NHS Sutton CCG Annual Report and Accounts 2016/17

NHS Sutton CCG Annual Report and Accounts 2016/17

Contents SECTION 1: PERFORMANCE REPORT... 7 Overview... 7 Welcome... 7 Who we are and what we do... 9 Our vision and strategic partners... 11 South West London Five Year Forward Plan... 11 The South West London Alliance... 13 Health and Wellbeing Board... 13 Joint Health and Wellbeing Strategy... 14 Joint Strategic Needs Assessment... 14 Joint Health and Social Care Strategy... 14 Taking forward devolution in health and care for London... 15 Health and wellbeing of people in Sutton... 16 Our borough... 16 How we spend your money... 18 Our achievements for 2016/17... 19 Primary Care... 19 Primary Care Estates... 19 Central Sutton Health Centre... 20 Hackbridge... 20 South Sutton Medical Centre... 20 Patient Experience Network National Awards... 20 Integrated Care... 21 Sutton Homes of Care... 21 Visits to Sutton Homes of Care... 22 Resources: Standardising information for care home staff... 22 Looking ahead... 22 Continuing Healthcare... 23 SWOOP team at St. Helier... 23 Sutton Integrated Digital Care Record... 24 Mental health... 25 Sutton Uplift... 25 Dementia diagnosis rates meet national target... 25 South West London Crisis Cafés... 26 Page 2

Children and Adolescents Mental Health Services (CAMHS)... 26 Helping people to help themselves... 27 Launch of Health Help Now... 27 National Diabetes Prevention Programme (NDPP) update... 27 Our providers... 28 Primary Care... 28 Mental Health... 28 Community Services... 28 Delivering high quality hospital standards... 29 Reducing time in hospital... 29 Improving patient pathways... 30 Challenges and risks... 30 Performance analysis... 32 Improving quality and performance... 32 Referral to Treatment Times (RTT)... 34 Diagnostic Test Waiting Times... 34 Cancer Waiting Time (CWT) standards... 34 Improving Access to Psychological Therapies (IAPT)... 34 Dementia Diagnosis Rate... 35 Transforming care for people with Learning Disabilities... 35 A&E 4 hour wait standard... 36 Category A Ambulance Calls... 36 Mixed sex accommodation... 36 Healthcare Associated Infections... 36 Performance Summary... 37 Quality, Improvement, Productivity and Prevention (QIPP)... 38 Respiratory... 38 Diabetes... 38 Musculoskeletal (MSK) conditions... 39 Better Care Fund... 40 Financial overview... 43 Managing risk... 45 Quality and Safety... 46 Patient experience... 46 Clinical effectiveness... 46 Quality and performance report... 46 Page 3

Transforming care... 47 Early warning and quality assurance... 47 CQC reports... 47 Patient safety... 47 Incident reporting... 47 Serious incidents... 48 Safety thermometer... 48 Healthcare associated infections (HCAIs)... 48 Safeguarding... 49 Medicines Optimisation... 51 Sustainable Development... 52 Patient and Public Involvement... 53 Patient and Public Involvement Report... 53 Patient Participation Groups... 53 Patient Reference Group... 54 Empowering patients and communities Planning for Commissioning... 55 Empowering patients and communities - Sutton Homes of Care... 56 Empowering patients and communities - Patient Education Sessions... 57 Reducing inequality... 58 Health and Wellbeing Strategy... 61 South West London Collaborative Commissioning... 62 Background... 62 2016/17 Engagement Activities... 62 Forward plans... 63 SECTION 2: ACCOUNTABILITY REPORT... 64 Members report... 65 Our achievements as a membership organisation in 2016/17... 65 Locality successes... 65 Delegated Commissioning of Primary Care... 66 Personal Medical Services (PMS) Contract Review... 67 Looking forward 2017/18... 67 How our member practices are organised - localities in Sutton... 68 Our Executive Committee... 69 Our Governing Body (Board)... 69 Our audit committee... 70 Statement of Disclosure to Auditors... 71 Page 4

Modern Slavery Act... 71 Statement of Accountable Officer s Responsibilities... 72 Governance statement... 74 Scope of responsibility... 74 Governance arrangements and effectiveness... 74 Committee Structure... 75 Governing Body... 75 Quality Committee... 77 Executive Committee... 78 Audit Committee... 80 Finance committee... 81 Charitable Funds committee... 82 Remuneration and Nominations Committee... 82 Primary Care Commissioning Committee (PCCC)... 83 Primary Care Commissioning Committee Meeting attendance... 84 UK Corporate Governance Code... 84 Discharge of Statutory Functions... 84 Risk management arrangements and effectiveness... 84 Capacity to Handle Risk... 86 Risk Assessment... 87 Other sources of assurance... 87 Control Issues... 90 Review of economy, efficiency & effectiveness of the use of resources... 90 Counter fraud arrangements... 91 Head of Internal Audit Opinion... 92 Review of the effectiveness of governance, risk management and internal control... 93 Conclusion... 94 Remuneration Report... 95 Remuneration committee report... 95 Remuneration Policy... 95 Senior Managers Performance Related Pay... 95 Senior Managers Service contracts... 95 Senior Managers Salaries and Allowances 2016/17 (audited)... 96 Senior Managers Pension Benefits 2016/17 (audited)... 97 Pay Multiples (audited)... 97 Off-payroll Engagements... 98 Page 5

Our staff... 100 Communicating and Engaging... 100 Training and Development... 100 Employee Consultation... 100 Policy on Disabled Employees... 100 Equalities for Staff... 101 Number of senior managers... 101 Staff numbers and costs... 101 Staff Composition (Audited)... 101 Sickness Absence... 101 Sickness absence data (data to be updated)... 102 Parliamentary Accountability and Audit Report... 103 Appendix 1: Head of Internal Audit Opinion 2016/17... 104 SECTION 3: ACCOUNTS... 106 Page 6

SECTION 1: PERFORMANCE REPORT Overview Welcome Welcome to NHS Sutton Clinical Commissioning Group s fourth Annual Report and Accounts. This Overview (pages 7-8) within the Performance Report provides a short summary of our organisation, its purpose, how it has performed over the year 2016/17 and the key risks and challenges we face going forwards. This is the first year that Sutton CCG has taken on delegated responsibility from NHS England for commissioning GP services. This means that in addition to planning and funding hospital, community and mental health services, we now also commission GP services for our local population. We have this year completed a Primary Care Strategy along with a Primary Care Estates Strategy, to articulate clearly how we are planning on delivering the vision for primary care set out in the NHS Five Year Forward View, and provide even better access to GP services in Sutton read more on page 19. Our Sutton Homes of Care Vanguard programme has gone from strength to strength, supporting our care homes to deliver better care for residents so they are less likely to need hospital care, and ensuring that if they do have to go to hospital they spend less time there. This means better care for patients and less pressure on hospital services, which are facing unprecedented demand. The programme has attracted attention at regional and national level, including a number of high profile visits and media coverage, and elements are now being rolled out across parts of London and in CCGs in elsewhere in the country see page 21. Our mental health services have met some key national targets for the first time - most notably in dementia care and in Improving Access to Psychological Therapies Services meaning that people with dementia and those in emotional distress are getting the care and support they need, helping to prevent people needing in-patient services wherever possible. At the same time, our main provider of acute mental health services, South West London and St. George s Mental Health Trust has moved from Requires Improvement to Good in its latest CQC inspection, which is reassuring for patients who do need a higher level of support for their mental health needs (more on page 25). We have been nominated for a number of national awards this year. Firstly the Sutton Uplift mental health service was nominated for a Health Services Journal award in the category of Services Redesign. The Sutton Homes of Care Vanguard was a finalist in the Skills for Care Accolades 2016/17. Finally, two primary care schemes, the CCG s Patient Education Events and Help Yourself to Health, were finalists in the Patient Experience Network National Awards. Page 7

