GOVERNING BODY LEAD: Phil Moore, Deputy Chair (Clinical) of Governing Body and Chair of Integrated Governance Committee REPORT AUTHORS: Jill Pearse, Head of Governance Brian Roberts, Performance and Information lead RECOMMENDATION: The Governing Body is asked to note this report ATTACHMENT: AGENDA ITEM: 9 GOVERNING BODY MEETING DATE: 7 th July 2015 F EXECUTIVE SUMMARY: INTEGRATED GOVERNANCE COMMITTEE REPORT This report highlights issues and includes feedback from the 19 th May 2015 meeting of the Integrated Governance Committee, and also a summary of the Integrated Performance Report. KEY SECTIONS FOR PARTICULAR NOTE: Performance across London is challenged across a number of key areas. NHS England has identified 8 key priority targets: 1. Diagnosis of dementia 2. Cancer waiting times 3. A & E Waiting times 4 hour Decision to Admit 4. Referral to Treatment Times (RTT) 5. Diagnostics 6. Improved Access to Psychological Therapies (IAPT) 7. Health Visitors This is reported by NHS England 8. Winterbourne View No patients have been identified as fitting the criteria for inclusion in this target i.e. nil return The performance scorecard focuses on these targets. The 3 main areas of concern are recording diagnosis of dementia, A&E waiting times and Cancer 1st treatment within 62 days The achievement of the Corporate Objectives for 2014/15 was reviewed and refreshed for 2015/16 RECOMMENDATIONS: The Governing Body is asked to note this report. Version: Final F - 1
RISKS IDENTIFIED: As per report GOVERNING BODY OBJECTIVES for 2014/15: Please indicate below all the domains which the paper provides evidence for: Domain One: Patients are receiving clinically commissioned, high quality services Domain Two: Patients and the public are actively engaged and involved Domain Three: CCG plans are delivering better outcomes for patients Domain Four: We have robust governance arrangements Domain Five: CCGs are working in partnership with each other Domain Six: We have strong and robust leadership EQUALITY IMPACT ASSESSMENT: Not applicable PRIVACY IMPACT ASSESSMENT: No personally identifiable information is used in this report Version: Final F - 2
Kingston Clinical Commissioning Group Board Objectives for 2014/15 Set out below are a set of objectives for the CCG Board. The format is based on the 6 authorisation domains. Within each domain there are a small number of mission critical key objectives where the Board should collectively focus the majority of its attention. Domain one: Are patients receiving clinically commissioned, high quality services? 1a) We will seek to improve the quality, safety and effectiveness of healthcare services commissioned on behalf of the local population 1b) We will deliver the National Outcomes Framework 1c) We will lead an innovative organisation, seeking to create and shape services to meet the changing needs of Kingston 1d) Clinicians will lead patient centered service change. Domain two: Are patients and the public actively engaged and involved? 2a) We will actively involve service users, carers and public feedback in service design and evolution 2b) We will engage with different groups that reflect the population profile of Kingston Domain three: Are CCG plans delivering better outcomes for patients? 3a) We will deliver the operating plan, 5 year plan 3b) We will deliver the Better Care Programme milestones for 2014/15 3c) We will deliver the 2014/15 financial and service plans Domain four: Do we have robust governance arrangements? 4a) We will govern with transparency, comply with best practice and meet our statutory obligations 4b) We will ensure that there are effective arrangements for the oversight of the quality and safety of commissioned services Domain five: Are CCGs working in partnership with others? 5a) We will work with NHSE towards co-commissioning primary care 5b) We will work in partnership with the Royal Borough of Kingston to develop the Kingston Commissioning Collaborative and work towards integrating commissioning of services with RBK. 5c) We will explore opportunities with neighbouring CCGs for joint working arrangements and for collaboration 5d) We will discharge our lead commissioning arrangements with Kingston Hospital NHS Trust, South West London and St Georges Mental Health NHS trust and Your Healthcare CIC. Domain six: Do we have strong and robust leadership? 6a) We will continue to develop the role and function of the Council of Members 6b) We will develop the skills of the Governing Body and ensure a succession planning framework is in place 6c) We will engage with the CCG workforce to develop their skills and reward excellence Version: Final F - 3
KINGSTON CCG MISSION & VALUES We are passionate about your health, compassionate about your care Our task is to: effective and provide the good experience you deserve o the health and wellbeing of people in Kingston o the support that s available to help people look after themselves o the quality of local health services We value: as the leader of the health care system in Kingston We plan to achieve this by: We will measure how well we do by: pectancy across Kingston Version: Final F - 4
