecast position reported at Month 8, with a worsening in the acute positon Acute SLA position of 0.7m being offset by the removal of the NCSO cost impact from the prescribing forecast outturn ( 1.0m) and instead being shown as a risk. The achievement of the planned deficit remains challenging with all reserves held being used to balance the positon and we are require the run rate position to improve by 1.0m in respect of higher QIPP performance during the rest of the year. The risk adjusted position improved slightly to 7.6m (M08 7.8m) with the 0.7m worsening in the acute position being offset by a number of improvements including further balance sheet release mitigations identified ( 0.2m) and a reduction in the acute seasonality risk ( 0.25m). NHS England Assurance Pack A draft copy of the NHSE Assurance Pack had been circulated for information, with the meeting due to take place later in the week. The pack covered both 2017/18 and 2018/19 issues. In respect of 2018/19 the planning refresh guidance had not been issued, so the CCG had modelled potential scenarios based on available information. In all scenarios there was a QIPP shortfall meaning additional schemes will need to be indentified. Version: Final G - 1 Date:

84 Contract Update The committee reviewed papers on the future of contracts for the Non-Emergency Patient Transport Eligibility Assessment and Transport Service, InHealth, Cross Deep Surgery Ultrasound and AQP Contracts Podiatry & MSK (Neck and Back). All were approved by the committee. Key sections for particular note See above Report recommendation The governing body is asked to note the discussions that took place at the Finance Committee Financial and / or resource implications As above Key risks identified & mitigation The key risks are outlined on page 13 of the Month 9 finance report. If all the risks were to materialise with the current mitigations available the CCG would report a 7.6m deficit rather than the planned 5m deficit currently reported. Equality and / or privacy impact analysis N/A Committees that have previously discussed / agreed the report and outcomes Finance Committee, 23rd January 2018 Communication plan / stakeholder involvement / patient engagement N/A Assurance The 2017/18 financial position is reported to NHS England as part of their monthly assurance of the CCG financial recovery. CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final G - 2 Date:

85 Richmond Clinical Commissioning Group Report Summary Meeting Title Governing Body in public Date 6 March 2018 Report Title Month 10 finance report Agenda Item 3.3 Attachment H Purpose (please indicate with X) Approval/ Ratification Discussion / Comment Information x Report Author: (name & job title) Liam Bayly (Head of Finance) Presented by: (name & job title) Yarlini Roberts (Local Director of Finance) Summary and purpose of report Richmond CCG submitted an operating plan on the 30th March 2017 that delivered a 5m deficit position, this aligned to the CCG s Financial Recovery Plan, this included QIPP schemes of 13.1m. At Month 10 the CCG is forecasting a 5.896m deficit for 2017/18; an adverse variance of 0.896m against plan reflecting the costs pressure caused by the impact of No Cheaper Stock Obtainable (NCSO) drugs costs. The YTD variance against plan of 0.737m reflects the YTD pressure of NCSO costs. We have been advised by NHS England that this variance from plan will not impact on the CCG assurance ratings given it is an unavoidable national cost pressure. After allowing for the NCSO pressure the CCG is continuing to forecast that it will achieve the planned deficit of 5m, but there is considerable risk in the position with the 0.5% contingency and reserves used in full to support the position. There is a risk ( 0.375m risk adjusted) that the run rate on acute will increase higher than profiled during the final three months, although we are trying to mitigate this pressure through reaching year end settlements on material contracts, and have agreed a positon with Kingston Hospital. Other risks include the collection of income from other CCGs for the recharging of costs for the Royal Hospital for Neurodisability. The underlying position reported at Month 10 reflects the considerable challenge in achieving the deficit planned, and the fact that the CCG has used non-recurrent measures, particularly the one-off release of unrequired accruals and creditors on the balance sheet ( 1.7m). This is offset by the fact that we have assumed the NCSO pressure is non-recurrent and will not be repeated in 2018/19. Key sections for particular note Financial Scorecard page 3 Key financial indicators page 4 Run rate analysis page 6 Report recommendation The governing body is asked to note the financial position at Month 10 and the challenges required to achieve the planned deficit at the end of the financial year. Version: Final H - 1 Date:

86 Financial and / or resource implications As outlined above. Key risks identified & mitigation The key risks are outlined on page 13 of the report. If all the risks were to materialise with the current mitigations available the CCG would report a 7.8m deficit rather than the planned 5m deficit currently reported. Equality and / or privacy impact analysis N/A Committees that have previously discussed / agreed the report and outcomes Finance and Performance Committee on 27 th February Communication plan / stakeholder involvement / patient engagement N/A Assurance The 2017/18 financial position is reported to NHS England as part of their monthly assurance of the CCG financial recovery. CORPORATE OBJECTIVES Please indicate below all the categories which the paper provides evidence for: 1. Better Health 2. Better Care 3. Sustainability 4. Leadership 5. Engagement Version: Final H - 2 Date:

87 RCCG Finance Report Month Yarlini Roberts Local Director of Finance Produced by: Liam Bayly Head of Finance Anisha Fraser-Morris - Senior Management Accountant Finance Report - Month 10 as at 31st January

88 Contents Finance Scorecard 3 Key Indicators 4 Finance Report - Month 10 as at 31st January 2018 Slide No Month 10 Summary 5-6 Run Rate Analysis 7 Acute Commissioning 8 Non Acute Commissioning 9 Primary Care Commissioning 10 Running Costs 11 Other Programme Commissioning 12 Risks and Mitigations 13 Underlying Position 14 QIPP (performance, commentary and run rate) Cash & Balance Sheet Statement of Financial Position 19 Cash Drawdown 20 Cash Flow Statement 21 Aged Debtors 22 Better Payment Practice Policy 23 Appendices Detailed tables of Acute, Non Acute, Primary Care, Other Programmes and Running Costs Acute Activity Graph showing all hospitals Acute Summary by POD

89 Finance Scorecard January 2017/18 Financial Strategy - As part of the STP work, Local Transformation Boards (LTBs) have been tasked with assessing the financial sustainability of each LTB. Initial work to assess financial gaps was submitted at the end of November 17 with a full refresh expected by March Guidance has now been issued on the planning update for 2018/19 and the CCG has started to update the 18/19 financial plan based on the 17/18 projected outturn and the revised business rules. Financial Performance - At month 10, the CCG is reporting an adverse movement on the outturn position and is in an agreed breech of its business rules for 2017/18 with NHS England. - All reserves have been used, full benefit of 1.7m prior year balances have been released and the full contingency released in to enable delivery of the deficit. - Better Payment Practice Code target was achieved in month The NHS England cash target was achieved for Month Slippage on some QIPP schemes however work is being done to recover Financial Governance - Deep dive budget meetings were held in December, focusing on QIPP opportunities - 18/19 Planning- we are taking a robust approach to setting the plan for 18/19, working with colleagues in SMT to identify possible budget reductions as well as working collaboratively with partners across the system. - Improved controls has resulted in a stabilisation in the unmitigated risk position from 6.5m. Financial Risk - Reserves have been fully utilised to cover the acute over performance seen in month 10 with the exception of half of the 1% on recurrent reserves which is to remain uncommitted as per NHS England guidance. - A combination of reduced allocation growth and increased national requirements had led to a challenging QIPP target in 17/18 - The CCG has made good progress against the 17/18 QIPP target, but there are unidentified schemes. We are using non recurrent benefits to support the recurrent QIPP shortfall. Finance Report - Month 10 as at 31st January

90 Key Indicators January 2017/18 Expenditure YTD '000 YTD RAG RATING Forecast '000 Acute Contracts 105, ,530 Continuing Care 18,736 22,500 Prescribing 17,938 21,522 Deficit ( 4,903) ( 5,897) Risk & Mitigations Worst Case Outturn N/A N/A ( 6,564) Best Case Outturn N/A N/A ( 5,896) Underlying position Closing 2017/18 underlying position N/A N/A ( 4,358) Opening 2018/19 underlying position N/A N/A ( 4,358) QIPP Full year plan N/A N/A 13,159 Forecast Outturn N/A N/A 9,427 Forecast RAG RATING Worst case scenario reflects the position (deficit) if all risks materialise, offset by uncommitted mitigations e.g. 0.5% contingency. Best case scenario reflects the position if none of the risks materialise and mitigations remain in place. Finance Report - Month 10 as at 31st January