We have continued our comprehensive programme of patient and public engagement, delivered in partnership with Healthwatch Sutton, which supports all of our GP practices to have their own Patient Participation Group, most of which are represented on the CCG s Patient Reference Group, also coordinated by Healthwatch Sutton. We were therefore delighted that the CCG was assessed as Good for delivery of its statutory obligations for patient and public involvement, following assessment of the work undertaken in 2015/16. As you will be aware, across the country, the NHS is facing unprecedented pressures in terms of demand on its services and a particularly challenging financial climate. In spite of this, we have met most national and local performance targets, meaning that we continue to deliver good, high quality health services for our local population. In April 2017, four of the six CCGs in South West London (Kingston, Merton, Richmond and Wandsworth) are coming together to form the South West London Alliance, to enable more joined up working as we progress with implementing the vision set out in the Sustainability and Transformation Plan for South West London. Sutton will continue to work closely with our South West London partners over the coming year, and will formally join the Alliance in April 2018. It is vital that we work with colleagues across a broader area in order to make crucial changes to the way health services are delivered, so that care is improved and services are more sustainable in the longer term. Equally Sutton CCG will continue to have a local focus, listening to your feedback and ensuring that we deliver the right services that provide the best possible care for Sutton s population. Dr. Brendan Hudson Chair Dr. Chris Elliott Chief Clinical Officer (Accountable Officer) May 2017 Page 8

Who we are and what we do Sutton CCG is a clinically-led membership organisation bringing together 25 GP practices in the London Borough of Sutton into one organisation responsible for commissioning local health services. We serve a population of over 200,000 people in Sutton. We work in partnership with the local NHS hospitals, community services, mental health services, pharmacists and dentists. We also work with Sutton Council, the voluntary sector and our local community to improve health and wellbeing, reduce health inequalities and ensure people in Sutton have equal access to high quality healthcare services. We commission (pay for) and monitor the quality of local healthcare for people in Sutton - helping them stay healthy, and caring for them if they become ill and need extra support. The services we commission include: Hospital services (for example, specialist investigations, routine operations, outpatient appointments). Urgent and emergency care (for example, out of hours GP service, urgent care centre and A&E departments). Services for people with mental health conditions. Community health services (for example, district nursing). Rehabilitation services (for example, physiotherapy). Services to support people with fully funded NHS continuing healthcare (for example, for people with learning disabilities or who are physically frail). Since 1 April 2016, Sutton CCG has been delegated responsibility by NHS England to commission primary medical services (GP services). We commission healthcare services from GP practices, acute hospitals, community healthcare providers and mental health providers. Our main local providers are shown in the table overleaf. Page 9

Main local NHS providers Provider Sutton GP practices Epsom and St Helier University Hospitals NHS Trust South West London and St George s Mental Health NHS Trust St George s University Hospital NHS Foundation Trust The Royal Marsden NHS Foundation Trust GP Services Acute Services Community Services Mental Health Services Cancer Services We also commission healthcare services from the independent and voluntary sectors. We do not commission specialised hospital services. These are commissioned on a national basis by NHS England and include services such as, renal dialysis, neonatal critical care and specialist mental health services. (https://www.england.nhs.uk/commissioning/spec-services/). Page 10

Our vision and strategic partners As doctors, nurses and other healthcare professionals, we work together to put patients first and improve health services in Sutton. Our vision is to commission high quality healthcare for the people in Sutton through joint working with health and social care organisations to ensure that patients physical, mental and social wellbeing needs are met. During 2016/17 we reviewed our vision and values to make sure that they continued to reflect where we are going as an organisation. In consultation with CCG staff, the membership and staff in GP practices, we refreshed our vision statement and developed a set of values to guide our decision making and direct our behaviours. The refreshed vision statement is: Achieving the best affordable health and wellbeing for the people of Sutton Our values are as follows: Innovative we use the creativity of our membership, staff and stakeholders to continuously improve Professional - we act with consistency, responsibility and transparency Compassionate - we actively demonstrate care and compassion for others Collaborative - we work in partnership to make a difference South West London Five Year Forward Plan Following publication of the NHS Five Year Forward View, each NHS region in England was required to publish a Sustainability and Transformation Plan (STP) for the next five years. These plans are intended to meet the clinical, staffing and financial challenges facing the NHS by coming up with a long term plan to ensure that services are safe, high quality and sustainable. Our STP the South West London Five Year Forward Plan covers the boroughs of Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth. It is the product of unprecedented collaboration between all parts of the local NHS - hospital consultants, doctors, nurses, therapists, hospitals, mental health trusts, pharmacists and commissioners working with our colleagues in local councils. There are a number of challenges the NHS needs to address, including increased demand for health services due to an ageing population, quality of care, getting the right staff and the state of some of our buildings. The costs of providing our services are rising far more quickly than the money we get from central government each year. While the financial and staffing challenges are significant, there is compelling evidence that if we spend our money differently, we can get services that are both better and more affordable. Page 11

What does the STP propose? The STP is not a detailed blueprint for the next five years. At this stage, it is a draft document containing a number of ideas and proposals, which are at different stages of development. Taken together, we think they will lead to a number of improvements for patients. These include: It will be easier to see a GP. We are investing in primary care services. We want to make more appointments available between 8am and 8pm and to free up GP time by making better use of other clinicians such as nurses and pharmacists. Our GPs are already working together in local federations and will be able to play a bigger role in coordinating their patients care. More care will be available in your community. We are setting up locality teams in each area to work together in supporting patients. These teams will be made up of your local GPs, nurses, pharmacists, social care staff, mental health and other health professionals, working closely with local hospitals. They will support people to look after themselves and stay well. It will be easier to get treatment in your local health centre, at a local clinic or at home, as we will be putting more resources into your local communities. You will get better advice and support to look after yourself and your loved ones, and NHS and social care staff will work together to support you. We will be launching an improved 111 telephone helpline to provide medical advice and guide you to the right local service. We will make more use of smartphone apps, Skype calls and telephone advice for those who need health advice but don t need to visit their GP. We will support patients who have long-term conditions like diabetes, dementia, asthma or a heart condition and their carers helping them to understand and monitor their condition and when and where they should seek help. Care navigators will increasingly support you to find your way around the system and make sure you only have to provide the same information once. We will run public health campaigns across south west London, helping people to live healthier lives. Your mental and physical health will be treated together. We know that mental and physical health are closely linked but are too often treated separately. A key part of our plan is to join up mental and physical health services. People with mental health problems can also expect to be helped sooner, before their condition gets worse and they end up in crisis at A&E or admitted to a mental health hospital when they do not need to be. By reducing the need for so many people to go to hospital and developing clinical networks between hospitals and other services, we will be able to deliver high quality hospital care more quickly for those who need it. Page 12

Buildings where health services are delivered will be safer for patients and suitable for 21st century healthcare. As a first step, we are asking Local Transformation Boards in each area (Croydon, Sutton, Merton/Wandsworth and Richmond/Kingston) to develop local clinical models for their area - how many community hubs we need, what services we can provide in the community and what each services each of the hospitals should offer. This local work will identify those services that cut across the four sub-regions and need to be considered at south west London level. Out of this, we will arrive at a model of care for the SWL region which is based on each area s needs, rather than trying to come up with a south west London top down solution. There are a number of other ideas and proposals being put forward. You can read our Five Year Forward Plan online at http://www.swlccgs.nhs.uk/our-plan/our-planfor-south-west-london/ Get involved It is important to remember that this is a draft plan, with emerging ideas at different stages of development. We would welcome your comments and queries and we will ensure these are taken into account as our plans develop. We have been talking to people in Sutton and across south west London for several years, and will continue to do so as our plans develop. During 2016/17, we worked with local Healthwatch teams in each borough to speak to 88 grassroots community groups, so we could discuss the issues with people that the NHS does not always succeed in talking to about its services. This included people with physical and learning disabilities, children and young people, older people, black and minority ethnic communities, mental health service users, LGBT communities, faith groups, homeless people, carers, Gypsy, Roma and Travellers, asylum seekers and several others. We have also arranged a public forum in each of the six south west London boroughs and we will look to repeat these in future. The South West London Alliance Four of the six south west London CCGs, including Kingston, Merton, Richmond and Wandsworth, came together on 1 April 2017 to form the South West London Alliance under one accountable officer. Sutton CCG will formally join the Alliance from April 2018. Croydon CCG is not joining the Alliance. Health and Wellbeing Board Sutton s Health and Wellbeing Board (HWB) provides local leadership across health and social care and enables good partnership working between the local NHS, the London Borough of Sutton and the wider community. The HWB considers matters relating to the provision of public health services and the commissioning of adults and children's services across health and social care and the impact of these on the health and wellbeing of the local population. Page 13

