NHS England (London) Assurance of the BEH Clinical Strategy

NHS England (London) Assurance of the BEH Clinical Strategy

NHS England (London) Assurance of the BEH Clinical Strategy Status Report 8 th September 203 - Version.0 2

Contents. Overview & Executive Summary 2. Introduction & Progress to Date 2.. Background & Process Aims 2.2. Development of Approach & Progress to Date 3. Interim Assurance Outcomes 3.. Dee Dive: CCG Assurance 3.2. Deep Dive: Clinical Assurance 3.3. Deep Dive: Operational Assurance 3.4. Deep Dive: Financial Assurance 3.5. Deep Dive EPRR Assurance 3.6. Deep Dive: System Assurance 4. Next Steps 3

. Overview & Executive Summary The Barnet, Enfield and Haringey (BEH) Programme is approaching a key phase in its delivery with regard to the expansion and redevelopment of maternity, neonatal, paediatric and A&E services at Barnet & North Middlesex Hospitals in order to provide safer and better healthcare for its population. Under direction from the Secretary of State (SoS) in 2008, and in 20, the programme is working towards implementing changes to services in November 203. While implementation of the BEH Clinical Strategy is not for debate having been directed by the SoS, NHS England continues to support its delivery as critical to securing sustainable, high quality and safe services for the populations of Barnet, Enfield and Haringey. Given the scale and importance of the above mentioned changes NHS England, through its role as an assurer, is undertaking an assurance process external to the programme and relevant organisations (CCGs/ Trusts). This seeks to inform the CCG decision making process on the 25 th September relating to the timing of the implementation. Thereafter it seeks to provide continued assurance up to the actual service transfer date. Through consultation with the BEH Programme Board, NHS England defined its assurance framework through six lenses: CCG assurance, clinical assurance, operational assurance, financial assurance, EPRR (Emergency Preparedness, Resilience and Response) assurance & system assurance. At the start of the process it was agreed with all parties that it would not be possible to secure full assurance in each of these lenses ahead of the CCG decision making process given the timeframes involved. Instead, a picture of increasing assurance is expected to develop over the course of programme delivery through to the actual transfer of services. NHS England has worked with the BEH Programme Board and its key stakeholders to secure assurance against the six lenses. Through a combination of existing governance mechanisms (e.g. CCG assurance meetings, attendance at the BEH Programme Board) and the submission of new supporting evidence from the BEH Programme Team a current status of assurance has been determined. NHS England has gained increased assurance around a number of key areas within its framework. This includes CCG, operational and financial assurance. Specifically, NHS England is encouraged that all relevant operational policies and procedures have been updated ahead of the planned transfer. In addition, it recognises the strength of the continued senior level involvement within partner organisations. As part of the process NHS England has also identified a number of areas that relevant CCGs should take into account with regard to their decision making on the 25 th September. Key areas that require on going focus include the recruitment of the nursing workforce, the delivery of the required bed capacity/contingency arrangement and the potential lack of contingency remaining in the build programme. This assurance process has also highlighted 4

some further work in relation to EPRR that we are now confident will be mitigated with support from NHS England. Should the CCGs decide to support the transfer of maternity & neonatal services from 5 th November and that of Adult A&E & paediatrics on 9 th December, it is clear that continued assurance to the transfer dates would be beneficial. In support of this, NHS England will continue its existing assurance process and continue to support the programme to ensure the safe transfer of services. During this period, it is anticipated that focus will centre on the key areas highlighted above. In addition, through this period NHS England will continue to work with the BEH Programme Board to support the identification of any potential risks and early implementation of appropriate mitigations. At present, given the range of activities undertaken to date by the Programme Board, NHS England has sufficient confidence that, should CCGs decide to proceed with the transfer of services from November, the BEH Programme Team and health economy will be able to deliver in line with their current plans and ultimately secure a safe transfer of services. 5