91 Month 10 Summary January 2017/18 Richmond CCG submitted an operating plan on the 30th March 2017 that delivered a 5m deficit position, this aligned to the CCG s Financial Recovery Plan, this included QIPP schemes of 13.1m. At Month 10 the CCG is forecasting a 5.896m deficit for 2017/18; an adverse variance of 0.896m against plan reflecting the costs pressure caused by the impact of No Cheaper Stock Obtainable (NCSO) drugs costs. The YTD variance against plan of 0.737m reflects the YTD pressure of NCSO costs. We have been advised by NHS England that this variance from plan will not impact on the CCG assurance ratings given it is an unavoidable national cost pressure. After allowing for the NCSO pressure the CCG is continuing to forecast that it will achieve the planned deficit of 5m, but there is considerable risk in the position with the 0.5% contingency and reserves used in full to support the position. There is a risk ( 0.375m risk adjusted) that the run rate on acute will increase higher than profiled during the final three months, although we are trying to mitigate this pressure through reaching year end settlements on material contracts, and have agreed a positon with Kingston Hospital. Other risks include the collection of income from other CCGs for the recharging of costs for the Royal Hospital for Neuro-disability. The underlying position reported at Month 10 reflects the considerable challenge in achieving the deficit planned, and the fact that the CCG has used non-recurrent measures, particularly the one-off release of unrequired accruals and creditors on the balance sheet ( 1.7m). This is offset by the fact that we have assumed the NCSO pressure is non-recurrent and will not be repeated in 2018/19. Finance Report - Month 10 as at 31st January

92 Summary Financial Position January 2017/18 YEAR TO DATE VARIANCE ANNUAL FORECAST VARIANCE 2017/18 Budgets - Source and Application of Funds BUDGET ACTUAL (Adverse) BUDGET FORECAST Favourable (Adverse) Favourable '000 '000 '000 '000 '000 '000 Revenue Resource Limit 215, , , ,315 0 APPLICATION OF FUNDS -PROGRAMME Acute Commissioning 105, ,613 (2,812) 126, ,137 (4,177) Non Acute Commissioning 64,309 65,235 (926) 77,171 78,481 (1,310) Primary Care Commissioning 42,435 42,928 (494) 51,210 51,632 (423) Other Programme Costs 2, ,045 3,277 1,180 2,097 Total Commissioned Services 215, ,381 (2,188) 258, ,431 (3,813) Running Costs 3,567 3, ,314 4, Reserves, Contingencies and Provisions: Total Reserves 1, ,316 4,383 1,531 2,852 Total Application after Reserves 220, ,813 (736) 267, ,212 (896) In Year Surplus/(deficit) after reserves movements - Programme (4,167) (4,903) (736) (5,000) (5,897) (896) C/Fwd Surplus/(deficit) after reserves movements - Programme (6,990) (6,990) 0 (8,388) (8,388) 0 Cumulative Surplus/(deficit) after reserves movements - Programme (11,157) (11,893) (736) (13,388) (14,285) (896) The financial position shows the in year position only. The resource limit of 262,218k does not include brought forward deficit of 8,388k As per NHS England guidance 0.5% of the 1% non recurrent reserves are fully uncommitted at the beginning of the financial year. Finance Report - Month 10 as at 31st January

93 Run Rate Analysis January 2017/18 The analysis shows that the in month spend for the first ten months, and the expected expenditure for the final two months based on a straight line extrapolation to the forecast outturn at Month 10. It shows that while acute expenditure had remained flat until October, it has peaked in November and December but dipped in January (which for each month has been extrapolated from the previous months data) as the seasonal impact of winter has kicked in. Other expenditure is broadly flat except for an decrease in other expenditure. This is due to the fact that in Month 10 c 1.7m has been released from the balance into the YTD position is respect of unneeded prior year accruals. Finance Report - Month 10 as at 31st January

94 Acute Commissioning January 2017/18 ISSUE The forecast position against contracts is an adverse variance of 5.9m, 4.0m on the Chelsea & Westminster contract. A full analysis of the position can be found in Appendix 3. Guy's & St Thomas at M10 is reporting 194k (M09 180k) over plan YTD, FOT 559 (M09 528k) over plan and is mainly driven by: Other POD - 82k under YTD plan mainly due to a reduction of the Trust s plan to match CCG agreed contract value ( 111k) offset by over performance on Dermatology ( 28k). Emergency POD - 27k under YTD plan mainly on Urology ( 20k). Elective ( 13k) spread across several TFCs e.g. T&O ( 4k) Plastic Surgery ( 3k Emergency ( 10k) spread across several TFCs (none higher the 2k). Out Patient FUP ( 5k) (iv) Critical Care ( 3k) on 1 organ supported activity. University London at M10 is reporting 321k (M09 364k) over plan YTD, FOT 318 (M09 389k) over plan and is mainly driven by: Critical Care - 100k PbR Excluded Items 64k (Adalimumba - Home Delivery, Eltrombopag and Vedolizumab) Out Patients Follow Ups - 41k (Neurology) Day Case - 26k - Haematological Procedures and Disorders - 22k - Ear, Nose, Mouth, Throat and Neck Procedures - 4k Monitor during the year Monitor during the year ACTION Finance Report - Month 10 as at 31st January

95 Non-Acute Commissioning January 2017/18 ISSUE FOT for Adult CHC increased by 0.5m for Month 10 and is expected to report an adverse forecast variance of 1.1m by year end. The increase was due to the lag by Local Authority in identifying the issues that have been flushed out as part of the Reconciliation work done by them to address the differences between their Finance payment system and database system. ACTION Local Authority Finance and CCG Finance to continue to bottom out the financial impact of gaps between LbR s Database and Finance systems. Payments and Brokerage functions were brought back in house from 1 st October 2017 and team is being embedded within the CCG. A new database being developed and strategies around targeting and prioritising more robust savings are being developed. As at Month 10 it was 50% cleansed Mental Health is 514k (M9 365k) YTD under spent against budget for M10 and is forecasting an favourable variance of 402k (M9 190k adverse). Mainly driven by Mental Health placements budgets for adult and older people are both projecting underspends. The main reason for this is the identification of fewer Adult and Elderly placements, than were previously forecasted for in M9, following a review of joint funded placements with the local authority. Potential savings in placements continue to be explored as part of CCG programme. The other main under spend is from Learning Difficulty 155k which was previously forecast for Transforming Care Partnership (TCP) where high cost In-Patient cases were due to transfer to the CCG from NHS England, but have now been confirmed as not needed this year. Finance Report - Month 10 as at 31st January

96 Primary Care Commissioning January 2017/18 ISSUE Prescribing reports to November were available at the time of reporting. The forecast position is 56k under spend (M08 919k underspend) using the NHS Prescription Services annual profiling forecast, with adjustments made for Pregabalin, the transfer of RHND patients and No Cheaper Stock Obtainable (NCSO) costs. In month 9, we were advised by NHS England to removed the NCSO pressure in full from the outturn, and instead showing it in the risk position, but we have now been allowed to include the NCSO pressure ( 896k) in the forecast as an allowable variance from the CCG control total, hence the movement in the position this month. The cost pressure identified does not include the cost pressure expected from drugs where they have been removed as NCSO concessions but added back into the drug tariff at increased prices. This cost pressure for this is 173k, with a forecast full year effect into 2018/19 of c 400k. ACTION Prescribing team will continue to monitor GP prescribing. CCG s have been notified that the reduction in Category M (generic drugs) prices will not flow through to CCG s through reduced medicines expenditure. Instead, NHS England will form an overall system reserve by asking the Business Services Authority to retain the benefit that would otherwise flow to CCGs. For delegated primary care the Month 10 position is showing a YTD over-spend of 442k (M08 440k) on the issued budget, this is forecast to increase to 379k (M08 597kk) by year-end. Quarterly list sizes are now confirmed and a reduction of 155k is now certain and the savings arising from service charge reimbursement for Whitton has now been included in the forecast. Finance Report - Month 10 as at 31st January 2018 Monitor actual spend against budgets to identify any future cost pressures. 10

97 Running Costs January 2017/18 ISSUE ACTION Running Costs budgets have been adjusted to reflect the new structure working under the local delivery unit (LDU). Continue to monitor budgets for potential risks and mitigations For Month 10, the CCG is reporting 64k favourable forecast outturn variance (M09 80k adverse), with YTD underspend of 135k (M09 100k) mainly caused by slippage on admin & support (vacancies) and QIPP (vacancies and reduced staff hours) offset by pressures on corporate (legal costs) and finance (interim cover). Both KCCG and RCCG are due to co-locate to Thames House from 26 th March 2018 Finance Report - Month 10 as at 31st January

98 Other Programme Costs January 2017/18 ISSUE ACTION Includes Non Recurrent Programmes such as SWL Collaborative Commissioning, Healthy London Partnership (HLP), London Levies (LL) and Clinical Running Costs such as Safeguarding and Medicine Optimisation. Clinical Overhead - The Community Health Partnerships property charge has reduced this year, resulting in an 119k YTD under-spend ( 143k FOT, 123k LMFOT). The reduced NHS Property Services void space charge from September as East London FT moved into St John s was confirmed this month. Continue to monitor budgets for potential risks and mitigations In Month 10 we have released an additional 900k of Prior Year benefits from all Commissioning areas into Non Recurrent, which were previously identified as potential mitigations. (Detailed on Appendix 2d Other Programme Costs Summary 2017/18 slide 33). Finance Report - Month 10 as at 31st January

