AGENDA Item Title Lead Action Paper Page

Meeting in Public of the Enfield Clinical Commissioning Group Governing Body 23 May 2018 13.30pm 15.30pm Holbrook House Cockfosters Road Barnet EN4 0DR AGENDA Item Title Lead Action Paper Page 1. Welcome and Apologies 1.1 Chair s welcome & apologies for absence Chair To note Verbal - 1.2 Chair s Report Chair To note Verbal - 2. Declarations of Interest 2.1 To confirm the entries in the Register of Declarations remain accurate 2.2 To declare any gifts and hospitality received 2.3 To declare any interest relating to items on the agenda 3. Minutes and Action Log 3.1 Minutes of the meeting in public held on 21 March 2018 Chair To review 2.1 5 Chair To declare Verbal - Chair To declare Verbal - Chair To approve 3.1 13 3.2 Matters Arising and Action Log Chair To note 3.2 25 4. Questions from the Public Chair The Chair will provide a written answer to those questions relating to items on the agenda and which have been received in advance and invite questions of clarification on the answers given. There will be a further opportunity to ask questions relating to agenda items at the conclusion of the meeting. 5. Overview Reports 5.1 Accountable Officer s Report Accountable Officer To note 5.1 31 6. Quality and Safety 6.1 Quality and Safety Exception Report Governing Body Nurse Member To note 6.1 37 7. Finance, Contracts and Performance 7.1 i. Finance and Contracts Report month 12 ii. 2018-19 Financial Plan Update Chief Finance Officer, NCL CCGs To discuss To note 7.1(i) 7.1(ii) 51 63 7.2 Integrated Performance and Quality Report for April 2018 Director of Performance, Planning and Primary Care, NCL CCGs 1 of 255 To discuss 7.2 69

8. Assurance Reports from Committees 8.1 Finance and Performance Committee report from meetings held on 28 March & 25 April 2018 Chair of Finance & Performance Committee To note 8.1 103 8.2 Procurement Committee report from meetings held on 11 April and 9 May 2018 8.3 Patient and Public Engagement Committee report from meeting held on 3 May 2018 Chair of Procurement Committee Chair of Patient & Public Engagement To note 8.2 105 To note 8.3 109 8.4 Quality and Safety Committee report from meeting held on 2 May 2018 Chair of Quality & Safety Committee To note and To approve 8.4 177 8.5 Audit Committee report from meeting held on 25 April and 21 May 2018 Chair of Audit Committee To note 8.5 & Verbal 183 9. Governance 9.1 Governing Body Assurance Framework and Corporate Risk Register 9.2 Delegation of Authority to the Audit Committee to approve the 2017/18 Annual Report and Accounts 9.3 NCL Audit Committee in Common Deputy Chief Officer and Director of Primary Care Commissioning Chief Operating Officer Chief Finance Officer, NCL CCGs To discuss 9.1 185 To approve 9.2 203 To approve 9.3 207 9.4 Annual Report on the Use of the CCG Seal Chair To note 9.4 231 10. Strategy and Partnerships 10.1 NCL Sustainability and Transformation Plan: 6 months progress report Head of Programme Management, NCL STP To note 10.1 233 11. Items for Information 11.1 NCL Joint Commissioning Committee - minutes of meeting on 1 February 2018 Chair To note Link - 11.2 NCL Primary Care Committee in Common - minutes of meetings on: (i) 17 January 2018 (ii) 22 March 2018 Chair To note Link Link - 11.3 Health and Wellbeing Board draft minutes of 17 April 2018 Chair To note Link - 2 of 255

12. Public Open Space on agenda items Chair Verbal 13. Any Other Business Chair Verbal 14. Date and Place of Public Meetings 13.30pm - 15.30pm unless stated otherwise. 18 July 2018 Millfield House 19 September 2018 Dugdale Centre 19 September 2018 Annual General Meeting (Dugdale Centre) 3 of 255

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NHS Enfield CCG Governing Body Register of Interests May 2018 Name Current position (s) held in the CCG i.e. Governing Body member; Committee member; Member practice; CCG employee or other Declared Interest (Name of the organisation and nature of business) Financial Interest Type of Interest Non-Financial Professional Interest Non-Financial Personal Interest Indirect Interest Nature of Interest/ Position From Date of Interest To Date Updated Dr Mo Abedi CCG Clinical Chair 1. East Enfield Medical Practice - GP Practice GP Principal Nov. 2002 Present 16.05.2018 2. Evergreen Surgery Limited - GP Practice Director/Shareholder 2004 Present 3. Brick Lane Surgery 4. Brick Lane Surgery 5. Medicare Medical services LLP - Runs walk in centre at Evergreen Partner Wife is GP Principal/Partner Director/Shareholder 2013 Jul. 2017 2003 Present Present Present 6. DM786 Limited Property management company Director 2002 Present 7. DM786 Limited Property management company Wife is a Director, mother and children shareholders 2002 Present 8. DM786 Health Ltd - Health Consultancy (not actively trading) Director 2012 Present 9. DM786 Health Ltd - Health Consultancy (not actively trading) Wife is a Director, mother and children shareholders 2012 Present 10. Prime Point Limited Primary care medical services provider Director/ shareholder 2012 Present 11. Enfield Health Partnership Limited, Provider of community gynaecology service Shareholder 2010 Present 12. Enfield Healthcare Alliance Ltd runs Chalfont Rd and Boundary Court GP Practices Shareholder 2014 Present 13. South East Locality Access hub Wife is a locum GP 2016 Present 14. Enfield Locum GPs Wife works in Enfield as a locum GP 2016 Present Dr Chitra Sankaran GP Member for South West Locality 1. Winchmore Hill Practice 2. Park Lodge Medical Centre GP Partner GP Partner May 2011 Apr. 2017 Present Present 16.05.2018 5 of 255

NHS Enfield CCG Governing Body Register of Interests May 2018 Name Current position (s) held in the CCG i.e. Governing Body member; Committee member; Member practice; CCG employee or other Declared Interest (Name of the organisation and nature of business) Financial Interest Type of Interest Non-Financial Professional Interest Non-Financial Personal Interest Indirect Interest Nature of Interest/ Position From Date of Interest To Date Updated Dr Jarir Amarin GP Member for North West Locality 1. Carlton House Surgery 2. Barndoc Appraiser and Clinical Auditor GP Partner Shareholder (nominal buying price 10) 10.12.93 01.04.08 Present Present 16.05.2018 3. Heart Valve Voice Charity Trustee 08.08.14 Present 4. NHS England Appraiser 22.12.14 Present 5. Enfield Healthcare Alliance Shareholder 13.06.14 Present Dr Fahim Chowdhury Clinical Vice Chair and GP Member for South East Locality 1. DUA Medical Services (inactive) 2. Angel Surgery (Part of GP Federation) Medical Director GP Partner Apr. 2017 Apr. 2017 Present Present 16.05.2018 3. Practices, HUBs and walk-in centres in Enfield. Locum GP Mar. 2017 Present 4. Royal Free NHS Trust and North Middlesex University Hospital NHS Trust Bank urgent care centre GP Nov. 2016 Present Dr Rebecca Olowookere GP Member for North East Locality 1. Boundary House Surgery (Boundary House Surgery is part of the GP Federation) GP Partner April 2017 Present 16.05.2018 2. Top Global Quality Limited (used for locum work within the UK) Director May 2008 Present Professor Robert Elkeles Secondary Care Member 1. St Luke s Hospice Harrow Trustee July 2015 Present 16.05.2018 6 of 255

NHS Enfield CCG Governing Body Register of Interests May 2018 Name Current position (s) held in the CCG i.e. Governing Body member; Committee member; Member practice; CCG employee or other Declared Interest (Name of the organisation and nature of business) Financial Interest Type of Interest Non-Financial Professional Interest Non-Financial Personal Interest Indirect Interest Nature of Interest/ Position From Date of Interest To Date Updated Dr Hetul Shah GP Member for South East Locality 1. Boundary Court Surgery 2. North Middlesex, Enfield 7 day Access Hubs and Edmonton WIC Clinical Lead GP GP working in clinical capacity ad hoc for local UCC Mar. 2017 Feb. 2016 Present Present 16.05.2018 3. Dr Hetul Shah Ltd Director Mar. 2017 Present 4. Dr Hetul Shah Ltd Wife is a Director Mar. 2017 Present 5. Enfield Healthcare Alliance Shareholder 2018 Present 6. Chalfont Road Surgery Member of management team Mar. 2017 Present 7. EHA (Enfield Healthcare Alliance) company seeking to do business with the NHS Employee (through being Clinical lead at Boundary Court) and Shareholder (through Dr Hetul Shah Ltd) June 2017 Present 8. Primary Care urgent access service at Evergreen Surgery Occasional shifts Dec. 2016 Present 9. South East locality Medicine Management Lead Lead for the CCG (additional role to Governing Body role) May 2016 05.03.2018 10. Latymer School Foundation, Edmonton Trustee Oct 2017 Present 11. GP surgeries in Enfield GP Locum Aug 2013 Present 12. CCG Enfield Referral Service GP Sep 2014 Present 13. Walk in centre at Evergreen Surgery Occasional shifts Aug. 2013 Present Angela Dempsey Nurse Lead 1. Salmons Brook residents Edmonton Non-Executive Director (flat owned within the complex) 2013 Present 16.05.2018 2. RSM UK Consulting (was Baker Tilly) RSM act as the CCGs internal auditors 3. Royal College of Nursing Board (London) Associate Director Board Member Jun. 2014 May 2017 Present Present 4. Trustee Lyndsey Leg Foundation Trustee 7 of 255

NHS Enfield CCG Governing Body Register of Interests May 2018 Name Current position (s) held in the CCG i.e. Governing Body member; Committee member; Member practice; CCG employee or other Declared Interest (Name of the organisation and nature of business) Financial Interest Type of Interest Non-Financial Professional Interest Non-Financial Personal Interest Indirect Interest Nature of Interest/ Position From Date of Interest To Date Updated Dr Elizabeth Babatunde GP Member for South West Locality 1. Woodberry Practice 2. Azile (NHS recruitment company - not actively engaged in services within Enfield CCG) Salaried GP Medical Director May 2017 October 2015 Present Present 16.05.2018 3. Christ Ambassadors Limited Christian organisation providing medical mentoring/ medical missions abroad no links with Enfield CCG) 4. Herts Valleys CCG Director and Charity Trustee Macmillan Cancer End of Life Clinical Lead Dec. 2008 Sept 2014 Present Mar 2018 Executive Clinical Lead for Primary Care May 2018 Present Dr Johan Byran GP Member for North West Locality 1. Enfield Practices 2. Enfield One Sessional GP Sessional GP Jan. 2016 Feb. 2017 Present Present 16.05.2018 3. Sessional GP in Enfield and salaried GP in Hillingdon Wife is GP Aug. 2015 Present 4. Byran Health LLP Health, Fitness and wellbeing company; social healthcare project (beatyourdemons) and locum and private medical services Director Mar. 2016 Present 5. Byran health LLP Wife is Director Mar. 2016 Present 6. Arthritis Research UK 7. Freezywater Primary Care Centre (part of North East federation/ Medicus Superpractice) NB: employed directly by Enfield One Hub 8. Enfield CCG Fundraiser GP Partner (formerly salaried GP from July 2017 to April 2018) MacMillan GP/ Clinical Lead 2004 Apr. 2018 Nov. 2017 Present Present Present 9. Chase Community School Governor Nov. 2017 Present 8 of 255

NHS Enfield CCG Governing Body Register of Interests May 2018 Name Current position (s) held in the CCG i.e. Governing Body member; Committee member; Member practice; CCG employee or other Declared Interest (Name of the organisation and nature of business) Financial Interest Type of Interest Non-Financial Professional Interest Non-Financial Personal Interest Indirect Interest Nature of Interest/ Position Date of Interest From To Date Updated Karen Trew Lay Vice Chair and lead for Governance and Audit 1. Haringey CCG, CCG Audit Committee Member of Haringey CCG Audit Committee Apr. 2013 Present 16.05.2018 2. NHS England Performer List Decision Panel (outside of North Central London) Chair of Panels Apr. 2013 Present 3. Broxbourne School Hertfordshire Chair of the Governing Body (previously Governing Body members since Nov. 2004) Jun. 2015 Present 4. Wormley C of E Primary School, Hertfordshire Chair of the Governing Body 2006 Present 5. Lloyds Pharmacy Clinical Homecare Son employed in operational role Apr. 2017 Present Dr Teri Okoro Lay Member for Patient Public Engagement 1. TOCA Design and project management consultancy services Enfield (likely to do business with the NHS) 2. TAHC (Affordable housing provider) Owner Director Feb. 1992 2014 Present Present 16.05.2018 3. Barnet, Enfield and Haringey Mental Health Trust (volunteer Lay Role) Associate (Mental Health Act Manager) 2001 Present 4. Vision Healthcare - Mental health service provider Barnet (volunteer Lay Role) Associate (Mental Health Act Manager) 2013 Present Christopher Curtis Practice Manager Representative 1. Freezywater Primary Care Centre (part of North East federation/ Medicus Superpractice) Practice Manager Sept. 2017 Present 16.05.2018 Helen Pettersen Accountable Officer 1. Royal Borough of Kensington and Chelsea Local Authority on behalf of the Tri borough Simon Goodwin North Central London Chief Finance Officer 1. NCL CCG Governing Bodies & CCG Finance Committees Husband is Programme Manager Partners in practice Social work training programme Member May 2018 June 2017 Present Present 16.05.2018 16.05.2018 2. East London Foundation Trust Wife is a Senior Manager Present 9 of 255

Name Current position (s) held in the CCG i.e. Governing Body member; Committee member; Member practice; CCG employee or other NHS Enfield CCG Governing Body Register of Interests May 2018 Declared Interest (Name of the organisation and nature of business) Financial Interest Type of Interest Non-Financial Professional Interest Non-Financial Personal Interest Indirect Interest Nature of Interest/ Position Date of Interest From To Date Updated Litsa Worrall Patient Participation Group (PPG) Representative 1. Enfield Voluntary Action (Charity) 2. Greek & Greek Cypriot Community of Enfield (Charity) Company Secretary Company Secretary & Chief Executive Oct. 2017 Present 16.05.2018 3. Home from Hospital Service & Let s Talk Counselling Service Work contracted through Section 75 Agreement with London Borough of Enfield 4. JSNA (Public Health) Member 5. Health & Well Being Board Deputy Voluntary Sector Rep 6. PPG representative Member of CCG PPE Committee 7. Take & Settle Service funded by the CCG Provider Parin Bahl Chair, Enfield Healthwatch 1. Healthwatch Enfield Healthwatch Enfield is run by a Community Interest Company, called Enfield Consumers of Care and Health Organisation CIC (ECCHO). ECCHO is commissioned by the London Borough of Enfield to provide the statutory Healthwatch service for Enfield. Chair Present 16.05.2018 Bindi Nagra Director of Adult Social Care, London Borough of Enfield Weightmans LLP on behalf of NHS Litigation Authority Wife is Senior Manager 2007 Present 16.05.2018 Stuart Lines Director of Public Health, London Borough of Enfield Nil declaration Nil 16.05.2018 John Wardell Chief Operating Officer Nil declaration Nil 16.05.2018 Deborah McBeal Director of Primary Care Commissioning/ Deputy Chief Officer 1. We Are Pareto consultancy: a non- trading limited company Managing Director 2013 Present 16.05.2018 10 of 255

Name Current position (s) held in the CCG i.e. Governing Body member; Committee member; Member practice; CCG employee or other NHS Enfield CCG Governing Body Register of Interests May 2018 Declared Interest (Name of the organisation and nature of business) Financial Interest Type of Interest Non-Financial Professional Interest Non-Financial Personal Interest Indirect Interest Nature of Interest/ Position Date of Interest From To Date Updated Dr Mateen Jiwani Clinical Director 1. Royal College of General Practitioners Education Lead Oct. 2016 Present 16.05.2018 2. Imperial College Clinical Research and Fellow Mar. 2018 Present 3. GPDQ Clinical Director and Shareholder Mar. 2016 Present 4. Digital GP Ltd. Director May 2016 Present 5. Barking, Havering and Redbridge Wife is a locum GP Aug. 2015 Present Vince McCabe Director of Planning, Transformation and Recovery 1. Barnet CCG Wife is Senior Manager 2007 Present 16.05.2018 Graham MacDougall Director of Commissioning Nil declaration Nil 16.05.2018 Aimee Fairbairns Director of Quality and Clinical Service 1. Barnet, Enfield and Haringey Mental Health Trust (BEHMHT) Daughter is employed within a specialist commissioned service Beacon Centre 08.2017 Present 16.05.2018 Arati Das Deputy Director of Finance Nil declaration Nil 16.05.2018 An interest will remain on this register for a minimum of 6 months after the interest has expired. In addition, the CCG will retain private record of historic interests for a minimum of 6 years after the date on which it expired. 11 of 255

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Agenda Item: 3.1 Voting Members: Dr Mohammed Abedi Dr Fahim Chowdhury Dr Jarir Amarin Dr Hetul Shah Dr Rebecca Olowookere Dr Elizabeth Babatunde Dr Chitra Sankaran Angela Dempsey Professor Robert Elkeles Karen Trew Dr Teri Okoro Christopher Curtis Helen Pettersen Simon Goodwin Non-Voting Members: Tha Han Litsa Worrall Bindi Nagra Parin Bahl In Attendance: John Wardell Deborah McBeal Vince McCabe Arati Das Bridget Pratt Brenda Thomas Apologies: Dr Johan Byran Dr Jahan Mahmoodi Mark Eaton Carole Bruce-Gordon MINUTES NHS Enfield Clinical Commissioning Group Governing Body Meeting in Public 21 March 2018 Held at the Dugdale Centre Chair and GP Governing Body Member North East Locality Clinical Vice Chair and GP Governing Body Member South East Locality GP Governing Body Member North West Locality GP Governing Body Member South East Locality GP Governing Body Member North East Locality GP Governing Body Member South West Locality GP Governing Body Member South West Locality Nurse Representative, Governing Body Member Secondary Care Doctor, Governing Body Member Lay Member for Audit and Governance Lay Member for Patient and Public Engagement Practice Manager Representative, Governing Body Member Accountable Officer, NCL CCGs, Governing Body Member Chief Finance Officer, NCL CCGs, Governing Body Member Public Health, London Borough of Enfield Enfield Patient Participation Group Representative Director for Adult Social Care, London Borough of Enfield Chair, Healthwatch Enfield Chief Operating Officer Deputy Chief Officer & Director of Primary Care Commissioning Director of Commissioning Deputy Director of Finance Assistant Director of Quality & Clinical Governance Board Secretary (Interim) GP Governing Body Member North West Locality Medical Director Director of Recovery Acting Director of Quality and Integrated Governance 13 of 255

1.0 WELCOME, APOLOGIES AND CHAIR S REPORT 1.1 Welcome and apologies for absence 1.1.1 The Chair welcomed members of the public and Members of the Governing Body to the meeting. 1.1.2 1.2 1.2.1 Apologies for absence were noted as recorded above. Bridget Pratt, Assistant Director of Quality and Clinical Governance was deputising for Carole Bruce-Gordon, Acting Director of Quality and Integrated Governance, and Tha Han was deputising for Stuart Lines, Director of Public Health. Chair s Report The Chair highlighted the following from his report: Practice Manager Representative: The Chair, on behalf of the Governing Body welcomed Christopher Curtis who was attending his first Governing Body meeting as a voting member, since assuming the role of Practice Manager Representative on 1 February 2018, succeeding Rathai Thevananth who had served two terms. Given his wealth of experience in Enfield and beyond, Christopher will no doubt be an asset to the CCG. Public Health Representative: Stuart Lines has been appointed into the role of Director of Public Health, London Borough of Enfield, effective 1 March 2018, taking over from Tessa Lindfield. The Chair welcomed Stuart (in absentia, as he was unable to attend) as a nonvoting member on the Governing Body and thanked Tessa Lindfield for her contribution during her time in the role. Joint Commissioning Committee: Items discussed at the Joint Commissioning Committee meeting held in public on 1 February 2018 were presented as a separate agenda item. GP Engagement Event: Enfield CCG held a GP Member Practices Engagement Event on Wednesday 21 February 2018, which was well attended by GPs and Practice Managers. Items discussed were noted as detailed in the report. Holbrook House Lease: The lease at Holbrook House has been extended for five years, with a two year break clause. 1.2.2 The Governing Body NOTED the Chair s report. 2.0 DECLARATIONS OF INTEREST 2.1 The chair invited Members of the Governing Body to declare any interests in respect to items on the agenda. Angela Dempsey, Nurse Representative, declared an interest in agenda items 5.1 Accountable Officer s Report and 8.6 Audit Committee report (verbal), as she is an Associate Director at RSM Risk Assurance Services (RSM), the CCG s Internal Auditors. These reports contain information about RSM. Karen Trew, Lay Member for Audit and Governance, declared an interest in agenda item 10.1 North Central London (NCL) Joint Commissioning Committee - summary of meeting held on 1 February 2018, as Chair of the Committee. 2.2 2.3 2.4 Both Angela and Karen would not be required to leave the meeting for these items; however, they would refrain from participating in discussions. The Chair invited Members of the Governing Body to declare any gifts and hospitality received. No gifts and hospitality were declared. Governing Body Members confirmed their entries in the Register of Declarations of Interest. 14 of 255

3.0 MINUTES AND ACTION LOG 3.1 Minutes of the meeting held on 24 January 2018 The Governing Body Resolved to APPROVE as an accurate record, the minutes of the Governing Body meeting in public held on 24 January 2018. 3.2 3.2.1 3.2.2 Action Log Actions GB/001/18, GB/002/18, 22/11 93, 15/03 64 were agreed to be closed. The following update were provided for the due actions: Action GB/003/18: Deborah McBeal to put forward at the next Clinical Commissioning Committee, the request by Parin Bahl, for the IFR data to be categorised and Procedures of Limited Clinical Effectiveness (PoLCE) implication to be shown. Action GB/005/18: Tha Han reported on the protocol for safeguarding issues for looked-after children under and above five years. He noted that school nurses and health visitors services are commissioned by the public health team and they deliver the healthy child programme as laid out by the Department of Health. The information received from Barnet Enfield and Haringey Mental Health Trust (BEHMHT) is that there is no specific protocol but there is a joint GP/ Health Visitors protocol for information sharing where the latter meet with their named GP practice every six to eight weeks to discuss families of concern including lookedafter children. If GPs remain concerned, a discussion at the Safeguarding Children Board may be more helpful than at the CCG Governing Body, as all relevant parties are represented at the Safeguarding Children Board. Agreed to close. Action 22/11 86: London Ambulance Service (LAS) would be attending Haringey CCG Governing Body seminar in April. It was agreed to keep this action open and raise at the meeting, the question of what the LAS have done in speaking to patients and ensuring the public is aware of the change in practice. 4.0 QUESTIONS FROM THE PUBLIC 4.1 The Chair referred to the written responses to public questions that had been circulated at the meeting, to which he invited follow up questions for clarity. He reminded members of the public of the opportunity for further questions on items covered on the agenda at the end of the meeting. 4.2 4.3 4.4 Question 1: A request was made for further consideration to be given to this question outside of the meeting. Question 2: Referring to Enfield Healthcare Co-operative Limited (EHCL), the use of the word co-operative was considered illegal, as the Financial Conduct Authority deems this word as sensitive and if used, should be registered under the Co-operative and Community Benefit Societies Act 2014. The Over 50s Forum would take up this matter with Co-op UK if the impression is given that EHCL is registered as a co-operative. Deborah McBeal undertook to look into this. (Post meeting note: It was confirmed after the meeting that the company is registered as Enfield Healthcare Cooperative Limited without the hyphen. The use of the hyphen was done in error and would not be used in future. This matter is therefore resolved). 5.0 OVERVIEW REPORTS 5.1 Accountable Officer s Report 5.1.1 Helen Pettersen, Accountable Officer for NCL CCGs, presented her report, outlining key work undertaken since the last meeting. 15 of 255

Winter Planning: The NHS is still considered to be in the winter period and a big thanks was conveyed to all primary care and health and social care staff who had worked relentlessly during this period. Commissioning Support Unit Service Update: Following agreement at the five NCL CCG Governing Bodies in January 2018, a notice letter was issued to North East London Commissioning Support Unit (NELCSU) of the intention to take in-house a range of services. The Governing Body Sub-group is overseeing this work and Dr Chitra Sankaran is Enfield CCG s representative on the group. A business case would be submitted to NHS England for approval. The Governing Body was asked to delegate authority to the Governing Body Subgroup to approve the business case, following which it would be circulated to Governing Body members for comments. Contract Award: Internal Audit and Counter-Fraud Services: Chair s action was taken to approve, on behalf of the Governing Body, the contract award to RSM, for the provision of Internal Audit and Counter Fraud services to CCGs in NCL, WELC (Waltham Forest, Newham, Tower Hamlets, City & Hackney) and BHR (Barking & Dagenham, Havering, Redbridge). The award is for a period of 3 years with an optional extension of 2 years. The process was conducted in accordance with the provisions of the CCG s Constitution. The Governing Body was asked to ratify the Chair s action. Remuneration Committee in Common: The Committee met on 1 March 2018 and agreed that due to the unsustainability of the role of the NCL Director of Performance and Acute Commissioning in its current format and the increasing complexity of scale and scope of the role, the recruitment of a shared Director of Acute Commissioning is a critical role and fundamental to the delivery of the CCGs objectives. Failure to recruit to this post would have significant risks associated with meeting the overall aims and objectives of the five NCL CCGs. The Committee approved the recommendation to split the role into two: NCL Director of Performance, Planning and Primary Care and NCL Director of Acute Commissioning. The Governing Body was asked to ratify this decision. Planning Guidance for 2018/19: The NHS Planning Guidance for 2018/19 was released at the beginning of February 2018. A number of items are included that would impact on local commissioners and providers. Commissioners are taking this new planning guidance into account during the contract negotiations that are taking place for 2018/19. The planning guidance also stipulated that final agreement on contract values needs to take place by 23rd March 2019. Information Governance (IG) Toolkit: The CCG is on course to achieve its target level two IG Toolkit submission. 5.1.2 5.1.3 The following queries were raised and responses noted: How the winter resilience money received was spent - an After Action Review of winter is to be carried out in April/ early May, after which findings would be presented to the Governing Body. The impact of the pay award for NHS staff on social care - this could have financial implication for social care, as the health sector is dependent on social care services. The project plan to bring in-house a range of CSU services and timeline for the business case - the business case, which requires NHS England is expected to be finalised over the next few days and it is envisaged that the entire process would be finalised between July and September 2018. The Governing Body: i. NOTED the Accountable Officer s Report; ii. RATIFIED the decision taken under Chair s action to approve on behalf of the Governing Body, the re-appointment of RSM to provide Internal Audit and Counter Fraud Services; 16 of 255

iii. iv. RATIFIED the decision by the Remuneration Committee in Common to split the role of NCL Director of Performance and Acute Commissioning into NCL Director of Performance, Planning and Primary Care, and NCL Director of Acute Commissioning; and AGREED to delegate authority to the Governing Body Sub-group to approve the business case to take in-house a range of CSU services. 6.0 QUALITY AND SAFETY 6.1 6.1.1 Quality and Safety Exception Report The Chair of the Quality and Safety Committee presented the report setting out key exceptions and quality issues and summary of activity from the Committee. The report was taken as read and summary of key exceptions outlined were as follows: Barnet, Enfield and Haringey Mental Health Trust The Care Quality Commission (CQC) report was published in January 2018. The Trust was rated as requiring improvement even though the report acknowledged some significant improvements. The Trust was awarded an overall rating of Good for Caring, Responsive and Well Lead domains and a rating of Requires Improvement for the Safe and Effective domains. The CQC highlighted areas of concern and the Trust has submitted its action plan to the CQC for approval and also shared it with Commissioners. The action plan will be subject to regular review through the Clinical Quality Review Group (CQRG). Over the last 12 months, the CCG made four insights visits to the Magnolia, Fairlands, Dorset and Suffolk wards. The Trust s mandatory training compliance reporting indicates long standing issues with achieving the required standards. However, the Trust has trained 1600 of its 1900 staff on Prevent and are confident of achieving the 85% compliance target. A detailed mandatory training report would be submitted to the CQRG meeting in May. North Middlesex University Hospital (NMUH) The General Medical Council (GMC) undertook a visit to the Accident & Emergency (A&E) department to review the learning environment for trainees. The outcome of the visit confirmed that improvements had been made and that no regulatory sanctions would be implemented at this time. However, the Trust would continue to be monitored by GMC through submission of weekly evidence. The last CQC report rated the Well Led domain for maternity services inadequate. In view of this, an action plan is in place and a key priority is to get maternity leadership from inadequate to requires improvement or better. Dr Fahim Chowdhury would be making an insight visit to the Trust in March 2018. A report would be submitted to the Governing Body in May, as part of the Quality and Safety Report. Given concerns about the workforce sustainability and safety on an on-going basis, NMUH commissioned Concordia services to provide the dermatology service from 15 January 2018 for 12 months in the first instance, with a six months break clause. Concordia are providing 11 clinics per week at NMUH, which is an increase on previous numbers of clinics that were run in the department, in order to clear the backlog. Saturday clinics are now available to patients who are unable to attend during the week, as well as a one-stop clinic previously not available. Royal Free London (RFL) The Trust reported eight Never Events in London, which is the highest number in London, seven of which occurred during surgical/ invasive procedures. The Trust held an assurance event, where their improvement plan was shared. The event was attended by NHS Improvement, NHS England and Commissioners. Barnet CCG (lead commissioner for RFL) produced an assurance paper on Never Events which was presented at the Enfield CCG Quality and Safety Committee in March. 17 of 255