2. Introduction & Progress to Date 2.. Background & Process Aims The BEH Programme aims to deliver service changes that will provide safer and better healthcare for the populations of Barnet, Enfield and Haringey. The IRP s findings published in 2008, following it being commissioned by SoS to review the strategy, and subsequent Clinical Review in early 202 confirm the case for changing services and the need to implement the proposed changes. The programme is now approaching a key phase in its delivery with regard to the expansion and redevelopment of maternity, neonatal, paediatric and A&E services at Barnet & North Middlesex Hospitals. On September 25 th 203 Barnet, Enfield and Haringey CCGs will meet in common to make a decision regarding the timing of implementation of the BEH Clinical Strategy. The CCGs will be asked to:- Agree that the changes to A&E, paediatrics, maternity and neonatal and planned care services agreed under the BEH Clinical Strategy (in accordance with the decision of the then Secretary of State in 2008 and 20) should happen as soon as possible from 5 November 203. Given its role as both a system assurer and a commissioner, NHS England has committed to undertake an assurance process ahead of the planned implementation. Specifically NHS England outlines in its Business Plan for 203/4-205/6 that it has a key role to oversee the priority service reconfigurations to ensure outcomes for people are improved. In addition it has a statutory responsibility to assure EPRR capability across London. The NHS England assurance process aims to assure the safe implementation of the BEH Clinical Strategy. To that end quality and safety are at the heart of the process. In the first instance, the process aims to inform the CCG decision making process on the 25th September regarding the timing of the implementation. Beyond the 25th September decision it seeks to provide on-going assurance of safe delivery during the final stages of the programme up until the transfer of services. 2.2. Development of Approach & Progress to Date A number of assurance processes are in place already as part of NHS England s business as usual operation. This assurance exercise has dawn on each of these and brought them together in an overall framework. In addition, other areas of further assurance were sought in relation to the programme implementation. This resulted in a final assurance framework focussed around the following lenses: CCG assurance, clinical assurance, operational assurance, financial assurance, EPRR assurance & system assurance. Figure : NHS England Assurance Lenses 6

It is important to recognise that full assurance against each lens is not expected ahead of the September 25 th CCG decision. It is acknowledged that a high level of activity is currently underway, and that a great deal of activity is planned for the remaining months of the programme, as would be expected for a programme of this type, ahead of the transfer of services. As such, an increasing picture of assurance is anticipated to be developed over the course of this period. 7

3. Interim Assurance Outcomes Following agreement of the assurance framework, through close working with the Programme Board and its key stakeholders, NHS England has undertaken exercises to gain assurance against each of its lenses. As outlined in each of the deep dive areas below, good progress has been made across the lenses to date. In line with expectations, at this stage of the Programme, there are a number of areas of further work which NHS England suggest are addressed ahead of the actual transfer in order to provide sufficient assurance to CCGs in relation to readiness to proceed with implementation. 3.. Deep Dive: CCG Assurance This lens considers Barnet, Enfield and Haringey CCG s governance arrangements in relation to the BEH Clinical Strategy. Specifically it looks at the mechanisms in place at each CCG that enable them to identify and manage risks relating to the programme. It also focuses on the clinical governance processes in place at each CCG, when reviewing their readiness to respond to the planned service changes. In respect to the upcoming CCG decision on 25 th September, it also considers whether an agreed process is in place to support joint decision making. Finally, it looks at whether the impact of the BEH Clinical Strategy has been considered and managed by each CCG with respect to their Balanced Scorecard rating (note: Balance Scorecard ratings form the basis of CCGs quarterly checkpoints and are designed to represent a holistic assessment of a CCGs performance against core statutory responsibilities). NHS England has confidence in the current governance arrangements in relation to Barnet, Enfield & Haringey CCGs and the BEH Programme. The Programme Board s terms of reference clearly set out the detailed governance arrangements, covering both London and Hertfordshire representation. Moreover, CCGs are working closely together to ensure they have appropriate assurance of programme progress ahead of the 25 th September decision making process. Further clarification that each CCGs clinical governance arrangements have been reviewed and are appropriate to pick up the planned transfer would be welcomed. NHS England is assured that all 3 CCGs have active risk registers that consider the BEH Clinical Strategy and feed into the Programme Board. For example, Enfield CCG has evidenced their mechanisms for identifying, managing and mitigating risks in relation the BEH Clinical Strategy. The key focus for Barnet, Enfield and Haringey CCGs going forward is to maintain this control on risks and mitigating actions as the programme moves toward implementation. Through assurance meetings with Barnet, Enfield and Haringey CCGs NHS England is assured that each CCG understands the current impact of poor performance at Barnet & Chase Farm Hospitals NHS Trust (BCF) and the fluctuating performance of North Middlesex University Hospital NHS Trust (NMUH) on their Balanced Scorecard ratings. Through the System Recovery & Improvement planning process each CCG has been working with both trusts to address current performance concerns and secure sustainable performance post implementation. NHS England will continue to work with the CCGs through future assurance 8