99 Risks and Mitigations January 2017/18 '000 '000 '000 '000 Risks Further Risks Acute contract commissioning Acute, including winter seasonality pressures (450) - QIPP (3,412) Acute IR impact (239) - Performance (2,479) Mental Health & LD pressures (63) Community (244) Continuing Care, including 16/17 recharges (393) Continuing Care (1,602) RHN recharge bad debts (345) Primary Care delegated (349) C&W transaction payment (1,250) Other acute underspends (26) Total Risks (8,111) Total Further Risks to Mitigate (2,739) Mitigations Further Mitigations Acute contract reserve 1,740 Further balance sheet releases 458 Mental Health underspend 402 Acute IR impact 239 Other non-acute underspends 378 Primary Care rates rebates 125 Investment slippage 1,548 C&W transaction payment - recharge to NWL CCGs 1,250 Contingency 1,304 Running cost undrspend 64 Balance sheet releases 1,722 Prescribing underspend 56 Total Mitigations 7,215 Total Further Mitigations 2,072 Total Reported Position (896) Potential Surplus/(Deficit) Risks to Mitigations (667) In Year Surplus/(Deficit) (5,896) In Year Surplus/(Deficit) (6,564) The table reflects the risks and mitigations of the 17/18 reported position ( 5.9m deficit) updated as at month 10. The risk adjusted control total is a deficit of 6,564k i.e. the CCG will not deliver the reported in year deficit by 667k if all the risks were to materialise with the current mitigations available. The risk adjusted position has been gradually reducing from 9,581k in Month 4, and has improved since Month 9 ( 7,599k), caused by a number of improvements including further balance sheet releases identified (c 300k) and a reduction in the acute seasonality ( 250k) following the agreement of YE settlements on the KHFT contract. We have also the potential refund of primary care business rates as a non-recurrent mitigation this month. Finance Report - Month 10 as at 31st January

100 Underlying Position January 2017/18 Please refer to guidance for definitions of Non- Recurrent items to be included Forecast Net Expenditure Remove Non Recurrent Items Part/Full Year Effects CCG UNDERLYING POSITION Plan Actual Variance Variance NR Allocations & Matched Expenditure NR QIPP Benefit 0.5% Risk Reserve m m m % m m m m m m m m m 0.5% NR Reserve Contingency Other NR Spend / Income QIPP Other 2017/18 Underlying Position REVENUE RESOURCE LIMIT (IN YEAR) (0.731) Acute Services (4.168) (3.3%) Mental Health Services % (0.797) Community Health Services (0.232) (1.0%) Continuing Care Services (1.602) (7.7%) Primary Care Services (0.036) (0.1%) (0.106) - (0.319) - (0.896) Primary Care Co-Commissioning (0.349) (1.4%) Other Programme Services % (0.097) - (1.157) (0.928) Commissioning Services Total (0.961) (0.4%) (0.692) - (1.157) (1.247) Running Costs % TOTAL CCG NET EXPENDITURE (0.897) (0.3%) (0.692) - (1.157) (1.247) IN YEAR UNDERSPEND / (DEFICIT) (5.000) (5.897) (0.897) 17.9% Underlying Underspend / (Deficit] (4.358) % RRL (1.7%) RCCG s underlying position at Month 10 of m (Month m), is a 0.077m improvement in underlying position and reflects 0.2m Acute improvement in risks and the removal of 1.037m NCSO from risks into the Month 10 position. Risks have to be covered by nonrecurrent mitigations of an additional 0.3m relates to non-recurrent balance sheet benefits released into the financial position and 1.25m Chelsea & Westminister transaction payment to be recharged to NWL CCGs. Finance Report - Month 10 as at 31st January

101 QIPP Commentary January 2018 Achievements: We have achieved 6.9m YTD against a Plan of 8.9m. Transactional delivery remains strong. Our FOT is now 9.4m, we believe this is a realistic assessment and takes into account current risks. Note: As previously reported our YTD position and forecast is taking some non-recurrent benefits into account- this is called Balance Sheet Releases. We now believe the full year value of this will be 1.8m and this has off-set the risk from transformational QIPP under-delivery. Our delivery focus is shifting to 18/19 to make sure that we are in a good place with those schemes that have failed to bite this year. See Appendix A for mitigations on Red and Amber QIPP Schemes and for Thematic QIPP Programme Risks Scheme Highlights: CHC is seeing an improvement in month 10. Significant work has been completed in cleansing the data and imbedding the brokerage function in-house. We remain confident that we can achieve the 1.4m QIPP. DXS/Kinesis is performing well, in M 9 which has been extrapolated for month 10 and we remain optimistic about delivery of this scheme. This is one of the key successes in our transformational QIPP for 17/18. POLCE continues to perform well, note in our reporting we have taken a very conservative view of the savings based on the value of declines on Blue Tech, circa 160K YTD. This will be under-counting the savings from any challenges arising from not using the system and will also not take account of any deterrent effect. Other methodologies are being developed by SWL and the CSU to more accurately track the financial benefits but we have completed some local analysis which potentially puts the savings at 400K FOT. RHND NEL- We are seeing a reduction in NEL admissions from RHND as a result of changing the registering GP. Frail Elderly while the scheme appeared to be delivering in previous months the trajectory over the winter month s has deteriorated. This is a patient population which are particularly sensitive to the effects of winter and so it is difficult to extrapolate causality. The pilot is due to be evaluates shortly to assess the impact against a broader range of matrix. Finance Report - Month 10 as at 31st January

102 QIPP Performance January 2018 Richmond CCG QIPP Programme to January Transactional Transformational Net QIPP Plan YTD Actual YTD Varaince to Plan RAG Project RAG AQP Cap 0 41,667 41,667 Green Green CHC 1,231,481 1,166,667-64,815 Green Green Contract change 250, ,250 80,250 Green Green FRP - Reduce AVLOS at Teddington 1,250,000 1,250,000 0 Green Green HRCH Contract Reduction 416, ,667 0 Green Green LD 420, ,333 94,460 Green Green Medicines 523, , ,896 Green Green Mental Health 583, ,334 0 Green Green RCAS Assessors 0 108, ,250 Green Green RHND NEL 333, ,610-33,723 Amber Green Balance Sheet Releases 0 760, ,000 Green Green Transactional Total 5,009,458 6,168,444 1,158,986 Plan YTD Actual YTD Varaince to Plan RAG Project RAG A&E 14, ,525 Closed Closed Children's/Paediatrics 228, ,941 66,370 Green Green Dermatology 50, ,836 Red Red ECI / PoLCE 363, , ,928 Amber Green ECI / PoLCE-IVF 228,033 36, ,691 Red Green Frail Elderly 72, ,623 Red Amber FRP - Cardiac- acute on chronic admissio 314, ,203 Red Amber FRP - Diabetes 74, ,957 Red Amber FRP - Early Respiratory Disease 67, ,130 Red Amber FRP - Reducing short stay admissions & A 32, ,981 Closed Closed Gastroenterology 117, ,649 Merged Merged Integrated Front End service (UCC, GP-OO 236, ,025 Closed Closed Mental Health 11, ,620 Closed Closed MSK Pathway Re-design 228, ,571 Red Green New Care Model: End of Life 72, ,623 Red Green Out-patient Referral Management (DXS & 472, , ,759 Amber Green Pathology 36, ,311 Closed Closed FRP - Ophthalmology 108, ,934 Red Amber Transformational Total 2,730, ,761-1,959,996 Subtotal Identified Schemes 7,740,216 6,939, ,010 Unidentified Schemes 1,172, ,945,472 Total 8,912,386 6,939,205-1,973,180 Benefits Delivery Summary: 6.9m achieved YTD vs 8.9m Plan Transactional: RAG rating for CHC has improved to Green on the basis of their improved run-rate on savings. Note: We are reporting some noncurrent benefits against Balance Sheet Releases. Transformational: Cardiac, Resp and Diabetes are mobilised but delayed in terms of financial impact. They have not achieved the anticipated benefits. Frail Elderly has become adverse but it is difficult to determine causality for this. An evaluation of the pilot will be completed. Outpatient DXS is achieving and is one of the CCG s key successes. POLCE is live and working- we have taken a more conservative view of the savings pending confirmation of a more robust counting method from the CSU. We taken 160K YTD but some estimates place the savings at closer to 400K Finance Report - Month 10 as at 31st January

103 QIPP Run Rate Summary January 2018 April May June July August September October November December January February March Total Transactional Plan 499, , , , , , , , , , , ,794 5,912,350 Forecast 507, , , , , , , , ,839 1,208,885 1,175,682 1,175,682 8,519,808 Actual 507, , , , , , , , ,839 1,208,885 6,168,444 Transformational Plan 181, , , , , , , , , , , ,078 3,730,710 Forecast 140,180 13,434 91, , , ,021 7,601 29,856-5,773 51,517 68,675 68, ,112 Actual 140,180 13,434 91, , , ,021 7,601 29,856-5,773 51, ,761 Total Plan 681, , , , , , , , , , , ,872 9,643,060 Forecast 647, , , , , , , , ,066 1,260,402 1,244,357 1,244,357 9,427,920 Actual 647, , , , , , , , ,066 1,260,402 6,939,205 Note: Acute data is one (1) month in arrears, in these cases we estimate the position for the reporting month and revise it the next month when we have actuals Finance Report - Month 10 as at 31st January