Integrated Urgent Care Services (London and Central West Unscheduled Care Collaborative (LCW)) A final report of the external review into the media Serious Incident (SI) commissioned by Enfield CCG on behalf of the NCL and Inner North West London CCGs was shared with all stakeholders in February 2018. The final report was received by the CCG and reviewed at the CQRG and Quality and Safety Committee meetings. The report confirmed the findings of the providers SI report concluding that there was no patient harm and no significant failing identified. However, it acknowledged that there were some care and service delivery issues and that recruitment procedures and preemployment check process could be improved. Of the 12 potential serious allegations made, nine were refuted and three which were of substance, have been addressed. The review identified that LCW has robust systems in place. The provider has implemented an action plan to address the issues raised and is due to provide an update at the March CQRG meeting. The report would be shared with all NCL CCGs Governing Body. 6.1.2 6.1.3 6.1.4 The following queries were raised and responses noted: LCW should be commended for their response to the Grenfell Tower incident whilst the SI investigation was ongoing, in addition to providing normal services. Vince McCabe offered to raise at Haringey CCG and report back on the contractual issue raised with Concordia for the dermatology service at NMUH, noting that there is a risk Concordia could withdraw from the contract in six months time. Action: GB/006/18. Contingencies are being discussed to ensure sustainability of the service and the Chief Operating Officers at Enfield and Haringey & Islington CCGs have had discussions with the Chief Executive Officer at NMUH about the Trust taking responsibility for the payment of the delivery of the service. In relation to the patients perspective not detailed in the report for the purpose of assurance, it was noted that as part of the SI process and NHS England SI framework, in addition to duty of candour, it is a requirement to take account of patient feedback and feed into the SI process; therefore, patient experience would have been embedded in the review. CQRG meetings are held on a monthly basis and patient representatives are part of these meetings. A programme of insight and learning visits has been scheduled with LCW. At intervals, a reflection on organisational culture is needed to ensure early warning signs are picked up to prevent reoccurrence. The Governing Body was assured that the CCG is not only supporting providers, but also holding them to account. The Governing Body NOTED the Quality and Safety Report. 7.0 FINANCE, CONTRACTS AND PERFORMANCE 7.1 7.1.1 Finance and contracts month 10 report Arati Das, Deputy Director of Finance introduced the month 10 financial performance report. The CCG is reporting a year to date (YTD) variance of 7.25m against a planned YTD surplus of 1.75m. In-year forecast outturn (FOT) is 5.75m deficit (cumulative 43.0m deficit) against a planned surplus of 2.1m. Based on current known risks, there is a continued net risk of exceeding the FOT by a further 2.7m. This remains under review and would continue to be revisited in the run up to 2017/18 close-down. 7.1.2 Month 11 position has been finalised, with the financial risk increased to 3.7m, largely due to the contracts with NMUH and RFL yet to be agreed, for which discussions are ongoing. A deep dive was carried out for Continuing Healthcare (CHC) which resulted in a cost pressure 18 of 255

of 3.7m, which is recognised in the position. 7.1.3 7.1.4 7.1.5 7.2 7.2.1 7.2.2 7.2.3 7.2.4 Simon Goodwin, Chief Finance Officer, NCL CCGs, explained that the CCG had set aside 0.5% to the National Risk Reserve, which the CCG would reflect at month 12. Month 12 position could be better by circa 2m as a result. The best case scenario is that the 5.75m deficit would be better by 2m, however, there are risks which could see the CCG end up with a 5-6m deficit. The implication of which could result in the CCG having a value for money qualification from the auditors. The 2018/19 Quality, Innovation, Productivity and Prevention (QIPP) target is made worse by the 2017/18 position. In discussing the report, the following comments were made: Disappointment was expressed with the increase in net risk to 3.7m and query raised on the confidence to deliver the revised forecast position and the risks of not achieving this position. Simon Goodwin commented that the 5.75m deficit position should be doable and it is not anticipated this position would get worse. Clarity was sought on the acute contracts yet to be finalised, further billing to be expected in 2018/19 and timeframe. Simon Goodwin advised that according to the national timetable for agreeing acute activity, this position remains unknown until July, after the accounts have been signed. Best estimates, based on discussions with the acute trusts are factored into the accounts, which might differ from the concluding figures when actual activity figures are known. Any difference arising would be factored into the 2018/19 figures. Data cleansing exercise was carried out on Caretrack, the tracking system used for CHC patients, which uncovered a cost pressure of 3.7m, recognised in the financial position. In relation to predictive modelling and potential extra cost, it was noted that the Head of CHC is currently drafting the Personal Health Budget Policy and reviewing the new NHS England CHC framework and its impact on the CCG s internal CHC framework. CHC budget have been discussed at both the Quality and Safety and Finance & Performance Committees, with the latter having detailed analysis. It was clarified that the 7.95m figure noted in table 1B includes the 3.7m risk position. The Governing Body NOTED: The Finance and Contracts month 10 report; and The movement in the forecast outturn from 2.1m surplus to 5.75m deficit. 2018/19 Financial Plan Update Simon Goodwin, Chief Finance Officer, NCL CCGs, presented the report, for the Governing Body to consider the overall strategic direction for the CCG s 2018/19 Financial Plan in the context of what is achievable against the default control total. The 2017/18 financial position and how this flows into 2018/19, taking into account national planning assumptions, was explained. Marginal rate, which is currently paid at 50% ( 5.3m) will be paid at 100% ( 10.6m) in 2018/19, resulting in the underlying position at the start of 2018/19 being 5.3m worse than the deficit the CCG would end up with. The starting financial position for 2018/19 is therefore 11.7m deficit. In relation to planning assumptions, the budget for the acute trusts is predicated on 3% growth, less 4.9% QIPP. The new planning guidance issued to CCGs note a higher percentage of growth for non-acute activity and A&E, and these percentages are deemed to be after savings. Trusts are therefore negotiating for more than 3% growth funding. The steer from NHS England at the January Financial Assurance meeting was that a break even budget would be reasonable for the CCG although the overall NCL control remains unchanged at 7.6m. Based on the CCG s latest FOT of 5.75m, delivery of a breakeven 19 of 255

budget in 2018/19 would prove challenging. This requires a QIPP delivery programme of 23.8m, higher than the 22.8m target. At least 17m of the 23.8m QIPP needs to be locked into acute contracts ( 10.8m in 2017/18) and it is highly unlikely that providers would sign up to the same value of QIPP. The risk going into 2018/19 is therefore higher than needing to achieve 23.8m QIPP savings. 7.2.5 7.2.6 7.2.7 7.2.8 7.3 7.3.1 7.3.2 This Plan was predicated on achieving breakeven. However, as a result of the CCG having historic deficit over a number of years, NHS England s assumption is that the CCG ought to repay some of the deficit, which would result in an additional circa 9.4m to the breakeven figure, totalling circa 35m of QIPP savings. The Accountable Officer, NCL CCGs and Chief Finance Officer, NCL CCGs are challenging this position with NHS England, which the Governing Body supported. Enfield CCG s position is the worst among the NCL CCGs, due to the greater underlying deficit and also due to the two Trusts (NMUH and RFL) with the most challenging growth/ QIPP situations being the CCG s biggest providers. The 31 March 2018 deadline to sign off the Plan was deemed impractical. The CCG is required to submit the 2018/19 Operating Plan to NHS England by 30 April 2018, by which time clarity would have been obtained from NHS England on the implications of the contracting round. It was therefore agreed that all Governing Body members receive papers for and attend the Finance and Performance Committee meeting on 25 April to sign off the 2018/19 Financial Plan. The Governing Body discussed the Plan and noted the following: It was flagged that the Plan as presented was quite challenging to sign off and to be held accountable for delivery. The question of what the realistic options are to cover the scale of gap was raised. Simon Goodwin commented that Trusts are encouraged by their regulator, NHS Improvement, to only accept the minimum QIPP that is justifiable, which differs from CCGs expectations. Any over performance is paid at 50%, likewise for underperformance. The implication for 2018/19 is that QIPP not obtained at the point of signing contracts, are only worth half their value in 2018/19. It was clarified that the trend in acute activity is fairly predictable, but the exact amount is not. It was noted that no information was included on equality impact assessment and patient and public involvement, as part of the requirement of the cover sheet. Healthwatch offered support to challenge the Plan as presented, noting that more information was required on its impact on patients. Referring to the question on what potential collective support is available from other NCL CCGs, it was noted that negotiation with NHS England and NHS improvement is done as a single NCL discussion. The Governing Body NOTED the 2018/19 Financial Plan Update. Integrated Performance and Quality Report for February 2018 Vince McCabe, Director of Commissioning presented the report which was taken as read to provide an update on the CCG s quality and operational performance against national and local standards and remedial actions where standards have not been achieved. The Governing Body s attention was drawn to A&E 4-hour wait, Cancer 62 day target, LAS response times and Referral to Treatment (RTT) times. As with many other CCGs, the CCG struggled to meet these targets. However, work is ongoing to achieve these. The January and early February data show that there has been improvement in the 62-day cancer waiting time and the A&E 4-hour waits. NMUH was the best performing Trust for A&E target in NCL on 19/ 20 March, achieving mid-80%. 20 of 255

7.3.3 7.3.4 7.3.5 7.3.6 The Governing Body discussed and raised the following: The new target for the LAS response times seem to be in red. It was therefore requested that an NCL wide picture is presented, as previously, there was deferential targets for the inner and outer boroughs, and an understanding was required as to whether this picture is re-emerging. Action: GB/007/18. RTT has been consistently red for some time, largely due to RFL being a significant outlier. The question was raised as to whether there is an understanding of its impact and whether this is being unravelled to get a proper baseline assessment which is critical in agreeing contract levels. To continue to challenge the Trusts to meet the targets, and ensure a sustained position is achieved. The reason for the deterioration in C.Difficile infections, as referred to in Appendix 7 of the report was queried. Vince McCabe to report on this position Action: GB/008/18. In response, Vince McCabe noted that comparisons would be done when borough based activity figures are received from LAS. In relation to RTT, Barnet CCG are lead for this contract and are consistently challenging this position. The NCL CCGs would not agree a financially motivated plan for 2018/19 and these form part of the contract negotiations. CCGs are expected to commission increased activity for Child and Adolescent Mental Health Services (CAMHS), for which Enfield CCG is an outlier. However, the Governing Body was assured that an initiative would start in April, where around 300k would be spent in ensuring that the CCG gets to as close as possible to the NHS England target for CAMHS activity and waiting times. It was also noted that demand for the community paediatrician service significantly outstrip supply and have been for some time. This is on the quality initiative and a proposal would be put to the next Clinical Commissioning Committee for transformation and investment. The Governing Body NOTED the Integrated Performance and Quality Report. 8.0 ASSUARANCE REPORTS FROM COMMITTEES 8.1 Finance and Performance Committee reports of meetings held on 31 January and 28 February 2018 The report was taken as read and it was noted that the items covered in the report have been highlighted under the Finance and Performance section. No further comments were made. 8.2 8.3 8.4 8.5 8.6 Procurement Committee report from meeting held on 14 February 2018 The report was taken as read and no comments were made. Clinical Commissioning Committee report from meetings held on 15 November and 13 December 2017 The report was taken as read and no comments were made. Patient and Public Engagement Committee report from meeting held on 8 March 2018 The report was taken as read and no comments were made Quality and Safety Committee report from meetings held on 17 January and 7 March 2018 The report was taken as read and no comments were made. Audit Committee report from meeting held on 21 March 2018 The Chair of the Audit Committee noted that a verbal update on the Audit Committee meeting had to be given, as the meeting was held in the morning of 21 March 2018. The two main areas highlighted were as follows: 21 of 255

The Committee reviewed and approved the External Audit Programme of work. The interim audit have been carried out and there were no areas of concern highlighted. The Committee also reviewed the draft Head of Internal Audit Opinion, which gave a current rating of amber-green, which is a positive statement noting that the CCG has adequate and effective risk management controls in place, but there are areas of improvement. Three particular areas highlighted are: o o o Contract Management - locally, borough and CSU level. Primary Care Delegated Commissioning - for which most of the areas highlighted have been delivered. A second review would be carried out and early indications suggests an improvement. Procurement support from the CSU - a programme of work is in place for 2018/19 to review the areas of improvement. Further work is required to be carried out on the report and the final audit report would be considered at the Committee meeting in May. 8.7 The Governing Body NOTED the Committee Assurance Reports. 9.0 GOVERNANCE 9.1 9.1.1 Board Assurance Framework and Corporate Risk Register Deborah McBeal presented the Board Assurance Framework (BAF) and Corporate Risk Register (CRR) for the Governing Body s review. The CCG aligned its BAF level risks to the NCL Joint Commissioning Committee Risk Register and a new NCL Risk Register has been developed which captures the key pan-ncl risks that are not captured by the CCG s other risk registers. 9.1.2 9.1.3 9.1.4 The Governing Body noted the following changes since the last report in January: There were six open BAF- level risks and 23 open risks on the CRR. There were no new or escalated risks to the BAF and two deescalated risks. These were: o Risk 13: Failure to comply with the CCG's Policy and statutory guidance on Conflicts of Interest, downgraded from 12 to 8 due to the significant progress made. o Risk 342: Risk to the delivery of Primary Care Transformation Programme - Phase I of the Enfield Single Offer - downgraded from 12 to 9. New risk added to the CRR was Risk 465: Personal Health Budgets concern regarding safety of commissioned care meeting patient health. Risk 454: Lack of treatment options for children in the transforming care cohort, and commissioning capacity to implement guidance, was increased from 9 to 12. Risk 59: Backlog of processing referrals within Enfield's Referral Service and Risk 297: Risk to delivery of current CAMHS services due to proposed funding reduction by Enfield Borough Council were deescalated from 9 to 6 and 12 to 3 respectively. Risk ID 33: Recommissioning of long stay dementia beds - potential legal issues arising from transfer of care from hospital to community setting was recommended for closure. The Audit Committee at its meeting on 21 March discussed the BAF and CRR and general risk management. The Committee had challenged that the Risk Registers are becoming quite complex and incredibly long and was assured that there is work in progress on collective Risk Management Strategy across NCL and appetite for risks across the five CCGs. All leads are reviewing their risks to keep them up to date. Risk 454 was flagged as an area of concern and assurance was sought on risk 297, which has been downgraded from 12 to three, contrary to reality on the ground. Action: GB/009/18. It was noted that a finance risk already exists, which encompasses the budget risk; therefore, there was no need to raise the budget risk as a new risk, as suggested. 22 of 255

9.1.5 The Governing Body NOTED: i. the Board Assurance Framework and Corporate Risk Register; ii. the escalated, deescalated and new risks; and iii. the NCL Joint Commissioning Committee Risk Register. 9.2 9.2.1 9.2.2 9.2.3 9.2.4 NCL Joint Commissioning Committee Terms of Reference The Terms of Reference for the NCL CCG Joint Commissioning Committee have been updated to provide greater flexibility in the appointment of the Committee Chair and Committee Vice Chair. The update was made in the light of the Committee being chaired by Karen Trew, Enfield CCG Lay Member representative in 2017/18, after an Independent Chair was not found following a recruitment process. The changes to the proposed Terms of Reference allow for the Committee Chair to be appointed from either a CCG Lay Member representative or through the appointment of an Independent Chair, should the Committee wish to pursue this option. The update allows for the appointment of a Committee Vice Chair from the remaining CCG Lay Member representatives. This approach was recommended to CCG Governing Bodies by the Joint Commissioning Committee at its meeting held on 1 February 2018. Karen Trew, Lay Member Enfield CCG was appointed as Chair and Kathy Elliott, Lay Member Camden CCG was appointed as Vice Chair of the Committee. The Governing Body APPROVED the amended Terms of Reference and Standing Orders of the NCL Joint Commissioning Committee. 10.0 ITEMS FOR INFORMATION 10.1 The Governing Body NOTED the following items for information: i. NCL Joint Commissioning Committee summary of meeting held on 1 February 2018. ii. NCL Joint Commissioning Committee minutes of 7 December 2017. iii. NCL Primary Care Committee in Common minutes of 17 November 2017. iv. Health and Wellbeing Board draft minutes of 8 February 2018. 11.0 PUBLIC OPEN SPACE 11.1 The Chair invited further questions from the public relating to items on the agenda. The following matters were raised: Safeguarding: a safeguarding issue was raised, which was agreed to be a Local Authority matter and therefore should be discussed outside of the meeting. 12.0 ANY OTHER BUSINESS There were no matters of other business. 13.0 CLOSING AND DATE/ PLACE OF THE NEXT MEETING The meeting closed at 15.07pm. The date of the next meeting is 23 May 2018 at Holbrook House. These minutes are agreed to be a correct record of the meeting in public of Enfield Clinical Commissioning Group held on 21 March 2018 Signed.. Date 23 of 255

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May 2018 Date Action Ref Minute No. Item/ action Owner Deadline Comments 21.03.2018 GB/006/18 6.1.2 Enfield Clinical Commissioning Group Governing Body ACTION LOG Quality and Safety Exception Report Raise at Haringey CCG and report back on the contractual issue raised with Concordia for the dermatology service at NMUH. Director of Planning, Transformation and Recovery Agenda Item 3.2 23.05.2018 Haringey and Enfield CCGs are currently supporting NMUH to continue to sub contract the service to Concordia, whilst a longer term solution to dermatology services is put in place. Propose to close. 21.03.2018 GB/007/18 7.3.3 Integrated Performance and Quality Report for February Director of 23.05.2018 See attachment to action log. Present an NCL wide picture of the new target for the LAS response Performance, Planning times and confirm whether deferential targets for the inner and outer and Primary Care, NCL Propose to close. boroughs is re-emerging. CCGs 21.03.2018 GB/008/18 7.3.3 Integrated Performance and Quality Report for February Report on the reason for the deterioration in C.Difficile infections, as referred to in Appendix 7 of the report. Director of Quality and Clinical Service 23.05.2018 Enfield CCG was set a C. difficile target of 76 in 2015/16, 2016/17 and 2017/18. The CCG had failed to achieve this target for the past two consecutive years. An Action Plan to meet the CCG's annual C.Difficile target set by NHS England was put in place. This included infection training for nursing homes, which occurred last year. Implementation of the action plan has resulted in a reduction in C.Difficile infection rates in Enfield. A report was taken to the Quality & Safety Committee meeting in March 2018. Propose to close. 21.03.2018 GB/009/18 9.1.4 Board Assurance Framework and Corporate Risk Register Deputy Chief Officer/ Provide assurance on the rationale for downgrading risk 297 Director of Primary (CAMHS - Child Adolescent Mental Health Service) from 12 to 3. Care Commissioning 23.05.2018 Enfield CCG has agreed a CAMHS waiting list initiate for 2018/19 in order to ensure the CCG meets the NHS CYP Mental Access target for 2018/19, which includes improved management of the Enfield CCG CAMHS waiting list, focussed on reducing the number of patients waiting in excess of 13weeks. The CCG has established weekly escalation calls with both BEH MHT and London Borough of Enfield to inform: - Development of the CAMHS waiting list trajectory 2018/19 in order to meet the national standard, in order to ensure future capacity is aligned to current demand and improving productivity - Understanding the workforce challenges in relation to recruitment and retention of staff across all CAMHS services provided for Enfield patients Ensuring patients waiting in excess of 13 weeks are clinically assessed and ensure they are seen by the appropriate service to meet their need. Propose to close. 25 of 255

Enfield Clinical Commissioning Group Governing Body ACTION LOG 24.01.2018 GB/003/18 8.4 Clinical Commissioning Committee report from meetings held on 15 November and 13 December 2017 Provide information on whether there are implications on the Individual Funding Requests (IFR) numbers as a result of the new Procedure of Limited Clinical Effectiveness (POLCE) in place. Medical Director Clinical Director 23.05.2018 18.07.2018 The Clinical Commissioning Committee meeting in April was cancelled and the next meeting is scheduled for 30 May after which an update will be provided. 24.01.2018 GB/004/18 10.1 Enfield Safeguarding Children Board Annual Report 2016-17 Look into the timescale for resolving missing children cases and report back. Enfield Safeguarding Children Board Independent Chair 23.05.2018 The ESCB met in March and a representative from the Metropolitan Police spoke to the Board around current operational issues relating to children and young people who are regularly missing. The ESCB was reassured that all appropriate follow up actions are being followed and whilst individual cases were not reported on, the partners meet regularly to monitor frequent and regular missing episodes. Propose to close. 22.11.2017 22/11 86 7.3 Integrated Performance and Quality Report for October 2017 Send out communication on the new Ambulance Response Programme 22.11.2017 22/11 92 8.4 NCL Sustainability and Transformation Plan: 6 months progress report Update on Last Phase of Life model to be monitored in future reports. NCL Director of Performance & Acute Commissioning Director of Strategy, NCL CCGs 24.01.2018 21.03.2018 21.03.2018 23.05.2018 The NHS England Ambulance response times were published by NHS England in July 2017. https://www.england.nhs.uk/2017/07/new-ambulanceservice-standards-announced/ Future performance reports against the new ambulance standards will be reported by STP footprint, by the London Ambulance Service in 2018/19. Propose to close. On the agenda. Propose to close. 26 of 255

Enfield Clinical Commissioning Group Governing Body ACTION LOG CLOSED ACTIONS FROM LAST MEETING 24.01.2018 GB/001/18 4 Questions from the public A detailed response in writing to be provided for the further clarity requested for the second part of question 8. Accountable Officer 24.01.2018 GB/002/18 6.1 Quality and Safety Report Governing Body Nurse Carry out a deep dive on the nine serious incidents (SIs) reported in Representative two months at Barnet, Enfield, Haringey Mental Health Trust (BEHMHT) and take to the Quality and Safety Committee. 12.02.2018 The response to question 8 was revised and sent to the member of the public who raised the question. AGREED TO CLOSE 23.05.2018 Quarter 3 BEHMHT thematic review on SIs has been received from the CSU which will include a deep dive on SIs, themes & trends. This will be discussed at the April Quality and Risk sub group. In addition, an annual BEHMHT SI themes & trends will be produced and a report presented to the Governing Body in May. AGREED TO CLOSE 24.01.2018 GB/005/18 10.1 Enfield Safeguarding Children Board Annual Report 2016-17 Find out the protocol on safeguarding issues for looked after children under and above 5 and report back. Public Health Representative 21.03.2018 School nurses and health visitors services are commissioned by the public health team and they deliver the healthy child programme as laid out by the Department of Health. The information received from Barnet Enfield and Haringey Mental Health Trust (BEHMHT) is that there is no specific protocol but there is a joint GP/ Health Visitors protocol for information sharing where the latter meet with their named GP practice every six to eight weeks to discuss families of concern including looked-after children. If GPs remain concerned, a discussion at the Safeguarding Children Board may be more helpful than at the CCG Governing Body, as all relevant parties are represented at the Safeguarding Children Board. AGREED TO CLOSE 22.11.2017 22/11 93 12 Public Open Space Organise a half day community session on the STP in collaboration with Healthwatch. 15/03/2017 15/03 64 7.5 Enfield CCG Staff Survey Report Provide update on the action plan developed by the Senior Management Team, to take forward identified actions at the Governing Body meeting in May 2017. Deputy Chief Operating Officer/ Director of Strategy, NCL CCGs Deputy Chief Operating Officer & Director of Primary Care Commissioning 21.03.2018 This session was undertaken as part of the Patient and Public Engagement event on 7 March 2018. AGREED TO CLOSE 30.09.2017 21.03.2018 Further discussion took place at the staff meeting on 22 February 2018. A Staff Forum has been set up which met in February. One of its remit is to look at the priorities raised from the staff survey. AGREED TO CLOSE 27 of 255

Action: GB/007/18 The aim of the London Ambulance Service ambulance response performance will be monitored by STP footprint for London. The focus of the new standards is to ensure that: The sickest patients receive the fastest response All patients get the best response allocated to them No one is left waiting for and unacceptably long time for an ambulance to arrive The London Ambulance performance against the national standards is shown in the table below: The London Ambulance service have confirmed that for February 2018, national standards category 1 and 4 responses for London services were achieved. Although the national standards for category 2 & 3 responses were not met in February 2018 the London Ambulance service was ranked fourth of the ten ambulance trusts across England and performed 50 seconds better than the England average for category 1. In February 2018 only one ambulance trust (North East Ambulance service) met the national standard category 1 mean response times. The table below shows how the London Ambulance Service performed by STP area. London Ambulance Service Performance by STP: February 2018 C1 Mean C1 90 th Centile C2 Mean C2 90 th Centile C3 90 th Centile C4 90 th Centile National Standard 7 minutes (00:07:00) 15 minutes (00:15:00) 18 minutes (00:18:00) 40 minutes (00:40:00) 120 minutes (02:00:00) 180 minutes (03:00:00) North Central 00:07:37 00:12:24 00:24:31 00:51:25 03:42:28 03:17:46 North East 00:07:45 00:11:50 00:25:45 00:54:33 03:14:55 02:49:53 North West 00:07:34 00:11:47 00:23:51 00:51:18 03:12:56 02:42:06 South East 00:07:14 00:11:33 00:19:55 00:40:43 02:18:08 02:06:48 South West 00:06:55 00:11:27 00:21:56 00:45:05 02:36:10 02:01:38 28 of 255

Hospital Handovers will have a direct impact on performance, particularly across the C3 and C4 categories as ambulances are less available for conveyances. The LAS is working through its operational resourcing model to meet the new requirements of ARP e.g. Fleet logistics are being looked at to ensure adequate levels of fast response units and double crewed ambulances are available to respond to those patients requiring conveyance. It has been recognised by regulators nationally that Ambulance services will not be in a position to meet ARP standards straight away and performance management against these standards comes into effect in September 2018. In London, there has been a significant increase in call volumes, though the percentage being conveyed has remained stable. National work is being undertaken to review call determinants within the C1 and C2 categories to review the increase being seen across C2. A spring review will provide information in terms of progress against this work. 29 of 255

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MEETING: Governing Body Meeting in Public DATE: Wednesday 23 May 2018 TITLE: Accountable Officer s Report to the Governing Body LEAD GOVERNING Helen Pettersen, Accountable Officer BODY MEMBER: AUTHOR & POSITION: John Wardell, Chief Operating Officer CONTACT DETAILS: John.wardell1@nhs.net Summary: Agenda Item: 5.1 This report updates the Governing Body on developments in the local NHS, wider policy issues and key activities. Supporting Papers: There are no supporting papers. Recommended action: The Governing Body is asked to: NOTE the Accountable Officer s Report Objective(s) / Plans supported by this paper: This report is for information only. Audit Trail: This report is for information only. Patient & Public Involvement (PPI): This report is for information only. Equality Impact Assessment: This report is for information only. Risks: This report is for information only. Resource Implications: This report is for information only. 31 of 255

Governing Body Meeting 23 May 2018 Accountable Officer Report 1. Introduction This report updates the Governing Body on the local NHS, wider policy issues and key activities since the last Governing Body meeting. 2. Operating Plan 2.1 The Operating Plan is one of a number of planning returns (the other significant return being the financial plan) required by NHS England each year and captures a certain set of activity figures and performance trajectories that are used for in year monitoring and assurance. 2.2 The activity figures have been prepared on the basis of historical trends, contractual negotiations and expected QIPP delivery. This plan has been prepared using the same assumptions as the financial plan. 2.3 Performance trajectories have been built up in discussion with providers, based on the planning guidance and appropriate Sustainability and Transformation Plan (STP) groups such as the Accident and Emergency (A&E) Delivery Board. 2.4 The plan was discussed at the Finance and Performance Committee to allow submission on 30th April in line with national deadlines. Governing body members were invited to attend to provide input. 3. Information Governance 3.1 The Information Governance (IG) Toolkit process for 2017-18 has been submitted with a self-assessment rating of satisfactory. This reflects the CCG s ongoing performance of all IG related matters and includes staff training. 3.2 With the support of the North East London Commissioning Support Unit (NEL CSU) IG Team and the Corporate Services Team, preparations continue for ensuring compliance with the new General Data Protection Regulation (GDPR), which comes into force on 25th May 2018. We will be providing Governing Body members with some clear information and guidance on this at a future meeting. We are also liaising closely with our member practices to provide support and guidance to aid their preparation in relation to GDPR. 3.3 The CCG s successful compliance with the annual IG Toolkit requirements at the end of 2017/18 has put the CCG in a strong position with regards to GDPR. 3.4 As part of GDPR, the CCG is required to assign the role of Data Protection Officer to provide specialist advice, support and training. This role will be undertaken for the North Central London (NCL) CCGs by NCL s IG Lead, Dayo Adebari, who is based in the Corporate Services Directorate. 32 of 255

4. Commissioning Support Unit Transfer Update 4.1 Governing Body members will recall that we are in the process of transferring a number of staff from NEL CSU into the NCL CCGs. These staff work mainly on contracts with NHS Trusts (contract monitoring, finance, analytics, clinical quality, performance monitoring etc.). This work is progressing well. Having previously gained Governing Body approval to proceed with this project, and give notice to NEL CSU for some services, we are required to submit a Business Case to NHS England as part of the staff transfer approval process. 4.2 The business case was submitted the week of 9th April 2018 and we await feedback. We have NCL CCGs Governing Body members on the oversight group for this project, and we will continue to keep all Governing Body members updated on progress and confirm the precise transfer date when it is finalised. 5. Additional North Central London Post 5.1 The Governing Body at its meeting on 21 March 2018 ratified the decision by the Remuneration Committee in Common to approve the split of the Director of Performance and Acute Commissioning NCL CCGs, role into two posts. Paul Sinden is the Director of Performance, Planning and Primary Care for the NCL CCGs. 5.2 I am pleased to announce the appointment of Eileen Fiori to the post of Director of Acute Commissioning, NCL CCGs. Eileen has a strong provider and contracting background and is a qualified nurse. Eileen has most recently been working at NELCSU as a CSU POD (Point of Delivery) Director and is experienced in leading transformational change. Eileen will start her new role on the 1st May 2018. 5.3 I am also pleased to announce the appointment and commencement of Alex Faulkes, Programme Director for NCL STP Urgent and Emergency Care. Alex brings a wealth of experience in urgent and emergency care and previously worked as Director of Performance and Planning where he worked with a number of challenged health economies to improve urgent and emergency care provision. 6. Enfield CCG Senior Management posts 6.1 I would like to update you on some changes to the senior leadership team at Enfield CCG. 6.2 Dr. Jahan Mahmoodi, Medical Director, has left Enfield CCG to take up a governing body role at Brent CCG. I would like to thank Jahan for his support to the CCG and wish him well in his new role. Dr. Mateen Jiwani has been appointed as Clinical Director and commenced on Monday 16 April. 6.3 Mark Eaton, Director of Recovery left Enfield CCG in April as his contract concluded. I would like to take this opportunity to thank Mark for all his support to the CCG and for his role in leading the highly successful QIPP programme. We have changed the remit of the Director of Recovery role to also focus on planning and delivery as well as financial recovery. Vince McCabe, who was covering the position of Director of Commissioning, has been appointed to take on this role of Director of Planning, Transformation and Recovery on an interim basis for 6 months from Monday 2 April. 33 of 255

6.4 I would like to welcome back Graham MacDougall who is returning to the role of Director of Commissioning on Tuesday 3 April after a 6 month secondment opportunity with NHS England. I would like to extend my appreciation to Vince McCabe for covering the role during this time. 6.5 I would also like to welcome back Aimee Fairbairns back to Enfield. Aimee s secondment role with NHS England has ended and she returned to her role as Director of Quality and Clinical Service (previously Director of Quality and Integrated Governance) on Tuesday 3 April. I would like to take this opportunity to thank Carole Bruce-Gordon who has been acting up in this role in the interim period. Carole returns to her substantive role of Assistant Director of Safeguarding. 7. Winter Planning 7.1 Following a very challenging winter period, the system has been reviewing its performance to understand those initiatives and actions that had the greatest impact on delivering greater system resilience and better A&E performance. A&E performance continues to improve overall but remains fluctuating over the course of a week or month and consistency of performance remains challenging. Some key areas of focus for CCG commissioners over the next two months are: Review of all three pathways for Discharge to Assess to ensure that those pathways are optimal in managing patient discharges Scoping the roll out of the Trusted Assessor model which has been commissioned through the Care Homes Assessment Team and which has proved successful for those care homes where it was piloted. Continue to review and monitor the improved escalation processes for Delayed Transfers of Care (DTOC) and Medically Optimized patients that is supporting discharges from hospital. Scoping an initiative to have GPs at the front door of A&E at North Middlesex University Hospital (NMUH) to help support clinical triage and enhance patient flow through A&E and to other parts of the urgent and emergency care system. Supporting the system to embed the use of the Choice Policy to support families to make long term care choices in an out-of-hospital setting. Ensuring the system responds to those issues highlighted in the Enfield Healthwatch report into A&E at NMUH. 8. QIPP Planning and Acute Contract Agreements 8.1 The draft QIPP programme previously agreed by the Governing Body is being implemented and reviewed to reduce the risks to delivery. The total target Quality, Innovation, Productivity and Prevention (QIPP) value, required to achieve break-even is 23.8 million. 8.2 An enhanced internal process is being put in place as we prepare for the first 2018/19 NHS England QIPP assurance meeting. 34 of 255