meetings to ensure that future impacts on their Balanced Scorecard ratings are accounted for and managed ahead of the service transfer. Recommended CCG assurance thresholds ahead of the planned transfer All CCGs have fully reviewed and appropriate internal governance arrangements (including clinical governance) in place in order to manage the planned transfer. All CCGs continue to specify and review risks and mitigating actions in relation to the BEH Programme as the programme moves toward the planned transfer. All CCGs and Trusts continue to demonstrate actions in relation to the delivery of sustainable improvements in urgent and emergency care. All CCGs ensure they have enhanced systems in place in order to support increased surveillance during the transfer period. In summary NHS England believes that strong governance structures are in place at all 3 CCGs in relation to the BEH Clinical Strategy. Accordingly, it has assurance that each CCG has appropriate oversight and control over the programme as it approaches its critical implementation phase. 3.2. Deep Dive: Clinical Assurance In the first quarter of 203 an external Clinical Review by NHS England (London) was commissioned by the BEH Programme Board. The purpose of this review was to provide expert clinical assurance to commissioners (both CCGs and NHS England) regarding the readiness to safely implement the BEH Clinical Strategy. The Clinical Review was designed to ensure that changes were managed safely and that the final timeline for implementing changes minimises clinical risk. The review confirmed that it is necessary to make the proposed changes prior to the forthcoming winter. In line with the BEH Clinical Assurance terms of reference, the review team took a balanced approach between documentation appraisal and engagement with staff through site visits and attendance at BEH Clinical Cabinets. Key recommendations for particular attention from the Clinical Review report formed the basis of the areas where assurance is sought through this lens. The review did confirm that not only are the changes necessary, but that not proceeding with the changes will increase patient risk and jeopardise safety. The following sections provide thematic overviews of these recommendations and detail additional assurance gained through this process to date. Urgent and Emergency Care Both NMUH and BCF had variable performance in the 95% four hour A&E standard and it was evident that the changes to the estate on both sites required to enable the service changes to take place impacted on current performance. As highlighted in the Clinical Review NMUH appeared to have an understanding of what was required to improve 9

performance to the required level. Based on BCF Trust s weekly sitrep data submissions to Unify, at trust level, BCF has not achieved the 95% 4 hour standard in A&E since the week ending 3/03/203. The Clinical Review team was aware that BCF is in the process of implementing a number of improvement initiatives, which at the time of the site visit showed limited evidence of impact, as they were at an early stage of implementation. It was recognised that the major building works had contributed to the poor performance and that the proposed transfer of services will concentrate care at Barnet Hospital (BH) with expected improvements in performance. A&E performance is a good measure of whole pathways in and through hospitals. Service changes in other reconfigurations have shown that on going attention is needed throughout implementation with continued focus on quality and safety through the period. The Clinical Review noted that board oversight is in place in order to mitigate against deteriorations in the quality and safety of service provision. It also recommended that plans to implement the London Adult Emergency Standards are fully described and that all aspects of accepted good practice with regard to urgent and emergency care be implemented and embedded before November. Given current levels of performance, NHS England and the NHS Trust Development Authority have together with BCF agreed to hold a clinical development session in the coming weeks. A key output from this process is expected to be an actionable plan that enables greater clinical leadership engagement and drives sustained performance improvement. Workforce NMUH has a requirement for 45 additional adult nurses as part of the BEH Clinical Strategy. There is also a requirement for 25 further midwives and a number of HCAs. Following the initial Clinical Review and as part of this assurance process the BEH Programme Board has provided NHS England with evidence that nurse recruitment at NMUH is at a high level, on track. The Trust has evidenced that it has made 8 adult nursing offers to date in line with its plans. Looking forward, the Nursing Director at NMUH has provided assurance of adult nursing recruitment to the required level by the necessary date, through planned recruitment events in September and November. In addition assurance has been received that midwife recruitment is expected to be completed to plan. Furthermore, induction and clinical support sessions have been planned for this new cohort. Additional HR staff having been brought on board, with named nursing support for new recruits identified. In addition, the training and integration of new staff will be achieved by extending existing staff hours and by appointing to temporary positions if necessary. With regard to medical recruitment, assurance has also been received as part of this process that 7 paediatricians, 2 obstetrician consultants and A&E consultant have been recruited. There are 2 further paediatric consultants to recruit at BCF and further A&E consultant required. Further assurance has also been received that LETB involvement has resolved the junior doctor rotation discrepancy between the two trusts and that the Medical Director of NMUH has provided assurance that the junior doctors will follow the appropriate activity. 0