104 Cash and Balance Sheet Month 10 January 2017 Finance Report - Month 10 as at 31st January

105 Statement of Financial Position January 2017/18 STATEMENT OF FINANCIAL POSITION Jan-18 Dec-17 ADJ-17 '000 '000 '000 Current Trade And Other Receivables 2,400 2,894 6,781 Cash And Cash Equivalents (465) (1,251) 193 Current Assets Total 1,934 1,642 6,974 Current Trade And Other Payables (30,815) (30,309) (27,232) Current Other Liabilities (436) (582) (1,371) Provisions 0 (122) (350) Current Liabilities Total (31,251) (31,012) (28,953) Grand Total (29,316) (29,370) (21,979) General Fund 29,316 29,370 21,979 Financed by Taxpayers Equity: Total 29,316 29,370 21,979 Grand Total 29,316 29,370 21,979 STATEMENT OF CHANGES IN TAXPAYERS EQUITY Jan-18 Dec-17 ADJ-17 '000 '000 '000 Opening Balance 21,979 21,979 23,010 Net Operating Cost for the Year 220, , ,493 Net Parliamentary Funding (213,477) (191,744) (265,524) Grand Total 29,316 29,370 21,979 The Statement of Financial Position as at Month 10 represents a snap shot of the CCG s finances as at 31 st January 2018, compared to the closing position at 31 st December 2017 and the beginning of the financial year. The Net Parliamentary balance of 213,477k (M09 191,744k) represents the YTD Cash drawn down and the Prescribing Top slice adjustment. The 220,813k (M09 199,134k ) on the Net Operating Cost for the Year, correlates to the Total Application After Reserves as shown on Appendix 2 NHS Richmond CCG Summary 2017/18 YTD & Outturn on page 26 represents totalled Commissioned Programme and Running Costs. Finance Report - Month 10 as at 31st January

106 Cash Drawdown January 2017/18 Monthly Drawdown 000s Cumulative Drawdown 000s Proportion of Annual Cash Resource Limit Cash Balance 000s KPI % Cash drawdown Apr-17 18,000 18, % % May-17 20,500 38, % 1, % Jun-17 18,900 57, % % Jul-17 22,100 79, % % Aug-17 21, , % 2, % Sep-17 20, , % % Oct-17 17, , % % Nov-17 18, , % % Dec-17 18, , % % Jan-18 20, , % % Feb-18 21, , % 0.0% Mar-18 26, , % 0.0% TOTAL 244,344 The NHS England cash target was achieved with Richmond holding a cash balance of 1.0% of cash drawn down. The Maximum Cash Drawdown (MCD) of 245.3m is based on the BSA Cash Report supplied by NHS England for Month 07. Finance Report - Month 10 as at 31st January

107 Cash Flow Statement January 2017/18 STATEMENT OF CASH FLOWS JAN-18 DEC-17 ADJ-17 (Increase) decrease in trade and other receivables 238,465 (53,767) (144,683) Increase (decrease) in provisions 0 (228,459) 350,000 Increase (decrease) in trade and other payables 494, ,122 (295,900) Net operating costs for the financial year (21,679,199) (22,039,571) (23,393,017) Provisions utilised Cash Flows from Operating Activities: Total (20,946,734) (21,703,675) (23,483,600) Net parliamentary funding received 21,732,735 20,418, ,523, Cash Flows from Financing Activities Total 21,732,735 20,418, ,523,782 Grand Total 786,000 (1,284,791) 242,040,183 Movement 786,000 (1,284,791) 242,040,183 Opening Amount (1,251,302) 33,489 0 Cash balance is within the required limit of 1.25% of monthly drawdown Closing Amount (465,302) (1,251,302) 192,640 Finance Report - Month 10 as at 31st January

108 Aged Debtors January 2017/18 January Aged Debt Summary AR due amount 22,681 AR overdue 1-30 amount 256,168 AR overdue amount 22,926 AR overdue amount 283,727 AR overdue 90+ amount 1,855,446 Total Aged Debt 2,440,949 Aged Debtors - 31st January 2018 AR due amount AR overdue 1-30 amount AR overdue amount AR overdue amount AR overdue 90+ amount Total Paid Collectable LONDON BOROUGH OF RICHMOND UPON THAMES 62,125 62,125 GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 4,500 4,500 HOUNSLOW AND RICHMOND COMM HLTH NHST 2,246 2,246 RICHMOND UPON THAMES BOROUGH COUNCIL 5,336 5,336 NHS BARNET CCG 8,500 8,500 NHS BRENT CCG 9,633 9,633 NHS CAMDEN CCG 8,500 8,500 NHS CENTRAL LONDON (WESTMINSTER) CCG 48,167 48,167 NHS CROYDON CCG 0 0 NHS EALING CCG 19,833 19,833 NHS ENGLAND 111, ,932 NHS GREENWICH CCG 53,833 53,833 MR MATTHEW SAGE 2,026 2,026 NHS HAMMERSMITH AND FULHAM CCG 67,433 67,433 NHS HARINGEY CCG 25,500 25,500 NHS HARROW CCG 2,833 2,833 NHS HILLINGDON CCG 9,633 9,633 NHS HOUNSLOW CCG 254, ,321 NHS ISLINGTON CCG 2,833 2,833 NHS KINGSTON CCG 713,385 16, ,612 NHS LAMBETH CCG 114, ,467 NHS LEWISHAM CCG 48,167 48,167 NHS MERTON CCG 33,296 33,296 NHS NEWHAM CCG 22,667 22,667 NHS REDBRIDGE CCG 22,667 22,667 NHS SOUTHWARK CCG 34,000 34,000 NHS SURREY DOWNS CCG 127, ,500 NHS SUTTON CCG 0 0 NHS TOWER HAMLETS CCG 450, ,812 NHS WALTHAM FOREST CCG 34,000 34,000 NHS WANDSWORTH CCG 0 0 NHS WEST LONDON (KENSINGTON AND CHELSEA, QU 110, ,363 PENNYCOOK ( HAMPTON HILL MEDICAL CENTRE) 36,682 36,682 Unspecified -6,241-6,241 2,440,949 16,773 2,424,176 The total aged debt at end of January was 2,440k. The CCG was able to recover 16.8k post 31 st January and a total of 2,424k remains collectable. After allowing for bad debt provisions the majority of the outstanding invoices relate to RHND recharges. Following discussion at the London CFOs in October the outstanding debt with one CCG (Hounslow) has been escalated to NHS England for mediation. If the decision is in Richmond s favour the result would be applied to other outstanding debts. Invoices for the first four months of 17/18 (up until the GP transfer) have also now been issued. There is also a significant debt in relation to 2016/17 charges to other CCG for CHC costs where other CCGs have been identified as the responsible commissioner. Discussions are continuing with other CCGs. Adult CHC LbR Other RHND Grand Total Total Aged Debt Collectable as at Month 10 1,358, , , , ,424, Provision 823, , ,035, Net Debt 535, , , , ,388, Finance Report - Month 10 as at 31st January

109 Better Payments Practice January 2017/18 Richmond Jan-18 Dec-17 NHS NON-NHS TOTAL TOTAL NUMBERS FOR THE MONTH Total number of invoices paid in the month ,007 1,030 Number of invoices paid within target Numbers %age for the month 97.81% 93.45% 94.44% 96.50% VALUES FOR THE MONTH ( 000s) Total value of invoices paid in the month 13,722 6,159 19,880 18,447 Value of invoices paid within target 13,852 5,986 19,838 18,301 Value %age for the month % 97.19% 99.79% 99.21% CUMULATIVE NUMBERS TO THE MONTH Total number of invoices paid YTD ,320 8,313 Number of invoices paid within target ,935 7,984 Numbers %age Cumulative 93.51% 96.85% 95.87% 96.04% CUMULATIVE VALUES TO THE MONTH ( 000s) Total value of invoices paid YTD 148,273 48, , ,241 Value of invoices paid within target 145,922 47, , ,883 Value %age Cumulative 98.41% 97.85% 98.28% 98.11% Under the Better Payments Practice Code (BPPC), CCGs are expected to pay 95% of all creditors within 30 days of the receipt of invoices. This is measured both in terms of the total value of invoices and the number of invoices by count. The month of January is reported in the table. The BPPC percentage achievement for Richmond in terms of number of invoices paid within target is 95.03% (M %). Cumulatively this stands at 95.93% (M %). Richmond only just passed the measure this month this was in a large part down to a ready to pay file dated in July only being received by the FASS team in January. This accounted for 24 invoices which would have pushed the compliance to over 97% for the month enabling non-nhs invoices to reach the target. GREEN = target of 95% met (have paid all creditors within 30 days), RED = target not met Finance Report - Month 10 as at 31st January