8.3 A review of the QIPP pipeline is being undertaken to cover any additional risk or slippage to current schemes. 8.4 Finalisation of the acute contracts will be an important part of the process determining on how best to manage demand within the acute sector through relevant QIPP schemes. 9. Enfield CCG staff meetings 9.1 Enfield CCG held a staff meeting on 25 April 2018. The monthly meetings include general updates on the CCG s financial position and QIPP progress plus other strategic developments across NCL. Staff received a presentation on the e-referral Service implementation project delivered by the Transformation Project Locality Manager. There was a further presentation by the Staff Forum Chair on the progress to date of the recently established Staff Forum. 9.2 At the previous staff meeting held on 22 March, there was a presentation by the Senior Information Governance Compliance Lead, NELCSU, focusing on the GDPR which will apply from 25 May 2018 (when it supersedes the UK Data Protection Act 1998). A further presentation was delivered by the Head of Continuing Care on the role and statutory responsibilities of the continuing healthcare team. END OF REPORT 35 of 255

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Agenda Item: 6.1 MEETING: Governing Body Meeting in Public DATE: 23 May 2018 TITLE: Quality and Safety Exception report LEAD GOVERNING Aimee Fairbairns, Director of Quality and Clinical Services BODY MEMBER: AUTHOR & POSITION: Rosalind Murphy, Clinical Quality Manager, NELCSU Nyasha Mapuranga, Head of Clinical Quality CONTACT DETAILS: Nyasha.mapuranga@nhs.net 020 3688 2873 This report provides a summary of the key exceptions and quality issues discussed with Providers in the quarter four Clinical Quality Review Group (CQRG) meetings. Using the three quality domains (patient safety, patient experience and clinically effective care) the report updates the Governing Body on Enfield CCG s work to improve quality in commissioned services. The report also provides key exceptions on discussions at the CCG Quality & Safety Committee and Sub Group meetings. Summary of key exceptions outlined in the report: Barnet, Enfield and Haringey Mental Health Trust (BEHMHT) The Care Quality Commission (CQC) report was published in January 2018. CQRG will receive monthly exception reports of compliance with due actions and quarterly presentation of the full plan. Two unannounced inspections were held in quarter four, one to Magnolia Unit and one to Silver Birches ward, final reports are not yet available. North Middlesex University Hospital (NMUH) NMUH is preparing for a comprehensive inspection by the CQC which is scheduled for 22-24 May 2018/19 and 19-21 June 2018. An interim programme lead and Care Quality Director have been recruited to lead on completion of the remaining improvement plan actions and support the organisation in preparing for the next inspection. In March 2018 NMUH reported four Serious Incidents (SIs), one of which was a Never Event; this brings the year to date total of Never Events to six. Royal Free London (RFL) The Trust has reported 12 Never Events during 2017/18. In response to the Never Events RFL is reviewing processes and planning to implement Local Safety Standards for Invasive Procedures. Along with NHS Improvement (NHSI), Barnet CCG is working with associate Commissioners to determine any additional measures that can be implemented. Barnet CCG is also organising a return quality visit in June 2018 to review implementation of recommendations made following the January assurance visit. Enfield CCG will be participating in this visit. 37 of 255

Integrated Urgent Care Services (LCW) The Care Quality Commission has published it latest report on the provider. The GP out of hours base at St Pancras was reviewed in January 2018, and has been awarded an overall rating of requires improvement. Quality & Safety Committee Revised Terms of Reference Following changes to the CCG s Committee governance arrangements in July 2017, the Quality & Safety Committee reviewed its Terms of Reference (ToR) at its meeting on the 6 th of September 2017 and recommended it to the Governing Body for approval. The following changes were agreed: The Committee to have additional responsibilities in relation to: Human Resource Policies Health & Safety Emergency Planning, Resilience & Response (EPRR) Transfer of responsibilities to the new Clinical Commissioning Committee in relation to: Clinical Reference Group (now the Clinical Review Working Group) Delegated operational responsibility for ECCG Medicines Management GP Transformation Group & primary care quality issues to the Individual Funding Request Quarterly & Annual Reports The Committee undertook a further 6 month review of its ToR at its meeting on 7 th March 2018 and the following was agreed: The Committee noted that the ToR was presently fit for purpose with the exception of Information Governance which will need to be amended following the NCL Corporate Service Review. Supporting Papers: Appendix A: Quality & Safety Committee Revised Terms of Reference. Recommended action: The Governing Body is asked to: Review the exceptions reported and agree the actions being taken. Raise and discuss any issues that require further clarification by the Quality and Safety Committee. Approve the Revised Terms of Reference for the Quality & Safety Committee (attached). Note the following policies were approved at the 2 nd May Quality & Safety Committee Continuing Healthcare (CHC) Operating Procedures. Quality Strategy 2018/2021. Health, Safety & Wellbeing Strategy 2018-19. Personal Health Budgets Operational Policy. CHC Support Tools Change Policy. 38 of 255

Objective(s) / Plans supported by this paper: This paper supports the Enfield Clinical Commissioning Group s (CCG) strategic plan to ensure there is continuous service quality improvement and achieve a robust governance framework. Audit Trail Minutes of the Enfield CCG Quality and Safety Committee. Minutes of Barnet, Enfield & Haringey Mental Health Trust (BEHMHT) CQRG. Minutes of the RFL CQRG. Minutes of the North Middlesex University Hospital (NMUH) CQRG. Enfield CCG Integrated Performance and Quality Report (IPQR). Exception report on the Quality & Risk Sub Group and Quality and Safety Committee Meeting. Patient & Public Involvement (PPI) This paper has not required patient and public involvement. Equality Impact Analysis: Not applicable. Risks: Capacity, development, and duplication are all risks to quality and safety and are reflected in the CCG s corporate risk register. 39 of 255

Governing Body Report Quality and Safety Exception report 1. Barnet Enfield and Haringey Mental Health Trust (BEHMHT) Headline: Care Quality Commission BEHMHT shared its Improvement Plan at the April Clinical Quality Review Group meeting (CQRG). The Trust is holding two weekly evidence review meetings with service staff, following which the plan will be updated. CQRG will receive monthly exception reports of compliance with due actions, and quarterly presentation of the full plan. There were two unannounced inspections during quarter four, one to Magnolia Unit and one to Silver Birches ward. The final report was not published at the time of writing but the Trust received informal feedback at the time of the inspection indicating that improvement is needed in providing nutrition and hydration, care planning, medicines management and physical health care. Patient Safety Well led Serious Incidents The Trust reported three Serious Incidents (SIs) during March 2018; in line with previous years the total number of incident during 2017/18 was 48. BEHMHT is working with the CCG and Commissioning Support Unit (CSU) to improve the quality of SI reports and reduce the number of requests for additional information. The number of overdue reports has reduced to three. The CSU reviewed historic requests for further information for themes and trends; the findings were shared with the Trust at the last quarterly meeting and were well received. GP Communication BEHMHT provided the CQRG with a review of its communication timescales with primary care. The review identified areas for improvement and has included this as a quality priority for 2018/19 in its draft report which currently circulated for comments. Freedom to Speak UP BEHMHT ran a successful project of having two service level staff acting as freedom to speak up guardians, each taking the role one day per week. The pilot was well evaluated by staff, 32 having come forward to raise an issue for discussion. The pilot has been extended until July 2018. Chief Executive BEHMHT has confirmed the appointment of Jinjer Kandola as Chief Executive. Ms Kandola, who is currently working as Deputy Chief Executive Officer and Director of Workforce and Organisational Development at Hertfordshire Partnership University NHS Foundation Trust, is due to take up post on 16 July 2018. Responsive Complaints The Trust continues to face challenges with meeting the complaints response deadlines. The policy has been revised to clarify roles and responsibilities and is currently awaiting ratification. Work has commenced 40 of 255

with services to ensure that each Directorate manages its own complaints effectively. A new Patient Experience Manager has been recruited and will lead on this initiative once in post. 2. North Middlesex Hospital (NMUH) Headline Care Quality Commission NMUH will be subject to a comprehensive inspection by the Care Quality Commission (CQC) between 22-24 May 2018/19 and 19-21 June 2018. The Trust has responded to the pre inspection provider information request and CQC has begun conducting staff engagement events. An interim programme lead and Care Quality Director have been recruited to lead on completion of the remaining improvement plan actions and support the organisation in preparing for the next inspection. A weekly steering group led by the Director of Nursing has been established to monitor progress. Peer reviews are underway; commissioners have offered support to join the reviews if required. Patient Safety Serious Incidents & Never Events In March 2018 NMUH reported four SIs, one of which was a Never Event; this brings the year to date total of Never Events to six. NMUH continues to have a number of delayed SI reports and Further Information Request responses. The Trust has revised its Serious Incident investigation process and has introduced dedicated SI investigators for a trial period to improve the quality and timeliness of investigation reports. The revised process and initial outcomes will be discussed at the May CQRG meeting. Theatres An insight and learning visit into theatres was undertaken on the 19 th April 2018. The insight and learning visit was held to gain assurances into the use of the World Health Organisation (WHO) surgical checklist after wrong site surgery Never Events which occurred last year. The visit highlighted many areas of improvement implemented by the Trust around ensuring the use of the WHO surgical checklist. The report is still being drafted by Haringey CCG (lead commissioner) and will be shared with the Quality and Safety Committee once it has been approved by the Trust. Clinical Effectiveness Accident and Emergency Performance against the national four hour standard in the emergency department continued to be a challenge in quarter four; NMUH underachieving against both the national standard and local trajectory. Compliance was affected by high ambulance conveyance rates, the wait to see a clinician and slow discharges from the wards. Improvement plans remain in place to try to regain compliance. New medial rotas to improve skill mix will be implemented during quarters one and two of 2018/19. Haringey CCG Director of Quality and NMUH s emergency department 41 of 255

Clinical Director are meeting to review the current emergency department dashboard and agree reporting requirements for 2018/19. NMUH has been conducting a retrospective review of emergency department SIs relating to patients with chest pain. The review found no common root cause but identified some care and service delivery themes that are being addressed by the Clinical Director. NMUH s Director of Nursing commissioned a Safety Review of incidents in emergency department between November 2017 and January 2018. The report will be shared with commissioners once internal due process has been completed. Well led Maternity Department In March 2018 NMUH received a CQC maternity outlier alert for emergency caesarean section rates. North Central London CCG data indicates that NMUH elective caesarean section rates remain low within the sector; emergency caesarean section rates are comparable with other hospitals within the sector. In response to the alert NMUH conducted a random sample review of emergency caesarean section rates between October 2016 and June 2017; the review identified that all procedures were carried out in response to appropriate indicators. A response has been submitted to CQC and the Trust is awaiting feedback. Responsive National Staff Survey The NHS Annual Staff survey was published on 6 March 2018. In 2017, 1237 staff at NMUH completed the survey. Nine themes of staff experience are surveyed. The Trust scored well with regard to staff motivation, feeling that their role made a difference to patients, the quality of care staff are able to delivery, the quality of training and development, and the quality of appraisals. The lowest scores were awarded to equal opportunities, experiencing discrimination experiencing violence from patients/abuse from staff, and work related stress. NMUH is implementing a programme of staff listening events commencing in quarter one 2018/19 and a Trust wide improvement plan has been developed and is being implemented. 3. Royal Free Hospital (RFL) Patient Safety Serious Incidents and Never Events RFL has reported the highest number of Never Events in the sector; having declared 12 in 2017/18. The majority of the incidents have involved surgical or invasive procedures. In response to the Never Events RFL is reviewing processes and planning to implement Local Safety Standards for Invasive Procedures. Along with NHSI, Barnet CCG is working with associate Commissioners to determine any additional measures that can be implemented. Barnet CCG is also organising a return quality visit in June 2018 to review implementation of recommendations made following the January assurance visit. Enfield CCG will be participating in this visit. 42 of 255

Responsive A&E and Cancer waiting times RFL compliance with emergency department waiting times is stable at 85-90% through February and March 2018. Both sites continue to be affected by short notice staff sickness, high levels of attendance and poor inpatient flow. Escalation beds at both sites remain open. Recovery action plans based on demand management, hospital patient flow, discharge management and workforce are being implemented and managed by multiagency urgent care and emergency transformation groups. Plans are regularly refreshed to reflect the other improvement work supported by NHS Improvement Emergency Care. RFL met six of the eight national cancer standards in January 2018. The 62 day performance was reported to be out of compliance due to an increased volume of referrals in breast, lower gastrointestinal and head and neck services. Capacity has been increased to address the increase in demand. The three day per week straight to test pilot in lower gastrointestinal service, funded by NCL Rapid Recovery Fund has been extended. The Trust has been out of compliance with referral to treatment times for several months. In January 2018 a monthly Performance Review Group was re-established to monitor performance issues and the Trust began reporting in February 2018. The report includes CCG and speciality level break down of the waiting list and treatment plans for those waiting a long time. The Trust has alerted commissioners to a risk of identifying additional patients waiting 52 weeks plus, and has submitted an application to NHS Improvement for funds to support reduction of the backlog. Consequently eliminating the backlog by April 2018 is unlikely. The clinical harm review processes has not identified any severe or moderate harm has been identified in those with extended waits. The Enfield CCG Quality & Risk Sub Group will be undertaking a cancer deep dive at its June meeting on behalf of the Quality & Safety Committee. The deep dive will focus on key quality indicators including themes from 62-day breach analysis, Outcomes of Clinical Harm Reviews, SI Themes & Trends, Quality Alerts, Healthwatch reports where applicable and Claims/Complaints. Patient Experience Mixed sex accommodation breaches The Trust continues to report a high number of mixed sex accommodation breaches. Breaches are usually experienced following step down from critical care services. The CQRG has agreed that where the patient and family were informed and patient safety is maintained, breaches in relation to stepdown will be recorded but not reported. 43 of 255

4. Patient Safety Integrated Urgent Care Services LCW Care Quality Commission Report In January 2018 the out of hour s base at St Pancras Hospital was inspected. The service was given and overall rating of requires improvement, in addition the safe and well led domains were deemed to require improvement. The three remaining domains were rated as good. The report noted that the service focused on patient need; needs were assessed and care delivered in a timely manner and there was positive feedback. Care records were well written and the information shared appropriately. Appropriate referrals were made. There was clear, accessible leadership and staff felt supported. Safeguarding systems and processes were in place to safeguard both children and adults at risk of harm or abuse. The reviewers found that some staff were out of compliance with safeguarding training; this was later found to be largely due to records not be updated with completed training. Some recruitment policies were not adhered to i.e. 6 monthly drive license reviews. Some vehicle cleaning /equipment checks were not recorded. LCW had decided to remove oxygen from cars as it was rarely used; CQC indicated GPs should carry oxygen for emergencies. Non-medical prescribers were employed and their practice was well managed however there was no written protocol. The central log of evidence of how CAS alerts were disseminated or supporting evidence of completion. The evidence of how learning was shared was limited and incident investigations did not demonstrate sufficient staff involvement. During quarter four there were no SIs reported. Responsive Patient Experience The service is currently reporting on historical performance and quality indicators pending final publication of revised national indicators. Commissioners and the provider are reviewing the current reporting structure to agree appropriate reporting during 2018/19. At present six quality indicators (five with specified targets) and nine performance metrics (six with specified targets) are monitored. All five quality indicators with target metrics were met during quarter four (Table 1). The remaining indicator (percentage of answered calls triaged) achieved 100%. NCL continues to achieve above the nationally mandated target of 30% of all calls to IUC being handled by a clinician. There is evidence, received via the monthly clinical quality review group meeting, that the provider responds to feedback from other health professionals and implements any improvement actions required. LCW contacts a percentage of service users each month to request feedback. The recommendation rate reported is high (97%) however return rate using the current process is low. Alternative methods of contact are being reviewed to try to increase the return rate. Where narrative comments are provided the majority of service users report being happy 44 of 255

with the care they were given and that staff were polite, friendly and helpful. Where service users reported being less happy the reasons given were the lack of physical assessment by a clinician leading to less confidence in a telephone diagnosis; the distance travelled to receive a face to face appointment and that the service is an extra stop in getting to the emergency department. A patient initiated visit to LCW was held on the 22 nd of March 2018. The visit took place at the Ladbroke Grove site where the call-centre for the, none emergency, 111 services is based. The visit was initiated by patient representatives who are members of the Clinical Quality and Review Meeting (CQRG). The patient representatives requested the visit to get more understanding of the patient pathway and how the service is operating. They did not have any concerns with the service before initiating the visit. The visit was an insight into staff training, governance process of the organisation and how feedback is used to improve the service. The only issue highlighted was the use of Coordinate my care (CmC) in Enfield. CmC is an online care plan for patient with long term conditions. In Enfield this care plan is not widely used only 43 patients in Enfield registered on the care plan compared to the 5198 registered patients in Croydon. The care plan use is funded by the CCG. The quality team has informed the CCG primary care team of the issue and the need to improve awareness of the care plan in Enfield. Enfield CCG has agreed four Insight and learning visits with LCW in 2018/2019. 5 5.1 CCG Quality Governance The 2 May Quality & Safety Committee approved the following policies: CHC Operating Procedures Quality Strategy 2018/2021 Health, Safety & Wellbeing Strategy 2018-19 Personal Health Budgets Operational Policy CHC Support Tools Change Policy End of Report. 45 of 255

Agenda Item: 6.1 Appendix A 1. GENERAL Quality and Safety Committee Terms of Reference 2. The Quality and Safety Committee is established in accordance with NHS Enfield Clinical Commissioning Group s Constitution, Standing Orders and Scheme of Delegation. These terms of reference set out the membership, remit responsibilities and reporting arrangements of the Committee 3. CONSTITUTION The Quality and Safety Committee (the Committee) is a committee of the Governing Body. 4. MEMBERSHIP 4.1 The Committee comprises eleven members appointed by the Governing Body as follows: 4.1.1 Chair the Registered Nurse on the Governing Body; 4.1.2 Two GP Locality Leads (Co-Vice Chair) 4.1.3 One additional Governing Body GP 4.1.4 Director of Service Quality and Clinical Services; 4.1.5 Clinical Director; 4.1.6 Head of Performance and Informatics; 4.1.7 One Lay Member; 4.1.8 CCG Secondary Care Doctor 4.1.9 Public Health Representative. 4.1.10 Head of Clinical Quality 4.1.11 Assistant Director of Quality & Clinical Governance 4.1.12 CSU Quality and Safety representative 4.1.13 Assistant Director for Safeguarding 5. QUORUM The quorum for the Committee will be four members, two of whom must be clinical members. 6. DECISION MAKING Each full member of the Committee has one vote. In the event of a tie vote the chair or the person chairing the meeting has a casting vote 7. ATTENDANCE Other members of CCG staff (including the following) will be in attendance where they have specific items on the agenda. 46 of 255

7.1 Other CCG GP Members or Members of the Governing Body should be invited to attend when the Committee is discussing areas of risk or operation that are their responsibility. 7.2 These will include the Safeguarding leads for adults and children, and medicines management. If unable to attend in person, the relevant person will nominate a suitable deputy to attend in their place. Other individuals will be invited to attend if specific specialist advice is required, e.g. Chief Finance Officer, Local Authority social care representation. 7.3 Other colleagues from supporting organisations including Commissioning Support Unit, Public Health, NHS England etc. will be invited to attend where appropriate and with their agreement. 8. FREQUENCY OF MEETINGS The Committee will meet at least five times a year. The chair of the Committee may call additional meetings as necessary. 9. PURPOSE The Committee is responsible for ensuring the quality and safety of all commissioned services. It will keep under review providers compliance with contracts relating to quality and safety, whilst taking into account patient experience which is a quality marker ensuring patients have a positive experience of services. Particular emphasis relates to CCG statutory responsibilities for quality in accordance with the Health and Social Care Act. 10. DUTIES The duties of the committee will be driven by the priorities for NHS Enfield clinical commissioning group and any associated risks or areas of quality improvement. The committee will operate to a programme of business, agreed by the Committee that is flexible to new and emerging priorities and risks. 10.1 To assure the Governing Body that quality and safety is integral to the commissioning function, by providing an overview of quality assurance and clinical governance; 10.2 To ensure the quality and safety of commissioned services, working with the CSU Quality and Contracts Team to keep under review providers compliance with terms and conditions of contracts relating to clinical quality, and taking account of patient experience, reporting quality issues regularly to the Governing Body 10.3 To oversee the development of local quality key performance indicators and metrics in order to ensure continuous improvement of the services that it commissions including improving patient experience; 10.4 To provide the Governing Body with a clear and comprehensive summary of quality, safety and effectiveness of commissioned services, with a focus on improving these as well as the patient experience; 10.5 To ensure a robust Clinical Quality Review (CQR) process is in place for commissioned services and regular reports are received from the CSU Safety Team ; 47 of 255

10.6 To ensure CQR oversight and that appropriate remedial action(s) is in place, where areas of poor performance are identified for commissioned services; work with the CSU to ensure compliance with the Health and Social Care Act 2012 including Quality Accounts; 10.7 Receive assurances from within the organisation and providers that areas relating to clinical quality and safety are implemented Ensure that the quality agenda leads to improvements in productivity and prevention through innovation and to develop a robust process for ensuring patient safety is paramount in commissioning decisions 10.8 To receive quarterly patient safety incident and Serious Incidents reports from the CSU Safety Team relating to NHS and service providers that identify themes and trends and recommend areas for change in practice through the commissioning process. Review exception reports in respect of clinical risks including serious incidents and investigations of poor quality care/patient safety issues where appropriate to identify organisational learning 10.9 To liaise with the CSU Contracts Team to escalate quality concerns that may lead to appropriate contractual notices being issued, where appropriate; (this is undertaken by the Director of Quality and Governance on behalf of the committee) 10.10 To receive assurance on remedial actions taken by providers in relation to breaches in quality standards; 10.11 To review any notification, advice or instruction issued by regulators; 10.12 To work with the CSU to approve provider annual quality accounts statements and review lead provider progress against existing Quality Account work plans 10.13 To advise the Governing Body following national inquiries, and national and local reviews undertaken by regulators for commissioned services, and to monitor the implementation of action plans; 10.14 To receive minutes from quality and performance meetings for which Enfield is a co-ordinating / lead commissioner e.g. BEHMHT Joint Performance & Quality group (JPQ) 10.15 To receive minutes from the Quality & Risk Sub Group with delegated operational responsibility for quality and safety and to feedback to the sub group as appropriate 10.16 To review quality and safety risks on the CCG Risk Register and ensure appropriate mitigation is in place, with relevant advice to the Governing Body; 10.17 To receive Safeguarding (adults and children) assurance reports that identify areas of compliance, themes and trends and recommend appropriate actions, advising the Governing Body appropriately; 10.18 To receive annual reports related to the Committee s remit including, but not limited to, Safeguarding Annual Report, Serious Incident Annual Report; 10.19 To oversee the development of a Quality Strategy and Plan, for approval by the Governing Body and to ensure oversight of the implementation plan in relation to this; 48 of 255

10.20 To receive patient experience reports (both qualitative and quantitative) from the CSU Complaints Team on a quarterly basis, including Patient enquiries reports and complaints reports, that identify themes and trends and recommend areas for change in practice through the commissioning, advising the Governing Body appropriately; 10.21 To receive assurance that trends in provider complaints are managed through the individual CQRG meetings; 10.22 To monitor the implementation and outcome of quality within the transformation schemes including CQUINs; 10.23 Receive, review and comment on information referred by Public Health relevant priority schemes relating to clinical safety and/or effectiveness. 10.24 To receive reports on Health & Safety matters; 10.25 To receive reports on Information Governance 10.26 To receive reports on progress and updates with emergency planning; 10.27 To receive reports on human resources policies and procedures; 10.28 To receive reports on infection control; 10.29 To receive reports on Insight & Learning quality visits to service providers 10.30 To receive reports on GP Quality Alert System themes and trends; 10.31 The Committee may discharge appropriate quality and safety monitoring and reporting requirements through other groups; Quality & Risk sub-group, Safeguarding group, Contract Meetings (in liaison with Commissioning Support Unit). However, the Quality and Safety Committee will retain accountability for assuring the Governing Body of the quality and safety of all commissioned services. 11. REPORTING The Committee will report to the Governing Body after each meeting. 12. MONITORING ARRANGEMENTS AND REVIEW DATE 12.1 The Committees performance will be monitored annually via agreed Key Performance Indicators to ensure its effectiveness in discharging its duties against the Terms of Reference. 12.2 The Committee s Terms of Reference will be reviewed annually. Version Control: Approved by Governing Body 30 April 2014 Reviewed by Quality & Safety Committee 12 November 2014 Approved by Governing Body 26 November 2014 Reviewed by Quality and Safety Committee 18.02.15 49 of 255

Amendment to paragraph 2, 18.08.15 Quality and Clinical Risk Committee amended to read Quality and Safety Committee. 23.09.15; Amendment to membership, add Assistant Director of Quality, Governance & Risk, Assistant Director for Safeguarding and CSU Quality and Safety Representative. Other members of CCG staff will be in attendance where they have specific items on the agenda: Head of Communications and Engagement, Head of Medicines Management Minor correction noted at the 14 th September Quality & Safety Committee confirming the GP Locality Lead (Vice Chair) does not chair the operational quality and risk sub group. v2.1 9.12.16 V3 27/03/17 & 21/08/17: Amendments to reflect changes to the CCG Committee governance arrangements. A new Clinical Commissioning Committee replaced the previous Executive Committee and the Clinical Reference Group. V4 Approved by Q&S Committee at its meeting 6 th September 2017. One additional amendment requested an additional Governing Body GP to be added to the membership. Next annual review due September 2018 V5 Reviewed and approved by Q&S on 7 th March 2018. Changes made to reflect the governance arrangements for information governance following the NCL corporate services review & organisational restructure 50 of 255

MEETING: Governing Body Meeting in Public DATE: Wednesday 23 May 2018 TITLE: Finance & Contracts Report Month 12 LEAD GOVERNING BODY Simon Goodwin, Chief Financial Officer, NCL CCGs MEMBER: AUTHOR & POSITION: Arati Das, Deputy Director of Finance CONTACT DETAILS: simon.goodwin@haringeyccg.nhs.uk SUMMARY: Agenda Item: 7.1(i) This report updates the Governing Body on our financial performance. The CCG s 2017/18 in year deficit is 3.4m ( 5.5m adrift from 2.1 surplus control total) taking the cumulative deficit to 40.6m. The improved movement from the Forecast Outturn (FOT) of 5.8m reported last month results from release of 0.5% uncommitted reserve ( 1.98m) and a drugs rebate from NHS England ( 0.37m). NHS England have instructed CCGs to reflect a like-for-like improvement in the CCGs bottom line and therefore although these items reduces the CCGs cumulative deficit going forward, they have no impact in offsetting any CCG risk. SUPPORTING PAPERS: This paper has been prepared from information provided by the North East London Commissioning Support Unit, CCG internal management and budgetary control processes. Detailed financial information is included in the schedules attached to this report. RECOMMENDED ACTION: The Governing Body is asked to note the reported outturn. Although the position is now closed, the committee should be aware that that in the absence of finalised 2017/18 agreements with key acute providers, a degree of risk is carried forward into 2018/19. This remains under review and will continue to be monitored in 2018/19. Objective(s) / Plans supported by this paper: Close management of the financial position supports the CCG s ongoing financial recovery plans and ensures that any corrective action is taken at the earliest opportunity. Patient & Public Involvement: N/A Equality Impact Analysis: N/A Risks: The risks in this paper are recorded on the Enfield CCG Risk Register and Board Assurance Framework (BAF) where appropriate. Specific risks are referenced in the text. Resource Implications: Not Applicable Audit Trail: Appropriate information from the finance report is included in reports to the Audit Committee and the Governing Body. Next Steps: Paper to be presented to the Governing Body 51 of 255

Summary Key points Overall Position The CCG s in year deficit is 3.4m and cumulative deficit is 40.6m. The improved movement from the FOT of 5.8m as reported last month results from release of 0.5% uncommitted reserve ( 1.98m) and a drugs rebate from NHSE ( 0.37m). NHSE instructed CCGs to reflect a like-for-like improvement in the CCGs bottom line and therefore these items have no impact in offsetting CCG risk, however does reduce the CCGs cumulative surplus going forward. Table 1: Summary financial position Year to Date m m m Budget Actual Var Revenue Resource Limit (414.8) (414.8) 0.0 Acute Care 244.6 251.8 7.3 Non Acute 183.6 186.9 3.3 Corporate & Running Costs 25.3 24.3 (1.0) Centrally held QIPP (6.0) 0.0 6.0 Total Recurrent 447.5 463.0 15.5 Contingency 2.6 0.0 (2.6) Non Recurrent Reserve 2.0 (7.6) (9.5) 16/17 Reconciliation 0.0 0.0 0.0 Total Non Recurrent 4.6 (7.6) (12.1) Total Expenditure 452.0 455.4 3.4 (Surplus)/Deficit 37.2 40.6 3.4 In year (Surplus)/Deficit (2.1) 1.3 3.4 Risks & Mitigations Position Although the position is now closed, the committee should be aware that month 12 final acute data will not be available until early June and in the absence of agreed position with acute providers, there is a degree of risk going into 2018/19. This remains under review and will continue to be revisited in the 2018/19. Key highlights/ Issues Acute Expenditure: Month 10 Flex data has been received and plans have now been re-allocated based on Sustainability Transformation Plan phasing. The benefit of marginal rate tariffs for over-performance is reflected in both the YTD and FOT positions. Year to Date Total budgeted expenditure on acute services is 244.6m. YTD expenditure on acute contracts is 251.8m which is a 7.2m overspend against plan after adjustments. Forecast Outturn Total budgeted expenditure on acute services is 244.6m. FOT on acute expenditure is 251.8m, which is a 7.2m overspend against plan. This includes Quality, Innovation, Productivity and Prevention (QIPP) slippage and other adjustments which contains further risks. Non Acute: Mental Health - Expenditure on Spot placements reduced by 0.2m with a number of clients stepped down from high cost complex care inpatient beds into lower cost S117 placements. Non Contract Activates (NCA) activity finalised on budget following successful challenge of erroneous amounts. Child & Adolescent Mental Health Services (CAMHS) and Expenditure on Children with complex needs, jointly funded with London Borough of Enfield (LBE) in 17/18, was also lower than anticipated. Continuing Healthcare In month 11 the Continuing Healthcare (CHC) forecast reports a 3.0m overspend. Prescribing The Prescribing forecast has seen a 0.7m improvement in Month 12. This reflects the release of the 0.4m of Cat M rebate, lower impact from No Cheaper Stock Obtainable (NCSO) drugs than previously forecast and challenge of 0.2m of drug recharges from Royal Free London (RFL). 52 of 255