NHS England will be working with the Programme Team to gain further assurance with respect to the progression of nursing recruitment at both the NMUH and BCF sites from September to the date of transfer. Given that nursing recruitment remains critical to the success of the programme NHS England suggests the Programme Board develop further clarity around the minimum levels of in post and inducted nurses required to ensure safe delivery of services from the date of transfer. It is important for the Programme Board to continue to further develop its Recruitment Tracker in order to clearly articulate the status of recruitment progress against plan. Importantly, as we approach the implementation date, a real time breakdown of the number of potential staff at various stages of the recruitment process, from appointment to completed induction will be essential. Quality and Safety of Services In major service change programmes, there is always a risk that the quality and safety of services will deteriorate before, during and following transition. It is important that the BEH Programme Board and the Trust Boards consider the processes that will be required to effectively manage risks to ensure there is a robust mechanism for systematically monitoring the quality and safety of services through out. The Clinical Review team reviewed the quality scorecard currently underdevelopment and felt that more work was needed in order to make the indicators closer to real time. NHS England currently understands that good progress is being made in this area and is confident that this will continue through the transition period. Recommended clinical assurance thresholds ahead of the planned transfer The BEH Programme Board and the respective Programme Boards of both Trusts continue to monitor quality and safety at all sites, with clear processes in place to enable increased senior surveillance up to the point of transfer. Both Trusts continue to remain on target against their recruitment plans with a minimum of 80% of staff having completed the mandatory training ahead of the planned transfer. A clinical developmental session is held with BCF, resulting in an agreed set of actions that are monitored through the BEH Programme Board to the planned transfer date. In summary, at this time NHS England is confident in the Programme s ability to deliver against it challenging recruitment plan. This however, does remain a key risk to the programme over the coming months. Recognising the current challenges at BCF, NHS England, together with NHS TDA, is committed to working with the Trust in order to support sustainable improvements. 3.3. Deep Dive: Operational Assurance This lens considers the operational elements relating to the transfer. It focuses on the delivery of additional bed capacity to enable effective service delivery. In addition it considers the embedment of updated operational policies that reflect the planned service changes. It also seeks to ensure that the planned service changes are communicated to all partner organisations in the wider health economy to ensure adverse impacts on performance are minimised post transition. With specific regard to the transfer of A&E

services, it seeks assurance that the relevant Urgent Care Boards (UCBs) continue to provide strategic oversight in the delivery of urgent and emergency care services and they are fully engaged ahead of the planned transfer. Bed Capacity & Building Works Bed activity modelling was carried out using 85, 90 and 95% occupancy rates. The decision to use the outcomes from the 90% occupancy rate was to provide greater flexibility in the system where current emergency bed occupancy is over 95%. This calculation resulted in the requirement for an additional 43 acute medical beds at BH. There has been further work since this initial modelling to ensure that schemes such as PACE, TREAT and RAID are implemented and also that improvements in discharge arrangements for patients are put in place. In addition, contingency arrangements with the Royal Free London NHS Foundation Trust and the Whittington NHS Trust have been agreed to provide additional acute medical beds, should they be required. Additional contingency in the community has also been identified. Furthermore, the Programme Board has also provided NHS England with assurance that local UCBs are tracking the capacity delivery of RAID & PACE schemes on a bi-weekly basis and that trust Directors of Operations share bed capacity numbers on a daily basis. Both through the provision of additional beds and the schemes put in place to improve efficiency, NHS England is confident that the additional capacity requirements will be met. However, NHS England suggests the delivery of this additional capacity continues to be monitored on a weekly basis. In addition the Programme is encouraged to frequently test the validity and robustness of its contingency plans, ensuring that it is able to implement them at pace should they be required. As with any building programme of this scale there is always the risk of delay. Following the discovery of asbestos in the tower at NMUH there was a worry that the current plan does not provide adequate further contingency in time should another major discovery be made as part of the building works. Since the Clinical Review, the BEH Programme Board has provided further evidence and assurance that the major building works have already been delivered and that any slippage to the outstanding minor works will be minimal and managed as low level project risks. Operational Policies & Procedures As part of the assurance process NHS England has received assurance that the Programme Board is appropriately tracking the required changes to all impacted operational policies across all sites. The latest position demonstrates that all operational policies and procedures have been updated in line with the planned service changes for all relevant directorates. Going forward NHS England will continue to work with the Programme Board to ensure that these policies are fully signed off and embedded well in advance of the actual service changes coming into effect. Programme Communications The Programme Board has a clear communications plan through to December 203 which it is implementing. As expected this plan is focussed around engagement with clinicians, GPs and community groups as well as providers and patients across the impacted health 2