110 APPENDICES Month 10 January 2017 Finance Report - Month 10 as at 31st January

111 Appendix 1a NHS Richmond CCG Summary 2017/18 YTD & Outturn 2017/18 Budgets - Source and Application of Funds Month 9 Month 10 Periods to Date Full Year Month 9 Total Budget Budget Movements Total Budget Budget Actual Variance Forecast Variance Forecast FOT Variance 000's 000's 000's 000's 000s 000s 000s 000s 000s 000s Revenue Resource Limit 262, , , , , ,315 0 APPLICATION OF FUNDS - Acute Commissioning: Kingston Hospital 46, ,758 38,965 39,403 (438) 47,991 (1,233) 47,991 (1,233) Chelsea & Westminster 32, ,300 26,917 29,973 (3,057) 36,310 (4,010) 35,900 (3,600) Imperial 10, ,073 8,394 8,418 (24) 10,166 (93) 10,217 (144) Queen Mary's (ex CSW) 6, ,329 5,274 4, , , St. George's 6, ,523 5,436 5,444 (9) 6,524 (1) 6,699 (177) LAS 5, ,813 4,844 4,928 (84) 5,914 (101) 5,914 (101) Other Acute Trusts 13, ,844 11,536 12,322 (786) 15,054 (1,210) 15,095 (1,252) Acute Contracts Reserve 1, , ,740 (989) 2,730 NCAs 3, ,171 2,643 2,703 (61) 3,244 (73) 3,174 (3) Other Acute Total Acute Commissioning 126, , , ,613 (2,812) 131,137 (4,177) 129,979 (3,019) Non-Acute Commissioning: Mental Health 27, ,202 22,668 22, , ,392 (190) Continuing Care 20, ,899 17,415 18,736 (1,321) 22,500 (1,602) 21,984 (1,085) Community 21, ,545 17,954 18,144 (190) 21,789 (244) 21,848 (303) Hospices (16) 268 (19) 268 (19) Community Geriatricians EOLC Better Care Fund 5, ,811 4,843 4, , , (37) (25) Programme Projects (2) 205 (5) 205 (5) Other Total Non Acute Commissioning 77, ,171 64,309 65,235 (926) 78,481 (1,310) 78,643 (1,472) Primary Care Commissioning: Prescribing 21, ,578 17,981 17, , , Enhanced Services/PC Commissioned Services 4, ,266 3,555 3,710 (154) 4,444 (177) 4, GP IT Delegated Primary Care 24, ,623 20,280 20,702 (422) 24,972 (349) 25,220 (597) Total Primary Care Commissioning 51, ,210 42,435 42,928 (494) 51,632 (423) 50, Total Other Programme Costs 3, ,277 2, ,045 1,180 2,097 2,125 1,152 Total Commissioned Services 258, , , ,381 (2,188) 262,431 (3,813) 261,550 (2,932) Running Costs 4, ,314 3,567 3, , , Reserves, Contingencies and Provisions: Non Recurrent Fund (1%) 1, , , ,157 0 Contingency (0.5%) 1, , , ,304 Other Reserves & Provisions 1, , , ,548 Total Reserves, Contingencies and Provisions 4, ,383 1, ,316 1,531 2,852 1,531 2,852 Total Application after Reserves 267, , , ,813 (736) 268,212 (896) 267,315 0 In Year Surplus/(deficit) after reserves movements - Programme (5,000) 0 (5,000) (4,167) (4,903) (736) (5,897) (896) (5,000) 0 C/Fwd Surplus/(deficit) after reserves movements - Programme (8,388) 0 (8,388) (6,990) (6,990) 0 0 (8,388) 0 (8,388) 0 Cumulative Surplus/(deficit) after reserves movements - Programme (13,388) 0 (13,388) (11,157) (11,893) (736) (14,285) (896) (13,388) 0 Finance Report - Month 10 as at 31st January

112 Appendix 2a General Acute Commissioning Summary 2017/18 Month 9 Month 10 Periods to Date Full Year Month /18 Acute Commissioning Budget Total Budget Budgets Application of Funds Total Budget Movements 2017/18 Budget Actual Variance Forecast Variance Forecast FOT Variance 000's 000's 000's 000's 000s 000s 000s 000s 000s 000s vlook up Richmond SLAM Analysis Mth 1 for Mth LB Kingston Hospital 46, ,758 King 38,965 39,403 (438) 19 47,991 (1,233) 47,991 (1,233) Chelsea & Westminster 32, ,300 Che 26,917 29,973 (3,057) R 36,310 (4,010) 35,900 (3,600) Imperial 10, ,073 Imp 8,394 8,418 (24) RY 10,166 (93) 10,217 (144) Queen Mary's (ex CSW) 6, ,329 St. G 5,274 4, RJ 5, , St. George's 6, ,523 St. G 5,436 5,444 (9) RJ 6,524 (1) 6,699 (177) LAS 5, ,813 4,844 4,928 (84) R 5,914 (101) 5,914 (101) Total Main Trusts 107, ,796 89,830 92,715 (2,886) 112,476 (4,680) 112,359 (4,564) Chelsea & Westminster 32,300 (32,300) 0 blan RQ ,900 (3,600) Epsom Orthopaedic 2, ,104 Eps 1,753 1,876 (123) RV 2,251 (147) 2,246 (142) Ashford & St. Peters 1, ,782 Ash 1,485 1, , , Guy's & St. Thomas' 2, ,030 Guy 1,691 1,886 (194) RJ 2,588 (559) 2,557 (528) Kings King RJ 411 (1) 450 (39) Moorfields 1, ,667 Moo 1,389 1, R0 1, , Royal Brompton Roy (124) RT 894 (122) 858 (86) Royal Marsden 1, ,570 Roy 1,308 1,463 (155) R 1,784 (215) 1,717 (148) Royal Surrey Roy (50) RA 152 (60) 155 (62) UCL 1, ,507 UCL 1,256 1,577 (321) R 1,825 (318) 1,897 (389) Barts Epsom & St. Helier Eps RV GOSH GOS (27) R 169 (32) 177 (40) North West London (11) 413 (19) 414 (20) Royal Free (18) 272 (22) 280 (29) Royal National Orthopaedic Roy (35) RA 318 (28) 311 (21) Total Other Providers 13, ,844 11,536 12,322 (786) 15,054 (1,210) 15,095 (1,252) Total Acute Contracts 121, , , ,037 (3,671) 127,530 (5,891) 127,455 (5,816) ISTC ISTC (59) 639 (77) 641 (80) Charges exempt overseas visitors (0) 0 (0) Pregnancy Advice Service BPA NCAs 3, ,171 2,643 2,703 (61) 19 3,244 (73) 3,174 (3) Private Providers (8) 24 (9) 26 (11) Secondary Care Drugs (13) RCAS Acute Trust SLAs Prior Year t b f Acute NCAs Prior Year t b f GUM recharge to Local Authority (1,437) 0 (1,437) 192 (1,198) (1,271) 73 (1,525) 88 (1,525) 88 GUM Expenditure 1, ,437 1,198 1,270 (73) 1,525 (88) 1,525 (88) C&W MFF adjustment (744) 0 (744) (744) 0 (744) 0 Acute Reserve 1, , ,740 (989) 2,730 Specialist Commisioning Transfer Out Res Specialist Commisioning Transfer In Reser Acute Other 5, ,322 4,435 3, ,608 1,714 2,525 2,797 Total Acute Commissioning 126, , , ,613 (2,812) 131,137 (4,177) 129,979 (3,019) Finance Report - Month 10 as at 31st January

113 Appendix 2b Non Acute Commissioning Summary 2017/ RY9NFT Month 9 Month 10 Periods to Date Full Year Month 9 Budget Total Budget 2017/18 Non Acute Commissioning Budgets Total Budget Budget Actual Variance Forecast Variance Forecast FOT Variance Movements 2017/18 Application of Funds 000's 000's 000's 000's 000s 000s 000s 000s 000s 000s MENTAL HEALTH vlookup to Ledger Tab by code string West London Mental Health (0) SWL & St.G's SLA 14, ,445 12,037 12,085 (48) 14,446 (1) 14,446 (1) SWL & St.G's SLA -Prior Year (1) SWL & St.G's - ADHD (4) 64 (4) Mental Health Crisis Homes (11) 135 (14) 135 (14) Mental Health Investments Mental Health Block SLAs 15, ,626 13,022 12, , , Child And Adolescent Mental Health (83) 583 (69) Dementia Psychological Therapies Access Improvement 3, , ,911 2, , ,493 0 Learning Difficulties 3, , ,518 2, , ,179 (158) Mental Health Services - Adults 2, , ,405 2, ,904 (18) 3,187 (301) Mental Health Services - Not Contracted Activity (45) 229 (52) 230 (53) Mental Health Services - Older People 1, , , Mental Health Services - Specialist Mental Health Services - Vol Sector Mental Health Services - Collaborative Fees Mental Health Placements and Other Mental Health 11, ,576 9,647 9, , ,916 (339) Total Mental Health 27, ,202 22,668 22, , ,392 (190) CONTINUING CARE CHC Adult Fully Funded 17, , ,202 15,077 (875) 18,093 (1,050) 17,593 (550) CHC Adult Personal Health Budget (0) CHC Asessment & Support (14) 792 (33) 776 (17) CHC Children 1, , ,294 1,726 (432) 2,071 (518) 2,071 (518) CHC Child Personal Health Budget Funded Nursing Care 1, , , ,193 0 Total Continuing Care 20, ,899 17,415 18,736 (1,321) 22,500 (1,602) 21,984 (1,085) Finance Report - Month 10 as at 31st January