1 Introduction This report highlights issues from the Integrated Governance Committee meeting held on 19 th May 2015. 2 Reports from the IGC subcommittees and groups Reports from sub committees and groups are presented to provide assurance, identify concerns, gaps in assurance, risks and actions. This format reflects of the risk register and assurance framework and, where appropriate, risks are added to the corporate risk register. The reports are available to CCG members on GPTeamNet and the minutes of the meeting record discussion at the IGC. Reports were received from the following: Assurance for Engagement in Commissioning Team (AFECT) Out of Hospital Contract Portfolio Safeguarding Children and Looked After Children Adult Safeguarding Kingston Hospital Foundation Trust Clinical Quality Review Group South West London & St. Georges Clinical Quality Review Group Your Healthcare Clinical Quality Review Group Primary Care Quality and Development Group Kingston Urgent Care and Systems Resilience Group Residential and Nursing Care Homes Continuing Healthcare Better Care Programme Sub Group Public Health Commissioned Health Services Medicines Management Committee Information Governance Steering Group Finance Committee 3 Policies The following Human Resources policies were approved: Serious Incident Policy Maternity & Paternity Policy Bullying & Harassment Policy 4 Kingston Wellbeing Service Clinical Quality Review Group The 2014-15 Annual Report of the Kingston Wellbeing Service Clinical Quality Review Group was presented and noted by the committee (copy available on GPTeamNet or on request) 5 Integrated Governance and Performance Report The 2014/15 Quarter 4 Integrated Governance and Performance Report was presented to the committee; updated highlights are reported below. The full report can be accessed by CCG members on GPTeamNet or is available on request. Version: Final F - 5
As at 29 th June 2015 Kingston CCG was showing the following overall position against the following areas, and is achieving 135 of the indicators (77%) as shown below Performance across London is challenged across a number of key areas. NHS England has identified 8 key priority targets which will be monitored through the assurance process. 1. Dementia 2. Cancer waiting times 3. A & E Waiting times 4 hour Decision to Admit 4. Referral to Treatment Times (RTT) 5. Diagnostics 6. Improved Access to Psychological Therapies (IAPT) 7. Health Visitors 8. Winterbourne View The chart overleaf shows performance against these targets with the exception of: Health Visitor numbers this is the responsibility of Public Health England and Winterbourne is a nil return i.e. there are no patients fitting the criteria for inclusion Commentary on these targets, and other areas where the achievement of targets is at risk, is detailed below. A full scorecard is available to CCG members on GPTeamNet at https://portal.gpteamnet.co.uk/library/viewitem/9de9bcc7-33a8-4357-9928-a21a01107284 or upon request. Version: Final F - 6
Performance against top 8 Priorities Indicator Reporting Latest Latest YTD YTD Frequency Actual target Actual Target Period Trend/ Direction NHS England - Top 8 Performance Measures Dementia Diagnosis Rate Year end forecast RAG Estimated diagnosis rate for people w ith dementia (NHS OF 2.6i) Monthly 63.7% 66.7% 63.7% 66.7% May-15 63.7% A Access to Cancer Services Cancer 1 st treatment 62 days: GP Urgent Referral Monthly 68.0% 85.0% 68.0% 85.0% Apr-15 75.1% R Cancer 1st treatment 62 days: Screening Referral Monthly 100.0% 90.0% 100.0% 90.0% Apr-15 100.0% G Cancer 1st treatment 62 days: Consultant upgrade Monthly NO DATA 75.0% NO DATA 75.0% Apr-15 NO DATA Cancer 1 st treatment 31 days Monthly 97.9% 96.0% 97.9% 96.0% Apr-15 97.9% G Cancer subsequent treatment w ithin 31 days for surgery Monthly 100.0% 94.0% 100.0% 94.0% Apr-15 100.0% G Cancer subsequent treatment w ithin 31 days for cancer drugs Monthly 100.0% 98.0% 100.0% 98.0% Apr-15 100.0% G Cancer subsequent treatment w ithin 31 days for radiotherapy Monthly 96.4% 94.0% 96.4% 94.0% Apr-15 96.4% G All cancer 2 w eek w aits Monthly 93.7% 93.0% 93.7% 93.0% Apr-15 93.7% G Cancer 2 w eek for breast symptoms (cancer not initially suspected) Monthly 91.7% 93.0% 91.7% 93.0% Apr-15 92.2% A Urgent and Emergency Care (Accident and Emergency Waits) A&E w aiting time >4 hours (Kingston Hospital) - Latest actual is 4 w eek rolling average Monthly 87.3% 95.0% 89.6% 95.0% 21-Jun 91.9% R Referral to Treatment (18 Weeks) RTT 18 w eeks incomplete pathw ays Monthly 95.2% 92.0% 94.8% 92.0% May-15 94.8% G Number of 52 w eek Referral to Treatment Pathw ays: incomplete pathw ays Monthly 0.00% 0.10% 0.00% 0.10% May-15 0.0% G Diagnostics Waiting Times Diagnostic tests w aiting 6 w eeks or more Monthly 99.3% 99.0% 99.3% 99.0% May-15 99.8% G Improving access to Psychological Therapies (IAPT) IAPT - Patient numbers as % of Population w ith Depression etc. Monthly 1.1% 1.3% 2.7% 2.53% May-15 6.9% G IAPT proportion moving to recovery Monthly 48.7% 50.0% 46.1% 50.0% May-15 49.4% A The proportion of people that w ait 6 w eeks or less from referral to entering a course of IAPT treatment The proportion of people that w ait 18 w eeks or less from referral to entering a course of IAPT treatment Monthly 65.9% 75.0% 71.3% 75.0% May-15 71.3% A Monthly 92.6% 95.0% 95.5% 95.0% May-15 95.5% G Version: Final F - 7