1. Financial Position - Outturn The table below sets out the CCG s financial performance for 2017/18. The CCG is 5.5m adrift from control target of 2.1m. The position reflects significant acute over performance and QIPP underperformance even after offsets by Acute reserves and mitigations. Table 1a: Financial position 2017/18 m m m Budget Actual Variance Allocation (414.8) (414.8) 0.0 Primary Care 8.2 8.0 (0.2) Primary Care Co-commissioning 41.0 39.8 (1.1) Prescribing 37.2 38.3 1.1 Acute Care 244.6 251.8 7.3 Mental Health 50.4 50.8 0.4 Learning Disabilities 2.6 2.7 0.2 End of Life care 1.4 1.4 0.0 Community Services 22.7 22.7 0.0 Continuing Care 20.2 23.1 3.0 Running Cost Allowance 7.1 7.1 0.0 Other Programme Costs 18.2 17.1 (1.0) 0.5% Uncommitted 2.0 0.0 (2.0) Mitigations 2.6 (5.4) (7.9) QIPP (6.0) 0.0 6.0 NCL Risk share drawdown (2.1) (2.2) (0.1) Cumulative (Surplus)/Deficit 35.1 40.6 5.5 In year (Surplus)/Deficit (2.1) 3.4 5.5 53 of 255

2. Expenditure rate by month The run rate table is provided for information only. Once month 12 final data is available a deep dive will be undertaken on high expenditure areas to inform additional areas for QIPP in 2018/19. Table 2: Expenditure rate m m m m m m m Qtr 1 Qtr 2 Qtr 3 Qtr 4 2017/18 Annual Ave. Ave. Ave. Ave. Actual Plan Var. Primary Care 0.3 0.9 0.6 0.8 8.0 8.2 (0.2) Primary Care Co-commissioning 3.3 3.3 3.3 3.3 39.8 41.0 (1.1) Prescribing 3.1 3.4 3.4 2.9 38.3 37.2 1.1 Acute Care 21.1 20.6 21.2 21.1 251.8 244.6 7.3 Mental Health 4.0 4.2 4.1 4.6 50.8 50.4 0.4 Learning Disabilities 0.2 0.2 0.2 0.2 2.7 2.6 0.2 End of Life care 0.1 0.1 0.1 0.1 1.4 1.4 0.0 Community Services 2.0 2.0 1.9 1.7 22.7 22.7 0.0 Continuing Care 1.7 1.8 2.1 2.1 23.1 20.2 3.0 Running Cost Allowance 0.6 0.6 0.6 0.6 7.1 7.1 0.0 Other Programme Costs 1.5 1.5 1.4 1.3 17.1 18.2 (1.0) 0.5% Uncommitted 0.0 0.0 0.0 0.0 0.0 2.0 (2.0) Mitigations (0.6) (0.8) (1.1) 0.6 (5.4) 2.6 (7.9) QIPP 0.0 0.0 0.0 0.0 0.0 (6.0) 6.0 NCL Risk share drawdown 0.0 0.0 0.0 (0.7) (2.2) (2.2) 0.0 Gross CCG Expenditure 37.4 37.9 37.8 38.7 455.4 449.9 5.5 54 of 255

3. Acute Contract Performance Based on working days (see Appendix 1) there is a slight year on year growth in routine referrals (0.8%). Data from other sources (MAR, SUS+, Trust data) shows a somewhat higher growth in all General Practice referrals. In particular cancer referrals as showing strong growth with an increase in referrals (note, cancer referrals are not processed by E-Referral Service (ERS). The increase in January and February could be a response to NMUH being an early adopter of choose and book. Table 3a: Financial performance of acute contracts by Point of Delivery Point of Delivery (POD) Year to date M12 Budget Actual YTD Var m m m A&E/UCC Attendances 17.33 18.46 1.14 Emergency Admissions 51.46 57.91 6.45 Maternity 38.05 38.09 (0.29) Planned Admissions 35.45 35.19 (0.26) Outpatients 38.36 43.58 5.23 Drugs and Devices 5.64 6.68 1.05 Critical Care 10.99 12.90 1.91 Diagnostic Imaging 15.39 14.52 (0.88) Other (4.94) (10.73) (5.46) CQUIN 4.97 5.10 0.13 LAS 11.74 11.75 0.01 Sub-total Contracted Acute Providers 224.44 233.47 9.03 Adjustments 20.12 18.36 (1.75) Total 244.56 251.83 7.27 Month 11 Flex data has been received. No data issues have been reported for month 11 data. Plans have now been re-allocated based on STP phasing. Impact of marginal rates have been factored into the FOT for NMUH, RFL, UCLH and the Whittington. Over performance is reported in A&E, Emergency admissions, Critical Care and Outpatients. This is partly mitigated by application of marginal rates shown in the underperformance in Other. 55 of 255

4. Non-Acute Contract Performance Continuing Health Care (CHC) Table 4a: Continuing Healthcare Summary Financial Position 2017/18 Service Budget Actual Variance Functional Mental Health 95,000 93,683 (1,317) Learning Disabilities 5,884,828 5,911,781 26,953 Organic Mental Health 245,000 317,547 72,547 In Month 12 the Continuing Healthcare (CHC) forecast reports a 3.0m overspend. The CHC QIPP efficiency programme put in place in quarter 4 is now in place and being embedded into the team s day to day processes in preparation for 2018/19. Palliative Care 1,893,498 2,622,228 728,730 Physical Disability <65 4,304,162 5,178,700 874,538 Physically Frail 65+ 3,989,162 5,581,810 1,592,648 FNC 2,700,000 2,329,612 (370,388) NEURO 480,000 251,191 (228,809) Total Adults CHC 19,591,650 22,286,552 2,694,902 CHC Children 598,984 857,853 258,869 Total CHC 20,190,634 23,144,405 2,953,771 56 of 255

Mental Health Table 4b: Mental Health Trust / Service 2017/18 Budget Actual Variance '000 '000 '000 Mental Health Contracts Barnet, Enfield & Haringey MHT 34,858 35,232 374 Camden & Islington NHS FT 141 194 53 South London & Maudsley NHS FT 59 42 (18) Tavistock & Portman NHS FT 196 196 (0) Sub-total 35,256 35,665 409 Adult Services S117's & OATs 6,258 6,964 707 London Borough of Enfield 3,488 3,341 (147) Other 0 0 0 Sub-total 9,746 10,306 560 CAMHS London Borough of Enfield 1,428 1,739 311 Royal Free London 77 106 29 CAMHS - NCA'S 77 24 (53) Other 1,266 367 (899) Sub-total 2,849 2,237 (611) Non Contracted Activity 2,475 2,476 1 Other Mental Health 92 120 28 Total Mental Health 50,417 50,803 386 Barnet Enfield & Haringey Mental Health Trust (BEH MHT) The reported variance relates to delays in closing Cornwall Villas ward, the remaining 0.5% CQUIN totaling 141k and 27k for Early Intervention in Psychosis (EIP) overperformance. Adult Spot Placements Expenditure on Mental Health Spot placements reduced by 158k from last month. Several clients stepped down from high cost complex care inpatient beds into lower cost Section 117 placements. Non-Contract Activity (NCAs) NCA activity ended up virtually on budget. Main providers were: East London 206k; North East London 77k; Tees, Esk & Wear Valley 28k The position also includes invoices for Attention Deficit Hyperactivity Disorder (ADHD) at BEH - 44k. CAMHS The underspend on CAMHS increased by 258k at the end of the year once it was clarified that several schemes jointly funded between the CCG, BEH MHT and the local authority, London Borough of Enfield (LBE), had slipped to a greater degree than previously envisaged. Expenditure on Children with complex needs, jointly funded with the local authority in 17/18 was also lower than anticipated. The overspend identified on the table largely relates to 16/17. 57 of 255

5. Better Care Fund The Better Care Fund final budgets was agreed with LBE through the Health & Wellbeing Board. It forms part of the section 75 contract which has been signed by the CCG and LBE. The majority of the CCG Better Care Fund (BCF) spend is linked to existing contracts, particularly the Community and Mental Health contracts with BEHMHT and therefore there is no expected material variance beyond what has already been reported above within Non Acute. Below is a summary of the current BCF forecast expenditure: Scheme / Project Integrated Care Schemes Mental Health Schemes Safeguarding Schemes Long Term Condition Schemes Children's Schemes Carers Schemes Third Sector Schemes Infrastructure Schemes Care Act Schemes Protection of social care BCF Savings Required Annual Budget Comm'd by CCG Planned Comm'd by LBE Total Final Outturn Comm'd by CCG Other Within SLAs* Comm'd by LBE Total Difference 9,359,428 8,142,428 1,217,000 9,359,428 992,331 6,982,428 1,217,000 9,191,759-167,669 1,195,808 1,160,808 35,000 1,195,808 266,839 910,808 35,000 1,212,647 16,839 449,000 70,000 379,000 449,000 70,000 0 379,000 449,000 0 756,000 0 756,000 756,000 0 0 756,000 756,000 0 385,000 385,000 0 385,000 385,000 0 0 385,000 0 489,000 0 489,000 489,000 0 0 489,000 489,000 0 410,000 0 410,000 410,000 0 0 410,000 410,000 0 116,000 0 116,000 116,000 0 0 116,000 116,000 0 734,000 0 734,000 734,000 0 0 734,000 734,000 0 6,163,000 0 6,163,000 6,163,000 0 0 6,163,000 6,163,000 0-528,236-264,118-264,118-528,236 0 0-264,118-264,118 264,118 BCF funding 19,529,000 9,494,118 10,034,882 19,529,000 1,714,170 7,893,236 10,034,882 19,642,288 113,288 The final position for the 17/18 Better Care Fund was an overspend of 113k. This reflects slippage target of 264k not being met. The target was required to mitigate excess cost against income of required schemes in Better Care Fund agreement. The council had the same slippage target. This slippage target of 528k ( 777k in 16/17) is due to be reduced significantly in 2018/19 as allocation increases specifically for the BCF will be put towards the slippage as a priority. 58 of 255

6. Other Programme Costs & Running Cost Allowance Programme corporate costs reported an underspend of 147k in 2017/18, largely due to vacancies. Corporate running costs were in line with the budget at Month 12. Estates Costs reported an underspend of 930k, reflecting further over achievement of QIPP target. This was due to savings relating to the negotiation of the new lease for Holbrook House and a number of successful challenges of void space charges. We were also successful in challenging the Business rate charges at Holbrook House which released a further 355k in 2017/18. We continue to challenge Community Health Partnerships (CHP) voids, and are awaiting a revised vacant space policy to advise on responsibility for local authority voids. 7. Statement of Financial Position There are currently no issues of concern with the Statement of Financial Position (Appendix 2) and key movements are in line with expectations. This statement will now be reviewed in detail as part of the external audit process. Better Payment Practice Code (Appendix 3) As of the year to date, the CCG has paid 92.6% of NHS invoices by number and 99.3% by value. For non-nhs creditors the CCG has paid 92.8% of invoices by number and 94.5% by value. Cash flow forecast The CCG is required to finish each month with a cash balance of below 1.25% of the month's drawdown figure. This was achieved in March and for 2017/18. 59 of 255

Statement of Financial Position Appendix 1 Statement of Financial Position as at 31 March 2018 31 March 2018 '000 31 March 2017 '000 Non-current assets: Property, plant and equipment 117 0 Total non-current assets 117 0 Current assets: Trade and other receivables 7,757 4,448 Cash and cash equivalents 325 284 Total current assets 8,082 4,732 Total assets 8,199 4,732 Current liabilities Trade and other payables (42,352) (36,582) Total current liabilities (42,352) (36,582) Assets less liabilities (34,153) (31,849) Financed by Taxpayers Equity General fund (34,153) (31,849) Total taxpayers' equity: (34,153) (31,849) 60 of 255

Better Payment Practice Code Appendix 2 Better Payment Practice Code 17/18 16/17 BPPC by number NHS 92.6% 93.3% BPPC by value NHS 99.3% 97.2% BPPC by number non NHS 92.8% 93.6% BPPC by value non NHS 94.5% 89.4% NHS: Performance in terms of number was in line with expectations of around 95% cumulatively. Non NHS: Performance in terms of value was in line with expectations of around 95% cumulatively. Aged Debtors report Days overdue k k k k k k k k 0-30 31-60 61-90 Enfield London Borough 24.4 0.0 0.0 0.0 0.0 0.0 20.9 45.3 2 Barnet Enfield & Haringey MHT 0.0 0.0 8.2 0.0 21.5 0.0 0.0 29.7 2 NHS Barnet CCG 4.5 0.0 0.0 0.0 0.0 0.0 0.0 4.5 2 NHS Camden CCG 0.2 7.5 0.0 0.0 0.0 0.0 0.0 7.7 2 NHS England 38.9 0.0 0.0 0.0 0.0 10.4 0.0 49.4 2 NHS Haringey 5.1 7.5 0.0 129.3 0.0 0.0 0.0 141.9 5 NHS Islington CCG 0.0 7.5 0.0 0.0 0.0 28.9 0.0 36.4 3 NHS NEL CSU 4.5 0.0 0.0 1.1 0.0 0.0 0.0 5.6 2 The Cataract Centre Ltd 6.9 15.1 0.0 0.0 0.0 0.0 0.0 22.0 2 91-120 121-180 181-360 >360 Total due Invoices Other 8.0 0.0 2.6 0.0 3.4 0.0 4.8 18.8 21 Total 92.5 37.6 10.8 130.4 24.8 39.4 25.7 361.2 43 The majority (78%) of the remaining balance is now with other NHS organisations and therefore at minimal risk. In March the following has been settled to date: NHS Islington 18.9k NEL CSU 10.4k Cataract Centre 15.1k 61 of 255

Appendix 3 Cash Position as at 31 st March 2018 Statement of Cash Flows for the year ended 31 March 2018 2017-18 2016-17 '000 '000 Cash Flows from Operating Activities Net operating expenditure for the financial year (455,422) (399,993) (Increase)/decrease in trade & other receivables (3,309) (237) Increase/(decrease) in trade & other payables 5,770 (17,178) Net Cash Inflow (Outflow) from Operating Activities (452,960) (417,408) Cash Flows from Financing Activities Grant in Aid Funding Received 453,118 417,412 Net Cash Inflow (Outflow) from Financing Activities 453,118 417,412 Net Increase (Decrease) in Cash & Cash Equivalents 40 4 Cash & Cash Equivalents at the Beginning of the Financial Year 284 280 Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year 325 284 62 of 255

Agenda Item: 7.1(ii) MEETING Governing Body Meeting in Public DATE 23 May 2018 REPORT 2018/19 Financial Plan Update LEAD GOVERNING Simon Goodwin, Chief Finance Officer, NCL CCGs BODY MEMBER: AUTHOR & POSITION: Arati Das, Deputy Director of Finance CONTACT DETAILS: Arati.Das@nhs.net EXECUTIVE SUMMARY Further to the financial plan update provided to the last Finance & Performance Committee (where all Governing Body members were invited), in compliance with the national timetable, a break-even financial plan 2018/19 was submitted to NHSE on 30th April 2018. The submission was caveated by the fact that it has not yet had formal sign-off from the Governing Body. This paper seeks to inform the Governing Body of the key assumptions and risks associated with the submitted balanced plan in order to secure formal approval. Overview of financial position (ECCG) Underlying positon: For 2017/18, Enfield CCG s (ECCG) outturn pending external audit is a deficit of 3.4m. The underlying position once non recurrent items have been allowed for is a deficit of 13.8m Draft 2018/19 Plan: ECCG s 2018/19 control total is a surplus of 9.4m within an NCL control total of 7.4m surplus. In light of (a) the steer from NHSE at the last Assurance meeting, (b) previous discussions at Governing Body, it has been accepted that even a break even plan, as submitted in April 2018 to NHSE remains extremely challenging for Enfield CCG. The ongoing contracting round has highlighted a number of risks pertaining to submission of a breakeven plan. Risk: The overall risk highlighted in the 30 th April submission was 25.17m. This was made up as follows: QIPP risk 8.4m Other Commissioner risk ( 14.4m less mitigation of 7.05m) 7.3m Risk before Control Total risk 15.7m Control total risk 9.4 Total risk on balanced plan(as per 30 th April submission) 25.17 The single biggest risk remains risk of Acute over performance and the ongoing challenging of coming to an agreed contractual position with Royal Free and North Middlesex University Hospital. 63 of 255

Key developments since submission of plan NHSE have confirmed in writing that: Enfield s 18/19 control total has been amended from 9.4m surplus to break even. This has been funded using regional resource and there is no impact on control totals elsewhere in NCL. Therefore the CCG plans submitted on 30 April are on control total across NCL. Recommended Action Members are asked to: (i) (ii) Note the revised risk assessment of 15.7 of delivering a break-even plan; Approve the balanced plan. Objective(s) / Plans supported by this paper: Close management of the financial position supports the CCG s on-going delivery of its financial requirements and ensures that any corrective action is taken at the earliest opportunity. Audit Trail This paper has been prepared from information provided by North and East London Commissioning Support Unit and CCG internal management and budgetary control processes. Next Steps Any actions noted and revisions incorporated into future financial reports to the F&P Committee and CCG Governing Body. Outcomes expected: Formal Governing Body approval of the plan. 64 of 255

2017/18 Underlying position Starting with the 2017/18 reported outturn, the underlying position once non recurrent items have been allowed for is a deficit of 13.6m 2017/18 Outturn (3.4) Comments Marginal rate benefit (6.2) Paying for over-performance at 50% of tariff Claims and challenges (2.0) Successful claims and challenges Delegated Commissioning Utilisation of contingency Contingency Release (1.1) Non recurrent funding (2.2) One off benefit in 2017-18 Reversal of Non Recurrent QIPP Some QIPP schemes will not be recur in schemes (1.9) 2018/19 NCSO Costs 1.6 One off short supply of drugs cost pressure 0.5% National Risk Share Not required in 2018/19 contribution 2.0 Pace, RAID, Treat 0.8 Given notice on service for 2018/19 Miscellaneous NR cost pressures 0.5 Cost pressures specific to 2017/18 2017/18 Underlying Position (13.6) 2018/19 Budget plan (as per 8 th March submission) In line with the minimum requirements of NHSE, a balanced plan was submitted requiring a QIPP programme of 23.8m. (NB Based on the worsened underlying position and the already high level of QIPP, a balanced plan will now require delegated commissioning contingency being fully committed.) 2017/18 Underlying Position (13.7) Allocation Increase 16.5 Growth (including PC) (16.3) Inflation impact (6.2) Re-instate 0.5% Contingency (2.3) 2018/19 Required/Planned QIPP 23.8 Non recurrent cost pressures (3.9) Delegated Commissioning Contingency Release 1.6 Further investment substitution ( Get More for same ) 0.5 2018/19 Break Even plan 0.0 There are now significant risks inherent in continuing to plan to a balanced plan. The 2018/19 planned QIPP is integral to this. 65 of 255

Risk 1 - QIPP delivery risk The balanced plan submitted on 8 th March 2018 required a net QIPP programme (after preprovision costs) of 23.8m. The QIPP programme required 18m of gross QIPP schemes to have been negotiated into contracts with Acute providers. Gross Investment Net Red Rated Acute Contract 18.0m ( 10.8m in 17/18) 2.6 15.4 8.4m Non Contract 8.9m 0.5m 8.3 Tbc Total 26.9m 3.1m 23.8m 8.4m* Based on the latest information and exchange of information with providers, there is now an extremely high level of risk of QIPP delivery of around 8.4m. This risk assessment assumes that there will be active management of the full QIPP programme and any QIPP not locked into acute contract will still deliver but without the benefit of 50% marginal rate tariff on acute over performance. Risk 2 - Other Commissioner risk In addition to the financial pressures resulting from QIPP related issues, there are a number of areas that will be a cost pressure on a balanced plan. Assuming mitigations are achieved this takes this down to 7.4m Other risk Integrated Urgent Care Contract (LCW Road Map costs) 1.07 Acute - Ongoing unagreed positions/challenges 4.0m Non Acute (CHC) Ongoing challenges 0.7m Non Acute Risks pertinent to further investment substitution 0.5m Non Acute (Other) - Further efficiency risk (less low lying fruit) 1.5m CAMHS additional cost pressures 0.5m NCL Transforming Care Partnership 0.4m NCSO/Cat M (Short supply drugs in supply at higher price0 0.5m Acute over-performance exceeding QIPP (2.1%) 5.25 Gross risk 14.42 Mitigation: Claims & challenges (on a robust contractual basis) ( 5.0m) Mitigation: Contingency (committed at outset) ( 2.05m) Mitigated risk 7.4m 66 of 255

Risk 3 - Gap to control total (Included for completeness) CCGs in London operate a STP CCG control total which is 7.6m for NCL as directed by NHSE in October 2016 in their letter to Chief Officers and Chief Finance officers. The distribution of this as agreed at a point in time was as follows: Barnet CCG Enfield CCG Camden CCG Islington CCG Haringey CCG NCL Total Control total 0.1m 9.4m (2.0)m Breakeven Breakeven 7.6m The default position for all CCGs is compliance with the business rules, ie the delivery of a break even position each year, and in addition the requirement to maintain a minimum cumulative 1 percent underspend in 2018/19. Notwithstanding the 9.4 control total, it has universally been accepted that Enfield CCG cannot plan for this without jeopardising service provision and NHSE have now formally recognised this. Members are asked to: (i) (ii) Note the revised risk assessment of 15.7 of delivering a break-even plan; Approve the balanced plan 67 of 255

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MEETING: Governing Body Meeting in Public DATE: Wednesday 23 May 2018 TITLE: Integrated Performance & Quality Report April 2018 LEAD GOVERNING BODY MEMBER: AUTHORS: CONTACT DETAILS: Agenda Item: 7.2 Deborah McBeal, Director of Primary Care Commissioning & Deputy Chief Officer Enfield CCG Performance & Informatics Team stephen.wells6@nhs.net SUMMARY: Performance Update The purpose of this report is to provide an update on the CCG s quality and operational performance against national and local standards and remedial actions where standards have not been achieved. The contents of the report are based on the latest available data and are informed by the NHS Constitution, The Five Year Forward View, CCG Improvement & Assessment Framework and other local priorities. The executive summary of the Integrated Performance & Quality Report (IPQR) gives an overview of key issues and progress update for April 2018, as reported to the CCG s Finance & Performance Committee on 23 rd April 2018. SUPPORTING PAPERS: Integrated Performance & Quality Report, April 2018 RECOMMENDED ACTION: The Committee is asked to: 1. Review the contents of the Integrated Performance and Quality Report and receive assurance on actions being taken by respective directorates to address areas of underperformance. 2. Note the key issues raised in the Executive Summary (page 2 of the IPQR) in relation to: Accident & Emergency (A&E) Cancer Waiting Times Referral to Treatment Times (RTT) Ambulance Response Times 3. Note the verbal update provided at the Governing Body meeting. This paper supports the following CCG Strategic Objectives: Deliver improvements in the quality of local health and primary care services. Deliver the goals in the Enfield Operating Plan and contribute to NCL Transformation. Deliver on the NHS Constitution and access standards. 69 of 255

Patient and Public Involvement PPI: Through Governing Body Public Engagement Equality Impact Analysis: Equality Impact Assessments are undertaken in relation to substantial commissioning changes and will be available where necessary in relation to individual work programmes. Risks: All risks identified are recorded on the Enfield Risk Register and Board Assurance Framework, or available as part of individual work programmes: BAF Risk 343: Performance and quality risk arising from non-delivery of NHS constitutional standards BAF Risk 347: Failure to ensure a safe and high quality service is commissioned from and delivered by our providers (Serious and specific concerns relating to the quality and safety of services at NMUH & LAS quality & patient safety concerns) Resource Implications: Where relevant these are detailed or available as part of individual work programme. Audit Trail: IPQR report is provided to each Finance & Performance Committee and Governing Body Public Meetings. Next Steps: An updated report will be provided monthly to the Finance & Performance Committee. 70 of 255

Integrated Performance & Quality Report APRIL 2018 Finance & Performance Committee Version 71 of 255

Table of Contents Executive Summary 2 Continuing Health Care (CHC) 19 Enfield CCG Scorecard 3 Transforming Care 21 NCL Performance Dashboard 5 Enfield Referral Service (ERS) 22 Elective Waiting Times 6 Workforce Statistics Staffing Profile 23 Cancer Waiting Times 7 Mandatory Training 24 NMUH & RFL Accident & Emergency 9 Appendix 1 Enfield CCG Activity 25 Out of Hospital Services 10 Appendix 2 Quality Premium 26 Emergency Response 11 Appendix 3 Better Care Fund Dashboard 27 Mental Health Performance Indicators 12 Appendix 4 NMUH Scorecard 28 Enfield Community Services (ECS) 13 Appendix 5 RFL Scorecard 29 Other Quality Measures 14 Appendix 6 MRSA & C. Difficile Infections NE London Providers Patient Experience 15 Appendix 7 C. Difficile Infections London CCGs 31 Serious Incidents (SI) 16 30 72 of 255 Enfield CCG 1

Executive Summary February's Integrated Performance & Quality Report (IPQR) is based on the latest nationally published data (December 2017, in most cases). The report provides an update on the CCG s performance and quality of services and responds to the following Board Assurance Framework (BAF) risks: BAF Risk 343: Performance and quality risk arising from non-delivery of NHS constitutional standards BAF Risk 347: Failure to ensure a safe and high quality service is commissioned from and delivered by our providers (Serious and specific concerns relating to the quality and safety of services at NMUH & LAS quality & patient safety concerns) Key Issues Updates A&E 4 hour Waits: North Middlesex University Hospital (NMUH) has not met its Sustainability & Transformation Fund (STF) trajectories so far in 2017/18. Royal Free London (RFL) has not met its trajectories for 10 consecutive months (June to March) Both NMUH & RFL A&E systems have successfully bid for winter monies. There was an expectation that the funding will deliver at least 90% performance by Q4 17/18; This was not delivered by either Trust. Escalation and assurance meetings on A&E performance, including weekly/monthly regional meetings, continue to take place. The Safer, Faster, Better programme remains in place. Local systems facilitating discharges from acute Trusts continue to deliver improvements in bed occupancy. Cancer Waiting Times: Consistent underperformance against 62-day urgent GP referral to treatment target London Ambulance Service (LAS) : Consistent underperformance against national standards and poorer performance in Enfield compared to other London CCGs Performance across NCL CCGs and providers in the 62-day standard improved somewhat in February although ECCG remains below the national standard. NMUH performance in February for the 62-day treatment from GP referral standard was 59%. Escalation meeting between NMUH, Haringey CCG, NCL Performance & NHS Improvement was held on 15 th March and an agreed set of actions for the Trust and commissioners has been agreed. Weekly PTL figures from RFL have showed a reducing backlog since February although this has increased in April. An NCL Standard Operating Procedure (SOP) for Trusts to follow on carrying out breach analysis and clinical harm reviews for all 62-day breaches, including deadlines for submission to commissioners, has now been agreed. New Ambulance Response Programme operational standards implemented since November 2017. Re-profiling of categories and response times to ensure the speediest response for those requiring it. Data now published for November March. Data shows LAS continuing to perform below four of the six standards, including both standards for Category 2 calls. Borough-level data not yet available, but NCL is generally lower performing than other STPs. Referral to Treatment (RTT): Failed to ECCG Performance is being monitored at specialty level with 13 out of 18 specialties below 92%. meet 92% target for 8 th consecutive Neurology is the worst performing speciality in February with 74.8% performance. month. Performance for February is Royal Free London submitted an RTT recovery action plan to NHSE, NHSI and Commissioners in 83.8%. Some patients waiting >52 December 2017. Barnet CCG agreed end-march 2018 deadline for Trust to submit a detailed weeks speciality-based recovery73 action of 255 plan. Dermatology completed in March; other specialities awaited. UCLH have submitted a recovery plan to return to 92% compliance in March 2018. Enfield CCG A RTT Steering Group has been established with input from NHSI. 2

Enfield CCG Scorecard Enfield CCG 2017/18 Performance Scorecard Q1 Q2 Q3 Q4 2017/18 Indicator Type Target/ Threshold 2016/17 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD RTT RTT Incomplete Pathways within 18 Weeks 92% 93.2% 92.8% 92.6% 92.6% 91.3% 87.4% 87.4% 86.2% 87.0% 86.8% 83.6% 83.8% 88.1% RTT 52+ week waiters 0 19 0 0 0 0 6 5 6 11 10 3 8 49 Diagnostics Diagnostics - 6+ week waiters 1% 1.2% 0.6% 0.5% 0.5% 0.4% 0.6% 0.5% 0.5% 0.4% 0.5% 0.3% 0.4% 0.5% A&E Enfield DTOCs (days) HCAI LAS (Enfield) LAS (London wide) A&E 4 Hour W aits 95% 85.2% 85.2% 86.9% 84.9% 84.4% 84.4% 86.0% 87.8% 84.9% 77.8% 80.4% 84.6% 80.3% 83.9% A&E attendance to emergency admission - 15.5% 16.2% 15.4% 14.6% 17.1% 16.9% 16.3% 17.1% 16.6% 15.9% 16.1% Delayed Transfers of Care - Acute 3820 3976 290 235 322 325 329 215 171 328 148 103 105 2571 Delayed Transfers of Care - Non-Acute 3648 3797 238 212 251 357 341 190 313 208 240 190 170 2710 Total delayed days per 100,000 18+ population - 3204.4 2487 2106 2699 3213 3156 1908 2280 2525 1828 1380 1295 2262 Cancer - 2 2 week wait 93% 94.2% 94.3% 93.8% 93.2% 93.4% 93.6% 93.7% week 2 week wait breast symptomatic 93% 93.7% 95.4% 92.8% 95.0% 90.4% 92.2% 94.1% 31 day 1st definitive treatment 96% 98.7% 97.7% 95.5% 99.1% 94.8% 99.0% 97.3% Cancer - 31 31 day 1st subsequent treatment - surgery 94% 99.4% 93.0% 100.0% 97.1% 100.0% 100.0% 97.2% day 31 day 1st subsequent treatment - chemotherapy 98% 99.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 31 day 1st subsequent treatment - radiotherapy 94% 99.5% 98.8% 97.9% 99.0% 100.0% 100.0% 98.7% 62 day standard 85% 80.7% 83.1% 78.3% 82.5% 76.9% 73.3% 80.1% Cancer - 62 62 day standard - screening 90% 85.2% 87.0% 97.1% 82.8% 100.0% 100.0% 91.4% day 62 day standard - upgrade No Target 90.3% 92.1% 90.9% 90.5% 85.7% 88.2% 90.4% Mixed Sex Mixed Sex Accommodation Breaches 0 73 4 0 4 11 9 6 10 10 8 8 6 76 MRSA Reported Cases (CCG Assigned PIR) 0 3 1 0 0 0 0 0 0 0 0 0 0 1 C.Difficile Trajectory - 5 5 5 5 5 5 5 8 9 9 8 7 69 76 (Annual) C.Difficile Reported Cases 85 3 4 7 3 8 8 7 5 11 3 10 69 E.Coli Reported Cases 178 195 13 29 23 28 28 20 24 17 17 15 13 227 Cat A (RED1): Response within 8 Min 75% 58.6% 70.4% 74.1% 67.3% 68.8% 73.1% 51.0% 66.2% 67.4% Cat A (RED2): Response within 8 Min 75% 54.5% 61.7% 65.1% 62.1% 60.7% 64.5% 69.9% 60.6% 62.1% Cat A: Response within 19 Min 95% 89.0% 91.5% 91.7% 90.6% 91.5% 92.7% 94.4% 92.3% 91.7% Cat A (RED1): Response within 8 Min 75% 69.2% 79.2% 73.7% 73.3% 72.3% 74.4% 70.6% 73.5% 73.9% Cat A (RED2): Response within 8 Min 75% 66.3% 73.6% 71.9% 69.7% 68.5% 72.0% 68.5% 68.7% 70.4% Cat A: Response within 19 Min 95% 93.5% 95.6% 95.0% 94.3% 94.1% 94.4% 93.9% 94.9% 94.6% Cat 1 Average response time 7:00 Mins. 0.0% 07:04 07:24 07:10 07:27 07:26 07:16 Cat 1 90% of response times 15:00 Mins. - 11:28 12:04 11:45 11:47 11:59 11:48 Cat 2 Average reponse time 18:00 Mins. - 18:27 24:11 20:25 23:21 23:21 21:37 Cat 2 90% of response times 40:00 Mins. - 36:32 51:11 42:08 49:21 49:20 45:11 Cat 3 90% of response times 120:00 Mins. - 135:00 178:56 145:38 178:44 172:21 157:23 Cat 4 90% of response times 180:00 Mins. - 148:54 171:49 139:04 154:16 155:52 151:57 74 of 255 Enfield CCG 3