Joint Health and Wellbeing Strategy The Joint Health and Wellbeing Strategy (JHWS) sets out our approach to improving the health and wellbeing of everyone in Sutton and reducing health inequalities between communities. The strategy is medium term and covers the financial years from 2016-21 read more on page 61. It is available on Sutton Council s website. Joint Strategic Needs Assessment The Joint Strategic Needs Assessment (JSNA) analysed the health needs of our local population. We use the JSNA to inform and guide our planning and funding of health and wellbeing services in the borough including, for example, the Joint Health and Wellbeing Strategy and the Joint Health and Social Care Strategy. The JSNA can be also be found on Sutton Council s website Joint Health and Social Care Strategy Developed and approved in 2014, our strategy sets out the joint vision of Sutton CCG and London Borough of Sutton (LB Sutton) for the integration of health and social care services locally to address the challenges we face. Building on the Joint Health and Wellbeing Strategy (JHWS), experience of self-directed support, personal budgets, integrated services and pilots, and other strategic documents such as urgent care strategies and mental health strategies, Sutton CCG and LB Sutton aim to develop and commission person-centred, co-ordinated care. The strategy underpins the Sutton Joint Better Care Fund Plan that outlines the programme of work underway to deliver integrated care to achieve seamless, consistent and efficient support for local people (see page 40 for more detail). The strategy is available on our website: Joint health and social care strategy Page 14

Taking forward devolution in health and care for London London faces significant population, health, organisational and financial challenges which must be addressed if we are to support Londoners to be as healthy as they can be and for services to be sustainable. London Partners, including London CCGs, have committed to work more closely together to support those who live and work in London to lead healthier, independent lives, prevent ill-health, and to make the best use of health and care assets. London health and care leaders have worked closely together at local, sub-regional and regional level over a number of years to develop a clear vision for better health and care, built on the views of Londoners, and central government and national bodies backed this commitment through the 2015 London Health Devolution Agreement. Throughout 2016, local, multi-borough and sub-regional (STP) areas in London have worked hard to plan rapid improvements to health and care within existing powers. Five London devolution 'pilots' have also explored how more local powers, resources and decision-making could accelerate the improvements that Londoners want to see. Our devolution work has underscored the importance of working at different levels in London under the three themes of prevention, integration and estates. We are clear that transformation must be locally-led and that many services can only be delivered at the borough or smaller locality level, whereas others are more appropriately aggregated across boroughs or London-wide. The forthcoming London Health and Care Devolution Memorandum of Understanding (MoU) will express commitments by national bodies to enable these improvements to go further and faster, based on the different ambition and appetite of local areas. We have also been working to commence delivery of more collaborative health and care governance and delivery capability at London-level working within the London Health Board arrangements. This aims to complement and support local areas in their transformation ambitions. As an example, the London Estates board has started to meet in shadow form, looking at what projects need help at a London level to progress more speedily, and how we use NHS buildings. This work will help to deliver the modern buildings which London's health service needs, use them as intensively as possible and potentially deliver the land for much needed new housing. NHS Sutton CCG has started discussions with the London Borough of Sutton to investigate how this might be taken forward in the best interests of local residents. Page 15

Health and wellbeing of people in Sutton Our borough Sutton is a healthy place to live with good life expectancy. The borough has an increasingly diverse and multicultural population of over 200,000 people, which is projected to rise to around 216,000 by 2021. Age Sutton is a young borough compared to the England average with children and young people aged 0-19 making up a quarter of the population (25.2%). By 2021 this age group will account for 25.5% of the population, a slightly higher proportion than for London (24.7%) and 23.6% for England. We also have an ageing population - over 65-year olds make up 15.1% of the population and this is forecast to rise to 15.5% by 2021, higher than the proportion expected for London by this date (12%) but lower than England (18.9%). People are tending to live longer, but may often have one or more long-term medical condition. Meanwhile medical technology continues to advance as new or improved treatments and medicines are made available to patients. This means that there is more demand than ever on our health services, and this demand is continuing to increase. We need more and better services provided outside of hospital in GP surgeries, community services and, where appropriate, at home. People need to be supported to live healthier lives and to avoid becoming ill. Better healthcare in the community would make us less reliant on hospitals, which could then focus on helping people in need of specialist care. All health services and social care services would benefit from better integration and working more closely together. Deprivation Overall the borough has good educational attainment and less long-term unemployment than elsewhere in England. Fewer children live in poverty compared to the London and England average. However, inequalities are increasing. Sutton has areas within it that are in the 20% most deprived in England. For the first time Sutton now has one area ranking in the bottom 10%. Some places within the borough have become more deprived over time since 2010 (the last time deprivation measures were published). Life expectancy Overall male life expectancy at birth in Sutton is longer than the England average and female life expectancy is similar. Life expectancy in Sutton increased by four years for men and three years for women from 2001-03 to 2013-15. Over this time, the increase for London was four Page 16

years for men and three years for women. For England it was three years for men and two years for women. Within the borough there is a difference in life expectancy of 7.4 years for males and 4.4 years for females within Sutton between the most and the least deprived populations (this is called the Slope Index of Inequality). Main areas of poor health Circulatory disease (including stroke) and cancer are still the major causes of death in Sutton. These diseases (as well as respiratory disease and diabetes) are among the main causes of long term illness and disability. Key risk factors include smoking, obesity, a lack of physical activity and excessive alcohol intake. Therefore many conditions are potentially preventable, for example by stopping smoking and exercise. Ethnicity Our population is becoming more diverse. In 2011, 21% of the population were from Black and Minority Ethnic (BAME) communities compared to 11% in 2001. Taking into account people from non-british white communities (other European communities and Irish) almost three in ten people are from an ethnic minority. Overall the ethnic profile of Sutton is becoming more diverse over time, but less so than many London boroughs. The extent of diversity has increased markedly over recent years with emerging new Polish, Urdu and Tamil communities. Religion According to the 2011 census 58.4% of people living in Sutton identify themselves as Christian compared to 48.4% in London and 59.4% nationally. The next most common religions were Muslim and Hindu. The profile of religious affiliation in Sutton is closer to the national profile than to London reflecting the current ethnic diversity of the borough. Disability Census data shows 14.3% of people living in Sutton reported having a limiting longterm illness. This is similar to London (14.2%) and lower than for England (17.6%). Page 17

How we spend your money Sutton CCG commissions healthcare services to meet the needs and improve the health of the population registered at 25 GP practices based in the London Borough of Sutton. The main NHS providers the CCG commissions from are Epsom and St Helier University Hospitals NHS Trust, St George s Healthcare NHS Foundation Trust, South West London and St George s Mental Health Trust and The Royal Marsden NHS Foundation Trust (who provide both acute and community services). The CCG commissions a number of other services, such as funded nursing care and continuing healthcare (from nursing homes) and palliative care from local hospices. The CCG also meets the prescribing costs of its practice population. From 1 st April 2016, the CCG is also responsible for the payments made to its practices via delegated primary care commissioning. This transfer of responsibility has seen the CCG s primary care spend jump from 3.5m in 2015/16 to 29.0m in 2016/17. NHS Sutton CCG s total expenditure for 2016/17 was 270.5 million. An analysis of this spend is shown in the following pie-chart: 2016/17 Sutton CCG expenditure by care type (total spend 270.5 million) All figures in millions Page 18