114 Appendix 2b Non Acute Commissioning Summary 2017/ RY9NFT Month 9 Month 10 Periods to Date Full Year Month 9 Budget Total Budget 2017/18 Non Acute Commissioning Budgets Total Budget Budget Actual Variance Forecast Variance Forecast FOT Variance Movements 2017/18 Application of Funds 000's 000's 000's 000's 000s 000s 000s 000s 000s 000s COMMUNITY YHC SLA - Older People (32) 121 (97) 70 (45) MSK AQP (109) 334 (131) 340 (136) Podiatry AQP (57) 211 (66) 216 (71) HRCH Contract - Adult SLA 17, , ,860 14, , ,832 0 HRCH Contract - Children SLA and S.A.L.T 2, , ,440 2, , ,928 0 LbR Contribution Step Down Beds at TMH (80) 0 (80) 19 (67) (25) (42) (30) (50) (30) (50) NCA Community invoices (34) Moorfields-Community@TMH&QMR Total Community 21, ,545 17,954 18,144 (190) 21,789 (244) 21,848 (303) HOSPICES Trinity Hospice (0) Princess Alice Hospice (16) 240 (19) 240 (19) Total Hospices (16) 268 (19) 268 (19) COMMUNITY GERIATRICIANS PALLIATIVE CARE BETTER CARE FUND 5, , ,843 4, , , CONTRACT (37) (25) CHILDREN PROGRAMME PROJECTS (2) 205 (5) 205 (5) OTHER NON ACUTE Interpreting Services Patient Transport Urgent Care (2) Sleep Clinic (16) Heart Failure Pilot (11) Total Other Non Acute Total Non Acute Commissioning 77, ,171 # 64,309 65,235 (926) 0 78,481 (1,310) 0 78,643 (1,472) Finance Report - Month 10 as at 31st January

115 Appendix 2c Primary Care Commissioning Summary 2017/ /18 Primary Care Commissioning Budgets - Application of Funds Month 9 Total Budget Budget Movements Month 10 Total Budget 2017/18 Periods to Date Full Year Month 9 Budget Actual Variance Forecast Variance Forecast FOT Variance 000's 000's 000's 000's 000s 000s 000s 000s 000s 000s vlookup to Ledger Tab by code string GP Prescribing 21, ,157 17,631 16, , ,588 1,569 Central Drugs RHND (1,100) 0 (1,100) (917) 51 (968) (309) (791) (309) (791) Prescribing Incentive Scheme WiC - Prescribing Oxygen Prescribing IT Prescr Total Prescribing 21, ,578 17,981 17, , , IT GP IT Total Primary Medical Services Diagnostic Services LES (12) 262 (15) Shared Care (69) 183 (83) 180 (79) Diabetes LES Respiratory (118) 142 (142) 27 (27) Mental health Referral management (276) 331 (331) 315 (315) Extended Hours LES (Tier 2) Complex Wound Care (6) Cancer Care Bowel Cancer Leg Ulcer Anti-Coagulant Monitoring (27) 408 (32) 404 (28) Demand Management Deman Complex needs Hormone Injection Prosta (9) 29 (11) 29 (11) Other Professional Fees (3) 13 (4) 13 (4) Phlebotomy Phlebo (40) 172 (48) 160 (36) MH Depot Injections Total Enhanced Services 2, ,389 1,991 2,255 (264) 2,706 (317) 2,516 (127) Finance Report - Month 10 as at 31st January

116 Appendix 2c Primary Care Commissioning Summary 2017/18 cont d 2017/18 Primary Care Commissioning Budgets - Application of Funds Month 9 Total Budget Budget Movements Month 10 Total Budget 2017/18 Periods to Date Full Year Month 9 Budget Actual Variance Forecast Variance Forecast FOT Variance 000's 000's 000's 000's 000s vlookup to Ledger Tab by code string 000s 000s 000s 000s 000s Primary Care Investment ( 3 p/head) Primar Total PRIMARY CARE INVESTMENTS Dermatology GPwSI Derma (3) ENT GPwSI ENT GP (3) (4) 63 (4) Ultra Sound Ultra S Minor Surgery GPwSI Minor (17) 34 (20) 21 (8) Vasectomy Service Vasect Kew Hostel Kew H Total Other Primary Care Commissioning DXS & Kinesis DXS & Care Navigator Care N (255) Extended GP Hubs 1, ,046 Extend Total Other Primary Care Development 1, , , , General Practice - GMS 16, ,134 Gener 13,311 13, , ,185 (51) General Practice - PMS 1, ,515 Gener 1,254 1,270 (15) 19 1,518 (3) 1,518 (3) QOF 1, ,865 QOF 1,554 1,567 (14) 19 1,881 (16) 1,915 (50) Premises 4, ,515 Premis 3,666 3, , , Enhanced Services Enhan (17) Seniority Senior (18) (49) Personally Administered Drugs Person (5) Other Administered Funds Other (279) Other Delegated Primary Care (742) 0 (742) Other (619) 169 (788) 36 (778) 36 (778) Delegated prior year GMS Delega 0 (14) (71) 0 0 Delegated prior year PMS Delega 0 5 (5) Total Delegated Primary Care 24, ,623 Delega 20,280 20,702 (422) 24,972 (349) 25,220 (597) Total Primary Care Commissioning 51, ,210 42,435 42,928 (494) 51,632 (423) 50, Finance Report - Month 10 as at 31st January

117 Appendix 2d Other Programme Costs Summary 2017/ /18 Other Programme Costs Commissioning Budgets Application of Funds OTHER PROGRAMME COSTS Month 9 Month 10 Periods to Date Full Year Month 9 Budget Total Budget FOT Total Budget Budget Actual Variance Forecast Variance Forecast Movements 2017/18 Variance 000's 000's 000's 000's 000s 000s 000s 000s 000s 000s Non Recurrent Prior Year (1,722) 1,722 (1,722) 1,722 (844) 844 Total Non reccurrent (1,722) 1,722 (1,722) 1,722 (844) 844 Clinical Running Costs Programme Projects - CSU SLA (1) Programme Projects - London Levies Medicines Management - Clinical # Safeguarding Clinical Leads Clinical Corporate Costs 1, , (6) 1, ,090 0 NHS Property Services Recharge Quality Premium SWL Collaborative Commissioning Total Clinical Running Costs 3, ,277 2,650 2, , , Finance Report - Month 10 as at 31st January

118 Appendix 2e Running Costs Summary 2017/ /18 Running Costs Budgets - Application of Funds Month 9 Total Budget Budget Movements Month 10 Total Budget 2017/18 Periods to Date Full Year Month 9 Budget Actual Variance Forecast Variance Forecast 000's 000's 000's 000's 000s 000s 000s 000s 000s 000s FOT Variance Source of Funds - Revenue Resource Limit 4, ,314 3,567 3, , ,314 0 ADMINISTRATION & BUSINESS SUPPORT COMMUNICATIONS & PR STRATEGY & DEVELOPMENT EDUCATION AND TRAINING TOTAL CORPORATE AFFAIRS CEO/ BOARD OFFICE (39) 621 (45) 621 (45) CHAIR AND NON EXECS (24) 203 (26) 178 (1) TOTAL CEO, CHAIR & GOVERNING BODY MEMBERS (63) 825 (71) 800 (46) CLINICAL SUPPORT TOTAL CLINICAL LEADS COMMISSIONING TOTAL COMMISSIONING TEAM CORPORATE COSTS & SERVICES 1, ,390 1,158 1,173 (14) 1,454 (64) 1,454 (64) OPERATIONS MANAGEMENT FINANCE (35) 437 (42) 435 (39) QIPP IM&T IM&T PROJECTS (12) 29 (14) 29 (14) TOTAL CORPORATE & CSU COSTS 2, ,264 1,893 1, ,303 (39) 2,300 (35) PATIENT AND PUBLIC INVOLVEMENT QUALITY ASSURANCE (3) 42 (1) 42 (1) TOTAL QUALITY TEAM GENERAL RESERVE - ADMIN (22) 0 (22) (34) TOTAL GENERAL RESERVE - ADMIN (22) 0 (22) (34) APPLICATION OF FUNDS - RUNNING COSTS 4, ,314 3,567 3, , , Surplus/(deficit) (0) 0 (0) (135) (80) Finance Report - Month 10 as at 31st January