Enfield CCG Scorecard (2) Enfield CCG 2017/18 Performance Scorecard Q1 Q2 Q3 Q4 2017/18 Indicator Type Target/ Threshold 2016/17 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD CPA Follow-ups 95% 98.9% 98.57% 100.00% 98.03% *nya 98.8% IAPT Access Trajectory - - 3.80% 3.97% 4.00% 4.20% IAPT Access Actual 4.2% (Q4) 16.3% 3.88% 4.32% 1.28% 1.29% 1.23% 1.4% 1.29% 16.0% IAPT Recovery Rates Actual 50% 49% 49.4% 52.5% 50.0% 49.0% 39.7% 46.7% 50.0% 49.2% 6 Weeks IAPT Waiting Times 75% 93.0% 93.9% 91.3% 90.7% 94.0% 92.3% 94.2% 90.3% 94.2% 94.6% 92.1% 92.9% 92.7% 18 Weeks IAPT Waiting Times 95% 99.4% 99.4% 99.5% 100.0% 100.0% 100.0% 99.5% 100.0% 99.4% 100.0% 99.6% 100.0% 99.8% Dementia Diagnosis Rate (Age 65+) 67% 69.7% 71.8% 71.9% 71.6% 71.5% 71.6% 71.6% 71.3% 71.3% 71.5% 71.2% 70.9% 70.9% Psychosis (EIP) - 2 Week Wait, NICE approved package 50% 73.6% 50.0% 100.0% 100.0% 80.0% 60.0% 75.0% 100.0% 50.0% 33.3% 85.7% 100.0% 79.2% Eating Disorders Waiting Times (4Wk Routine) - Trajectory - - 62.5% 62.5% 75.0% 75.0% Mental Health Eating Disorders Waiting Times (4Wk Routine) - Actual Eating Disorders Waiting Times (1Wk Urgent) - Trajectory 64% 100.0% 100.0% 100.0% *nya 100.0% - - 100.0% 100.0% 100.0% 100.0% Eating Disorders Waiting Times (1Wk Urgent) - Actual 75% 100.0% 100.0% no activity *nya 100.0% New children and young people receiving treatment from NHS funded community services - Trajectory - - 90 90 91 93 180 New children and young people receiving treatment from NHS 364 (Annual) funded community services - Actual 340 315 233 *nya 548 Individual children and young people receiving treatment by NHS funded community services - Trajectory - - 610 620 630 635 1230 Individual children and young people receiving treatment by NHS funded community services - Actual 2497 1500 315 369 *nya 684 e-rs Utilisation of e-rs booking, Trajectory - - 32.0% 32.0% 32.0% 40.0% 60.0% 80.0% 80.5% 80.5% 81.0% 81.0% 81.5% 81.5% Utilisation of e-rs booking, Actual 80% (Oct.'17) 29% 34.7% 32.2% 38.5% 33.5% 41.3% 27.6% 41.2% 46.1% 52.5% 71.8% 60.9% *nya 60.9% Wheelchair Service RTT Childrens Wheelchairs within 18 Weeks 92% 96.0% 95.2% 97.4% 100.0% 96.3% 97.2% Personal Health PHBs per 100,000 GP registered pop. - Trajectory - - 23.97 28.47 34.46 40.45 Budgets PHBs per 100,000 GP registered pop. - Actual - 18.28 20.68 22.47 23.37 23.67 23.67 Emergency Readmissions Emergency Readmissions within 30 days of discharge No Target 10.6% *wip *wip *wip *wip *wip *wip *wip *wip *wip *wip *wip 75 of 255 Enfield CCG 4

NCL CCGs Performance The table below shows Enfield CCG s performance against the key national performance metrics, in relation to the NCL CCGs and London and national position where applicable. Reporting Total NCL CCG London CCG Barnet CCG Camden CCG Enfield CCG Haringey CCG Islington CCG Month Performance Performance RTT Incomplete Pathways within 18 Weeks 85.6% 90.7% 83.8% 91.5% 91.9% 88.0% 88.0% RTT Feb-18 RTT 52+ week waiters 16 10 8 8 0 - - Diagnostics Diagnostics - 6+ week waiters Feb-18 0.6% 0.8% 0.4% 0.6% 0.6% 0.6% 0.7% A&E A&E 4 Hour Waits Mar-18 84.7% 85.2% 80.3% 80.8% 85.6% - - 2 week wait 92.0% 93.8% 93.6% 94.4% 94.7% 92.8% 93.6% 2 week wait breast symptomatic 95.7% 96.7% 92.2% 97.3% 97.3% 91.3% 90.8% 31 day 1st definitive treatment 96.4% 100.0% 99.0% 100.0% 97.5% 96.5% 96.1% 31 day 1st subsequent treatment - surgery 83.3% 100.0% 100.0% 100.0% 95.3% 100.0% 95.0% Cancer 31 day 1st subsequent treatment - chemotherapy Feb-18 100.0% 100.0% 100.0% 100.0% 99.5% 100.0% 99.1% 31 day 1st subsequent treatment - radiotherapy 96.3% 100.0% 100.0% 94.1% 99.3% 97.7% 94.7% 62 day standard 78.9% 89.3% 73.3% 68.4% 80.7% 78.9% 82.4% 62 day standard - screening 90.9% 0.0% 100.0% 100.0% 86.5% 94.7% 84.9% 62 day standard - upgrade 100.0% 50.0% 88.2% 80.0% 84.1% 86.7% 86.6% Mixed Sex Accommodation Breaches 20 5 6 2 2 - - MRSA Reported Cases (CCG Attributed) 1 0 0 0 0 - - Quality Indicators C.Difficile Reported Cases Feb-18 9 5 10 12 10 - - E.Coli Reported Cases 22 14 13 7 12 - - IAPT Access Actual TBC TBC 1.3% TBC TBC TBC TBC IAPT Recovery Rates Actual TBC TBC 50.0% TBC TBC TBC TBC Mental Health Feb-18 Dementia Diagnosis Rate (Age 65+) 73.0% 88.49% 70.9% 68.5% 91.16% - - Psychosis (EIP) - 2 Week Wait, NICE approved package 100.0% 81.8% 100.0% 60.0% 77.8% - - e-referral Service Utilisation Utilisation of e-rs booking Jan-18 63% 50% 72% 51% 51% - - DTOCs Total Delayed Transfers of Care - Acute & Non-Acute Feb-18 498 388 275 403 515 - - 76 of 255 Enfield CCG 5

18 Weeks Referral to Treatment (RTT) Enfield s performance for 18 Weeks Referral to Treatment (RTT) times was almost unchanged at 83.8% in February 2018, 8.2% below the 92% standard. This is the second lowest CCG performance in London. At Trust level, North Middlesex University Hospital (NMUH) was still compliant at 92.5% (a fall of 0.6%), while Royal Free London s (RFL) performance rose slightly to 83.4%. The number of Enfield patients already over 18 weeks rose again in February. At the end of the month, the total was 4069 (see chart). However, the median incomplete wait fell to 7.3 weeks. There were 8 Enfield patients reported as still waiting over 52 weeks at the end of February, of which 7 were at RFL. The Trust continues to conduct independent clinical harm reviews for the 52+ week patients, with the reports presented to the monthly RTT steering group. No cases of moderate or severe harm have been identified to date. Duty of Candour will be applied in line with standard practice. The RTT steering group will continue to scrutinise the clinical harm reviews and report exceptions to the CQRG meetings. Elective Waiting Times 77 of 255 Following a first draft in December 2017, a more detailed, speciality-based Recovery Action Plan is under development by the Trust. Dermatology was presented at the March steering group meeting. The other specialties are expected. CCGs have not agreed additional funding for backlog clearing initiatives. Performance continues to be monitored at specialty level, including risk assessments to identify potential issues for rectification. The CCG s specialty-level performance is seen below. Neurology is now the lowest performing specialty ( treatment function ) at 74.8%; while ENT performance has improved by 10% compared to January, driven mainly by UCLH. Treatment Function Total waiting % < 18 weeks Other 7,057 86.8% General Surgery 2,842 75.3% ENT 2,576 78.8% Trauma & Orthopaedics 2,206 77.5% Ophthalmology 1,725 92.3% Dermatology 1,509 83.6% Urology 1,358 89.0% Gastroenterology 1,320 80.3% Cardiology 1,188 89.7% Neurology 898 74.8% Gynaecology 776 91.1% Thoracic Medicine 665 86.3% Rheumatology 438 92.9% General Medicine 211 96.2% Plastic Surgery 179 76.0% Geriatric Medicine 97 99.0% Neurosurgery 55 81.8% Cardiothoracic Surgery 3 100.0% Total 25,103 83.8% 6 Weeks Diagnostic Waits Enfield CCG met the 6 weeks diagnostic target in February 2018, with performance of 0.4% against the 1.0% standard. At Trust level, both NMUH and RFL met the standard with performances of 0.8% and 0.6% respectively. The England average across all providers is 1.6%, and 0.8% for London providers. Enfield CCG 6

Enfield CCG Data for February 2018 indicates that Enfield CCG met six of the eight national cancer standards - failing the 2 week wait (2WW) breast and 62-day first definitive treatment from GP referral targets. Performance in the 62-day GP referral standard has continued to fall and is it at the lowest performance since July 2017. Standards Target 2016/17 Q1 Q2 Q3 17/18 17/18 17/18 Jan-18 Feb-18 2 Week Wait 93% 94.2% 94.3% 93.8% 93.2% 93.4% 93.6% 2 Week Wait (Breast) 93% 93.7% 95.4% 92.8% 95.0% 90.4% 92.2% 31 Day 1st Definitiv e Treatment 96% 98.7% 97.7% 95.5% 99.1% 94.8% 99.0% 31 Day Subsequent Treatment (surgery) 94% 99.4% 93.0% 100.0% 97.1% 100.0% 100.0% 31 Day Subsequent Treatment (chemo) 98% 99.6% 100.0% 100.0% 100.0% 100.0% 100.0% 31 Day Subsequent Treatment (radio) 94% 99.5% 98.8% 97.9% 99.0% 100.0% 100.0% 62 Day 1st Definitiv e Treatment (GP Referral) 85% 80.7% 83.1% 78.3% 82.5% 76.9% 73.3% 62 Day 1st Definitiv e Treatment (Screening) 90% 85.2% 87.0% 97.1% 82.8% 100.0% 100.0% 62 Day 1st Definitiv e Treatment (Upgrade) N/A 90.3% 92.1% 90.9% 90.5% 85.7% 88.2% A total of 60 patients were treated on the 62-day GP pathway in February 16 of which had breached. As with previous months, the breaches were predominantly on the Urological pathway (7 patients) and the remainder on Lower GI (3), Upper GI (2), Lung (2), Skin (1) and Gynaecological (1). The split by hospital was NMUH (7.5), UCLH (4.5) and RFL (4) and due to patient complexities and late inter-trust transfers. The 2 week breast pathway had a total 6 breaches (of 77 seen) due to 5 patient choice delays and 1 administrative delay. Cancer Waiting Times 78 of 255 The NCL standard operating procedure for Trusts to follow in relation to completing breach analysis and clinical harm reviews has now been approved via the NCL Cancer Performance Leadership Group. The policy will enable providers and commissioners a timely review of the themes and trends that emerge from the breaches and put mitigations in place to prevent recurrence in future patients. The Trusts have committed to providing the breach analysis within 10 working days of their data upload, and for all 62-day and 104-day breaches. The NCL Cancer Performance Leadership Group also recently approved the inter-trust transfer (ITT) standard operating procedure. The policy aims to clarify the process, streamline the pathways and reduce delays for patients that need to transfer to another hospital for either a treatment or diagnostic test. It also includes an escalation process to ensure that the receiving Trust can treat the patient in a timely manner. The Enfield CCG Cancer Action Group continues to meet once a month. The meeting in April will include a review of the CCG s Cancer Improvement Plan and look at the provider action plans to improve patient experience. As a response to Trusts raising their concerns about patient-initiated delays in the Cancer pathways, NCL Commissioners are developing a plan to deliver improvement actions via primary care. This will include audits of incomplete and inappropriate 2WW referrals and an education & communications plan with primary care. Enfield CCG 7

North Middlesex University Hospital (NMUH) The Trust met seven of the eight cancer standards in February 2018. Performance in the 62-day GP referral standard dropped further to 59% - the lowest performance in 2017/18. The Trust expect to see an improvement in performance in March, although not up to the national standard target. NMUH had 16 patients that were shared breaches in February (inter-trust transfers). Of these, 10 were sent by NMUH to the treating Trust late. The 9 internal breaches at NMUH (where receiving and treating Trust is the same) were down to patient complexity (6) and patient DNAs (3). Haringey CCG, NCL Performance team and NHS Improvement called an escalation meeting with the Trust s Chief Operating Officer and Cancer team to discuss their recent deterioration in Cancer performance. A set of actions were agreed including short-term support from the Vanguard & NHSI and the reinstating of the weekly Patient Tracker Lists (PTL) calls to address the number of patients that are currently waiting past 62 days each week. Commissioners will also continue to work with primary care clinicians to ensure patients are well-informed about the 2-week wait pathway at the point of referral. Royal Free London (RFL) The Trust achieved all of the eight cancer standards in February. The 62-day GP referral standard was just met with performance of 85% against the 85% target. Cancer Waiting Times 79 of 255 The straight-to-test lower gastrointestinal pathway, which has been operational at Barnet site for three days a week from January 2018, has been extended past its initial one month period and a business case is in progress to extend the pilot for 5 days a week. An early report suggested that 75% of two week wait Lower GI patients are eligible for this test although this depends on the referral having all the relevant clinical workup included. Enfield and Barnet CCGs are working with the Trust to deliver a communications plan to ensure that GPs are aware of the pathway and all the elements that must be included with the referral. The Trust have highlight an increased volume of GP 2 Week Wait referrals since January 2018 and the risk of impact on the 62-day performance. RFL arranged a deep dive meeting for Head & Neck in March 2018 to understand system issues including inter- Trust transfers. A locum consultant will now support the specialist multidisciplinary team meeting to expedite the inter trust transfers. The chart below illustrates the Enfield status of RFL s 62 Day Patient Tracker List (PTL) by week. Since late- December 2017, this has averaged around 15 patients. Enfield CCG 8

NMUH s performance fell to 76.5% in March, down by 5.9% from the previous month. The 2017/18 year-end position was performance of 81%. NMUH A&E Performance against 4 hour target (2017/18) NMUH & RFL Accident & Emergency 16/17 April May June July Aug Sept Oct Nov Dec Jan Feb March YTD STF - 85.0% 87.0% 89.0% 91.0% 93.0% 92.0% 92.0% 90.0% 90.0% 90.0% 90.0% 95.0% Trajectory Actual 82.0% 82.4% 83.9% 82.1% 81.9% 80.3% 85.8% 87.2% 82.0% 72.6% 75.5% 82.4% 76.5% 81.0% Staff shortages and high sickness levels continue amongst medical and nursing staff. A new consultant rota has been implemented with a dedicated Ambulatory Early Senior Assessment and Treatment (ESAT) role now in place. System Resilience Update In March 2018, the average number of Medically Optimised Patients for Enfield patients at NMUH was 16 (an average of 33% of the Trusts total delays). Average DToC numbers for Enfield patients remained consistent at 2 or below. The total delays combined consistently remains under the set trajectory of 22. Ambulance handover targets (15 and 30 minutes) are challenging across North Central London and none of the NCL providers are meeting these targets. Work is underway in collaboration with the NHS Improvement Emergency Care Improvement Programme team. RFL performance fell to 84.1% in March 2018. RFL A&E Performance against 4 hour target (2017/18) 16/17 April May June July Aug Sept Oct Nov Dec Jan Feb March YTD STF - 86.6% 87.2% 88.7% 89.6% 89.8% 90.1% 90.3% 91.9% 91.3% 93.8% 94.8% 95.0% Trajectory Actual 87.60% 87.6% 90.3% 87.0% 86.1% 88.7% 84.3% 87.0% 87.8% 83.7% 86.1% 86.5% 84.1% 86.6% Royal Free Urgent and Emergency Care transformation board are refreshing their Urgent & Emergency care transformation plans for each site with the aim to improve 4-hour A&E performance to 90% by September 2018 as per their operational plans for 2018/19. Enfield Medically Optimised delays at Barnet & Chase Farm averaged 7; average DToC for Enfield were at 2 or below. Further work is taking place with Barnet & Chase Farm on early identification of delays to reduce the number of DToC going forward as the total delays are slightly above trajectory. Discussions are being held to continue the nurse streaming pilot at the Barnet A&E front door into business as usual following the early indication of its effectiveness. 80 of 255 A workshop to review resilience to support NMUH is taking place in April with Haringey and Enfield CCG s as well as NMUH and Community Partners. The workshop will aim to review challenges and learning for resilience 2018/19. Enfield CCG 9

Discharge to Assess (DTA) In total 103 patients were discharged from acute sites across Enfield DTA pathways in March - 80 patients on Pathway 1, 9 on Pathway 2 and 14 on Pathway 3. Of these 103, 79 patients were from NMUH. As of February 2018 the trajectory step change brought the target to 25 patients across DTA pathways; all pathways are not yet meeting this trajectory. A discussion is to take place at the System Resilience Group in mid-april to review the trajectory and also revise a trajectory for 2018/19. Pathway 1 (in place since February 2017 at NMUH and October 2017 Barnet Hospital). 644 patients have gone through this pathway to date; 500 of these have been from NMUH. Pathway 2 has a Home First element which has been in place since November, and a bed based element which has been in place since January. 24 patients have been discharged via this pathway. Pathway 3 has been in place since October, with a total of 61 patients who have successfully been discharged to date. Out of Hospital Services Primary Care Access Hubs Enfield CCG commissions three extended access providers to deliver additional primary care appointments between 18:30-20:00 weekdays and 8:00-20:00 weekends and bank holidays. ECCG has further deployed three WIC services across Enfield, in addition to the pre-bookable capacity. Two of these services are co-located with the existing primary care access hubs. 3 Primary Care Access Hubs - Carlton House (North West Locality), Woodberry Avenue (South West Locality) and Evergreen PCC (South East Locality); and 3 WIC services Carlton House (North West Locality), Evergreen PCC (South East Locality) and Eagle House (North East Locality). The table below illustrates the capacity provided and activity booked for the reporting period of March 2018. In summary, Primary Care-led services provided an additional 6790 appointments during March 2018 (988 more appointments than in the previous month). In total 5918 (87%) appointments were utilised. Did not attend (DNAs) rates were slightly higher during March, increasing from 5% to 8%. HUB Utilisation Day # appts # appts DNAs Utilisation available booked Monday 168 163 20 97% Tuesday 168 154 16 92% Wednesday 168 157 29 93% Thursday 210 202 46 96% Friday 688 635 95 92% Saturday 3871 3274 280 85% 81 of 255 Sunday 1517 1333 68 88% Total this month 6790 5918 554 87% Enfield CCG 10

Integrated Urgent Care (IUC) Service There were 28,113 calls to the NCL IUC service in March 2018; a 14% increase on the previous month. The following pilots have been extended until the end of March 2018: Enhanced access for Care Homes LAS crews to an IUC Clinician and Enhanced access to Rapid Response Teams. The NCL-wide service continues to achieve above the nationally mandated target of 50% of IUC being handled by a clinician. March performance was 58%. The 50% target will remain in place until March 2019. The NHS111 Online pilot which commenced in February 2017 has been extended to November 2018. The table below shows service performance from April to March 2018. Call waiting time continues to be impacted by rostering issues and shortfall in WTE. Workforce plan progressing to trajectory. Qrt 1 Qrt 2 Qrt3 Qrt4 Quality and Performance Indicators KPI Type Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC Engaged calls Performance 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Abandoned calls Performance 0.4% 0.9% 0.8% 1.4% 1.5% 3.0% 3.2% 4.8% 3.5% 4.7% 8.5% 7.4% Answ er Time Performance 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Average time to answ er Performance 00:00:31 00:00:34 00:00:54 00:00:55 00:01:35 00:01:30 Call w aiting time Performance 95.6% 91.0% 91.2% 86.3% 88.3% 81.6% 80.5% 73.3% 77.4% 76.7% 62.6% 66.6% Life threatening referrals Quality 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Meeting individuals needs Quality 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Safeguarding Quality 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Triage rate Quality 106.6% 108.1% 108.2% 106.4% 104.9% 104.0% 109.1% 106.8% 104.2% 104.4% 103.5% 103.4% Transfer to 999 Performance 9.6% 9.7% 10.3% 10.4% 10.9% 11.7% 11.5% 11.6% 11.7% 12.0% 12.3% 11.6% Attend Accident & Emergency Department Performance 9.4% 9.8% 10.1% 10.5% 9.4% 10.1% 10.0% 9.8% 9.0% 10.2% 10.3% 10.6% Referred to Primary Care and other dispositions Performance 55.5% 52.8% 52.5% 52.9% 51.9% 51.0% 51.5% 51.9% 55.4% 55.3% 56.6% 57.0% Warm Transfers Performance 68.1% 66.0% 68.0% 71.6% 73.8% 66.5% 73.3% 72.2% 72.4% 78.5% 80.7% 84.0% Time taken for call back Performance 10.6% 13.1% 10.8% 54.6% 54.0% 53.5% 49.1% 48.7% 46.9% 44.8% 37.6% 41.3% Notifications Quality 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Patient Education Quality 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Emergency Response 82 of 255 London Ambulance Service (LAS) The service has been reporting against the national Ambulance Response Programme (ARP) since 31 st October 2017. The latest published data shows that in February 2018, as in the previous four months, LAS did not meet four of the six new standards. Performance levels were similar to those in February. Ambulance Quality Indicator % of responses National Standard Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD in category (March) LAS Cat 2 Average reponse time 18:00 18:27 24:11 20:25 23:21 23:21 21:37 London Cat 2 90% of response times 40:00 36:32 51:11 42:08 49:21 49:20 45:11 Cat 1 Average response time 07:00 07:04 7:24 07:10 07:27 07:26 07:16 Cat 1 90% of response times 15:00 11:28 12:04 11:45 11:47 11:59 11:48 9.5% 59.8% Cat 3 90% of response times 120:00 135:00 178:56 145:38 178:44 172:21 157:23 22.9% Cat 4 90% of response times 180:00 148:54 171:49 139:04 154:16 155:52 151:57 7.8% Category 2 response times are below standard on both the mean and the 90 th percentile measures, with NCL performance lower than that for London as a whole. Category 2 incidents were supposed to form 48% of the total, according to results from the three trial regions, but are running at around 60% in London. Overall, performance remains challenged, much as it was before November (see table below). Due to the national roll-out of the ARP, NHS Standard Contract sanctions for 2017/18 no longer apply. Updated sanctions will be considered for 2018/19. Enfield CCG 11 National Standard 2016/17 perf. Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 2017/18 YTD Cat A (RED1): Response within 8 Min 75% 58.6% 70.4% 74.1% 67.3% 68.8% 73.1% 51.0% 66.2% 67.4% LAS Cat A (RED2): Response within 8 Min (Enfield) 75% 54.5% 61.7% 65.1% 62.1% 60.7% 64.5% 69.9% 60.6% 62.1% Cat A: Response within 19 Min 95% 89.0% 91.5% 91.7% 90.6% 91.5% 92.7% 94.4% 92.3% 91.7% LAS Cat A (RED1): Response within 8 Min 75% 69.2% 79.2% 73.7% 73.3% 72.3% 74.4% 70.6% 73.5% 73.9% (London Cat A (RED2): Response within 8 Min 75% 66.3% 73.6% 71.9% 69.7% 68.5% 72.0% 68.5% 68.7% 70.4% wide) Cat A: Response within 19 Min 95% 93.5% 95.6% 95.0% 94.3% 94.1% 94.4% 93.9% 94.9% 94.6%

Mental Health Performance Indicators Improving Access To Psychological Therapies (IAPT) The 2017/18 national ambition for Improving Access to Psychological Therapies (IAPT) local services is 4.2% (in Quarter 4). To achieve this, Enfield CCG plans to commence treatment for 5,668 service users this year. In February 2018, 458 patients entered treatment. This was 41 below the plan of 499. On a year-to-date, the planned number of treated patients has been exceeded by 48 patients (or 0.9%). However, for Quarter 4 alone, there is a shortfall of 34, with only March remaining. IAPT access is now included in the 2017/18 CCG Improvement & Assessment Framework, and the CGG continues to monitor this closely. February s recovery rate rose to 50.0%, just meeting the target. On a year-to-date basis, the recovery rate is 49.2%. The service s improvement plan to support sustainable achievement of the recovery rate standard remains in place, and was updated in January 2018 at the request of the CCG. Recovery rate issues and progress against actions are closely monitored and reviewed monthly. NHS England s weekly monitoring for Quarter 4 has now completed. The 6-week and 18- week Referral to Treatment time targets continue to be met. Child and Adolescent Mental Health Services (CAMHS) Waiting times for Enfield CAMHS continue to be a concern. The number of patients waiting over 13 weeks had fallen to 25 at the end of October 2017, but has risen steadily since, reaching 111 at the end of February. The CCG is monitoring this closely and has a weekly telephone conference with BEHMHT. 83 of 255 Capacity and demand modelling to be undertaken by the Trust to improve delivery against access targets, and re-profiling of the skill-mix and focus of team members to better meet demand. Early Intervention in Psychosis (EIP) Performance in February 2018 was 100%, against the 50% standard. ECCG has met the standard in 22 of the previous 23 months, with December 2017 seeing the only outlying value. The March 2018 submission (due in April) is scheduled to be the last one on Unify2. Future submissions will be via NHS Digital s Strategic Data Collections Service (SDCS). However, the timetable for the migration from Unify2 reporting to the new system is subject to weekly review. Agreement was reached on an 800k investment to enable BEHMHT to offer National Institute for Health and Care Excellence (NICE) recommended care packages to service users in 2017/18. A Data Quality Improvement Plan for 2017/18 to improve EIP reporting to NHS Digital has been formally agreed with the Trust. The Trust plans to introduce SNOMED classification codes to assess compliance with NICE standards. Dementia Diagnosis The latest data, for February 2018, shows that ECCG has a diagnosis rate of 70.9% for the 65+ population. This is above the national standard of 66.7%. The dementia prevalence for the 65+ population is estimated at approximately 2800. Waiting times and service performance are reviewed at the monthly contract meetings. The Enfield consultant vacancy is being recruited to; and the Dementia Steering Group is being re-established to look at local issues. Enfield CCG 12

Enfield Community Services Scorecard Enfield Community Services (ECS) The table below details the services where Key Performance Indicators (KPIs) were not met in the last quarter or during 2017/18 as a whole. The new KPI dashboard for 2018/19 is close to agreement. There is an issue in the Lymphoedema clinic regarding the availability of clinic space and staff. ECCG and the provider are reviewing achievability of the KPIs. The Heart Failure Service has a new team in place (4 new staff since August 2018) which will require training. The service minimises risk to patients by fitting in a telephone call in between receiving referral and see them on 1st face to face contact. Target Q1 The Podiatry service has recently recruited to vacant positions and provisional figures show a 9% increase in waiting times in March. The service expects to see a notable improvement in May once the new employees are embedded. Community Physiotherapy times were affected due to unusually high staff sickness. A request for interim cover has been made. The Adult & Child Speech and Language Therapy teams have had capacity issues which are being addressed. Priority is given to urgent and statutory referrals. Q2 2017/18 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Q3 Q4 Intermediate Care Team Lymphoedema Nursing Heart Failure Diabetes Percentage of urgent referral triaged seen within 2 hours of receipt (CCRT) 95% 100% 97% 89% 88% 100% 100% 100% 99% 86% 92% 99% Percentage of cancer patients seen within 4 weeks 95% 100% 100% 71% 43% 67% Percentage of Heart Failure patient seen and commencing treatment within 4 weeks of referral Percentage of patients seen and commencing treatment within 6 weeks of routine referral 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 73% 82% 95% 22% 15% 47% 61% 81% 35% 50% Podiatry % non-urgent referrals assessed within 13 weeks 90% 76% 79% 75% 66% 64% 48% 56% 66% 63% 56% 57% Respiratory Service Community Physio Adult Speech and Language Therapy Nutrition and Dietetics Children Looked After Percentage of patients seen and commencing treatment within 6 weeks of referral Percentage of urgent referrals seen and commencing treatment within 5 working days Percentage of urgent referrals responded to within 5 days of referral Percentage of patients seen and commencing treatment within 4 weeks of routine referral Percentage of first appointments seen within 4 weeks of routine referral % health assessments carried out by the specialist nurses within timescale 95% 98% 100% 77% 63% 96% 85% 75% 90% 100% 100% 100% 100% 100% 100% 100% 100% 86% 100% 67% 90% 36% 47% 56% 60% 75% 88% 44% 95% 0% 0% 59% 57% 60% 45% 33% 95% 62% 48% 43% 49% 56% 51% 80% 95% 88% 96% 93% 100% 74% 100% 97% 100% 95% 96% 83% % School Age Therapy routine referrals seen 75% 89% 84 of 87% 255 75% 75% 58% 58% 46% 64% 100% 87% 28% Children's Speech and within 13 weeks Language Therapy % School Age Therapy complex referrals seen No No No 75% 100% 82% 33% Enfield CCG within 4 weeks referrals referrals referrals 13

Other Quality Measures Infection Control The NHS England Quality Premium for 2017-19 asks CCGs to reduce their E.Coli infections by 10% in 17/18. For Enfield CCG, this means a target of 178 cases at the end of March 2018. There were 13 cases of E.coli reported in Enfield in February 2018, bringing the year-to-date total as of the end of February 2018 to 227 cases, meaning the target reduction of 10% for 2017/18 has been exceeded. C. Difficile rates for February were 10 cases against an in-month target of 9. There is a year-to-date total of 69 cases against a YTD target of 69, therefore ECCG is on target to achieve its C.diff target for the first time in two years. There can be a maximum of 7 cases in March 2018 in order for the CCG to stay within its annual target of 76 cases. Provisional data indicates that this has been achieved. Year to date in February 2018, RFL is exceeding its annual trajectory (75 cases against the year to date trajectory of 61 cases). The Trust has therefore exceeded its annual objective of 70 cases. NMUH is within it s annual trajectory year to date; 30 cases recorded against a YTD target of 32. There were no CCG-assigned cases of MRSA in February. There were also no MRSA cases reported at either RFL or NMUH. Mixed Sex Accommodation (MSA) There were six MSA breaches for Enfield patients in February 2018, at RFL (5) and UCLH (1). RFL Trust-wide reported 39 MSA breaches in February 2018 34 recorded at the Barnet General site and 4 at Royal Free Hampstead site. Commissioners continue to monitor the impact on patient experience through complaints received (none to date) and will escalate concerns as necessary. RFL has the second highest number of breaches in London after UCLH. Mortality Rates The Summary Hospital-level Mortality Indicator (SHMI) measures the ratio between patients who die following Trust hospitalisation and the number expected to die based on national average figures, adjusted for local case mix. The most recent set of data published in March 2018 (October 2016 September 2017) shows RFL (86.8) and NMUH (83.6) scoring lower than 'expected' mortality rate. The report states that a majority of lower than expected SHMI are located in the London Region. Further research is required to understand the reason. The next set of SHMI data is due to be released in June 2018. 85 of 255 Enfield CCG 14