Our achievements for 2016/17 Following are some examples of areas where we have made good progress this year. Primary Care Since April 2016, Sutton CCG has taken on delegated responsibility from NHS England for commissioning GP services. We work with our GP practices to ensure that all residents in Sutton have access to good quality GP services. The CCG has also established a new Primary Care Commissioning Committee, with representation from the local community, to ensure we manage appropriately any potential conflicts of interest arising out of these arrangements. The CCG has developed a new Primary Care Strategy, in collaboration with our member practices and other local NHS partners, as well as Sutton Council and our patient engagement network. The document sets out the strategic vision for primary care in Sutton for the next four years, taking into consideration patient access and quality of services, as well as workforce, finance, estates and IT. The strategy is in line with the NHS Five Year Forward View, Transforming Primary Care in London and the SWL Sustainability and Transformation Plan. Early in 2017/18 the CCG will open a new Primary Care Extended Access Service, working closely with Sutton s GP Federation, Sutton GP Services Limited. The new service will ensure that patients will have access to GP and practice nurse appointments from 8am to 8pm, seven days a week. The service will initially be provided from one GP Practice site, with appointments bookable for all patients registered with practices in Sutton, with a second site opening later in the year following engagement with patients and public. Primary Care Estates The CCG has also developed an Estates Strategy for primary and community services, in order to respond to the challenges set out in the NHS Five Year Forward View, which include: Developing seven day per week services Developing more health services in community settings, out of hospital Improving use of current estate capacity Making greater use of information technology to improve clinical efficiency and safety Moving away from small single-handed GP surgeries and developing fit for purpose premises to accommodate larger practices or multiple practices Closer cooperation between and integration of health and social care services. The Estates Strategy takes into account planned housing developments in Sutton that will increase population size over time, meaning that capacity of GP services will Page 19

need to be expanded. The strategy identifies a number of priority areas for premises development, including three significant developments as follows: Central Sutton Health Centre Sutton CCG has been successful in the first stage of the NHS England bid process (Estates and Technology Transformation Fund - ETTF) for funding for a significant development on the existing health centre site and adjacent land at Robin Hood Lane in Sutton town centre. The proposed large development has potential to house GP services for approximately 50,000 patients, along with additional community and out of hospital health and care services, to meet the needs of the growing population in and around Sutton town centre. The next stage of the process is to submit a detailed business case, and the CCG is undertaking further patient and practice engagement to help shape this as it progresses. Hackbridge A new health centre will be built as part of a large housing development in Hackbridge in north Sutton. The GP practice nearby, Hackbridge Medical Centre, will relocate to the new, larger premises when this is complete, which is planned for 2019. South Sutton Medical Centre The CCG has approved plans for a new GP surgery in South Sutton, subject to planning permission being granted. This would relocate the Belmont surgery, the branch of the Benhill and Belmont GP Centre, to Homelands Drive, the site of the former Henderson Hospital, which closed in 2009. The plans for the new building were developed to meet the requirements of expected growth in the south Sutton population over the next few years and the need for an improved primary care network in the area, given plans to build both a new cancer hub and a large school. In addition to these developments, the CCG is seeking other primary care premises in the Cheam, North Cheam and Worcester Park area, which would provide increased capacity for general practice, and would help ease the pressure on services created by an increasing population in this area. Patient Experience Network National Awards Two primary care schemes aiming to improve patient experience in Sutton were among six finalists from across the country in the Access to Information category of the Patient Experience Network National Awards, held on 21 March 2017 at the Birmingham Repertory Theatre. Although not overall winners on the night, the nominations for the CCG s Patient Education Events and Help Yourself to Health highlighted the excellent work done by Sutton CCG staff and their partners in reaching out to local people to help them proactively take care of their own health. The Patient Education Events were designed to support GPs in educating their patients about proactively managing their own healthcare. A series of targeted sessions about long term conditions, children s care and health in older age, were Page 20

delivered in community venues across Sutton, in partnership with colleagues across general practice, pharmacy, community services and many others. Over the year from March 2016 to March 2017, around 1000 patients attended 11 patient education events and 34 short talks, with overwhelmingly positive feedback from attendees. Help Yourself to Health (runner up in the category) is a 6 week interactive educational course for Sutton s Tamil, Urdu and Polish communities, delivered by Health Advocacy Workers speaking those languages. The courses are designed with input from Public Health, Livewell Sutton, the Health Advocacy Workers, the participants and Sutton CCG. The London Borough of Sutton is becoming increasingly diverse and the growth of various ethnic communities necessitates increased sensitivity to cultural diversity. The programme aims to improve knowledge and access to services, remove barriers, reduce health inequalities and improve local services, as historically these groups have experienced poorer health and greater barriers to accessing health services. Course content, materials and tools have been designed to be flexible and respond to the groups needs and capabilities, with 90% of participants completing the course. Integrated Care Sutton Homes of Care It s been two years since Sutton Homes of Care was selected to be one of only two sites in London to become a vanguard site as part of the national New Care Models Programme Five Year Forward View. Over the last year we have continued to work with our local partners in health, social care and the voluntary sector, to provide support to local care homes, with the aim of improving safety and quality of services for residents. The Sutton Homes of Care team have celebrated many successes, a few of which are below: The streamlined, integrated care through the hospital transfer pathway (known as the red bag pathway) has reduced residents length of stay in hospital by four days, saving approximately 183,000 a year in running costs and minimising the time care home residents stay in hospital unnecessarily. To celebrate the red bag s success, we have created a new video with St. Helier Hospital, London Ambulance and Crossways Nursing Home which you can find on Youtube The Care Home pharmacist has carried out 367 medication reviews (up from 305 last year) and 614 medication alterations (up from 530) at twelve nursing homes, saving around 100,864 in total (about 275 saved for each review). This has also improved the quality of care for residents by providing them with more appropriate medication Page 21

Specialised resource packs contributed to a drop in urinary tract infection rates. Visits to Sutton Homes of Care There have been a few notable visits to the Sutton Homes of Care vanguard team this year, most recently, Professor Don Berwick from the King s Fund, formerly President Barack Obama s director for Medicare and Medicaid, and David Mowat MP, Parliamentary Undersecretary of State for Care and Support. Both visits highlighted how the successes of the vanguard team will help pave the way for similar projects across the NHS in the future, and how supporting small, brilliantly simple initiatives can make a big difference in care homes residents health and wellbeing. Resources: Standardising information for care home staff Finding time to release care home staff for training sessions can be challenging. Care homes can also face high staff turnover, meaning any formal training that is provided may only yield short-term benefits, making it an inefficient means of educating and empowering staff. To combat this, a series of resources have been produced to provide care home staff with up-to-date and immediate information about appropriate referrals and best practices in providing care. Sutton Homes of Care developed posters and reference cards along with training films and e-learning packages as resources to address key issues like dehydration, sepsis and falls. The resources have been distributed across the care home network in Sutton, and are embedded by the care home support team, helping to standardise the training and information available to improve the health of care home residents. The resources have led to better decision-making by care home staff, improving health outcomes for the residents as well as significant benefits for the wider health economy. The resources available are posters which are fixed in key visible locations in the care homes and credit-card-sized reference cards which are attached to staff key rings or lanyards along with training films and e-learning packages. The content was developed in conjunction with a range of local partners including community services, acute hospital staff and the London Ambulance Service. The Link Nurses and Supportive Care nurses play a vital role in supporting care home staff to apply these resources in practice. The low cost production of these resources has led to significant benefits for the NHS, including reductions in ambulance callouts and A&E attendances, freeing up much needed beds and other resources at a critical time. Looking ahead The success of Sutton Homes of Care vanguard is now spreading across the country. The red bag hospital transfer pathway initiative has been adopted in two Page 22