5.1 Estimated diagnosis rate for people with dementia As part of the 2014-15 Operating Plan, CCGs are expected to diagnose 66.7% of the estimated number of people with dementia in 2014-15; the expected prevalence taken from the national dementia calculator. For Kingston CCG the expected prevalence is 1,553; 66.7% of this figure is 1,036 people. As at 31 st May 2015 Kingston CCG is achieving a 63.7% dementia diagnosis rate (989 people). This is a slight deterioration on the April 2015 figure of 64.4%. To increase the diagnosis rate for people with dementia, Kingston CCG has taken the following actions: a. A clinical review of all patients that are not on the dementia register where there have been drugs prescribed for dementia, where there are read codes within the practice systems that signify dementia or where dementia can be identified from notes. This will be repeated in March 2015. b. Acute hospital data has been made available for GP Practices to review. c. The review of people in care homes within Kingston. Kingston CCG has approved a business case for a GP with Special Interests in Dementia to work within the existing Memory Assessment Service (MAS) to enhance the current capacity. The expectation is that these actions will enable the CCG to meet 66.7% in June 2015. 5.2 Cancer 2 week standard for breast and 1st treatment within 62 days Kingston CCG did not achieve the breast symptoms standard in April 2015 with performance of 91.7% against targeted levels of 93%. Of these three breaches, these were all due to patients cancelling their appointments and rebooking outside of the 2 weeks. Kingston CCG did not achieve the 62 day standard in April 2015 with performance of 68% against the target of 85% (achievement missed by 8 people). The majority of the breaches seen for the 62 day target are as a result of late transfers across to the Royal Marsden, which have resulted in shared breaches across these two organisations. Joint PTL meetings with the SWL Trusts and the Royal Marsden have been set up to tackle tumour sites like Urology and GI in the first instance, where there are definite performance issues, and this is expected to improve performance to achieve the standards in May 2015. Kingston Hospital has appointed a New Director of Nursing for Cancer Services and has also embarked on providing a programme of education to the Service Line Managers on cancer related subjects including cancer targets and breach reporting, and the Transforming Cancer Services Team is working with trusts to ascertain breach reports for further analysis of the issues, and to support the trusts in South West London to work through the issues in the pathways and transfer of patients. NHS England has started a weekly 62-day cancer PTL, which will be discussed with Kingston Hospital during a weekly performance conference call. 5.3 Accident and Emergency waiting times: Kingston Hospital has been one of the top 5 performing trusts in London for the majority of 2014. However, performance has deteriorated from the end of November 2014, with the monthly targets being missed from December 2014. There has also been a marking increase in emergency admissions from December, which have increased again in April and May 2015. The deterioration in performance centre on the following causes: Large variations in demand resulting in frequent overheating in ED Staff shortages across all providers, including specific resource issues for supporting the variation in demand within ED Whole system capacity imbalance to enable flow. Bed capacity work stream has identified different models for bed capacity based on seasonality (summer/winter) and to reconfigure and enhance bed mix. Version: Final F - 8
Flows within the hospital and to services within the community not sufficiently robust and there are delays discharging those medically fit people and DTOCs. Detailed demand and capacity work has been carried out and there are a range of whole system actions which will be taken forward. These include: Implementing Discharge to Assess and integrated discharge planning, management and delivery across the whole system Explore options for growing and managing market to respond to the decreasing private sector provision of care home capacity. Explore options to increase capacity, which includes establishing a community run non-acute facility in the community or on the Kingston Hospital site and enhancing the care at home model by providing care 24/ 7. Validation of Delayed Transfers patients and implementation of DISCO patient tracking system to give earlier Estimated Date Version: Final F - 9