Patient Experience Friends & Family Test (FFT) Royal Free London FFT February 2018 RFL The Trust maintains their high response rate in A&E (London average of 18%), but places 13 th out of the 19 London Trusts for recommendation rate (83% Trustwide). For the Barnet site alone, recommendation rate is lower at 78%. North Middlesex University Hospital FFT February 2018 NMUH Response Rate Dec-17 Response Rate % % Recommend Recommend Response Rate Response Dec-17 Jan-18 Feb-18 A&E response rate increased notably in February to 70% - the highest in London. Recommendation rates remain low at 69% (London average 82%). Patient experience is part of the Trust s A&E action plan which is discussed at the monthly CQRG. NMUH are delivering their action plan to improve patient experience in the Outpatient department. A repeat Insight & Learning visit is planned for early 2018. % Recommend Response Rate % Recommend A&E FFT 27% 63% 17% 67% 70% 69% Birth FFT 21% 91% 21% 93% 28% 88% Inpatients FFT 16% 91% 20% 90% 19% 94% Outpatients FFT 4.4% 86% 2.8% 86% 5.7% 85% Rate Jan-18 % Recommend Response Rate Feb-18 % Recommend A&E FFT (BGH) 41% 79% 46% 79% 44% 78% Birth FFT (BGH) 9% 97% 18% 100% 11% 100% Inpatients FFT (BGH/CFH) 28% 90% 32% 88% 32% 88% Outpatients FFT (RFL Trust) 0.8% 94% 1.6% 95% 0.9% 94% 86 of 255 BEH Mental Health Trust FFT February 2018 BEHMHT achieved a recommendation rate of 87.8% in February 2018, in line with previous months and the London average. The Trust consistently places around 6 th place (of 12 Trusts) for recommendation rate across London. Response rate remains well above the London average (3.1%). The response rate is also the highest for similar sized Trusts in London - in comparison West London Mental Health Trust, which has a similar number of eligible patients, had a response rate of 0.2% in February. Enfield CCG and the Trust have agreed a series of Insight & Learning Visits for 2017/18. The visits will focus on areas where additional assurance against essential standards of safety are sought and/or where external intelligence has identified concern i.e. CQC inspection, Healthwatch Enter & View reports. Visits have already taken place at the Barnet and Haringey inpatient sites and have been a valuable insight into ward processes and patient experience. The latest visit in February was to an inpatient ward and district nursing team. The next visit is due to take place in April 2018 at the section 136 suite. Enfield CCG 15

Serious Incidents (SI) - NMUH Note this slide has not been updated this month due to data release dates. The Trust reported three Serious Incidents (SI) in January 2018 categorised in the chart above. By the end of January 2018, the Trust had 25 overdue SI reports. The number of open Further Information Requests (FIR) remained elevated at 50. Haringey CCG and NMUH continue to meet to expedite SI closure. The Trust is introducing a new model of dedicated SI investigators and are recruiting to two interim positions with the view of converting them into substantive posts. During 17/18, five Never Events have been reported three wrong site surgery and two retained foreign objects. This is an increase of reported Never Events from 2016/17 when three Never Events had been reported. Haringey CCG are undertaking a thematic analysis of the learning following previous Never Events of the same type and are planning an assurance visit with a focus on root causes and action plans for March 2018. 87 of 255 Enfield CCG 16

Serious Incidents (SI) - RFL Note this slide has not been updated this month due to data release dates. In January 2018, the Trust reported 9 Serious Incidents (SIs), as categorised in the chart above. There were 14 open further information requests (FIR) at the end of January. The Trust had overdue serious incidents. The Trust has reported 9 Never events for 2017/18 making them the highest reporter of never events in London. The Trust held an assurance never event workshop to assure the CCG that they are learning from never events. Barnet CCG and NEL CSU will also be undertaking a quality visit to RFL to review the surgical never events. Overdue serious incident reports have been increasing over the past three months. However, the Trust gave assurance at the February 2018 Clinical Quality Review Group that overdue serious incidents would start to decrease next month. 88 of 255 Enfield CCG 17

Serious Incidents (SI) BEHMHT Note this slide has not been updated this month due to data release dates. BEH MHT reported 2 Serious Incident during January 2018, as categorised in the chart above. Five SI reports remain overdue as of the end of January 2018 and there were twelve Further Information Requests (FIR) open. Improving the quality of the serious incident reports submitted remains a key priority of the CCG and the work with the Trust is ongoing through quarterly SI meeting between the Trust and the CCG Quality team. The next quarterly meeting is scheduled for March 2017. NEL CSU provided the Trust with a report highlighting areas of improvement required in the quality of reports submitted. Using the report, ECCG will support the Trust in improving the quality of reports through the quarterly SI meeting. 89 of 255 Enfield CCG 18

Activity Overview The table below gives an overview of CHC activities for the past 6 months; Fast tracks 2017/18 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD New patients referred 30 37 45 29 31 33 205 New patients care commissioned 25 29 37 21 26 28 166 Number RIP/Closed 30 23 21 19 13 21 127 Fast tracks 2016/17 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 YTD New patients referred 30 31 32 31 31 21 176 New patients care commissioned 20 25 28 33 24 22 152 Number RIP/Closed 18 16 21 22 17 16 110 Non fast tracks 2017/18 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD New patients referred 33 24 17 33 31 37 175 New patients care commissioned 4 5 3 5 0 10 27 Number RIP/Closed 11 7 6 12 1 5 42 Non fast tracks 2016/17 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 YTD New patients referred 27 24 25 15 25 28 144 New patients care commissioned 8 6 5 10 9 12 50 Number RIP/Closed 13 8 4 9 9 6 49 CHC Reviews Conducted Oct Nov Dec Jan Feb Mar YTD Reviews Conducted 2017/18 118 113 93 119 90 117 650 Reviews Conducted 2016/17 143 124 98 102 101 120 688 The service is on track to deliver its commitment that all patients are reviewed annually. The implementation of Home First pathway has had a positive affect on the referral turnaround times. Quality Premium 2017/19 Targets This is a two part indicator, each part of which attracts 50% of the payment for the indicator: Continuing Health Care (CHC) 90 of 255 a) To achieve the Quality Premium for this part, CCGs must ensure that less than 15% of all full NHS CHC assessments take place in an acute hospital setting Significant work has been done to deliver the target over the past few months. The Home First team based at the hospital are working with the discharge teams to ensure we continue meeting the target of 80% out of an acute setting. b) CCGs must ensure that in more than 80% of cases with a positive NHS CHC Checklist, the eligibility decision is made by the CCG within. NHS CHC 28 DAYS REFERRAL TIME A This is a challenging target as it required a partnership approach with the LA to meeting the 28 day rule. The Social Worker available capacity is hindering the timeframe. The service is working with the LA to implement a joint funded post which will enable delivery the QP. Enfield CCG 19 Month NHS CHC LOCATION OF DST IN MONTH A Month November December January February Number of DSTs completed in month November 8 4 50% December 7 4 57% January 20 5 25% February 24 2 8% March 9 1 11% Total referrals completed in a month B Number of completed referrals within 28 days How many referrals in column [A] were completed within 28 days? Snapshot Activity Number of incomplete referrals exceeding 28 days as at end of month 10 6 60% 17 7 4 57% 14 20 7 35% 13 25 10 40% 6 March 9 3 33% 6 B Number of DSTs in acute hospital setting in month How many DSTs in column [A] were completed in an acute hospital setting in month? C % of referrals completed within 28 days C % of DSTs completed in an acute hospital setting

Continuing Health Care (CHC) Key Performance Indicators Note this slide has not been updated this month and is under review. CHC Assurance, two Key Lines of Enquiry (KLOEs) rated yellow. These are marginal and NHS England has rated Enfield as Assured Good with an Assured Outstanding for Fast Track in the Deep Dive review of CHC. 177 Funded Nursing Care (FNC) & CHC reviews were due in Q1 and 98 were completed in quarter. 16 were completed in advance of the due date. This represents 64.4% of reviews completed on time or in advance. Of the 63 outstanding reviews 21 have been completed so far in July 2017. The remainder have been scheduled. The engagement of additional review resource has reversed the downward trend experienced in 2016/17. Further progress towards the KPI target is anticipated as the permanent roles are filled. The rolling 12 month review rate remains at 95% of patients having been seen within the last 12 months. Two new staff were engaged towards the end of the quarter and are now completing mandatory training. 91 of 255 *Please note this report is updated on a quarterly basis Enfield CCG 20

Transforming Care Ref. Date of most Recent Care Plan Review Anticipated Discharge/ Transfer Date Most recent updates 07/16 10/04/18 Not ready Following CPA it was felt that patient is not ready for discharge as behaviour deteriorated again and is considered dangerous. A 3 rd gateway assessment to be carried out to forensics. Community explored and Normanshire found not to be suitable to meet the patient s needs. Following the CTR on 14/2/18 Partnership in Care evicted her and EILDS had to find an emergency bed in Jeesal hospital and was admitted informally on 16/2/18 with a view to continue to refer to appropriate placements in the community. 07/18 14/02/18 Date not set Was placed under Doctor s Holding Powers section 5(2) on 22/2/18 after a few incidents at Jeesal Cawston park. Then placed on section 2 for 28 days following more aggression. Placements still being explored. Court case: 1/3/18. The court has asked that assessments be carried out regarding the traits that RM is showing in the area of OCD and Personality Disorder. The deadline for submission is the 12/04/18. Placement with Stewardson abandoned for reasons -- they do not have a secure behaviour management policy in place as agreed by the Judge and all parties. 92 of 255 Enfield CCG 21

The total of referrals (from GPs and community clinics) received in March 2018 was about 9% lower than in March 2017. Allowing for the difference of 2 working days, daily referral rates were similar to last year. Across the whole year, referrals were about 2% higher than in 2016/17. Average referral turnaround times appear to be improving, and the booking backlog kept at manageable levels, as familiarity with the use of Docman embeds further. ERS continues to be affected by staff shortages, including sickness and vacancies. The Docman IT system is in use for all specialties except Cardiology. A migration of data from Docman version 7 to 10 is underway, with reporting outputs in development. Data quality issues are being addressed also, e.g. PoLCE type. Adherence to Evidence Based Medicine (AEBM) referral outcomes are now recorded. In March, 22.5% of AEBM referrals were declined. Electronic Referral Service (e-rs) utilisation In their 2017-19 Operational Plans, CCGs were expected to increase their utilisation rate of the electronic-referral Service (e-rs) to 80% by October 2017, and to 100% a year later. In January 2018, the published rate for Enfield was 71.8%, representing a 19% improvement against the previous month. All of Enfield s 48 GP practices have received training in booking Two-Week Wait (2WW) referrals for suspected cancer. The majority are now making these bookings. Some re-training has been required. Enfield Referral Service (ERS) Enfield Referral Service Dashboard 2017/18 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total referrals received 4301 5047 4933 5270 3806 5608 4712 5164 3591 4988 4820 4605 PoLCE referrals received* 76 295 373 294 264 314 287 345 263 371 311 TBC PoLCE approvals* 46 177 209 142 178 198 200 241 195 259 213 TBC PoLCE rejections* 29 99 130 127 56 73 56 71 50 54 48 TBC Crude rejection rate (where outcome known) 38.7% 35.9% 38.3% 47.2% 23.9% 26.9% 21.9% 22.8% 20.4% 17.3% 18.4% TBC e-rs bookings made (by ERS) 2021 2270 2699 1817 2596 1710 2441 2519 2278 3412 2443 2521 CCG e-rs utilisation rate (Op.Plan trajectory) 32.0% 32.0% 32.0% 40.0% 53.3% 66.7% 80.0% 80.5% 81.0% 81.0% 81.5% 81.5% CCG e-rs utilisation rate (actual) 34.7% 32.2% 38.5% 33.5% 41.3% 27.6% 41.2% 46.1% 52.5% 71.8% 60.9% TBC e-rs booking backlog at month-end** 1260 1591 548 >1500 c. 1000 c. 300 c. 100 c. 1000 c. 180 c. 200 c. 380 c. 600 * from Docman only. PoLCE captured from end-april ** approximate figures In March 2018, 587 2WW bookings (from 39 GP practices) were made electronically. NMUH is in Wave 1 of a national e-rs rollout programme, and is discouraging non-electronic referrals ahead of its imminent paper switch off date of 16 th April. The CCG is working locally to support the Trust. RFL is in Wave 3, with a target date for completion of 31 st August 2018. 93 of 255 Enfield CCG 22

Workforce Statistics - Staffing Profile Note this slide has not been updated this month. The table below shows staff movements between December 2017 and February 2018. The 4 leavers in the reporting period were due to retirement (3) and voluntary resignation (1). In the same period, 5 new members of staff joined the organisation. Short/long term absence rate: The annual absence rate for Enfield CCG (at 31 January 2018) is 3.26%. Short term absence is similar to December; currently 1.96%. There have been 10 cases of long term absence in the last 12 months. Management support have been put in place to ensure that sickness absence is actively managed in line with the Policy. The cost of absence over that last 12 months has totalled 175,395 The annual turnover rate over the last 12 months for Enfield CCG is 22.16%. The table below outlines Enfield s turnover in comparison to other NCL CCGs. 94 of 255 Enfield CCG 23

Note this slide has not been updated this month. Mandatory Training Quarter 2 Report & Actions Information Governance elearning Course Changes: The Dept of Health has released a new IG elearning course titled Data Security Awareness Level 1. All staff, including interims and contractors, are required to complete this course by March 2018. For January 2018, the CCG were compliant against the national 95% target. Completion is only required when IG is up for renewal, so if staff are IG compliant there is no need to complete this course until renewal is due. Interim staff can register and complete the course directly from the NHS Digital website (https://nhsdigital.e-lfh.org.uk/), but permanent staff should complete it via OLM. This new course replaces both Introduction to IG and IG Refresher. Changes to elearning User Access: When staff log into OLM they are usually presented with a navigation screen with two links elearning User and Employee Self Service. From the 1 st October users will only be able to access Employee Self Service. elearning/olm access will still be available but via the Employee Self Service route only. Staff will have limited access to employee self-service but along with OLM, other functionality such as the ability to view Payslips and P60s, access Total Reward Statements, monitor compliance with training and update personal information will be available. OLM drop in sessions at Enfield CCG (GPIT Room) will be held; Friday March 9, Friday June 1 & Wednesday July 18. These sessions can assist with logging in and advice on how to navigate around the system to complete mandatory training. Line managers are reminded to ensure staff have fully completed 95 of 255 required mandatory training by 31 st March 2018, also to include mandatory training objectives in appraisals for 18/19. Enfield CCG 24

POD Appendix 1 - Enfield CCG Activity Month 11 (February) hospital activity data is now available from SUS+. The table below compares the latest data to the final version of the 2017/18 Operational Plan, as submitted in August 2017. The main issue again this month is that EM11 (non-elective spells) is showing a year-to-date variance of 5.0%. The February total itself was 14.3% above plan, driven by increases in non-elective admissions at NMUH in particular. Winter pressures and increased A&E attendances were contributory factors. Admissions with zero length of stay showing greatest growth (>10%). This is being investigated further. Elective spells (EM10) are now 4.4% below plan. There has been a shift this year from elective (day case) to outpatient attendance (with procedure) at several Trusts; and a shift from follow-up to first for Diagnostic Imaging (affecting EM8 and EM9). RFL has performed less elective activity than last year, with a backlog of waiting patients with a decision to admit. The national direction concerning permitted suspension of non-urgent / non-cancer elective care in January 2018 is likely to have been another factor, which might have extended into February also. Latest Month: February 2018 E.M.7: Total Referrals for a First Outpatient Appointment (G&A) E.M.8: Consultant Led First Outpatient Attendances (Specific Acute) E.M.9: Consultant Led Follow-Up Outpatient Attendances (Specific Acute) E.M.10: Total Elective Spells (Specific Acute) E.M.11: Total Non-Elective Spells (Specific Acute) E.M.12: Total A&E Attendances (Excluding Planned Follow-Up Attendances) Key: In-month variance +/-5%; YTD variance +/-2% 2016/17 2016/17 Month Variance April May June July August September October November December January February 2017/18 Plan 128,115 9,318 10,880 11,401 10,867 11,388 10,867 11,365 11,365 9,802 11,360 10,319 118,932 Actual 126,327-1.4% 8,901 10,992 11,847 10,267 10,360 10,847 11,079 10,968 8,980 9,735 8,639 112,615 Variance -1,788-417 112 446-600 -1,028-20 -286-397 -822-1,625-1,680-6,317 Plan 131,668 9,463 11,050 11,579 11,037 11,566 11,037 11,543 11,543 9,956 11,538 10,480 120,792 Actual 134,252 2.0% 9,727 11,624 11,657 11,449 11,049 11,183 12,191 12,984 10,234 13,026 11,621 126,745 Variance 2,584 264 574 78 412-517 146 648 1,441 278 1,488 1,141 5,953 Plan 246,869 19,623 22,990 24,112 22,857 23,979 22,857 23,750 23,750 20,383 23,699 21,454 249,454 Actual 244,475-1.0% 19,258 23,573 23,341 22,307 21,213 21,332 23,077 23,760 18,522 23,143 20,244 239,770 Variance -2,394-365 583-771 -550-2,766-1,525-673 10-1,861-556 -1,210-9,684 Plan 36,942 2,874 3,362 3,524 3,306 3,469 3,306 3,406 3,406 2,919 3,400 3,075 36,047 Actual 36,884-0.2% 2,974 3,156 3,207 3,199 3,193 3,153 3,422 3,374 2,791 3,188 2,786 34,443 Variance -58 100-206 -317-107 -276-153 16-32 -128-212 -289-1,604 Plan 26,112 2,395 2,475 2,395 2,449 2,449 2,369 2,432 2,352 2,432 2,421 2,181 26,350 Actual 28,287 8.3% 2,358 2,585 2,405 2,363 2,429 2,464 2,603 2,681 2,640 2,643 2,493 27,664 Variance 2,175-37 110 10-86 -20 95 171 329 208 222 312 1,314 Plan 158,918 13,561 14,015 13,561 13,989 13,989 13,535 13,987 13,533 13,987 13,987 12,625 150,769 Actual 159,242 0.2% 13,527 14,585 13,728 96 13,947 of 255 12,336 13,106 14,192 14,154 14,154 14,931 13,350 152,010 Variance 324-34 570 167-42 -1,653-429 205 621 167 944 725 1,241 Enfield CCG 25 2017/18 Variance -5.3% 4.9% -3.9% -4.4% 5.0% 0.8%

Appendix 2 2017/18 Quality Premium The table below sets out the criteria for achieving Quality Premium funding in 2017/18. This is also subject to two prequalification criteria which will be reviewed throughout the course of the year. National 1 Improvement in the proportion of cancers (specific cancer sites, morphologies and behaviour*) diagnosed at stages 1 and 2 in the 2017 calendar year compared to the 2016 calendar year 2 Improvement in overall experience of making a GP appointment 3 Measures a) NHS Continuing Health Care - proportion of CHC eligibility decisions to be made within 28 days from receipt of the Checklist b) NHS Continuing Health Care - proportion of all full NHS CHC assessments taking place in an acute hospital setting 4 Mental Health Out of Area Placements a)i Reducing gram negative blood stream infections across the whole health economy - Reduction in all E coli BSI reported at CCG level Target 4% point improvement OR At least 60% diagnosed at stage 1 & 2 85% OR 3% point increase between July 2017 to July 2018 publications Latest Data % Allocation Maximum Available Likely Deductions 54.7% (Yr to Dec 2016) 17% 275,256 0 66.4% (Jul 17) 17% 275,256 275,256 Risk Rating Reporting Frequency Comments Quarterly; Enfield requires a 4% improvement on 2016 performance, to next update reach 58.7% for 2017. Next data publication is in May 2018. May 18 Annual (after Jul 16) >=80% within 28 days 27% Q4 8.5% 137,628 137,628 Quarterly <15% in acute hospital setting 15.4% Q4 8.5% 137,628 137,628 Quarterly >= 33% reduction on 16/17 baseline (baseline TBC) 178 (i.e. 10% reduction on 2016 baseline of 198) 1280 inappropriate days in last year; 180 Nov- Jan; 30 in Jan. 227 cases in 17/18 (Feb YTD) 17% 275,256 0 Monthly 5.95% 96,339 96,339 Monthly For Enfield, this means a 3% increase to 69.4% is required. But trend is downwards for last 4 years. 3% extremely challenging to achieve in a single year. 20/74 within 28 days for Q4. Target missed. Requires partnership approach with LA to meet 28 days. Social Worker available capacity is hindering delivery of challenging target. 8/52 in acute for Q4. 15% target just missed in Q4. Significant improvement compared to Q1-3. Home First team based at hospital is working with the discharge teams. Baseline to be determined by CCGs, but unclear for which period. Published data deemed 'experimental statistics'. BEH didn't make some submissions, including Dec.16 & Jan.17. Hard to understand CCG position. Jan.18 best of recent few months. Target already exceeded by 49. An E Coli action plan is to be agreed. Paper went to Quality & Safety Committee 17/01/18. Local 5 a)ii Reducing gram negative blood stream infections across the whole health economy - Collection and reporting of a core primary care data set for all E coli BSI in Q2-4 2017/18. b)i Reduction of inappropriate antibiotic prescribing for UTI in primary care - Trimethoprim: Nitrofurantoin prescribing ratio b)ii Reduction of inappropriate antibiotic prescribing for UTI in primary care - number of trimethoprim items prescribed to patients aged 70+ c) Sustained reduction of inappropriate prescribing in primary care Collect and report a core primary care data set 1.413 (i.e. 10% reduction on CCG baseline data June15- May16); 58.6% as a percentage 4696 (i.e. 10% reduction on CCG baseline data June15- May16) <= 1.161 antibiotic items per STAR-PU (13/14 England mean) collection not commenced 1.7% 27,526 27,526 TBC 0.765 (Yr to Jan18) 3.825% 61,932 0 Monthly 3857 (Yr to Jan18) 3.825% 61,932 0 Monthly 0.867 (Yr to Jan18) 1.7% 27,526 0 Monthly 6 Number of patients on GP registers diagnosed with Atrial Fibrillation Increase to 3755 3976 (Mar17) 15% 242,873 0 TBC Sub total (achievement) 100% 1,619,150 674,376 944,774 Plan is to agree for a paid individual to undertake on behalf of Enfield, Barnet and Haringey CCGs. Paper went to Quality & Safety Committee 17/01/18. Trend is downwards. 10% reduction achieved already. Ratio now less than 1:1. Medicines Management Team now has access to epact2. 96% of items now prescribed electronically. High volume practices targetted, e.g. messaging on Script Switch. Enfield is significantly below the target value and current England value (1.030). 16/17 QoF data (published 26th. Oct. 2017) shows target has been reached a year early. 18 Week RTT - Incomplete Pathway A&E waits (CCG mapped from HES provider data) Cancer waits - 62- Day Standard (Urgent GP referral to 1st definitive treatment for cancer) Cat A Red 1 ambulance calls (LAS performance) Sub total (penalties) Net Total Constitutional Measures Target Latest Data Weighting Weight Likely Reporting Risk Rating Value Adjustment Frequency 92% 83.8% (Feb 2018) 25% 404,788 25% Monthly Enfield is 8.2% below the standard, due to performance at RFL and UCLH. S&TF/ Op Plans for 17/18 80.3% (Mar 2018) 25% 404,788 25% Monthly Enfield did not achieve this measure in 16/17. Below target every month in 17/18, with lowest performance in March 18. 85% [S&TF/ Op Plans for Enfield did not achieve this measure in 16/17. For 17/18, good 73.3% (Feb 2018) 25% 404,788 25% Monthly 17/18] performance in Dec.17, but deterioration since then. S&TF/ Op Plans for 17/18 73.9% (Oct 2017) 25% 404,788 0% Monthly Awaiting confirmation of NHSE's approach in 17/18, given rollout of new Ambulance Quality Indicators from end-oct.17. 100% 1,619,150 75% 708,581 97 of 255 236,194 * Based on 5 per head of adjusted ONS registered population for 2017 (323830) Enfield CCG 26

Appendix 3 Better Care Fund Dashboard nfield CCG Integarated Care 2017/18 Scorecard Q1 Q2 Q3 Q4 2016/17 Indicator Type Source 2016/17 Target/ Threshold Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD ILT OPAU Number of 'frail or high-risk pre-frail' Category who access MDT approaches in primary care includes the CHAT MDT ASC and Community Health 1421 125 77 90 102 92 72 90 84 74 48 32 761 Percentage of individuals who felt dignity was always ASC and Community respected Health 95% 98% 99% 97% 98% 99% 99% 99% 99% 98% Percentage of individuals who felt involved in their care ASC and Community planning Health 95% 94% 96% 96% 96% 97% 97% 94% 97% 96% Percentage of individuals who thought their care was well ASC and Community co-ordinated Health 95% 100% 97% 100% 97% 100% 97% 100% 91% 97& Planned no. of patients seen in service (Cap) MI Activity 2244 2244 180 180 180 180 180 180 180 180 180 180 180 180 Actual no. of patients seen in service MI Activity 1612 Actuals 114 154 149 152 196 162 205 220 147 211 194 1904 % of patients who had an A&E Attendance and OPAU Attendance on same day MI Activity <4% 5% 0% 1% 1% 1% 1% 0% 0% 0% 0% 2% 2% % of individuals who felt dignity always respected Patient Survey (Quarterly) 100% 95% 100% 100% 100% % extremely likely to use the service again or recommend Patient Survey (Quarterly) it to family and friends. 97% 95% 93% 98% 100% % of deaths in preferred place BEH MHT / Rio 100% 95.0% 97% 95% 98% 98% 100% 100% 100% 100% 98% 100% % of new residents seen within 2 weeks BEH MHT / Rio 87% 90.0% 92% 90% 93% 70% 80% 90% 90% 89% 87% 88% CHAT % of falls going to A&E BEH MHT / Rio 13% 10.0% 13% 8% 12% 10% 11% 18% 12% 15% 7% 7% % of A&E attendances per regsitered bed (CHAT coverage) BEH MHT / Rio 12% 10.0% 8% 13% 7% 6% 6% 7% 7% 7% 9% 9% No. of people with dementia and their carers accessing Community Navigation function Voluntary Sector Providers N/A 250 33 54 39 30 25 38 40 36 26 29 24 374 % of people with dementia and their carers who reported Patient Survey (Quarterly) N/A 95% 92% 98% 100% they are satisfied with their experience of the service Age UK % of people with dementia and their carerswho feel able to Patient Survey (Quarterly) N/A 90% 92% 89% 87% 90% carry out daily activities that are important to them (Started April 2016) No. of people accessing Community Navigation function for Voluntary Sector Providers N/A 250 12 30 16 25 17 22 20 21 163 falls prevention % of older people who were satisfied with falls prevention services Patient Survey (Quarterly) N/A 95% 95% 90% 92% 98% Community Crisis Response Team - % of patients seen within 2 hours of receipt of referral BEH MHT / Rio 91% 95% 100% 97% 89% 88% 100% 100% 100% 99% 86% 92% 99% CCRT Total no. of patients seen by CCRT BEH MHT / Rio 92 50/mth 31 68 50 44 65 47 65% 78 79 104 79 646 No. of patients who had a positive experience of care and treatment Patient Survey (Quarterly) 96% 98% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98% Dementia Diagnosis % on GP registers recorded with dementia aged 65+ Health&Social Care Information Centre 67.5% 67.0% 71.8% 71.9% 71.5% 71.6% 71.6% 71.5% 71.3% 71.5% 71.2% 70.9% 70.9% 98 of 255 * Dashboard Under development More up-to-date information is being pursued from the provider Enfield CCG 27

Appendix 4 - North Middlesex University Hosp. Scorecard North Middlesex University Hospital 2017/18 Scorecard Q1 Q2 Q3 Q4 2017/18 Indicator Type Target/ Threshold 2016/17 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD RTT RTT Incomplete Pathways 92% 95.9% 96.1% 96.5% 95.9% 96.1% 94.4% 94.4% 94.7% 94.3% 93.1% 92.5% 94.8% RTT 52+ week waiters 0 0 0 0 0 0 0 0 0 0 0 0 0 Diagnostics Diagnostics - 6+ week waiters 1% 1.3% 0.9% 0.6% 1.0% 0.6% 0.9% 0.7% 0.6% 0.2% 0.2% 0.6% 0.8% 0.6% A&E 4 Hour Trajectory - - 85.0% 87.0% 89.0% 91.0% 93.0% 92.0% 92.0% 90.0% 90.0% 90.0% 90.0% 95.0% - A&E A&E 4 Hour W aits 95% 82.0% 82.4% 83.9% 82.1% 81.9% 80.3% 85.8% 87.2% 82.0% 72.6% 75.5% 82.4% 76.5% 81.0% A&E 12 Hour Waits 0 25 0 0 0 0 0 2 0 0 0 0 0 0 2 A&E attendance to emergency admission - 18.2% 16.2% 15.8% 15.9% 16.2% 18.8% 20.0% 18.6% 18.5% 17.7% 16.8% 18.8% 16.8% 17.5% DTOCs Delayed Transfers of Care (days) - Trust level - 3927 450 317 403 510 496 302 182 334 254 228 143 3619 Delayed days per occupied beds % 3.5% 2.2% 3.1% 2.1% 2.8% 3.6% 3.5% 2.2% 1.3% 2.5% 1.8% 1.6% 1.1% 2.3% Cancer - 2 2 week wait 93% 94.9% 96.4% 94.1% 93.4% 91.8% 94.6% 94.4% week 2 week wait breast symptomatic 93% 93.7% 98.2% 96.0% 98.5% 87.6% 94.0% 96.7% 31 day 1st definitive treatment 96% 99.1% 97.4% 99.6% 98.6% 100.0% 98.8% Cancer - 31 31 day 1st subsequent treatment - surg. 94% 100.0% 93.3% 100.0% 100.0% 100.0% 98.3% day 31 day 1st subsequent treatment - chemo 98% 100.0% 100.0% 100.0% 86.7% 100.0% 99.2% 31 day 1st subsequent treatment - radio 94% 99.4% 99.4% 100.0% 97.4% 100.0% 99.5% 62 day standard 85% 88.3% 80.5% 79.8% 66.0% 59.0% 78.8% Cancer - 62 day 62 day standard - screening 90% 82.1% 96.3% 82.6% 100.0% 100.0% 89.1% 62 day standard - upgrade No Target 91.4% 88.5% 86.5% 87.0% 92.0% 88.8% Mixed Sex Mixed Sex Accommodation Breaches 0 10 0 0 0 0 0 0 0 0 0 0 0 0 Cancelled Ops for non-clinical reasons Cancelled Ops rebooked >28 days 0 1 1 1 3 *nya 5 Urgent operation cancelled for the 2nd time 0 0 0 0 0 *nya 0 MRSA Reported Cases (Trust assigned) 0 2 0 0 0 1 1 0 0 0 0 0 0 2 HCAI C.Difficile Trajectory 34 (Annual, Trust 3 3 3 3 3 3 3 3 3 3 2 2 32 C.Difficile Reported Cases apportioned) 33 4 2 4 2 2 3 0 1 2 2 8 30 Handover time over 30min of arrival 0 3453 112 179 180 127 140 116 125 90 235 273 194 1771 Ambulance Handover Handover time over 60min of arrival 0 286 1 10 5 7 24 0 2 4 31 92 39 215 % of Data recorded electronically 90% 91% 94% 93% 93% 93% 91% 93% 91% 93% 92% 91% 93% 92% VTE VTE Risk Assessed Admissions 95% 95.2% 95.44% 95.37% 95.1% 95.3% SHMI Summary Level Hospital Mortality Indicator <100 83.6 October 2016 September 2017 (next set of data due to be released in June 2018) - Where trajectories are stated, this is in line with the Trust's Sustainability and Transformation Fund (STF) trajectories as agreed with NHS England. These milestones must be delivered on in order for the provider to be eligible for the funds. Where applicable, performance is rag-rated against the in-month STF trajectory and not against the national target for that standard. 99 of 255 Enfield CCG 28