other care home Vanguards: Wakefield, and East and North Herts; as well as sites across London and nationally who have purchased bags to implement the pathway. Continuing Healthcare The CCG works with partners including London Borough of Sutton, Epsom and St Helier and St George s hospitals, Sutton Community Health Services and St Raphael s hospice to assess whether patients meet the national eligibility criteria to receive NHS Continuing Healthcare (CHC), for example whether their healthcare needs are intense, unpredictable, complex or if their needs impact on how their care is delivered. The CHC Placement Team will liaise with patients who are eligible for CHC and arrange a package of care to meet their needs, either in a care home or in their own home. The team can also offer patients a Personal Healthcare Budget within the community, which promotes autonomy and independence when deciding their care arrangements. The CHC team comprises of nurses who undertake the assessments, supported by administrators and commissioners. All Nursing Homes registered with a Sutton CCG GP have a dedicated nurse assessor from the CHC team, to ensure open and transparent communication between the nursing homes, service users and families. During 2016/17, following completion of NHS England s London region Assurance Framework for CHC assessment and commissioning, Sutton CCG was assessed as Good. In January 2017 Sutton CCG s CHC team was visited by Ed Rose, Senior Health Advisor to Simon Stevens, NHS England s Chief Executive. The purpose of the visit was to meet with health and social care professionals to look at the success of the CHC assessment process in Sutton. NHS Continuing Healthcare is a new national improvement priority, and NHS England is working closely with commissioners to transform CHC commissioning in a development programme that aims to provide fair access to CHC, better outcomes, better experience and better use of resources. CCGs were invited to apply to become a development partner for this programme, and Sutton CCG has been appointed as one of only 10 development partners across the country, and the only one in London. SWOOP team at St. Helier The SWOOP Team is an integrated multi-agency community team based at St Helier Hospital to support discharging patients with complex needs back into the community. The team consists of community nurses, therapists, healthcare assistants and social workers, and is funded from Winter Resilience money. It acts as a single point of referral for patients who may need support from community services after their discharge from hospital. The team works 8am 8pm, seven days a week on the Acute Medical Unit, Surgical Assessment Unit and escalation wards in the hospital, ensuring patients with complex needs are managed safely back home. As a result of the team s work, Sutton has one of the lowest delayed discharge Page 23

figures in London, and this has also contributed to the Trust s strong performance against the four hour A&E target - see more on page 36. Sutton Integrated Digital Care Record Over the past year, the CCG and the London Borough of Sutton (LBS) have been working together to further develop the Sutton Integrated Digital Care Record (Sutton IDCR), enabling relevant health and social care professionals to share records for the benefit of residents registered with a GP in Sutton. The Sutton IDCR enables information from residents GP and adult social care records to be shared with local Urgent Care, Accident and Emergency, mental health and community health services. We are currently working on enabling GP out of hours services to access the Sutton IDCR, along with the development of data feeds from Sutton Community Health Services and St Helier Hospital. We will also be rolling out access to GPs, who will be able to access the Sutton IDCR through their own clinical system while sitting with their patient. Initially they will be able to access Adult Social Care records, along with additional health data once feeds have been developed. The system makes information exchange safer, speedier and more accurate, accessible by both health and social care professionals, which in turn should lead to better health outcomes for the patient. Information will only be accessed from the Sutton IDCR after patients have had the opportunity to confirm their consent (or opt out if they wish) to their record being accessed by their GP, health professional and/or social care professional. There are many benefits to enabling health and social care professionals to share patient/service user records. It is estimated sharing information between GPs and Urgent Care 1 could save up to half a day in time and/or prevent a hospital admission in comparison to when information is requested over the phone. For example, staff in St Helier A&E are able to see patients up to date medical history and test results from the GP patient record, avoiding delay and duplication. In November 2016 the CCG and LBS were successful in securing the first stage of the NHS England Estates and Technology Transformation Fund (ETTF) bid process. The ETTF is an NHS England fund set up to support primary care transformation through capital support for primary care premises and technology schemes for the next three years. If granted, the additional funding will support extending available data and organisational access to further improve delivery of care and enhance operational efficiency. It will also enable the development of Sutton IDCR to support mobile working, integrated care planning and a patient portal. 1 A clinic focused on the delivery of care for injuries or illnesses requiring immediate care, but not serious enough for the Emergency Room. Types of injuries treated at Urgent Care Centres include sprains and strains and broken bones. Page 24

Mental health Sutton Uplift Launched in 2015, Sutton Uplift continues to provide an innovative primary care mental health service that is an integral part of the CCG s ongoing commitment to offer enhanced primary care mental health services and evidence-based psychological therapy services to Sutton s communities. The service is provided by South West London and St. George s Mental Health Trust and voluntary sector partners: Imagine, Age UK Sutton, Off the Record and the Sutton Carers Centre. As well as providing Improving Access to Psychological Therapy (IAPT) Services, it has created a well-being arena which links IAPT services and the recovery team, employment support and outreach to all sectors of the community, including those which have been historically difficult to reach. The programme s partnership model and collaborative working with other providers has engaged a broader number of people and community groups who are often considered harder to reach and who would not normally seek help or access health services. The service received 7,649 referrals during its first year, and approximately 86% of these went on to be seen by the Sutton Uplift service. Since its launch in July 2015, there has been a continual growth of services and progress towards achieving the challenging National Improving Access to Psychological Therapy Key Performance Indicators. During 16/17 the IAPT National access target of 15% of need has been exceeded, with 16% entering treatment across the year to date (April February). The numbers reaching recovery has also improved with an average recovery rate of 48.4% across 16/17, just short of the 50% national target. The Sutton Uplift team, L-R: Corinna White, Alex Roger, Dr Chris Keers, Sue Roostan, Navroop Kullar Sutton Uplift was nominated for a 2016 Health Service Journal Award, in the category of Services Redesign, in light of the radical restructure of Sutton s primary care mental health services. Unfortunately the Sutton Uplift wasn t the winner on the night, but being one of the finalists was recognition of the hard work and tremendous progress made to date. A video was developed to support the HSJ nomination, which can be viewed here. Dementia diagnosis rates meet national target NHS Sutton CCG s member practices achieved a Dementia Diagnosis rate of 67.0% in October 2016, meeting the national target (66.7%) for the first time. This means that more people with dementia are being diagnosed and offered the care and support they need, with the diagnosis rate currently at 68.5% (as of February 2017). We have come a long way from our starting diagnosis rate of 39% in 2014, thanks to our member practices sustained efforts, alongside the CCG s Mental Health and the Primary Care teams, with the Vanguard team s support. Page 25

Sutton CCG has also undertaken dementia training for local GPs to increase confidence in making a diagnosis. South West London Crisis Cafés South West London and St. George s Mental Health NHS Trust have commissioned two Mental Health Crisis Recovery Cafés for Merton, Sutton, Wandsworth, Kingston and Richmond following a tender process. The two cafes will operate from Tooting and West Wimbledon, which have good transport networks to enable wide access to these services. The providers of the café services will work closely with the Trust and local communities to develop a non-stigmatising, accessible service that can provide peerled support to people in mental health crisis in the evenings and at weekends. The crisis cafes will open in April 2017 and will be open seven evenings a week from 6.00pm -11.00pm, offering an alternative to A&E for people in crisis. The service will have directs link to the Trust s Community Home Treatment Teams and will offer peer-led support to people who feel they are in crisis, helping them to develop self-management strategies and to build resilience. The service will also signpost people to other local resources and mental health services. The definition of crisis for this service is self-determined and therefore the Cafés will be open to anyone in the five South West London boroughs who feels they would benefit from this support. The cafés will be evaluated from the outset and findings reported on late in the first year, with consideration given to further expanding the service. Children and Adolescents Mental Health Services (CAMHS) During 2016/17, Sutton and other south west London CCGs have developed a south west London eating disorder hub, with funding from the Department of Health CAMHS transformation programme. The new hub provides an effective day service for people with eating disorders, reducing the need for specialist in-patient admission. This year we have also increased psychiatric liaison at A&E in St Helier and the other South West London acute hospitals, to improve care for children and young people with mental health needs. Following investment in 2015/16 in a Single Point of Assessment, this has meant that all CAMHS referrals from GPs, schools and others health and care professionals are assessed promptly, enabling children and young people to quickly access the most appropriate service. Other areas of development in Sutton included a new online counselling service, self-referral for CAMHS services, and Open Space, a Sutton drop-in service that started in May 2016. Each school now has a named mental health lead, with a training programme to support them in their role. Page 26