economies. NHS England is assured that an appropriate governance mechanism is in place that enables the fortnightly review of progress against the plan. This involves communication leads from Barnet, Enfield and Haringey CCGs, both hospital Trusts and the North Central and East London Commissioning Support Unit. To date the communications plan has been delivered to over a million people across Barnet, Enfield, Haringey as well as Hertsmere and Broxbourne. Going forward the programme of communication and engagement is planned to intensify during the critical September to December period. Urgent Care Boards Finally, NHS England is assured that both the Haringey & Enfield UCBs have appropriate mechanisms in place to ensure they are providing strategic leadership in preparation for the planned service changes relating to A&E. Both UCBs have appropriate membership and terms of reference that facilitate engagement across the urgent and emergency care pathway, providing direction and encouraging delivery of high quality care before, during and after the transition. As highlighted through the clinical assurance lens, both UCBs are actively tracking the delivery of increased capacity ahead of the planned transfer. Recommended operational assurance thresholds ahead of the planned transfer Confirmation that the planned number of beds is greater than or equal to the required number of beds at all sites. Where this is not the case, within the limits of completed sensitivity analysis, robust contingency arrangements are in place to manage any shortfall. Continual delivery of schemes (e.g. PACE, TREAT and RAID) against agreed trajectories in order to deliver additional capacity as planned up until the transfer. Level of minor works continues to progress against plan to allow the operational commissioning of clinical areas in time for safe opening. The BEH Programme Board ensures that all updated operational policies and procedures are fully signed off and embedded well in advance of the planned transfer. The BEH Programme continues to deliver against its existing communications plan with appropriate ramp up arrangements in place by the end of October. The UCBs continue to meet and provide strategic oversight across the urgent and emergency care pathway for the local health and social care economies. In summary, NHS England is assured that the major portion of the building works are now completed, minimising the risk of further discoveries that may impact implementation. In addition, NHS England is confident that the bed capacity requirements will be met. However, it recommends that increased monitoring is put in place in the period leading up to the planned transfer. 3

3.4. Deep Dive: Financial Assurance The implementation of the BEH clinical strategy will have significant impacts on the level of activity for each service line that is transferred. The flow of activity drives the financial values of the activity commissioned to each provider and by each commissioner. Therefore, it is important that activity is triangulated across the area, in order that all potential cost impacts are factored in. A summary of modelling has been provided by the BEH Programme Board, along with confirmation these assumptions have been used in the current contracting round. Further to this, contractual Heads of Terms (HoTs) have been received in relation to BCF from relevant CCGs. This demonstrates material alignment of contracting to relevant financial recovery plans. However, at present this is limited to a single trust sample which provides NHS England with assurance that work has taken place ensuring BCF and its commissioner plans materially triangulate. To gain additional assurance NHS England will be seeking to sample the reconciliation of financial recovery plans against the HoTs of the other affected Trust. This will help demonstrate full triangulation of activity flows and confirm the implementation plans are tied into contractual values. By the nature of a business case including forecasts of uncertain future finances, there is an element of risk that the actual position will deviate from the forecast. In order to mitigate this it is expected that an adequate level of contingency funding across the commissioners has been factored in, and is demonstrated in both the business case and the associated CCG financial plans. A North Central and East London risk share agreement has been received showing 9.7m indicative transitional investment fund to support the BEH Clinical Strategy. Additional assurance highlighting all calls in addition to the NMUH business case on this funding would be welcomed. Due to the risk of future events not matching the forecasts within the business case, it is important to demonstrate the impact of changes on key variables, to reflect the likely impact of those variables deviating from plan. Section 5.5 of the NMUH business case shows sensitivity analysis has been performed on activity fluctuations showing tolerance of a 9m in activity shifts. As such assurance has been gained on this aspect. Sensitivity analysis has also been performed on the capital cost which demonstrates assurance that the business case withstands the test of building costs escalating during the course of the work. NHS England suggests it would be beneficial to understand the impact of any slippage on building works in order to fully understand potential risks to the current sensitivity analysis performed in the business case. In addition it would be useful to consider the financial impact of temporary staffing premiums that may be required in the event of delays in the recruitment plan. To gain a greater level of assurance NHS England will be seeking to expand this demonstration of sensitivity analysis across the broader spectrum of the full BEH strategy business case. Suggested financial assurance thresholds ahead of the planned transfer Demonstrate the triangulation of activity in CCG and Provider plans via reconciling contractual HoTs for a material 80% of the commissioned value, at each of the remaining Trusts. 4