Appendix 5 - Royal Free London Hosp. Scorecard Royal Free London Foundation Trust 2017/18 Scorecard Q1 Q2 Q3 Q4 2017/18 Indicator Type Target/ Threshold 2016/17 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD RTT RTT Incomplete Pathways 92% 92.0% 92.2% 92.6% 92.2% 92.0% 87.4% 87.4% 86.9% 87.5% 86.7% 83.0% 83.4% 88.4% RTT 52+ week waiters 0 28 0 0 3 2 34 30 37 60 45 34 32 277 Diagnostics Diagnostics - 6+ week waiters 1% 0.6% 0.5% 0.5% 0.5% 0.7% 1.3% 1.6% 1.5% 0.9% 1.0% 0.7% 0.6% 0.9% A&E 4 Hour Trajectory - - 86.6% 87.2% 88.7% 89.6% 89.8% 90.1% 90.3% 91.9% 91.3% 93.8% 94.8% 95.0% - A&E A&E 4 Hour W aits 95% 87.9% 87.6% 90.3% 87.0% 86.1% 88.7% 84.3% 87.0% 87.8% 83.7% 86.1% 86.5% 84.1% 86.6% A&E 12 Hour Waits 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 A&E attendance to emergency admission - 17.5% 17.4% 18.6% 16.8% 16.0% 18.3% 17.8% 18.4% 20.2% 19.3% 16.4% 18.0% 18.0% 17.9% DTOCs Delayed Transfers of Care (days) - Trust level - 11390 1319 895 905 831 899 875 987 811 689 753 392 9356 Delayed days per occupied beds % 3.5% 3.5% 4.8% 3.1% 3.5% 3.3% 3.0% 3.3% 3.4% 2.9% 2.4% 2.6% 1.5% 3.1% Cancer - 2 2 week wait 93% 93.6% 93.3% 93.4% 92.2% 93.0% 93.4% week 2 week wait breast symptomatic 93% 92.5% 93.8% 95.1% 93.2% 95.5% 93.8% 31 day 1st definitive treatment 96% 97.5% 96.8% 98.6% 99.1% 98.5% 97.9% Cancer - 31 31 day 1st subsequent treatment - surg. 94% 98.4% 96.0% 98.5% 96.9% 95.7% 97.4% day 31 day 1st subsequent treatment - chemo 98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 31 day 1st subsequent treatment - radio 94% 100.0% 100.0% 100.0% 100.0% 97.1% 99.8% 62 day standard Trajectory 83.6% 84.0% 80.6% 85.1% 85.8% 85.6% 85.7% 85.8% 86.0% 85.7% 85.7% 86.0% - Cancer - 62 62 day standard 85% 83.7% 79.6% 85.2% 84.5% 85.0% 83.1% day 62 day standard - screening 90% 90.4% 96.3% 89.2% 96.8% 94.4% 92.8% 62 day standard - upgrade No Target 86.4% 88.1% 91.1% 90.8% 90.8% 89.1% Mixed Sex Mixed Sex Accommodation Breaches 0 260 24 22 40 42 32 33 41 30 33 45 39 381 Cancelled Ops for non-clinical reasons rebooked Cancelled Ops >28 days 0 28 9 23 3 *nya 35 Urgent operation cancelled for the 2nd time 0 0 0 0 0 *nya 0 MRSA Reported Cases (Trust assigned) 0 4 1 1 0 0 0 0 0 1 0 1 0 4 HCAI C.Difficile Trajectory 66 (Annual, Trust 6 6 5 6 5 5 6 6 5 6 5 5 61 C.Difficile Reported Cases apportioned) 70 4 5 9 9 5 8 7 7 8 4 9 75 Handover time over 30min of arrival - Barnet 258 198 202 259 161 267 255 100 277 268 212 2457 Handover time over 60min of arrival - Barnet 129 30 99 65 37 148 102 17 101 118 41 887 Ambulance % of Data recorded electronically - Barnet 97% 95% 95% 95% 94% 95% 96% 97% 95% 95% 95% 95% Handover Handover time over 30min of arrival - Royal Free 0 195 172 183 199 128 161 131 156 166 179 138 1808 Handover time over 60min of arrival - Royal Free 0 73 87 102 137 65 95 99 132 105 73 45 1013 % of Data recorded electronically - Royal Free 90% 88% 87% 86% 87% 89% 89% 89% 88% 86% 89% 90% 88% VTE VTE Risk Assessed Admissions 95% 96.6% 96.58% 95.66% 95.9% 96.0% SHMI Summary Level Hospital Mortality Indicator <100 86.8 October 2016 September 2017 (next set of data due to be released in June 2018) - Where trajectories are stated, this is in line with the Trust's Sustainability and Transformation Fund (STF) trajectories as agreed with NHS England. These milestones must be delivered on in order for the provider to be eligible for the funds. Where applicable, performance is rag-rated against the in-month STF trajectory and not against the national target for that standard. 100 of 255 *nya - not yet available Enfield CCG 29

Appendix 6 MRSA & C Difficile Infections NC & E London Providers NB. Trajectories for 2017-18 are Zero for MRSA. This data has been extracted from un-validated weekly HCAI Data. This is only available to NHS and certain other eligible bodies for HCAI reporting and monitoring purposes. Please prevent inappropriate use by treating this information as restricted; 101 refrain of 255 from passing information on to others who have not been given prior access; and use it only for the purposes for which it has been provided. Enfield CCG 30

Appendix 7 - C Difficile Infections London CCGs Sector CCG Name Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 NCL Barnet 7 10 8 9 8 9 9 6 7 8 8 8 9 99 NCL Enfield 2 9 3 4 7 3 8 8 7 5 11 3 10 78 NCL Camden 8 5 3 5 8 10 5 8 4 4 6 5 5 68 NCL Islington 4 4 3 7 5 7 5 4 8 2 4 6 10 65 NCL Haringey 0 3 6 5 6 3 8 3 4 2 3 1 12 56 NEL Tow er Hamlets 1 7 5 4 6 5 3 4 3 7 4 4 4 56 NEL Waltham Forest 3 4 5 5 3 5 2 1 3 6 1 6 2 43 NEL Havering 1 4 3 4 3 7 5 3 4 3 1 2 2 41 NEL Redbridge 4 5 1 6 3 1 5 3 6 1 2 2 3 38 NEL New ham 5 1 5 3 2 8 4 1 0 5 2 3 2 36 NEL City and Hackney 2 3 1 2 1 3 4 3 1 3 1 4 2 28 NEL Barking and Dagenham 2 0 2 1 1 1 1 1 1 1 2 1 0 12 NWL Ealing 3 9 4 6 5 8 3 10 16 6 8 4 2 81 NWL Brent 4 7 6 4 1 8 6 8 6 4 6 5 5 66 NWL West London 3 10 2 1 7 5 4 4 6 5 8 3 7 62 NWL Hillingdon 1 9 7 2 4 0 4 4 7 8 5 4 5 59 NWL Central London (Westminster) 1 3 3 4 9 5 3 2 3 4 3 6 4 49 NWL Hounslow 3 9 5 7 1 5 3 6 2 4 1 0 3 46 NWL Harrow 5 3 3 6 3 8 3 3 4 4 2 2 0 41 NWL Hammersmith and Fulham 1 4 3 3 0 2 3 4 6 5 3 3 3 39 SEL Bromley 4 8 4 4 7 8 11 9 4 6 8 6 2 77 SEL Southw ark 3 4 1 1 7 7 5 6 5 3 2 6 7 54 SEL Bexley 5 6 3 5 5 5 3 2 5 1 2 4 3 44 SEL Lambeth 3 6 4 5 2 4 6 3 3 2 3 2 4 44 SEL Greenw ich 1 5 6 3 4 6 1 5 2 1 1 2 1 37 SEL Lew isham 3 2 1 2 7 0 2 2 4 4 3 4 4 35 SWL Croydon 3 2 4 7 7 9 4 2 8 3 4 3 5 58 SWL Wandsw orth 2 3 3 1 2 1 6 6 7 3 6 3 8 49 SWL Sutton 1 4 0 2 2 1 4 2 4 2 6 1 4 32 SWL Kingston 2 1 2 0 0 3 7 3 3 1 1 4 4 29 SWL Richmond 2 5 3 5 1 2 2 1 2 2 2 2 1 28 SWL Merton 3 2 3 3 2 1 3 2 4 2 0 1 2 25 Monthly count of C. difficile infections for patients aged 2 years and over by CCG. Publication date: 4 th 102 of 255 April 2018 Source: Public Health England 12 Month rolling total Enfield CCG 31

Agenda Item: 8.1 MEETING: Governing Body Meeting in Public DATE: Wednesday 23 May 2018 TITLE: Finance and Performance Committee Report LEAD GOVERNING Simon Goodwin, Chief Finance Officer BODY MEMBER: AUTHOR & POSITION: Arati Das, Deputy Director of Finance CONTACT DETAILS: arati.das@nhs.net SUMMARY: The purpose of this report is to summarise the key matters discussed by the Finance and Performance Committee at its meetings on 28 March and 25 April 2018 respectively. 28 March 2018 Month 11 Finance and Contracts Report The Committee noted the Month 9 Finance and Contracts report and the reported financial position. The CCG is reporting a forecast outturn (FOT) of 5.8m deficit against a planned surplus of 2.1m. Based on the current known risk there is continued risk of missing the control total by a further 3.3m. The Committee were informed that financial risk levels had been maintained at 3.3m in anticipation of some forthcoming support, although quantum unknown at this stage. Quality, Innovation, Productivity and Prevention (QIPP) Report The Committee received a report setting out a 7.2m shortfall on the required efficiencies for 2017-18. The 2018-19 QIPP plan was also shared with members being asked to note an inherent risk of around 8.5m. Integrated Performance and Quality Report The Committee reviewed the report for March 2018 noting the actions and progress made to deliver national and local priorities. The risks relating to Accident & Emergency, Cancer Waiting Times, and Referral to Treatment (RTT) and London Ambulance Service (LAS) Response times and Emergency waiting times continue to be monitored closely. Business Cases Last Phase of Life - Part of the Sustainability Transformation Plan (STP) Urgent & Emergency Programme was presented. The Committee requested further clarity and assurance of the proposed services contained in the business case. 25 April 2018 Month 12 Finance and Contracts Report Annual Accounts The Committee received an update report on the Month 12 Finance and Contracts report setting out an in year deficit of 3.4m ( 5.5m adrift from 2.1 surplus control total) and cumulative deficit of 40.6m. This was an improved movement from the Forecast Outturn (FOT) of 5.8m as reported in month 11. 2018/19 Plan Update The Committee reviewed a revised financial plan 2018/19 which highlighted the risks associated with the previously submitted balanced plan in March. The next submission to NHSE would be on 30 th April. 103 of 255

2018/19 Contract Update The Chief Finance Officer updated the Committee that the Accountable Officer and he had attended a meeting with NHSE. There would be ongoing discussions with an update being provided at the earliest opportunity on next steps for the contracting negotiations process. QIPP 2017/18 and QIPP Report Assurance & 2018/19 QIPP Plan The Committee noted that as of month 12, the CCG is reporting a negative outturn variance on QIPP of 7.12m which is a slight improvement since M11 of ~ 130k. All potential mitigations have been built into the CCG year-end position. The 18/19 QIPP Plan had to allow for the 7.12m shortfall in 17/18 resulting in a net requirement of 23.8m. Integrated Performance and Quality Report April 2018 The Committee reviewed the report for April 2018 noting the actions and progress made to deliver national and local priorities and receive assurance on actions being taken by respective directorates to address areas of underperformance. SUPPORTING PAPERS: None. RECOMMENDED ACTION: The Governing Body is asked to NOTE the report and seek clarifications as necessary. Objective(s) / Plans supported by this paper: To ensure a robust system of Financial Governance is in place. Patient and Public Involvement (PPI): N/A. Equality Impact Analysis: N/A. Risks: Specific risks are identified in Finance and Performance Committee papers. Resource Implications: There are no specific resource implications. Audit Trail: The Finance and Performance Committee is accountable to the Governing Body. Next Steps: None. 104 of 255

Agenda Item: 8.2 MEETING: Governing Body Meeting in Public DATE: Wednesday 23 May 2018 TITLE: Procurement Committee Report from meeting held on 11 April and 9 May 2018 LEAD GOVERNING Karen Trew, Procurement Committee Chair BODY MEMBER: AUTHOR & POSITION: Graham MacDougall, Director of Commissioning CONTACT DETAILS: g.macdougall@nhs.net SUMMARY: The purpose of this paper is to outline matters discussed by the Procurement Committee at its meeting held on 11 April and the draft agenda items for 9 May 2018 respectively. Summary of key matters discussed on 11 April 2018 1. Register of Procurement Decisions: The Committee approved one decision for addition to the Register as set out below details of which can be found on the CCG Web Site: http://www.enfieldccg.nhs.uk/about-us/expenditure-over-25k.htm 2. Contract Governance: It was highlighted that 2018/19 contracts will be reviewed to ensure they are shown once agreed. The Committee noted that new dates and values will be added to MIND and RSM contracts. The Committee noted details of the 2017/18 contracts and annual value details of which are published on the CCG s website: http://www.enfieldccg.nhs.uk/about-us/expenditure-over-25k.htm 3. Workplan The Committee was informed that a paper for Scriptswitch would be taken to the May s Procurement Committee and that a paper in reference to My Support Broker will be shared with the Finance and Performance Committee. It was suggested mapping the Workplan at the Directors meeting. The Chief Operating Officer will work with the Head of Acute Contracting to take this forward. 4. Post Diagnostic Support for People with Dementia and Falls Prevention The Committee received a report relating to the current contract with Age UK to provide post-diagnostic support for people with dementia and their carers, and fall prevention for older people. The intention is to work with the voluntary sector to develop a multi agency voluntary sector hub as part of the locality-based offer in primary care management to provide advice, information, navigation and support for frail and older people. The Committee approved the waiver for 2018/19 that allowed a procurement exercise to take place for 2019/20 and approved the extension of current contract with Age UK to allow for a short procurement exercise. 5. North Central London Any Qualified Provider Termination of Pregnancy Services 105 of 255

The Committee received a report which provided recommendations of the award of two contracts. The first contract is for the provision of clinical Termination of Pregnancy Services (TOPS). The contract will be an Any Qualified Provider (AQP) contract. The second contract is for the provision of a shared central booking service, which will be provided through a block contract. The Procurement Committee noted that it will be a collaborative procurement between the five Boroughs in North Central London (NCL) and recommended the award of contract for the shared Central Booking Service (CBS) service to British Pregnancy Advisory Service (BPAS). The Committee reviewed and moderated on the analysis and evaluation of the new tariff reconfiguration and implementation of these only if this results in no further cost to the CCGs. 6. Any Qualified Provider (AQP) Contract Management Policy The Committee considered the Any Qualified Provider (APQ) Contract Management Policy. It was agreed to include as an agenda item to the Senior Management Team meeting. 7. Medicines Management Locally Commissioned Service Specification The Committee reviewed the service specification which set out the Medicines Management Locally Commissioning Service (LCS) for 2018/19. The Committee considered whether the scheme should be aligned to the practices and various Care Closer to Home Integrated Networks (CHINS). Whilst the Committee approved the scheme, it was agreed that the Medicines Management Committee would be asked to review the 2019/20 development of the scheme. 8. Dermatology North Middlesex University Hospital (NMUH) A verbal update was given on the NMUH dermatology service. NMUH had given notice on the contract with Concordia but have been asked to retract the notice or form a partnership with Royal Free London (RFL). Feedback received from a recent Senior Management Team meeting was that NMUH have agreed to continue with the contract. 9. SMS Text Messaging Service Re-procurement for General Practice The Committee received an update on the GPIT Operating Model which requires CCGs to commission an electronic messaging functionality i.e. Short Message Solution (SMS) messaging, for direct unidirectional individual patient communication, to be utilised for clinical and associated administrative purposes. The Committee noted the content of the report and approved the procurement timetable which is modelled to commence from 1 st July 2018. 10. Primary Care Extended Access The Committee received the Primary Care Extended Access 12 month evaluation paper which had previously had virtually approval. The evaluation concluded that Enfield s service has been one of the leading successes during 2017/18, is the highest utilised service within the NCL footprint, and one of the most utilised across all 32 London CCGs. To build on this success for 2018/19, the report identified a number of service improvement recommendations. Disappointment was noted that there is little evidence to demonstrate that patients presenting at emergency services are being signposted/redirected to local primary care services. The Committee received clarity that the service would consider development of a jointly agreed pathway that enables repatriation of patients. 11. Anti-Coagulation Service Specification The Committee noted the service specification report which was produced to fit in line with the Enfield Single Offer, it is based upon the current Anti-Coagulation Service which 106 of 255

sees stable Patients discharged from secondary care and monitored within a local primary care setting. The Committee approved in principle the use of this service specification for inclusion in the Enfield Single Offer pending review from the Clinical Working Reference Group (CRWG) and Finance & Performance Committee. Summary of key matters discussed on 9 May 2018 1. Register of Procurement Decisions The Committee approved four decisions and one waiver for addition to the Register as set out below, details of which can be found on the CCG web site: http://www.enfieldccg.nhs.uk/about-us/expenditure-over-25k.htm 2. Contract Governance It was highlighted 2018/19 contracts will be reviewed to ensure they are shown once agreed. The Committee noted details of the 2017/18 and 2018/19 contracts and annual value details of which are published on the CCG s website: http://www.enfieldccg.nhs.uk/about-us/expenditure-over-25k.htm 3. Workplan: The Committee accepted the identification of contracts by Director. This will be discussed at the Directors meeting and each Director asked to produce a timeline for contract due for renewal in 2018/19. 4. General Practice Prescribing Support software The Committee received a report relating to the current contract for prescribing support software with Scriptswitch and approved the procurement of the service under the framework. 5. SMS Text Messaging Service The Committee received a report which provided recommendation of the award of the contract. The contract is for the provision of the Patient Communication SMS for General Practice. The Committee supported the recommendation to award the contract to IPlato Healthcare Limited for 5 years. 6. Dermatology North Middlesex University Hospital A verbal update was given on the NMUH Dermatology service. NMUH had given notice on the contract with Concordia but have been asked to retract the notice or form a partnership with the RFL. Feedback from the Trust is that they continue providing the service. 7. Primary Care Extended Access The Committee received a paper on the Primary Care Extended Access and asked that a full business case be developed to be presented at Finance & Performance Committee. 8. Patient transport services The Committee received a paper on ad-hoc Patient Transport Services. This follows the withdrawal of London Ambulance Service as a provider. The Committee agreed to the recommendation to use alternative providers on the NHS London Procurement Partnership framework. 9. CHC Support Personal Budget Systems 107 of 255

The Committee received a paper on Personal Budget Systems and accepted the recommendation that the current provider is extended for six months to allow for a due diligence exercise to be carried out on a provider from the framework. SUPPORTING PAPERS: None RECOMMENDED ACTION: The Governing Body is asked to note the summary of items discussed at the Procurement Committee meetings held on 11 April and 9 May 2018. Objective(s) / Plans supported by this paper: The Procurement Committee supports delivery of Enfield CCG Corporate Objectives. Patient and Public Engagement (PPE): Engagement with patients and the public takes place when designing services ahead of the Committee approving a specification. Equality Impact Analysis: This is conducted in line with the procurement process. Risks: As outlined in the CCG s Assurance Framework and Risk Register. Resource Implications: These will have been part of proposals approved by the Finance and Performance Committee. Audit Trail: None. 108 of 255

MEETING: Governing Body Meeting in Public DATE: Wednesday 23 May 2018 TITLE: LEAD GOVERNING BODY MEMBER: Patient and Public Engagement (PPE) Committee Report Agenda Item: 8.3 Teri Okoro, Governing Body Lay member for Patient and Public Engagement & Deborah McBeal, Deputy Chief Officer and Director of Primary Care Commissioning AUTHOR & POSITION: Gail Hawksworth, Head of Communications and Engagement CONTACT DETAILS: Summary: gailhawksworth@nhs.net This Patient and Public Engagement (PPE) report provides a summary of the PPE Committee s meeting held on 3 May 2018. The Committee approved the minutes of the meetings 11 January and 8 March 2018. The Committee reviewed and commented on the: Equality Delivery System Grading (EDS2) Grading Goals One (Better health outcomes for all) and Two (Improved patient access and experience) in relation to Mental Health- The redesign of the Complex Care Rehabilitation Pathway and Primary Care The identification and Referral to Improve Safety (IRIS) Service (Domestic Violence). Both presentations provided details of: How patient centred care was being delivered Key outcomes Monitoring of the key performance indicators Patient satisfaction Future developments Members were asked to provide their comments and grading scores on these and the End of Life Care- Care Home Assessment Team presentation pack by 18 May 2018. Annual Report and Accounts 2017-2018 section - Draft text on Engaging People and Communities; members asked that the establishment of a Patient Reference Group be added as an action for 2018/2019. Members were also asked to send any further comments to the Head of Communications and Engagement by 10 May 2018. Staff Survey Actions - Members noted the work being carried out following the review of the Staff Survey 2017 results, which included the setting up of an organisational development group that devised an action plan based on themes that staff voted as their priorities; a new CCG Health and wellbeing lead; Staff Forum established in December 2017 and a new Health, Safety, Wellbeing Strategy plan for Enfield CCG. Members looked forward to seeing an improvement in the findings of the Staff Survey for 2018. 360 Degree Stakeholder Survey 2018 - Enfield CCG has shown improvement in 109 of 255

many areas compared to the 2017 results, particularly in: Effective working relationship: 69% ( 13%) Involving the right individuals and organisations when commissioning/decommissioning services: 49% ( 13%) Confidence in leadership of the CCG to deliver improved outcomes for patients: 44 % ( 8%) Confidence in leadership of the CCG to deliver its plan and priorities: 47% ( 7%) The leadership has the necessary blend of skills and experience: 47 % ( 7%) Effectiveness of the CCG as a local system leader: 60% ( 7%) Stakeholder comments received and considered: 38% ( 7%) Members noted that although there had been improvements, that Enfield CCG scores were still below the cluster, the group of CCGs that are most similar to the CCG based on several population characteristics; concerns were expressed that the Health and Wellbeing Board stakeholders did not complete the survey and that only 21% of member practices felt that they had been able to influence the CCG s decisionmaking process. The Improvement Action Plan that will be developed will incorporate the actions to be taken as a result of the findings of the 360 stakeholder survey and Improvement Assessment Framework. General Data protection Regulations - Members noted that all stakeholders would have to be contacted to ask for their explicit consent for the CCG to continue to send information/newsletters. Supporting Papers: Appendix A 360 Degree Stakeholder Survey 2018 Main Report. Recommended action: The Governing Body is asked to note this report and to support the ongoing work of the PPE Committee. Objective(s)/Plans supported by this paper: This paper supports the Enfield Clinical Commissioning Group s (CCG) communications and engagement plan and the equality and diversity plan, both of which the PPE Committee is responsible for delivering and monitoring. Audit Trail: This paper is a summary of 3 May 2018 PPE Committee meeting. It is a regular Governing Body report. Patient & Public Involvement (PPI): Enfield CCG s PPE Committee takes a strategic lead in embedding patient and public involvement at all levels within the CCG and planning how the organisation can best achieve this through continuous development and review of the PPE work programme. 110 of 255

Equality Impact Analysis: The PPE committee is responsible for ensuring the CCG is working to fulfil both its statutory obligations under the Equality Act 2010 and embed patient and public involvement in the CCG. The EDS2 Task and Finish Group reviews the implementation of the EDS2 Action plan. This group reports to the PPE Committee. Risks: The risk identified by the PPE Committee is recorded on the risk register as risk number 345 - CCG does not fully engage stakeholders, patients and residents in commissioning and service improvement. Resource Implications: Not applicable. Next Steps: The 360 Degree Stakeholder Survey Public Report will be sent to all our stakeholders, week commencing 21 May 2018, including PPG members and members of the Voluntary & Community Stakeholder Reference Group. Development of the Improvement Action plan will start mid-june; Enfield CCG Improvement Action Plan will also incorporate the actions to be taken from Enfield CCG Improvement Assessment Framework assessment carried out by NHS England. 111 of 255

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Enfield CCG CCG 360 o Stakeholder Survey 2017-18 Findings 113 of 255 CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 1

Table of contents Slide 3 Slide 6 Slide 7 Slide 8 Slide 10 Slide 11 Slide 13 Slide 36 Slide 40 Slide 43 Slide 55 Slide 62 Summary Introduction Background and objectives Methodology and technical details Interpreting the results Using the results Combined stakeholder findings Upper tier and unitary local authorities Healthwatch and voluntary/patient groups GP member practices NHS providers Appendix CCG cluster 114 of 255 CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 2

Summary 115 of 255 CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 3

Summary This report presents the results from Enfield CCG s 360 Stakeholder Survey 2017-18. The annual CCG 360 Stakeholder Survey, which has been conducted online and by telephone since 2014, allows a range of key stakeholders to provide feedback on working relationships with their CCG. The results are used to support CCGs ongoing development and feed into improvement and assessment conversations with NHS England. The following chart presents the summary findings across the CCG for the questions asked of all stakeholders. This provides the percentage of stakeholders responding positively to the key questions, including year-on-year comparisons where the question was also asked in 2017 and 2016. Base = all stakeholders except CQC (2018; 45, 2017; 45, 2016; 46) unless otherwise stated Overall Engagement 2018 2017 2016 Overall, how would you rate the effectiveness of your working relationship with the CCG? 69% 56% 63% % very/fairly good How satisfied or dissatisfied are you with how the CCG involves patients and the public?* 53% - - % very/fairly satisfied Commissioning services 2018 2017 2016 The CCG involves the right individuals and organisations when commissioning/decommissioning services The CCG provides adequate information to explain the reasons for the decisions it makes when commissioning/decommissioning services % strongly/tend to agree % strongly/tend to agree 49% 36% 35% 51% - - I have confidence the CCG s plans will deliver high quality services that demonstrate value for money 44% - - % strongly/tend to agree I have confidence in the CCG to commission/decommission services appropriately % strongly/tend to agree 47% - - The CCG demonstrates it has considered the views of patients and the public when making commissioning decisions* 36% - - % strongly/tend to agree Enfield CCG 116 of 255 *Base = all stakeholders (2018; 45, 2017; 45, 2016; 46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Fieldwork: 15th January - 28th February 4

Summary cont. Leadership of the CCG 2018 2017 2016 How effective, if at all, do you feel your CCG is as a local system leader? 60% 53% 48% The leadership of the CCG has the necessary blend of skills and experience* 47% 40% 43% There is clear and visible leadership of the CCG* 47% 49% 50% I have confidence in the leadership of the CCG to deliver its plans and priorities* 47% 40% 37% The leadership of CCG is delivering high quality services within the available resources* 40% - - I have confidence in the leadership of the CCG to deliver improved outcomes for patients* 44% 36% 37% % strongly/tend to agree The leadership of the CCG is contributing effectively to local partnership arrangements (including Sustainability Transformation Partnerships (STPs), Accountable Care Systems (ACSs) where 44% - - applicable and/or other local partnership arrangements)* % strongly/tend to agree I have confidence that the CCG monitors the quality of the services it commissions in an effective manner If I had concerns about the quality of local services I would feel able to raise my concerns within the CCG % very/fairly effective % strongly/tend to agree % strongly/tend to agree % strongly/tend to agree % strongly/tend to agree Monitoring and reviewing services 2018 2017 2016 % strongly/tend to agree % strongly/tend to agree 53% 51% 52% 78% 76% 72% I have confidence in the CCG to act on feedback it receives about the quality of services 51% 49% 48% % strongly/tend to agree Plans and priorities 2018 2017 2016 How much would you say you know about the CCG s plans and priorities? % a great deal/fair amount 76% 76% 67% I have been given the opportunity to influence the CCG s plans and priorities 42% 38% 46% % strongly/tend to agree When I have commented on the CCG s plans and priorities I feel that my comments have been considered (even if the CCG has not been able to act on them) % strongly/tend to agree 38% 31% 39% The CCG has effectively communicated its plans and priorities to me 44% 58% 43% % strongly/tend to agree Enfield CCG 117 of 255 Base = all stakeholders except CQC (2018; 45, 2017; 45, 2016; 46) unless otherwise stated CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Fieldwork: 15th January - 28th February 5

Introduction 118 of 255 CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 6

Background and objectives Clinical Commissioning Groups (CCGs) need to have strong relationships with a range of stakeholders in order to be successful commissioners within their local health and care systems. These relationships provide CCGs with valuable intelligence to help them make the effective commissioning decisions for their local populations. The CCG 360 o Stakeholder Survey enables stakeholders to provide feedback about their CCGs. The results of the survey serve two purposes: 1. To provide a wealth of data for CCGs to help with their ongoing organisational development, supporting them to build strong and productive relationships with stakeholders. The findings can provide a valuable tool for all CCGs to evaluate their progress, and inform the way that they work and make decisions. 2. To help NHS England to assess CCGs stakeholder relationships and leadership within their local health and care systems, and how effectively they commission services to improve service quality and health outcomes. 119 of 255 Enfield CCG CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 7

Methodology and technical details It was the responsibility of each CCG to provide the list of stakeholders to invite to take part in the CCG 360 o stakeholder survey. CCGs were provided with a specification of core stakeholder organisations to be included in their stakeholder list. Beyond this, however, CCGs had the flexibility to determine which individual within each organisation was the most appropriate to nominate. CCGs were also given the opportunity to add up to ten additional stakeholders they wanted to include locally (they are referred to in this report as wider stakeholders ). These included: Commissioning Support Units, Health Education England, lower tier local authorities, MPs, private providers, Public Health England, local care homes, GP out-of-hours providers and others. Stakeholders were sent an email inviting them to complete the survey online. Stakeholders who did not respond to the email invitation, and stakeholders for whom an email address was not provided, were telephoned by an Ipsos MORI interviewer who encouraged response and offered the opportunity to complete the survey by telephone. 120 of 255 Enfield CCG CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 8