119 Appendix 3a Acute Graphs January 2017/18 Finance Report - Month 10 as at 31st January

120 Appendix 3a Acute Graphs cont d January 2017/18 Finance Report - Month 10 as at 31st January

121 Appendix 3a Acute Graphs cont d January 2017/18 Finance Report - Month 10 as at 31st January

122 Appendix 3a Acute Graphs cont d January 2017/18 Finance Report - Month 10 as at 31st January

123 Appendix 3a Acute January 2017/18 All SL CCGs Annual Budget Elective YTD Variance Against Plan (Adverse)/Favourable Non-Elective Maternity Pathway A&E Out Patient Other TOTAL S/L FOT S/L FOT Variance (Adverse)/ Favourable FOT FOT Variance (Adverse)/ Favourable '000s '000s '000s '000s '000s '000s '000s '000s '000s '000s '000s '000s Kingston Hospital 46, , , Chelsea and Westminster Hospital 32, , ,703 35,543-3,243 35,886-3,586 Imperial College Healthcare 10, , , St. George's Community Services At Queen Mary's Hospital 6, , , St George's Healthcare 6, , , London Ambulance 5, , , Other Contracts 13, , , TOTAL ACUTE CONTRACTS 121,639-1,296-2, , ,933-4, ,259-5,620 The table above shows the position against the agreed acute contract values (or CCG envelope where not finalised), with the YTD position split at a summary Point of Delivery (POD) level. The other POD category includes unbundled diagnostics, critical care, direct access, drugs & devices, patient transport, CQUIN and others. The reported variance reflects the likely position from the month 9 activity SLAM data received. The straight line forecast (FOT) variance shows the scenario if the contracts were to continue at the rate seen in the first 10 months of this financial year. Finance Report - Month 10 as at 31st January

124

125 11 TH MEETING IN PUBLIC OF RICHMOND CLINICAL COMMISSIONING GROUP S PRIMARY CARE COMMISSIONING COMMITTEE (PCCC) Attachment I Held on Tuesday 5 December 2017 from 10:00 to 12:00 In the Salon, York House MINUTES Attendance Log: PCC Members (voting) 25/4 27/6 22/8 03/10 05/12 06/2 Bob Armitage (BA), Lay member for Finance, A A A A A Remuneration, Primary Care and Governance (Chair) Susan Smith (SS), Lay member for PPI (Vice Chair) SA A A SA A Tonia Michaelides (TM), Managing Director SA SA SA A SA Yarlini Roberts (YR), Director of Finance (DoF) SA A SD A A Fergus Keegan (FK), Director of Quality (DoQ) SA DNA A (4.4 & 2.3) A A Anne Dornhorst (AD), Secondary Care Doctor N/A N/A N/A A SA Pete Smith (PS), Independent GP SD A A A A Gareth Hull (GH), Independent GP A SD SD SA SA Non-voting Charles Humphry, Lay member for Audit, Remuneration and Governance SA A SA SA SA Kathryn MacDermott (KMac), Director of Primary Care A A A A A and Planning John Anderson (JA), Healthwatch Richmond A SA A SA A representative Julius Parker (JP), Surrey & Sussex Local Medical A A A A SD Committee (LMC) Terry Silverstone (TS), Local Pharmaceutical Committee A A SD SA A (LPC) Maggie Ennis (ME), Patient Participation Group (PPG) A A SD A A representative Bonnie Green (BG), Patient Participation Group (PPG) N/A N/A A A A representative Maureen Chatterley (MC), Patient Participation Group N/A N/A A N/A N/A (PPG) representative William Cunningham-Davies (WCD), SWL Alliance SA A SD SA A Primary Care Contracting Team Dr Graham Lewis (GL), CCG Chair A A A A SA Dr Kate Moore (KM), Vice Clinical Chair (VCC) A A SA A SA Dr Nicola Bignell (NB), RCCG Governing Body GP N/A N/A N/A N/A A Dr Alireza Salehzadeh (AS), RCCG Governing Body GP N/A N/A N/A N/A A In Attendance: Emma Richmond (ER), Chief Pharmacist, RCCG A SA A A A Houda Al-Sharifi (HAS), Director of Public Health, LBRuT SA SA SA SA SA Anna Raleigh (AR), Public Health Consultant, LBRuT SA A SA SA SA Liam Bayly (LB), CCG Head of Finance, RCCG A N/A A N/A N/A Attracta Asika (AA), Head of Commissioning Primary and Urgent Care, RCCG A A A A A Caroline O Neill, Engagement Manager, RCCG A A A SA From item K A A A A A Lindsay Marshall (LM), Corporate Office Mgr (notes), RCCG KEY: A = Attended, DNA = Did not attend, SA = Sent Apology, SD = Sent Deputy, N/A = Not needed Page 1 of 7

126 Additional attendees on Clare Sieber (CS), LMC (for Julius Parker) Item Item/Discussion no. A STANDING AGENDA ITEMS 1.1 Welcome and apologies for absence; Confirmation of meeting quoracy Bob Armitage, Chair, welcomed members to the eleventh meeting in public of the Richmond CCG Primary Care Commissioning Committee (PCCC). Apologies for absence were received as per the attendance chart. The meeting was confirmed as quorate. Attachment/ Action 1.2 Declaration of interest in matters on the agenda Members of the Richmond General Practice Alliance (Dr Alireza Salehzadeh & Dr Nicola Bignell) In addition, the following declarations were noted: o Dr Alireza Salehzadeh & Dr Nicola Bignell: providers of locally commissioned services (LCS) providers of primary care GMS services interests in local primary care finance o Dr Nicola Bignell: GP at Thameside Practice In addition, the following declarations were noted: o Dr Pete Smith: Tudor Drive practice, located in Ham, has around patients within the Richmond CCG boundary. o Bonnie Green, PPG representative: elected public governor of Kingston Hospital for Richmond. o Terry Silverstone, LPC: elected governor of Kingston Hospital for Richmond. In relation to the conflicts of interest pertaining to the agenda, the chair considered the general nature of the report relating to these items did not require further action with regard to these declarations and the members concerned could remain at the table. 1.3 Minutes of the primary care commissioning committee meeting on 3 October 2017 The minutes were agreed as a correct record. 1.4 Matters arising and rolling action log The PCCC received attachment B and the action log was updated. Attachment A Attachment B 1.5 Items taken in private on 3 October 2017 It was noted that no private meeting had been held on this occasion. 2 Primary Care Commissioning 2.1 Locally Commissioned Services The PCCC received the minutes of the last meeting of the LCS group dated 1 st November. KMac gave an update on locally commissioned services. It was noted that the CCG needed to provide notice on the current diabetes LCS to allow the updated LCS to be offered to practices. KMac would check that clarification had been issued. C KMac In response to a question from Bonnie Green, it was noted that patients would be asked to engage on the review in due course. Page 2 of 7

127 Item Item/Discussion no. 2.2 Update from the SWL Alliance primary care contracting team - GP contract updates Attachment/ Action D The committee received the GP contract updates. WCD drew attention to the workforce statistics previously requested by the chair (BA) in order to assure the committee that there was sufficient capacity in primary care locally, and reported that he would discuss these with BA and bring them back to the next PCCC in February. It was noted that a report on out of hours provision would also come back to the PCCC in February as GPs were opting out from May 2018 and RCCG would be responsible for commissioning GP OOH for the Richmond population. 2.3 Extended Primary Care Commissioning Intentions Attachment E The PCCC received the extended primary care commissioning intentions. KMac asked for comments and suggestions on areas of further development, change and inclusion in primary care in 2018/19, and particular attention was drawn to the following: PMS: The CCG was in the process of asking two PMS practices to transition from PMS to GMS. The extra PMS monies would be re-absorbed back in the LCS budget. Out of hours: Work was underway to plan the future provision of the GP out of hours service as RCCG would take on responsibility for the planning and provision of GP out of hours services from May The current service was being decommissioned by Richmond GPs as the cost had increased and was no longer seen as value for money. Procurement would commence in December. Technology: There was a need for a technology strategy that would tie in with the work across SW London. There would be engagement with practices to ask them which of the digital options offered by SWL they would like to use. It had been suggested that one IT strategy should be developed across Kingston and Richmond CCGs in order to achieve the same level of good quality support but this was not easy as the two CCGs used different providers. Locality teams: It had been suggested that PCCC receive a presentation around OBC at a future meeting. Terry Silverstone (TS) raised concerns that the document contained little reference to community pharmacy and he outlined some of the initiatives undertaken by pharmacists to improve primary care for patients. He asked for guidance from the PCCC on how community pharmacy could take this work forward. Work was underway on developing a 2 year forward plan for working with primary care and once completed he would discuss it with Tonia Michaelides and Kathryn MacDermott and bring back to the PCCC. Emma Richmond (ER) endorsed the inclusion of community pharmacy in the plans and went through a number of areas where community pharmacy and primary care could work together. KMac thanked them for their helpful suggestions. It was noted that NHSE were responsible for commissioning community pharmacy services but had asked CCG clinicians for ideas to make it work locally. There was the potential for locally commissioned services which would be funded by the CCG and ER was keen to look at these opportunities. Bonnie Green (BG) supported the move towards greater involvement of community pharmacy in the plans as she had been disappointed with the lack of reference in the STP. The need for good communications to support the inclusion of community prescribing was emphasised. Page 3 of 7