Helping people to help themselves Launch of Health Help Now NHS Sutton Clinical Commissioning Group (CCG) launched a new digital tool in November 2016, to help local people to understand where they should go for treatment, especially when they need healthcare in a hurry or late at night or at the weekend. Health Help Now is an app and website which will help people check their symptoms and find advice, and also recommends the best place for treatment showing which nearby services are open. Importantly, it will help people get the right advice on the right services, helping to reduce unnecessary trips to A&E. Residents can access the site online at www.healthhelpnow-nhs.net or download it from the App Store or Google Play. The app is broken down into different age groups baby, child, teenager, adult and older adult - making it easier for people to find the right treatment for them. Health Help Now also offers advice on lots of health problems, such as what to do if you accidentally run out of medication, and has links to dozens of local services in Sutton. The advice on the app and website has been checked rigorously by local GPs. National Diabetes Prevention Programme (NDPP) update As part of the ongoing diabetes transformation initiative in Sutton, more than 500 patients have now taken part in the Healthier You, National Diabetes Prevention Programme (NDPP) here in Sutton, since its launch in August 2016. Even though this is great news, we still have a long way to go as a health economy identifying and sign posting our patients deemed as "at risk" of Type 2 diabetes. Public Health England has predicted that there are up to 9,000 people in Sutton who have not yet been identified and sign posted to an intervention programme. The NHS NDPP is a nine month, evidence-based behaviour intervention programme designed to help those at risk of Type 2 diabetes to significantly reduce their chances of developing the condition. This programme is currently being funded by NHS England for the next 3 years in Sutton. A series of programmes is currently being run at the Sutton Centre for Independent Living and Learning (SCILL) centre in Sutton at different times and days of the week to suit patients' lifestyles. The programme is available to all patients aged 18+ registered with a Sutton GP and who are deemed as at risk of developing Type 2 diabetes and patients need to also have a glycated haemoglobin level in the past 12 months that falls into the pre-diabetes range. Participants receive support to change their lifestyle in a friendly and supportive group environment, facilitated by specialist staff trained in behaviour change and Page 27

diabetes prevention. The multi-component intervention programme includes discussions such as: Be Aware - Understanding health risks Eat Well - Nutrition guidance Take Control - Behaviour change Move More - Physical activity support There has been fantastic patient feedback so far from those who are currently enrolled on the programme, with an increasing number of Sutton GPs referring patients into the service. Our providers Primary Care Please see Primary Care section on page 19. Contracts We are looking at innovative ways of contracting with our providers, the organisations we commission services from, to ensure that we provide the best possible health services for local people that are also financially sustainable in the longer term. We are also looking at how we deliver new models of care, so that people are treated in the best place for their healthcare needs. Mental Health We were delighted that our mental health provider, South West London and St. George's Mental Health NHS Trust (SWLSTG) was rated as Good by the Care Quality Commission following an inspection in September. The Trust had previously been rated as requires improvement. In March, the CQC inspected ten services and praised caring staff across all services saying care was delivered by hard-working, caring and compassionate staff who were enthusiastic, passionate and demonstrated a clear commitment to their work. The Inspectors also said that they saw many examples of where staff really knew the patients and their carers well and were attentive to their individual needs. Returning to carry out a follow up inspection in September, the Inspectors said that they were impressed by the improvements that were evident in the Trust s supervision, administrative and medicines management processes and they were now confident that eight out of the ten core services were rated as good. The Trust therefore now rates as good overall for being well-led, caring, effective and responsive. Community Services Sutton CCG and the London Borough of Sutton selected The Royal Marsden to Page 28

provide and run Sutton Community Health Services, and Sutton Children s Health Services from 1 April 2016. Community health services include adult community nursing and specialist therapies, long-term conditions, end-of-life care, services for people aged 65 and over, adult musculoskeletal and neurotherapy services as well as children s therapies. Children s services include a new model of public health services from pregnancy to 19 years of age in Sutton ensuring a more consistent joined up pathway for all children, young people and their families in the borough. In the first year we have been working closely with the Trust to bed in new services and enhance access and quality of care. A key enabler for this is attracting and retaining the right workforce. Royal Marsden has been looking at innovative ways to approach this and has made good progress towards the end of 2016/17. Delivering high quality hospital standards We have been working with the other five CCGs in South West London and the four hospital trusts to continue working towards delivering the London Quality Standards. More information about this work can be found on the South West London collaborative commissioning website. Epsom and St. Helier has opened a new dementia ward, an environment created to support the delivery of personalised care based on the specific needs of people with dementia. The ward has been designed to help people with dementia feel less disorientated or confused, with dementia-friendly colours, pictures of scenes from nature, a bespoke reminiscence area and regular afternoon tea parties. The CCG has also worked with the Trust to implement the new Safety Huddle, a morning meeting led by ward matrons focusing on a checklist of high risk patients, to bring to everyone s attention those patients that need the most support. The Trust has recently been awarded the British Journal of Nursing Award for Innovation, for this initiative which is known as the Perfect Handover. Reducing time in hospital A key target for Sutton CCG is to prevent admissions to hospital where appropriate and possible. Within the Better Care Fund programme, our target is to work together with health and social care partners to deliver a 3.5% reduction in non-elective admissions. More information on actions taken and outcomes can be found on page 40 onwards. As described on page 21, the Sutton Homes of Care Vanguard s red bag initiative has helped to reduce the time care home residents are spending in hospital by up to four days. In addition, the initiative to standardise information and training for care home staff has helped them deliver better care, reducing ambulance callouts, A&E attendances and therefore admissions to hospital for care home residents. Page 29

Improving patient pathways We have been working with our hospital and community partners to develop new pathways of care for patients, to ensure they are getting the right care in the right place, out of hospital and closer to home where possible. This year we have focused on pathways for patients with respiratory conditions, diabetes and those needing musculoskeletal treatment and care. As part of the CCG s Cancer Work Plan, we have also introduced a Straight to Scope pathway to improve early detection and diagnosis for patients with colorectal cancer, and a community follow-up service for patients with prostate cancer. Challenges and risks Scale of challenge across South West London The NHS as a whole is facing a massive financial challenge. In recent years our budget has increased each year in line with inflation, but the costs of providing care are going up much faster than that. People are living longer and the population is rising. We have an ageing population in which many more people have ongoing physical or mental health conditions, meaning we are treating more people than ever, with more complex conditions. If we do nothing and continue to provide exactly the same services, then by 2018, we will be 210 million short across south west London. That would lead to the risk of an unacceptable decline in the quality of services. That is why we are working with the other south west London CCGs to transform local health services as set out in the South West London Sustainability and Transformation Plan, to ensure that in the longer term we are able to deliver safe, effective services that are financially sustainable. In order to work effectively, it is crucial that we bring our organisations together in the South West London Alliance, as set out on page 13. We will be working with our Alliance colleagues through 2017/18 to align our organisations and ensure we have clear and robust plans in place for Sutton CCG when we formally join the Alliance in April 2018. Local financial challenge Locally we have worked hard over the last year to manage our finances effectively, and have managed to remain within our financial plan. However, as the financial pressures continue to grow, we know we may have to make some more difficult decisions in the period ahead. System pressures We continued to see immense pressure across the local healthcare system, both in our hospitals and in primary care. Despite this, Epsom and St. Helier Hospitals managed extremely well all through the winter, and were consistently among the highest performers in the country for meeting their A&E waiting time targets. This was in part due to CCG initiatives such as Sutton Homes of Care and the SWOOP Page 30

team, which aimed to minimise the amount of time people spent in hospital, thus reducing the pressure on hospital services. Page 31