Demonstrate an adequate level of contingency funding across the commissioners has been factored in, by confirming all potential calls on the funds from the full BEH strategy. Evidence whether in the disaggregation of PCT funds to the CCGs, provisions have been made for any of the transitional costs identified in the business cases. Through the review of evidence submitted to date NHS England has a good deal of assurance that the BEH Programme Board and its constituent CCGs have considered the activity and financial implications and have appropriate contingency in place to mitigate potential financial risks. As outlined above NHS England seeks to gain further assurance in some areas over the coming period. 3.5. Deep Dive EPRR Assurance All NHS provider organisations have a statutory responsibility under the Health and Social Care Act (202) and the Civil Contingencies Act (2004) to prepare for responding to major incidents, and ensuring continuity of priority services. For the EPRR elements of the assurance process, the impacts of patient dispersal across the area following a major incident such as the Hatfield Train crash were considered. The overall strategy employed was to review the major incident and business continuity risks to each of the organisations across the area; ensuring that they had reviewed the impact of the proposed service changes against their major incident and service level business continuity plans. The organisations that were included in the EPRR assurance process were: Barnet and Chase Farm Hospital North Middlesex University Hospital NHS Trust The Royal Free London NHS Foundation Trust Whittington Healthcare Services Barnet, Enfield and Haringey Foundation Trust Central London Community Healthcare The EPRR team at NHS England (London) had already embarked on an annual assurance process across all provider organisations, in conjunction with commissioning partners. However, given the need for BEH Clinical Strategy EPPR assurance exercised within the context of new national EPRR arrangements this was conducted within a much reduced timeframe. This prompted a set of additional questions and the provision of additional evidence. This evidence was reviewed by a panel of EPRR specialists from NHS England (London) EPRR team, and representatives from Enfield CCG, NELCSU and the London Ambulance Service. The review considered specific criteria against which evidence had been sought from the relevant organisations and was tailored to consider the impact across the whole 5

health economy, impact on blue light services, and impact across the borders into other regions in the event of a major incident. The panel recognised that evidence submitted only provided partial assurance and further work is required during September and October to conclude the assurance process. The panel acknowledge that further work is required to ensure that the impact of a major or business continuity incident is adequately mitigated. All relevant organisations have further work to do to ensure that clear actions plans are in place prior to the transfer. This includes a programme of training and exercising staff in anticipation of the large organisational changes proposed. Any large scale incident in North London will impact across all of the organisations in that area, as well as across mutual aid borders into other NHS England regions. Evidence for this mapping will need to be submitted prior to the transfer of services. In addition the panel would welcome further consideration in relation to the impact on the Royal Free and the Whittington. Specifically, during September and October the panel would encourage the Programme Board to progress work on the clearer identification of the risks to these two trusts. The panel would encourage the review of all major incidents and business continuity plans prior to the proposed changes to services across the area, and suggest that these plans are tested and embedded into the individual organisations and across the wider health economy. Along with local testing, the panel would welcome a more extensive programme of testing and exercising across the patch area, to ensure that the true impacts on the wider services are understood and mitigated. The panel felt that the Programme Board should ensure that a clear risk management strategy is in place for each organisation affected to ensure due consideration has been taken of the impact of the service redesign, and that this is reflected within local and wider action plans. The panel would encourage the Programme Board to model the impact of surges in patient demand and how they will be dealt with, both for business as usual winter challenges, as well as in the event of a big bang major incident. This should be mapped out to provide a true understanding of the agreed responses and the proposed contingency arrangements checked and implemented across the wider health partnership. During September and October the Programme Board is asked to continue to review training and exercising plans, both before and after the changes, across all organisations for relevant EPRR and business continuity plans and any preparatory command and control strategy. The panel noted the on-going work to agree action plans with each organisation, with a completion date of all work by the end of October 203. The EPRR patch team in the North East and North Central London area will oversee the progress against the agreed action plan. A member of this team will provide full time support to BCF during this time. A further assessment of the evidence will take place at the end of October to ensure that actions have been completed, and provide confidence that arrangements in place are robust. 6