128 Item no. Item/Discussion It was also proposed to work on improving engagement and input of the younger section of the population in primary care services. Recommendation/action: The PCCC supported the commissioning intentions and it was agreed that the community pharmacy 2 year forward view would be dovetailed into improving the primary care strategy. ER undertook to meet with KMac to take this work forward. The committee received the draft 2018/19 London Extended Access Guidance and Specification which had been developed by the Healthy London Partnership to set out core requirements for the funding and delivery of extended access services for 2018/19. The intention locally was to develop the model for the hub and update communications around TMH. In relation to the east side hub, practices had been asked to submit expressions of interest but the location had not yet been confirmed. BG raised that the PPG had asked that the CCG undertakes a modelling of the services needed on the east side and KMac agreed to take forward development of the service model based on the activity that was needed. TS reported that he would be happy to look at pharmacy cover for the extended hours that were proposed. It was noted that the LMC was also keen to monitor how the funding was spent as some funding was from the GP forward view and should be used for GP resilience. Therefore appointments should not just be available through 111. KMac commented that the national view was that appointments need to be booked by 111. The 2018/19 HLP London Extended Access briefing would be adopted by the national team which had said that GPFV funding could be used to provide 8 to 8 services. Attention was drawn to the fact that KMac was suggesting 10 minute appointments which would create more capacity. However, clinicians felt that 10 minute appointments were not sufficient in an out of hours setting as the patients were new to the clinicians. Fergus Keegan (FK) supported the view that 15 minutes would be preferable over 10 minutes. KMac agreed to model services in the hubs based on 15 minute slots. In relation to equity of access, she would ensure that whilst a proportion would be booked by 111, all practices would have access to booked appointments. It was noted that it would be unrealistic to discourage non-registered patients at TMH as many patients were from Hounslow. Richmond had offered to be the responsible commissioner and would work with Hounslow using a similar model. It was agreed that an update would be brought back to the PCCC in February, together with data around practices using the hub. Attachment/ Action ER/KMac 2.4 E-consult proposals Verbal It was agreed to defer the item to the February PCCC pending further information from SW London. 2.5 Primary care operational group (PCOG) report Notes of PCOG meeting of 8 August 2017 Attachment F The PCCC received and noted the minutes of the PCOG meeting on 8 th August. Page 4 of 7

129 Item Item/Discussion no. 3 Finance & Performance 3.1 Primary Care Finance update Attachment/ Action Attachment G The PCCC received the primary care finance update. YR took the committee through the report. She reported that there was an adverse variance at month 7. The 2016/17 accounts had been closed and it had been found that the CCG had under-accrued in some areas. Cost pressures were shown under delegated commissioning, GP hubs and an unexpected cost pressure on prescribing due to the no cheaper stock issue. TS commented that the no cheaper stock options issue was affecting pharmacists incomes nationwide as well as CCGs budgets and represented a significant risk for community pharmacists. It was noted that DoFs had expressed their concerns over the category M drugs. 3.2 Extended Primary Care Access Report Attachment H The PCCC received attachment H, and KMac took the committee through the report which was a dashboard detailing access to the GP extended primary care services provided through the two existing Richmond hubs and utilisation of the hubs. Further information would be brought back to the February meeting. KMac highlighted the continued low use on a Sunday and also a large number of DNAs from Monday to Saturday. It was recognised that some DNAs may be systemgenerated as some appointments could not be cancelled easily. 3.3 Risk stratification options Attachment I The PCCC received a briefing on the proposal that Richmond CCG change its risk stratification system from NELIE to Sollis which would mean that it was using the same risk stratification system as the other CCGs across South west London. The proposal had been discussed at other CCG committees including CET and the membership group. Feedback from practices was that Sollis was easier to operate and more cost effective than NELIE. Dr Kate Moore, vice clinical chair and chair of the CET, had attended a demonstration and had confirmed that she was happy for the move to go ahead. Another advantage was that the Sollis was used by HRCH which would help pathway changes. Training would be implemented. Recommendation/action: The PCCC approved the recommendation. 4 Quality & Governance 4.1 Primary Care Risk Log Attachment J The PCCC received the primary care risk log which was an excerpt from the 4Risk portal, and KMac took the committee through the risks. The Kingston risk log had also been included in error and would be redacted. It was noted that there had previously been a request to add a new risk for prescribing but this did not appear to have been added. KMac would ask Clare Woollett, Risk Manager, to add the risk and to liaise with ER. PR47 (Implementation of NHS E referral): The PCCC discussed the implementation of ERS and whether the timelines were achievable. There had been feedback from practices that it is a difficult system to use and was leading to duplication. The target coverage was 80% from April, with 100% from October. Any referrals into hospital from October will not be paid if not through E referral. Nicola Bignell commented that E referrals were putting a huge burden on general practice as practices were having to pay for extra admin to put bookings onto ERS. A working group had been established across K&R and Page 5 of 7

130 Item no. Item/Discussion there was also a SWL user group looking at how to resolve the problems. It was agreed that NB would send her concerns to WCD. In view of the negative patient and GP experience of E referrals BG questioned whether there were any patient reps on the working group and KMac undertook to check. Attachment/ Action NB KMac 4.2 Interface and pathways between general practice and community pharmacists Verbal TS reported that he had based his research on the interface between pharmacists, GPs and patients and had asked LPC and K&R contractor colleagues for their input. Amongst the areas highlighted for improvement were: 1. Contacting and communications with GPs 2. Brand switches 3. Patients ordering on line at surgeries 4. SMART cards (especially locums) 5. Repeat prescribing and batch prescribing 6. No consistency about how patients order medicines 7. Dosage 8. Electronic prescriptions (risky to patients and the CCG) 9. Pharmacy to You 10. Price concessions and NCSO Amongst solutions were improved communications via a dedicated surgery address and training. He proposed a meeting to discuss the issues. Any issues that could not be resolved could be considered for putting on the risk register. PS drew attention to a solution TS had mentioned around brand switching and asked for it to be shared with GPs. With regard to electronic prescriptions he felt that the benefits outweighed the risk of lost prescriptions. AS commented that there may be more cost effective options to be found. It was agreed that there was further work needed with IT providers to resolve issues with batch prescriptions. ER proposed to ask practice pharmacists to look at these process issues more in K&R so that there could be some collaborative working across SW London to implement solutions. Recommendation/action: It was agreed that a meeting would be scheduled between TS, KMac, ER, WCD and the LMC, with the patient experience incorporated into discussions, to consider how these issues can be resolved. 4.3 Patient participation group (PPG) network highlights report (standing item) KMac Attachment K The PCCC received the PPG report and BG took the committee through it. Amongst issues discussed had been the extended primary care, east of borough service modelling, capacity issues for primary care, communication and behaviour change. 4.4 Interim report of the engagement programme for the quality in primary care project Attachment L The PCCC received the interim report of the engagement programme, and Caroline O Neill (CO N) took the committee through the report. She reported that over 500 residents had responded so far. Community pharmacy was also covered by the programme and she would share the insight gained with Page 6 of 7

131 Item no. Item/Discussion prescribing colleagues. She was suggesting extending the programme to the end of January and was particularly looking to increase uptake of underrepresented groups. She took the committee through the recommendations. KMac felt that it was an excellent piece of work and informative report. There was a lot the CCGs can build on including linking it into work around quality indicators. AS suggested that a useful addition would be to help improve patient understanding of what is achievable during a consultation of 10 minutes. PS drew attention to discussions at Kingston PCCC around a wider analysis of quality in general practice and a paper that showed the results of an analysis of patient choice by a university between 2012 and 2015 which had been published 3 months ago. One of the findings was that a significant number of problems and negative comments were around the attitudes of staff, which showed that communication is paramount. PS would circulate the paper to Richmond colleagues. It would be beneficial to have a two-way conversation between general practice and the public around what is possible and how to manage the lack of capacity. SS stated that she was pleased with report but would be keen for further engagement and feedback from GPs. BG agreed and pointed out that improved engagement with GPs might also encourage further responses from patients in their practices. CO N would follow this up. Recommendation/action: The PCCC agreed all recommendations and to add in the suggested extra one. Attachment/ Action 5 To note 5.1 Any other business TS reported that Kingston and Richmond public health departments had both completed their pharmacy needs assessments. They were out to consultation and would be taken to NHSE and issued from April Dates of next meetings (please note change of dates and time to 10:00 to 12:00): 6 February 2018 The Salon, York House 3 April 2018 The Salon, York House 5.3 Reference document: Glossary of terms The committee received the glossary of terms with abbreviations used in recent meetings. Attachment M 6 PUBLIC QUESTION TIME 6.1 There were no members of public present and no questions. The meeting ended at 12:05 (V2: KMac) Page 7 of 7