5.4 Referral to Treatment (RTT) As of the NHS England letter of the 24 th June 2015 there is now one main 18 weeks RTT target - Patients who are still on their treatment pathway are within 18 weeks. There has been consistent good performance 2014-15, in main due to Kingston Hospital continuing to achieve these targets and good waiting list management, seeing patients chronologically. However March 2015, the admitted target was not achieved due to a small level of breaches in Plastic Surgery and Gynaecology at Kingston Hospital (Kingston Hospital achieved the RTT admitted standard overall) due to appointment and scheduling issues, which are now being resolved. There have been no 52 week waiters in April 2015 or May 2015. 5.5 IAPT Patient numbers as a proportion of population with depression, and IAPT proportion of patients moving to recovery The proportion of people with anxiety and depression entering the Kingston service in April and May 2015 is above planned levels (2.7% YTD actual against 2.5% YTD plan). However the proportion of people moving to recovery after having been seen by the IAPT service is under the 50% target (46.1% YTD). Commissioners are meeting with the service regularly, and work is being carried out with the service to ensure that there is sufficient capacity to achieve these targets, as well as to ensure achievement the new 6 and 18 waiting times targets. 5.6 Ambulance clinical quality Category A response times and Ambulance Handover time (Global London Ambulance Service performance) Since the beginning of 2014-15, the London Ambulance Service has signalled capacity and demand issues, with very high staffing attrition rates regionally. While these demand issues have not been seen locally, LAS performance is well below the performance seen in 2013-14 and before. While performance is shown as the global LAS position, Kingston has consistently shown better performance against the Red 1 & 2 targets. Handover breaches are monitored through the weekly South West London CCG Pressure & Performance conference calls with all SWL Trusts, and LAS are putting in place actions such as intelligent conveyance to provide a managed spread of patient flows. Kingston Hospital has consistently strong performance in both 30 and 60 minute handovers and are the best performing trust in South West London, and the 15 minute breaches are being monitored through the Kingston Hospital Performance group. 5.7 Proportion of Bed days lost to Delayed Transfers of Care (per 100,000 adult population) This target reflects the DTOC metric within the Better Care Fund, with the targeted level for 2014-15 taken from the programme. The number of bed days lost to Delayed Transfers of Care in May 2015 has decreased significantly to 263.7 per 100,000 adult population, which equates to 362 bed days lost. These delays were mainly at Kingston Hospital (294 bed days lost) and South West London and St Georges MH Trust (64 bed days lost). Kingston CCG is now receiving daily DTOC information from Kingston Hospital, and is liaising with Your Healthcare community services, the RBK adult social care and other CCGs to ensure that people are discharged safely, effectively and in a timely manner. It is expected that the range of actions relating to A&E performance (above) and timely discharge, such as discharge to assess will make significant improvement to DTOC levels. A full scorecard and copies of the action plans are available to CCG members on GPTeamNet or upon request. Version: Final F - 10
6 Corporate Objectives, Risk Register & Assurance Framework The achievement of the corporate objectives for 2014/5 was reviewed (see separate paper) and agreed subject to approval by the Council of members and the Governing body, The objectives were refreshed, based on the 2014-15 objectives, but categorised using the following new CCG assurance framework categories: 1. Well-led organisation 2. Performance: delivery of commitments and improved outcomes 3. Financial management 4. Planning (short term and long term) 5. Delegated functions The risk register refreshed for 2015/16 once the corporate objectives have been formally approved by the Governing Body. The chart overleaf provides a summary of the risks identified against each corporate objective as at 20 th June 2015. There are 22 risks with a residual risk as follows: Very high 0 High 17 Moderate 5 Two risks have been closed: 947: Uncertainty of charges from NHS Property Services and Community Health Partnerships 953: Failure to successfully complete consultation on mental health inpatient services provided by SWL&StG One new risk has been added 1015: Risk of breaching the NHS Continuing Care Framework on Continuing Healthcare review guidelines The full risk register and assurance framework are available on GPTeamNet. There is currently one remaining risk classified as very high which concerns Continuing Care the details of which are shown below. A summary of all risks is shown overleaf and more detailed reports are available the CCG members on GPTeamNet or on request. Version: Final F - 11