Recommended EPRR assurance thresholds ahead of the planned transfer Barnet and Chase Farm Hospital & North Middlesex Hospital Development of EPRR risk profile and mitigating action plan against the proposed clinical service redesign, to include: Draft major incident plans, clearly demonstrating the proposed command, control and communication strategy for post transition Evidence that the trust has identified its high priority service areas that are impacted on by the changes and their business continuity plans post transition. Training and exercise programme to demonstrate that major incident and business continuity processes are embedded; including attendance registers (past and forecast) demonstrating when the training has been given and who to. London Ambulance Service Provision of evidence of mapping of patient dispersal for a Hatfield rail crash type incident across the BEH health economy; including any predicted impacts across regional boundaries Evidence of mutual aid arrangements across geographic borders with other ambulance services Royal Free Hospital, Whittington Healthcare, Barnet Enfield and Haringey MHT, Central London Community Healthcare Development of EPRR risk profile and mitigating action plan for any risk highlighted, specifically in relation to: Increased surge pressure Increased support required to facilitate rapid discharge of patients during a major incident Changes to their major incident plans reflecting any changes in patient flows and communications with stakeholders during an incident Hertfordshire NHS England (London) suggest that the development of EPRR risk profile and mitigating action plan for Hertfordshire be considered through discussion with NHS England (Midlands & East). In summary, whilst this lens has identified further work in relation to the preparedness of the system with regard to EPPR, NHS England is confident that an actionable plan is in place that should support the completion of all work by the end of October 203. 3.6. Deep Dive: System Assurance In the new system NHS England plays a unique role as the single agency with responsibilities across the whole of the health and social care system. Whilst not the system manager role of old, it falls to NHS England to facilitate and assure that the various stakeholder organisations are working together in the interests of the wider population they serve. This lens seeks assurance that those organisations have understood and are prepared to manage the before, during and after transition implementation phases of this change. 7

As outlined through the clinical and operational lenses, the UCBs of the health economies impacted by the proposed transfer are well engaged in the programme. As further evidence of system collaboration Barnet, Enfield and Haringey CCGs are working with their respective Health & Wellbeing Boards (including Local Authorities) to agree and sign off section 256 monies to support the transfer of services. NHS England also welcomed the programme s detailed planning looking at available nursing homes, rehabilitation capacity and additional bed capacity from other local sources. This was clearly identified with associated costings and lead contacts for each resource. The Programme Board membership and attendance provides further assurance that senior representatives at executive level from key organisations are active participants in the meeting. The programme work streams and risk register give further evidence that partner organisations are fully engaged. The EPRR assurance lens aims to demonstrate that the wider health system including outlying providers has taken into account the impact on surge management arrangements at times of increased system pressure. Recommended system assurance thresholds ahead of the planned transfer Continued senior level cross system involvement and attendance in key governance arrangements relating to the BEH Programme. Agreed approaches to the use of section 256 monies between each CCG and their respective Health & Wellbeing Boards (including Local Authorities). Continued collaborative working across health and social care in support of the joined up delivery of the urgent and emergency care pathway. In summary, NHS England encourages the continued collaborative working with other health economies beyond those within the immediate geography of the programme (including the health systems of outer North West London, outer North East London & Hertfordshire) to ensure strong delivery of emergency care over winter 203/4 and beyond. 8

4. Next Steps NHS England has received a good level of assurance as part of this process. In addition it has highlighted a number of key areas where it is recommended the Programme Board secure further assurance ahead of any transfer of services. It is now suggested that Barnet, Enfield and Haringey CCGs use this status report alongside other sources of assurance to inform their decision relating to the timing of the implementation on 25 th September. As outlined earlier in the paper, there is a high level of planned activity that is due to take place as part of the programme between now and any future implementation date. To that end, in that period NHS England will continue with this process in order to provide an increasing picture of assurance ahead of any planned implementation. Moreover, it is committed to providing the Programme and the relevant organisations with any support they feel is required. 9