Performance analysis Improving quality and performance The CCG is required to commission health services that are safe, that maintain or improve quality and offer information to inform patients choice on how, when and where they receive their healthcare services. We have a range of performance measures by which we judge whether we have delivered what we set out to do, as set out below. We also work with our providers to ensure that continuous improvement is made against the NHS Constitution measures. We have established weekly calls with providers to ensure risks are being mitigated. In addition, monthly System Resilience Group Meetings are held where the CCG monitors performance and reviews demand and capacity plans. The CCG Chief Officer leads fortnightly internal performance meetings. We have effective quality assurance processes. The Quality Committee oversees these processes which include attendance at Quality Surveillance Group (QSG); Clinical Quality Review Group (CQRG) meetings with commissioned services; attendance at other CCG CQRG meetings with services that affect Sutton CCG s local population and Serious Incident Sub-Committee meetings with a specific focus on the scrutiny of serious incident investigations. CCG improvement and assessment framework NHS England introduced a new Improvement and Assessment Framework for CCGs (CCG IAF) from 2016/17 onwards. The new framework to cover indicators located in four domains: Better Health: this section looks at how the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve; Better Care: this principally focuses on care redesign, performance of constitutional standards, and outcomes, including in important clinical areas; Sustainability: this section looks at how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends; Leadership: this domain assesses the quality of the CCG s leadership, the quality of its plans, how the CCG works with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity, for example in managing conflicts of interest. The following diagram summarises the framework: Page 32

Assurance with NHS England takes place through a continuous monitoring process of submissions, meetings and teleconferences, with organisations that have a lower level of assurance required to provide more frequent assurance. NHS Sutton CCG s overall assessment for the financial year 2016/17 was requires improvement. The 2016/17 year-end assurance assessment for Sutton CCG will be available from July 2017, after publication of the CCG annual report, on www.nhs.uk/servicesearch/performance/search The year-end results for the Quality of Leadership Indicator will also be available from July 2017, at www.nhs.uk/service-search/scorecard/results/1175 The latest available result on MyNHS (Quarter 2, 2016/17) shows Sutton CCG as Green for leadership, and fully compliant for probity and corporate governance. The NHS Outcomes Framework measures performance against NHS Constitution standards and national performance indicators. Performance indicators provide a means for us to measure and assess the quality and productivity of the services we commission to ensure they are equitable, safe, accessible, effective, compassionate, well-led, responsive, and deliver a good patient experience. We know that services that deliver good quality care are more cost effective and efficient than services that demonstrate poor quality. Performance indicators help us to know where our local services are performing well and where they need to improve. This information is used to identify and spread good practice Page 33

ideas, as well as to inform us where to focus our attention to improve the care our patients receive in partnership with our service providers. We cannot judge performance on one single measure and therefore we look at a range of information using national and local performance data that helps us to compare performance standards between similar health service providers (benchmarking). Referral to Treatment Times (RTT) The Referral to Treatment (RTT) operational standards are that 90 per cent of admitted and 95 per cent of non-admitted patients should start consultant-led treatment within 18 weeks of referral. In order to sustain delivery of these standards, 92 per cent of patients who have not yet started treatment should have been waiting no more than 18 weeks. Sutton s performance for this standard for April 2015 January 2016 was 92.5% achieving the national standard. However, this figure does not include data from St George s who stopped reporting of RTT data in June in order to improve data quality and accuracy. Diagnostic Test Waiting Times The operational standard is that no more than one per cent of patients should be waiting more than six weeks or more for a diagnostic test. Sutton CCG achieved the six week wait diagnostic standard in seven out of the last ten months, however, overall for the year to date performance is at 98.6%, slightly below the national target. Cancer Waiting Time (CWT) standards For the majority of cancer waiting times standards the CCG performs well. In a number of cases performance is more than two percentage points above the required levels of performance. The only standard where Sutton CCG has not achieved the required performance standard for the year so far is 62 days screening where the CCG s performance is currently 84.4% against a target of 90%. Improving Access to Psychological Therapies (IAPT) Sutton s new Primary Care Mental Health Service, Sutton Uplift has now been operating for almost two years, following its launch in 2015. The service includes a well-being arena, the IAPT service and recovery support for those with stable but severe mental health concerns, and is provided by SWL & St George s and voluntary sector partners: Imagine, Age UK Sutton, Off the Record and the Sutton Carers Centre. The single point of referral for mental health services received 7,649 mental health referrals during its first year, approximately 86% of which were considered appropriate for further support from Sutton Uplift s treatment services, with 14% referred on to other (secondary care or specialist) mental health services. Page 34

Since its launch in July 2015, there has been a continual growth of services and progress towards achieving the challenging National Improving Access to Psychological Therapies Key Performance Indicators. During 16/17 the IAPT National access target of 15% of need has been exceeded, with 16% entering treatment across the year to date (April February). The numbers reaching recovery has also improved with an average recovery rate of 48.4 across 16/17, ranging from 44% in April 2016 to 49% in February 2017, thus just short of the 50% National target. Apart from meeting these key performance indicators Sutton Uplift works innovatively in a number of ways to ensure: Ease of access Wider treatment/support options across a broader range of concerns, as well as a holistic package of care, are available Employment support is included in all treatment options where need is identified Engagement with a broader number of people and community groups, offering drop-in services and bespoke workshops, which enhances access to those who tend to be harder to reach and may not normally seek help or access health services. Dementia Diagnosis Rate Sutton CCG has made significant progress throughout the year to meet the national standard of 66.7% of people estimated to have dementia to have received a diagnosis. Since October 2016 we have exceeded this standard and currently have a diagnosis rate of 68.5% (February 2017). This improvement has been down to a number of work streams including support for GPs to run regular coding checks and dementia register updates, good communication and ensuring data consistency between the specialist mental health team and GP practices and introduction of a dementia identification tool in Sutton s 29 local care homes. Transforming care for people with Learning Disabilities In March 2017, the CCG hosted a Learning Disabilities (LD) Summit, which brought together a broad range of LD providers, commissioners, service users and carers. The aim of the summit was to understand current provision and pathways across age groups, and to identify service gaps, to inform commissioning intentions for people with learning disabilities going forward. This year we have developed a LD performance management framework and we have undertaken contract monitoring of Specialist LD Health Service providers, undertaken by a Clinical Health Team for people with Learning disabilities and the Mental Health and Learning Disability team. We have worked with our providers to bring about service improvements for people with LD in mainstream health services, including at St Helier Hospital, Royal Marsden Community Health Services and South West London and St George s Mental Health NHS Trust. Page 35

We are currently developing a Joint LD Health and Social Care Strategy, which will be finalised early in 2017/18. We are also reviewing continuing healthcare and looking at transformation of care for people with LD. The assessment and diagnostic services for Autism Spectrum Disorders and for Attention Deficit and Hyperactivity Disorder that were commissioned in Jan 2016 are due for review early in 2017/18. A&E 4 hour wait standard The national standard states that 95 per cent of patients should be seen within four hours in an A&E department. Epsom and St. Helier has met the four hour standard with a performance for the year to date of 95.2% Trusts across the country and London alike have struggled to consistently meet this requirement. St. George s University Hospital Trust achieved 91.9% against the national standard for the year to date. Category A Ambulance Calls London Ambulance Service experienced severe activity and utilisation pressures throughout 2016-17. London Ambulance Service (LAS) have not met two (Red 1 and Red 2) of the three standards London-wide for response times since May 2014 and have an improvement plan in place. Local response times in Sutton are improving towards the action plan trajectory. Cat A (19 minute target) is on plan at 96.1% (target 95%) year to date to February. Commissioners across London continue to monitor progress against the agreed action plan. Mixed sex accommodation During 2016/17 we have had no mixed sex accommodation breaches in our major hospital providers. Healthcare Associated Infections Please refer to the relevant section in Patient Safety on page 47 for more detail. Page 36