Ref Risk Title Risk Owner Inherent Risk Residual Risk Direction Target Risk 1a: We w ill seek to improve the quality, safety and effectiveness of healthcare services on behalf of the local population 166 Risk to patient safety and Safeguarding Adults Tonia Michaelides Very High (15) High (10) fg High (10) 314 Effectiveness of multi-agency arrangements for Safeguarding children and looked after children services Tonia Michaelides Very High (15) High (12) fg High (8) 611 Risk of not recognising or acting on early w arning signs of failings in the quality and safety of services Laura Jackson High (9) High (9) fg Moderate (6) 1015 Risk of breaching the NHS Continuing Care Framew ork on Continuing Healthcare review guidelines Laura Jackson High (9) High (9) Moderate (6) 1b: We w ill deliver the National Outcomes Framew ork 921 Risk of failing to meet national performance targets Brian Roberts High (12) High (12) fg Moderate (6) 1d. Clinicians w ill lead patient centred service change 926 Inability to demonstrate Clinical Leadership in patient centred service change Nazim Jivani High (9) High (9) fg Moderate (6) 2b: We w ill engage w ith different groups that reflect the population profile of Kingston 924 Inability to demonstrate that the patients, carers and population of Kingston are effectively engaged and involved w ith service planning and delivery Michelle Johnson High (9) Moderate (6) i Moderate (6) 3b: We w ill deliver the QIPP milestones for 2014/15 331 QIPP schemes w ill not deliver anticipated financial savings. Rachel Bartlett High (12) High (12) fg Moderate (6) 4a: We w ill govern w ith transparency, comply w ith best practice and meet statutory duties 173 Risk of breaching Information Governance Rules and Regulations (e.g. Data protection act) Jill Pearse High (9) High (9) fg High (9) 334 Inability to demonstrate sufficient assurance of effectively embedded governance arrangements Jill Pearse High (8) Moderate (4) fg Moderate (4) 621 Risk of fraud or bribery occuring leading to financial and reputational loss; financial penalties and possible criminal proceedings. Tina Jones High (9) Moderate (6) fg Moderate (6) 622 Failure to discharge our statutory duties and/or adhere to established best practice Tonia Michaelides High (12) High (12) fg Moderate (6) 4b: We w ill deliver the 2014/15 Strategic Financial Plan 945 Continuing Care Grow th Jennifer Sinnot Very High (16) High (12) fg High (8) 946 Potential overperformance in acute services Julia Gosden High (12) High (12) fg High (8) 4c: We w ill ensure that there are effective arrangements for oversight of the quality and safety of commissioned services 934 Risk of failing to sustain quality, safety and effectiveness of patient care at South West London & St. Georges Mental Health Trust. Joanne How ard Moderate (6) Moderate (6) fg Low (3) 5a: We w ill w ork w ith NHSE tow ards co-commissioning primary care 613 CCG is unable to maximise usage of clinical space available in Surbiton Health Centre Tony May High (12) Moderate (4) fg Moderate (4) 925 Ineffective commissioning of primary care Rachel Bartlett High (12) High (12) fg Moderate (6) 5b: We w ill w ork in partnership w ith the Royal Borough of Kingston to develop the Kingston Commissioning Collaborative and w ork tow ards integrating commissioning of services w ith RBK. 920 Joint w orking arrangements w ith Royal Borough of Kingston cannot be effectively implemented Tonia Michaelides Very High (15) High (9) fg Low (2) 5c: We w ill explore opportunities w ith neighbouring CCGs for joint w orking arrangements 922 Failure to deliver 2015/16 objectives w ithin SWLCC Strategic 5 year plan Tonia Michaelides High (9) High (9) fg Moderate (6) 5e: We w ill w ork w ith others to transform health and social care through the Better Care Fund programme 923 Failure to deliver the Better Care Programme Rachel Bartlett Very High (16) High (12) fg High (8) 6b: We w ill develop the skills of the Governing Body and ensure a succession planning framew ork is in place 927 Lack of succession planning and people development means that the quality of future leadership and management of the CCG is compromised Tonia Michaelides High (9) High (9) fg Moderate (6) 6c: We w ill engage w ith the CCG w orkforce to develop their skills and rew ard excellence 952 If the CCG fails to engage and develop staff this w ill impact on their motivation to deliver the business of the organisation Jill Pearse High (9) High (9) fg Moderate (6) Version: Final F - 12