Performance Summary Page 37

Quality, Improvement, Productivity and Prevention (QIPP) In 2016-17 QIPP schemes were identified at the beginning of the financial year to the value of 6.5m. We are currently reporting an outturn for 2016-17 of 6.432m savings against that target. This equates to 95.11% of the total. The CCG has a full programme of QIPP schemes, and throughout 2016/17 has undertaken comprehensive programmes of work for adult patients with the following conditions: Respiratory This was chosen as an area of focus because: National benchmarking data identifies Sutton as an outlier on spend for nonelective care, primary prescribing and day case admissions for adults with respiratory conditions Local intelligence suggests that more patients over 65 attend A&E frequently via the London Ambulance Service Exacerbations for patients living with respiratory conditions are high Evidence suggests that effective management of people with respiratory long term conditions can reduce numbers of unplanned hospital admissions for respiratory disease by up to 20% Consultant input into primary care is shown to improve primary care patient management Pulmonary rehabilitation delivers evidence based benefits, and there is scope in Sutton to expand and improve the pulmonary rehabilitation service. The programme of work aims to ensure: Effective transfer of patients into appropriate care settings A streamlined pulmonary rehab service is in place Primary care benefits from a programme of education Patients benefit from a multidisciplinary approach, particularly those patients who regular attend A&E Improved communications between all providers and patients Access for primary care clinicians to specialist advice from the acute Trust Diabetes This was chosen as an area of focus because: Comparative data suggest that Sutton spends more on non-elective admissions, medicines and day cases than other similar CCGs Local intelligence suggests that patients with type 1 diabetes need more access to education Evidence from elsewhere suggests that up-skilling primary care could reduce the need for hospital care Sutton has the highest levels of diabetic amputations in London Supporting patients to self-manage their condition can reduce numbers of unplanned hospital admissions There is scope for earlier management of diabetes long term conditions through increasing effective prevention programmes There are patients who could be managed in primary and community care who currently attend the hospital. Page 38

The programme of work aims to ensure: A reduction in the number of amputations Robust education is available to patients Robust education is available to primary care We maximise the benefits of National Diabetes Prevention Programme in Sutton Improved communications between all providers and patients Musculoskeletal (MSK) conditions This was chosen as an area of focus because: Compared to other similar CCGs we spend more on MSK conditions Clinical and patient feedback suggests that patients currently experience an un-coordinated care pathway that could be significantly improved and streamlined Sutton CCG is currently not maximising the use of conservative management prior to or instead of referral to secondary care Examples of best practice nationally suggest that from a similar baseline up to 20% of cost can be re-directed from secondary care. Whilst the work has been undertaken in this year, benefits are expected to be realised in 2017-18. A new triage model is being developed with Sutton s community provider Royal Marsden Community Services. From 1st April 2017 all MSK referrals will be triaged by Advanced Physiotherapy Practitioners into the most appropriate service based on patients needs and the detail from improved GP referral. Pathways are also being developed to enhance service provision and increase efficiency at all levels. Expenditure on diagnostics will be more closely managed through diagnostics being ordered after triage, rather than before. This will lead to more appropriate use of diagnostics and consequently savings. Investments are being made in the MSK Centre and physiotherapy to meet increased service delivery outside of an acute setting. Page 39

Better Care Fund The Better Care Fund is a national programme of work to drive forward greater levels of integration of planning, commissioning and delivery of health and care services. In Sutton this is being used as an opportunity to implement the integration components of the Joint Strategy for Health and Social Care, which was agreed by the Health and Wellbeing Board in June 2014. The 2016/17 Better Care Fund Plan focused on five key workstreams. Highlights of successes from each workstream are detailed below: Integrated Localities Significant progress has been made towards creating Integrated Locality Hubs (ILH) that will house staff from both health and social care with the first ILH opening in Wallington Locality in June 2017. These moves will provide opportunities for integrated working and facilitate and promote joint assessment and care planning and the use of multi-disciplinary team meetings. A second project involving implementation of clinical resource has been completed. Locality Nurse Facilitators support General Practices in establishing their multi-disciplinary teams and develop robust case management plans for those patients who require them. One of the early pieces of work undertaken was working with the Frequent Attendees Forum to facilitate joint care planning across all agencies including primary care; secondary care; mental health and London ambulance services. Integrated Intermediate Care The successful pilot accessing intermediate care via the hospital in-reach ( SWOOP ) team has been implemented with an integrated multi-agency in-reach team based at St Helier Hospital to facilitate complex discharges back into the community. The team consists of community nurses, therapists, healthcare assistants and social workers and acts as a single point of referral for patients who may require intermediate tier support after their discharge and has received positive feedback. Integrated Equipment This service has been commissioned as an Integrated Community Equipment Store. It is designed to minimise unnecessary spending and maximise the potential of this budget stream in supporting independence at home. The service is currently available 6 days per week, in line with safe discharge requirements. The budget was increased for 2016/17 to reflect the need for additional equipment for a higher number of residents that are expected to be managed safely at home. Page 40

Seven Day Services Building on the two successful weekend discharge initiatives held in 2015/16 the Trust has implemented the findings and operates a 7 day service as per NHSE/NHSI 2016/17 Rapid Implementation Guidance. Mental Health Work continued to focus on reaching the National dementia diagnosis rate as detailed on page 25. Our work aims to ensure that people with dementia and their carers can get early support to live well with dementia, as well as on-going support throughout their dementia journey from both health and voluntary sector partners. An enabler workstream has focused on the creation of an Integrated Digital Care Record (IDCR). The Sutton IDCR project, a joint initiative between NHS Sutton Clinical Commissioning Group and LB Sutton facilitates smoother flow of information between health and social care. Data from 24 out of the 25 GP practices has now been successfully loaded. Currently consent has been obtained for over 1200 clients and social care records have been uploaded to the Sutton IDCR. Access to the system has been provided to all clinicians at St. Helier Hospital using single sign on from their clinical manager system. Feedback from clinicians, particularly in A&E and the Acute Medical Unit, has been very positive with growing recognition of the positive impact of the new access to clinical records. Work is underway to provide SELDOC out of hours GP service with access to the system using single sign-on from their patient record system and Sutton Community Health Services. Progress against Better Care Fund National Performance Metrics 2016/17 Reduction in Non Elective Admissions Although we achieved a reduction of 1360 non-elective admissions for 2016-17, this was below the planned reduction of 2145 for the year. Despite all schemes performing well and meeting their contractual KPIs the anticipated reduction was not achieved. This is due to a number of contributing factors including a period of increased respiratory illness particularly in July and August 2016 and the excessive pressures over Winter. Page 41

Admissions to residential and care homes Permanent admissions of older people (65+) to residential homes, per 100,000 population will be met during 2016/17 with a rate of 186.6 against a target of 282.7. Effectiveness of re-ablement (patients still at home 91 days after discharge) Sutton CCG and the London Borough of Sutton both contribute funding to our highly successful START (Short Term Assessment and Reablement Team). The number of clients still at home 91 days after a discharge from hospital after their period of reablement is consistently above 95% against a target of 90%. Delayed Transfers of Care Following development of our local action plan for escalating delayed transfers of care issues, we have seen a significant improvement. For delayed transfers of care (delayed days) from hospital per 100,000 population, across the year we have met the 198.9 target. Page 42