Methodology and technical details Within the survey, stakeholders were asked a series of questions about their working relationship with the CCG. In addition, to reflect each core stakeholder group s different area of expertise and knowledge, they were presented with a short section of questions specific to the stakeholder group they represented. Fieldwork was conducted between 15 th January and 28 th February. 45 of the CCG s stakeholders completed the survey. The overall response rate was 57%, which varied across the stakeholder groups as shown in the table opposite. Survey response rates for Enfield CCG Stakeholder group GP member practices One from every member practice* Health and wellbeing boards Up to two per HWB* Local Healthwatch/voluntary patient groups Up to three per local Healthwatch* NHS providers Up to two from each acute, mental health and community health providers* Invited to take part in survey Completed survey Response rate 47 29 62% 2 0 0% 8 6 75% 6 2 33% Other CCGs Up to five* 6 2 33% Upper tier or unitary local authorities Up to five per LA* 5 3 60% Wider stakeholders 5 3 60% *Specification from the core stakeholder 121 of 255 framework Enfield CCG CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 9

Interpreting the results For each question, the response to each answer is presented as both a percentage (%) and as a number (n). The total number of stakeholders who answered each question (the base size) is also stated at the bottom of each chart and in every table. For questions with fewer than 30 stakeholders answering, we strongly recommend that you look at the number of stakeholders giving each response rather than the percentage, as the percentage can be misleading when based on so few stakeholders. This report presents the results from Enfield CCG s stakeholder survey. Throughout the report, the CCG/your CCG refers to Enfield CCG. Where results do not sum to 100%, or where individual responses (e.g. tend to agree; strongly agree) do not sum to combined responses (e.g. strongly/tend to agree) this is due to rounding. 122 of 255 Enfield CCG CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 10

Using the results the reports This report contains a summary section, a section on overall views of relationships and a section for each of the main stakeholder groups who were invited to complete the survey. The overall summary slides show the results at CCG level for the questions asked of all stakeholders (i.e. only those in section 1 of the questionnaire). This provides CCGs with an at a glance visual summary of the results for the key questions, including direction of travel comparisons where appropriate. The stakeholder specific sections of the report contain those questions which were targeted at individual groups of stakeholders only. These questions were often around specific issues which were only relevant to the specific group of stakeholders. The remainder of the report shows the results for all questions in the survey including any local questions where CCGs included them. The results for each question are provided at CCG level with a breakdown also shown for each of the core stakeholder groups where relevant. This allows CCGs to interrogate the data in more detail. 123 of 255 Enfield CCG CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 11

Using the results comparisons The comparisons are included to provide an indication of differences only and should be treated with caution due to the low numbers of respondents and differences in stakeholder lists. Any differences are not necessarily statistically significant differences; a higher score than the cluster average does not always equate to better performance, and a higher score than in 2017 does not necessarily mean the CCG has improved. The comparisons offer a starting point to inform wider discussions about the CCG s ongoing organisational development and its relationships with stakeholders. For example, they may indicate areas in which stakeholders think the CCG is performing relatively less well, for the CCG to discuss internally and externally to identify what improvements can be made in this area, if any. 124 of 255 Enfield CCG CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 12

Combined stakeholder findings 125 of 255 CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 13

Overall, how would you rate the effectiveness of your working relationship with the CCG? All stakeholders 2 2 4 4% 4%4% 11 24% By stakeholder group Stakeholder group No. of respondents Very good/ Fairly good Fairly poor/ Very poor GP member practices 29 69% (20) 10% (3) 8 18% Health & wellbeing boards 0 - - Healthwatch and voluntary/patient groups 6 83% (5) - CCG change across time 44% Very good Fairly good Neither good nor poor 20 Fairly poor Very poor I/We do not have a working relationship with CCG Don't know Percentage of stakeholders saying very good/fairly good NHS providers 2 - - Other CCGs 2 100% (2) - Upper tier/unitary LA 3 100% (3) - Wider stakeholders 3 33% (1) 33% (1) Regional and cluster comparisons Percentage of stakeholders saying very good/fairly good 63% 56% 69% CCG 2018 National Cluster* DCO** 69% 76% 78% 78% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics.. 126 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 14

To what extent do you agree or disagree with the following statements about the way in which the CCG commissions/decommissions services? The CCG involves the right individuals and organisations when commissioning/decommissioning services All stakeholders 6 13% 6 13% 13% 6 By stakeholder group Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 48% (14) 21% (6) Health & wellbeing boards 0 - - 5 11% 13% 36% 16 Healthwatch and voluntary/patient groups 6 50% (3) 33% (2) NHS providers 2-50% (1) Other CCGs 2 100% (2) - 6 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Upper tier/unitary LA 3 100% (3) - Wider stakeholders 3-67% (2) CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree 35% 36% 49% CCG 2018 National Cluster* DCO** 49% 57% 62% 61% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics. 127 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 15

To what extent do you agree or disagree with the following statements about the way in which the CCG commissions/decommissions services? The CCG provides adequate information to explain the reasons for the decisions it makes when commissioning/decommissioning services All stakeholders 7 1 16% 2% 16% 7 By stakeholder group Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 52% (15) 24% (7) 7 16% 16% 36% 16 Health & wellbeing boards 0 - - Healthwatch and voluntary/patient groups 6 50% (3) 50% (3) NHS providers 2 50% (1) - Other CCGs 2 100% (2) - 7 Upper tier/unitary LA 3 67% (2) 33% (1) Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Wider stakeholders 3-100% (3) CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree There is no trend data available for this question, as it was asked for the first time in 2018. CCG 2018 National Cluster* DCO** 51% 55% 58% 59% CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics. 128 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 16

To what extent do you agree or disagree with the following statements about the way in which the CCG commissions/decommissions services? I have confidence the CCG s plans will deliver high quality services that demonstrate value for money All stakeholders 6 1 13% 2% 13% 6 By stakeholder group Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 41% (12) 17% (5) 6 13% Health & wellbeing boards 0 - - 27% 31% 14 Healthwatch and voluntary/patient groups 6 50% (3) 33% (2) NHS providers 2-100% (2) Other CCGs 2 100% (2) - 12 Upper tier/unitary LA 3 100% (3) - Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Wider stakeholders 3-100% (3) CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree There is no trend data available for this question, as it was asked for the first time in 2018. CCG 2018 National Cluster* DCO** 44% 59% 65% 65% CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics.. 129 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 17

To what extent do you agree or disagree with the following statements about the way in which the CCG commissions/decommissions services? I have confidence in the CCG to commission/decommission services appropriately All stakeholders By stakeholder group 8 18% 5 11% 16% 7 Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 48% (14) 21% (6) Health & wellbeing boards 0 - - 24% 31% 14 Healthwatch and voluntary/patient groups 6 50% (3) 50% (3) NHS providers 2-100% (2) Other CCGs 2 100% (2) - 11 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Upper tier/unitary LA 3 67% (2) - Wider stakeholders 3-67% (2) Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree There is no trend data available for this question, as it was asked for the first time in 2018. CCG 2018 National Cluster* DCO** 47% 60% 66% 65% CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics.. 130 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 18

To what extent do you agree or disagree with the following statements about the leadership of the CCG? The leadership of the CCG has the necessary blend of skills and experience All stakeholders 3 3 7% 7% 7 16% 2 4% 42% 19 By stakeholder group Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 45% (13) 17% (5) Health & wellbeing boards 0 - - Healthwatch and voluntary/patient groups 6 50% (3) 17% (1) 24% NHS providers 2 - - Other CCGs 2 100% (2) - 11 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Upper tier/unitary LA 3 100% (3) - Wider stakeholders 3 - - CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree 43% 40% 47% CCG 2018 National Cluster* DCO** 47% 59% 66% 66% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7884), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics. 131 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 19

To what extent do you agree or disagree with the following statements about the overall leadership of the CCG? There is clear and visible leadership of the CCG All stakeholders 5 11% 4 1 9% 2% 11% 5 By stakeholder group Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 52% (15) 17% (5) Health & wellbeing boards 0 - - 31% 36% 16 Healthwatch and voluntary/patient groups 6 50% (3) 17% (1) NHS providers 2-50% (1) 14 Other CCGs 2 100% (2) - Upper tier/unitary LA 3 33% (1) - Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Wider stakeholders 3-67% (2) CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree 50% 49% 47% CCG 2018 National Cluster* DCO** 47% 69% 74% 69% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7884), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics.. 132 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 20

To what extent do you agree or disagree with the following statements about the clinical leadership of the CCG? I have confidence in the leadership of the CCG to deliver its plans and priorities All stakeholders 4 9% 4 1 9% 2% 13% 6 By stakeholder group Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 45% (13) 17% (5) Health & wellbeing boards 0 - - 33% 33% 15 Healthwatch and voluntary/patient groups 6 50% (3) 17% (1) NHS providers 2-50% (1) 15 Other CCGs 2 100% (2) - Upper tier/unitary LA 3 100% (3) - Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Wider stakeholders 3-33% (1) CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree 37% 40% 47% CCG 2018 National Cluster* DCO** 47% 62% 69% 70% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7884), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics.. 133 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 21

To what extent do you agree or disagree with the following statements about the leadership of the CCG? The leadership of the CCG is delivering high quality services within the available resources All stakeholders 7 2 16% 3 4% 7% 13% 6 27% 12 By stakeholder group Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 38% (11) 10% (3) Health & wellbeing boards 0 - - Healthwatch and voluntary/patient groups 6 67% (4) 33% (2) 33% 15 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know NHS providers 2-50% (1) Other CCGs 2 100% (2) - Upper tier/unitary LA 3 33% (1) 33% (1) Wider stakeholders 3-67% (2) CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree There is no trend data available for this question, as it was asked for the first time in 2018. CCG 2018 National Cluster* DCO** 40% 63% 67% 68% CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7884), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics.. 134 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 22

To what extent do you agree or disagree with the following statements about the leadership of the CCG? I have confidence in the leadership of the CCG to deliver improved outcomes for patients All stakeholders 6 13% 3 1 7% 2% 13% 6 By stakeholder group Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 48% (14) 17% (5) Health & wellbeing boards 0 - - 31% 14 Healthwatch and voluntary/patient groups 6 50% (3) 17% (1) 33% NHS providers 2-50% (1) 15 Other CCGs 2 100% (2) - Upper tier/unitary LA 3 33% (1) 33% (1) Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Wider stakeholders 3-33% (1) CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree 37% 36% 44% CCG 2018 National Cluster* DCO** 44% 61% 68% 69% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7884), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics.. 135 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 23

To what extent do you agree or disagree with the following statements about the leadership of the CCG? The leadership of the CCG is contributing effectively to local partnership arrangements (including Sustainability Transformation Partnerships (STPs), Accountable Care Systems (ACSs) where applicable and/or other local partnership arrangements). All stakeholders By stakeholder group 5 3 11% 7% 4 9% 16% 7 Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 41% (12) 14% (4) Health & wellbeing boards 0 - - 29% 29% 13 Healthwatch and voluntary/patient groups 6 67% (4) 33% (2) NHS providers 2-50% (1) Other CCGs 2 100% (2) - 13 Upper tier/unitary LA 3 33% (1) 33% (1) Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Wider stakeholders 3 33% (1) - CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree There is no trend data available for this question, as it was asked for the first time in 2018. CCG 2018 National Cluster* DCO** 44% 62% 66% 66% CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7884), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics. 136 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 24

To what extent do you agree or disagree with the following statements about the way in which the CCG monitors and reviews the quality of the services it commissions? I have confidence that the CCG monitors the quality of the services it commissions in an effective manner All stakeholders 3 4 9 7% 9% 20% 5 11% 9% 4 44% 20 By stakeholder group Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 55% (16) 14% (4) Health & wellbeing boards 0 - - Healthwatch and voluntary/patient groups 6 50% (3) 17% (1) NHS providers 2-50% (1) Other CCGs 2 100% (2) - Upper tier/unitary LA 3 67% (2) 33% (1) Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Wider stakeholders 3 33% (1) - CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree 52% 51% 53% CCG 2018 National Cluster* DCO** 53% 63% 67% 66% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics. 137 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 25

To what extent do you agree or disagree with the following statements about the way in which the CCG monitors and reviews the quality of the services it commissions? If I had concerns about the quality of local services I would feel able to raise my concerns within the CCG All stakeholders 4 3 9% 3 7% 7% 11 24% By stakeholder group Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 72% (21) 17% (5) Health & wellbeing boards 0 - - Healthwatch and voluntary/patient groups 6 83% (5) 17% (1) NHS providers 2 100% (2) - 53% 24 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Other CCGs 2 100% (2) - Upper tier/unitary LA 3 100% (3) - Wider stakeholders 3 67% (2) - CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree 72% 76% 78% CCG 2018 National Cluster* DCO** 78% 83% 83% 84% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics.. 138 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 26

To what extent do you agree or disagree with the following statements about the way in which the CCG monitors and reviews the quality of the services it commissions? I have confidence in the CCG to act on feedback it receives about the quality of services All stakeholders 3 5 7% 11% 3 7% 16% 7 By stakeholder group Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree GP member practices 29 48% (14) 17% (5) Health & wellbeing boards 0 - - 11 24% 36% 16 Healthwatch and voluntary/patient groups 6 50% (3) 33% (2) NHS providers 2 50% (1) - Other CCGs 2 50% (1) - Upper tier/unitary LA 3 67% (2) 33% (1) Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Wider stakeholders 3 67% (2) - CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree 48% 49% 51% CCG 2018 National Cluster* DCO** 51% 64% 69% 69% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics. 139 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 27

How much would you say you know about the CCG s plans and priorities? All stakeholders By stakeholder group 2 8 Stakeholder group No. of respondents A great deal/ a fair amount Not very much/ nothing at all 9 20% 4% 18% GP member practices 29 72% (21) 28% (8) Health & wellbeing boards 0 - - Healthwatch and voluntary/patient groups 6 83% (5) 17% (1) NHS providers 2 50% (1) 50% (1) 58% 26 A great deal A fair amount Not very much Nothing at all Other CCGs 2 100% (2) - Upper tier/unitary LA 3 100% (3) - Wider stakeholders 3 67% (2) 33% (1) CCG change across time Percentage of stakeholders saying a great deal/a fair amount Regional and cluster comparisons Percentage of stakeholders saying a great deal/a fair amount 67% 76% 76% CCG 2018 National Cluster* DCO** 76% 78% 80% 82% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics.. 140 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 28

To what extent do you agree or disagree with each of the following statements about the CCG s plans and priorities? I have been given the opportunity to influence the CCG s plans and priorities All stakeholders 2 6 4% 2 13% 4% 11% 5 By stakeholder group Stakeholder group No. of respondents Strongly/ Tend to agree Strongly/ Tend to disagree GP member practices 29 34% (10) 17% (5) Health & wellbeing boards 0 - - 31% 14 Healthwatch and voluntary/patient groups 6 50% (3) 17% (1) 36% 16 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know NHS providers 2 50% (1) 50% (1) Other CCGs 2 50% (1) - Upper tier/unitary LA 3 67% (2) 33% (1) Wider stakeholders 3 67% (2) - CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree 46% 38% 42% CCG 2018 National Cluster* DCO** 42% 53% 57% 55% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics. 141 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 29

To what extent do you agree or disagree with each of the following statements about the CCG s plans and priorities? When I have commented on the CCG s plans and priorities I feel that my comments have been considered (even if the CCG has not been able to act on them) All stakeholders By stakeholder group 3 4 7% 9% 4 9% 9% 4 29% 13 Stakeholder group No. of respondents Strongly/ Tend to agree Strongly/ Tend to disagree GP member practices 29 31% (9) 14% (4) Health & wellbeing boards 0 - - Healthwatch and voluntary/patient groups 6 50% (3) 17% (1) 38% 17 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know NHS providers 2 - - Other CCGs 2 50% (1) - Upper tier/unitary LA 3 100% (3) - Wider stakeholders 3 33% (1) 67% (2) CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree 39% 31% 38% CCG 2018 National Cluster* DCO** 38% 53% 57% 55% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics.. 142 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 30

To what extent do you agree or disagree with each of the following statements about the CCG s plans and priorities? The CCG has effectively communicated its plans and priorities to me All stakeholders 7 16% 3 7% 11% 5 By stakeholder group Stakeholder group No. of respondents Strongly/ Tend to agree Strongly/ Tend to disagree GP member practices 29 41% (12) 21% (6) Health & wellbeing boards 0 - - 33% 15 Healthwatch and voluntary/patient groups 6 67% (4) - 31% 14 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know NHS providers 2-50% (1) Other CCGs 2 100% (2) - Upper tier/unitary LA 3 33% (1) 33% (1) Wider stakeholders 3 33% (1) 67% (2) CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree 43% 58% 44% CCG 2018 National Cluster* DCO** 44% 62% 65% 64% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics. 143 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 31

How effective, if at all, do you feel the CCG is as a local system leader? By local system leader we mean that the CCG works proactively and constructively with the other partners in its local health and care economy, prioritising tasks-in-common over formal organisational boundaries, for example as part of an STP/ACS/other local partnership. All stakeholders 3 7% 4 9% 9% 4 By stakeholder group Stakeholder group No. of respondents Very/fairly effective Not very/ not at all effective GP member practices 29 59% (17) 28% (8) Health & wellbeing boards 0 - - 11 24% 51% 23 Healthwatch and voluntary/patient groups 6 67% (4) 33% (2) NHS providers 2-100% (2) Other CCGs 2 100% (2) - Upper tier/unitary LA 3 67% (2) 33% (1) Very effective Fairly effective Not very effective Not at all effective Don't know Wider stakeholders 3 67% (2) 33% (1) CCG change across time Percentage of stakeholders saying very/fairly effective Regional and cluster comparisons Percentage of stakeholders saying very/fairly effective 48% 53% 60% CCG 2018 National Cluster* DCO** 60% 72% 75% 75% 2016 2017 2018 Number of respondents: 2018 (45), 2017 (45), 2016 (46) CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7881), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics. 144 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 32

How satisfied or dissatisfied are you with how the CCG involves patients and the public? This may be done in various ways, for example through public meetings, focus groups, working with Patient Participation Groups (PPGs), voluntary organisations and local Healthwatch, and through the CCG s website, newsletters, and communications in GP surgeries. All stakeholders By stakeholder group 4 1 3 2% 7% 9% 13% 6 Stakeholder group No. of respondents Very/fairly satisfied Fairly/very dissatisfied GP member practices 29 55% (16) 3% (1) Health & wellbeing boards 0 - - 13 29% 40% 18 Healthwatch and voluntary/patient groups 6 67% (4) 33% (2) NHS providers 2-50% (1) Other CCGs 2 100% (2) - Upper tier/unitary LA 3 33% (1) 33% (1) Very satisfied Neither satisfied nor dissatisfied Very dissatisfied CCG change across time Fairly satisfied Fairly dissatisfied Don't know Percentage of stakeholders saying very/fairly satisfied Wider stakeholders 3 33% (1) - Regional and cluster comparisons Percentage of stakeholders saying very/fairly satisfied There is no trend data available for this question, as it was asked for the first time in 2018. CCG 2018 National Cluster* DCO** 53% 64% 68% 71% CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7884), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics.. 145 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 33

To what extent do you agree or disagree that the CCG demonstrates it has considered the views of patients and the public when making commissioning decisions? All stakeholders By stakeholder group 5 5 Stakeholder group No. of respondents Strongly/Tend to agree Strongly/Tend to disagree 9 3 20% 7% 11% 11% 24% 11 GP member practices 29 38% (11) 21% (6) Health & wellbeing boards 0 - - Healthwatch and voluntary/patient groups 6 50% (3) 50% (3) NHS providers 2-50% (1) 27% Other CCGs 2 50% (1) - Strongly agree Tend to agree Neither agree nor disagree 12 Tend to disagree Strongly disagree Don't know Upper tier/unitary LA 3 33% (1) 33% (1) Wider stakeholders 3-33% (1) CCG change across time Percentage of stakeholders saying strongly agree/tend to agree Regional and cluster comparisons Percentage of stakeholders saying strongly agree/tend to agree There is no trend data available for this question, as it was asked for the first time in 2018. CCG 2018 National Cluster* DCO** 36% 56% 60% 61% CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7884), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics. 146 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 34

To what extent do you agree or disagree with the following statement? How effective is the CCG at working with others to improve health outcomes? All stakeholders 8 18% 9% 4 By stakeholder group Stakeholder group No. of respondents Very/fairly effective Not very/at all effective GP member practices 29 62% (18) 14% (4) Health & wellbeing boards 0 - - 9 20% Healthwatch and voluntary/patient groups 6 50% (3) 33% (2) 53% NHS providers 2-100% (2) 24 Other CCGs 2 100% (2) - Upper tier/unitary LA 3 100% (3) - Very effective Fairly effective Not very effective Not at all effective Don't know Wider stakeholders 3 67% (2) 33% (1) CCG change across time Percentage of stakeholders saying very/fairly effective Regional and cluster comparisons Percentage of stakeholders saying very/fairly effective There is no trend data available for this question, as it was asked for the first time in 2018. CCG 2018 National Cluster* DCO** 62% 74% 78% 80% CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Number of respondents: CCG 2018 (45), National (7884), Cluster (781), DCO (449). *A cluster is the group of CCGs that are most similar to the CCG based on several population characteristics. 147 of 255 **The DCO is the group of local CCGs that fall under the same Director of Commissioning Operations as the CCG. Enfield CCG Fieldwork: 15th January - 28th February 35

Upper tier and unitary local authorities 148 of 255 CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 36

How well, if at all, would you say the CCG and your local authority are working together to plan and deliver integrated commissioning? All upper tier/unitary local authority stakeholders 100% 3 Very well Fairly well Not very well Not at all well Don't know 149 of 255 Total responses: All upper tier / unitary local authority stakeholders (3) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 37

How effective, if at all, has the CCG been as part of the Local Safeguarding Children Board? All upper tier/unitary local authority stakeholders 1 1 33% 33% 33% 1 Very effective Fairly effective Not very effective Not at all effective Don't know 150 of 255 Total responses: All upper tier / unitary local authority stakeholders (3) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 38

How effective, if at all, has the CCG been as part of the Safeguarding Adults Board? All upper tier/unitary local authority stakeholders 1 1 33% 33% 33% 1 Very effective Fairly effective Not very effective Not at all effective Don't know 151 of 255 Total responses: All upper tier / unitary local authority stakeholders (3) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 39

Healthwatch and voluntary/patient groups 152 of 255 CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 40

To what extent, if at all, do you feel that the CCG has engaged with hard to reach groups? Hard to reach groups are those who may experience barriers to accessing services or who are underrepresented in healthcare decision making, for example, black and minority ethnic (BME) groups, Gypsies and Travellers, lesbian, gay, bisexual and trans (LGBT) people, asylum seekers, and young carers. All Healthwatch and voluntary/patient group stakeholders 1 1 17% 17% 67% 4 A great deal A fair amount Just a little Not at all Don't know Total responses: All healthwatch and voluntary/ patient groups (6) Enfield CCG 153 of 255 Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 41

To what extent do you agree or disagree that the CCG demonstrates that it considers and acts appropriately in response to concerns, complaints or issues raised by patients and the public? All Healthwatch and voluntary/patient group stakeholders 1 1 17% 17% 1 17% 50% 3 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know 154 of 255 Total responses: All healthwatch and patient group stakeholders (6) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 42

GP member practices 155 of 255 CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 43

To what extent, if at all, do you feel able to influence the CCG s decision-making process? All member practices 3 10% 21% 6 21% (6) A great deal/fair amount 2018 21% (6) A great deal/fair amount 2017 10 34% 25% (7) A great deal/fair amount 2016 34% 10 A great deal A fair amount Just a little Not at all Don't know 156 of 255 Total responses: All member practices (2018: 29; 2017: 28; 2016: 28) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 44

To what extent do you agree or disagree with the following statements about the clinical leadership of your CCG/CCG? I have confidence in the clinical leadership of the CCG All member practices 2 2 7% 1 7% 3% 21% 6 45% (13) 39% (11) Strongly/Tend to agree 2018 Strongly/Tend to agree 2017 50% (14) Strongly/Tend to agree 2016 38% 24% 7 11 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Total responses: All member practices (2018: 29; 2017: 28; 2016: 28) 157 of 255 Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 45

To what extent do you agree or disagree with the following statements about the clinical leadership of your CCG/CCG? There is clear and visible clinical leadership of the CCG All member practices 1 2 5 7% 3% 17% 55% (16) Strongly/Tend to agree 2018 10 34% 38% 11 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Total responses: All member practices (2018: 29) 158 of 255 Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 46

To what extent do you agree or disagree with the following statements about the clinical leadership of your CCG/CCG? The clinical leadership of my CCG has effective influence within local partnerships (STPs/ACSs/other) All member practices 2 6 21% 7% 31% (9) Strongly/Tend to agree 2018 7 24% 3 10% 38% 11 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don't know Total responses: All member practices (2018: 29) 159 of 255 Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 47

How well, if at all, would you say that you understand? The financial implications of the CCG s plans All member practices 3 4 1 3% 10% 14% 45% (13) 64% (18) Very/Fairly well 2018 Very/Fairly well 2017 41% 31% 9 43% (12) Very/Fairly well 2016 12 Very well Fairly well Not very well Not at all well Don't know 160 of 255 Total responses: All member practices (2018: 29; 2017: 28; 2016: 28) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 48

How well, if at all, would you say that you understand? The implications of the CCG s plans for service improvement All member practices 4 1 1 14% 3% 55% (16) Very/Fairly well 2018 3% 57% (16) Very/Fairly well 2017 8 28% 52% 15 50% (14) Very/Fairly well 2016 Very well Fairly well Not very well Not at all well Don't know Total responses: All member practices (2018: 29; 2017: 28; 2016: 28) 161 of 255 Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 49

How well, if at all, would you say that you understand? The referral and activity implications of the CCG s plans All member practices 1 1 5 4 14% 3% 3% 17% 79% (23) 68% (19) Very/Fairly well 2018 Very/Fairly well 2017 61% (17) Very/Fairly well 2016 62% 18 Very well Fairly well Not very well Not at all well Don't know 162 of 255 Total responses: All member practices (2018: 29; 2017: 28; 2016: 28) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 50

How well, if at all, would you say that you understand? The CCG s plans to improve the health of the local population and reduce health inequalities All member practices 2 2 2 7% 7% 7% 62% (18) Very/Fairly well 2018 7 24% 55% 16 Very well Fairly well Not very well Not at all well Don't know 163 of 255 Total responses: All member practices (2018: 29) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 51

To what extent do you agree or disagree that value for money is a key factor in decision-making when formulating the CCG s plans and priorities? All member practices 1 2 5 3% 7% 17% 62% (18) Strongly/Tend to agree 2018 8 28% 57% (16) 50% (14) Strongly/Tend to agree 2017 Strongly/Tend to agree 2016 45% 13 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don t know 164 of 255 Total responses: All member practices (2018: 29; 2017: 28; 2016: 28) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 52

How familiar are you, if at all, with the financial position of the CCG? All member practices 2 1 4 7% 3% 14% 69% (20) Very/Fairly familiar 2018 6 21% 68% (19) Very/Fairly familiar 2017 71% (20) Very/Fairly familiar 2016 55% 16 Very familiar Fairly familiar Not very familiar Not at all familiar Don t know 165 of 255 Total responses: All member practices (2018: 29; 2017: 28; 2016: 28) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 53

To what extent do you agree or disagree that representatives from member practices are able to take a leadership role within the CCG if they want to? All member practices 4 4 2 14% 14% 52% (15) Strongly/Tend to agree 2018 7% 61% (17) Strongly/Tend to agree 2017 8 28% 38% 11 50% (14) Strongly/Tend to agree 2016 Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Don t know 166 of 255 Total responses: All member practices (2018: 29; 2017: 28; 2016: 28) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 54

NHS Providers 167 of 255 CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 55

How well, if at all, would you say the CCG and your organisation are working together to develop long-term strategies and plans? All NHS providers 1 50% 50% 1 Very well Fairly well Not very well Not at all well Don't know 168 of 255 Total responses: All NHS providers (2) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 56

Would you say that the amount of monitoring the CCG carries out on the quality of your services is too much, too little or about right? All NHS providers 1 50% 50% 1 Too much About right Too little Don't know 169 of 255 Total responses: All NHS providers (2) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 57

To what extent do you agree or disagree that when there is an issue with the quality of services, the response of the CCG is proportionate and fair? All NHS providers 1 50% 50% 1 Strongly agree Neither agree nor disagree Strongly disagree There has never been an issue with the quality of services 170 of 255 CCG 360 Stakeholder Survey 2018 - Report April 2018 Public Tend to agree Tend to disagree Don't know Total responses: All NHS providers (2) Enfield CCG Fieldwork: 15th January - 28th February 58

How involved, if at all, would you say clinicians from the CCG are in discussions with your organisation about: Quality All NHS providers 1 50% 50% 1 Very involved Fairly involved Not very involved Not at all involved Don't know 171 of 255 Total responses: All NHS providers (2) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 59

How involved, if at all, would you say clinicians from the CCG are in discussions with your organisation about: Service redesign All NHS providers 1 50% 50% 1 Very involved Fairly involved Not very involved Not at all involved Don't know 172 of 255 Total responses: All NHS providers (2) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 60

How well, if at all, would you say the CCG understands the challenges facing your provider organisation? All NHS providers 1 50% 50% 1 Very well Fairly well Not very well Not at all well Don't know 173 of 255 Total responses: All NHS providers (2) Enfield CCG Fieldwork: 15th January - 28th February CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 61

Appendix 174 of 255 CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 62

CCG clusters Each CCG is compared to a cluster of the other CCGs to which they are most similar. The clusters are based on the following variables: Index of Multiple Deprivation averages (overall and health domain) Population registered with practices Age of population Population density Ethnicity Ratio of registered population to overall population Based on these variables, the following CCGs form the CCG cluster for Enfield CCG Luton CCG Lewisham CCG Barking and Dagenham CCG Walsall CCG Havering CCG Greenwich CCG Hillingdon CCG Bromley CCG Haringey CCG Milton Keynes CCG Croydon CCG Waltham Forest CCG Bexley CCG Thurrock CCG Barnet CCG Wolverhampton CCG Sutton CCG Sandwell and West Birmingham CCG Crawley CCG Dartford, Gravesham and Swanley CCG CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 175 of 255 Enfield CCG Fieldwork: 15th January - 28th February 63

For more information ccg360stakeholder@ipsos-mori.com Version 1 Internal Use Only 176 of 255 This work was carried out in accordance with the requirements of the international quality standard for market research, ISO 20252:2006 and with the Ipsos MORI Terms and Conditions which can be found here CCG 360 Stakeholder Survey 2018 - Report April 2018 Public 64

Agenda Item: 8.4 MEETING: Governing Body Meeting in Public DATE: Wednesday 23 May 2018 TITLE: Quality and Safety Committee Report from meeting held on 2 May 2018 LEAD GOVERNING Angela Dempsey, Quality & Safety Committee Chair BODY MEMBER: AUTHOR & POSITION: Bridget Pratt, Assistant Director of Quality & Clinical Governance CONTACT DETAILS: bridget.pratt@nhs.net SUMMARY: The purpose of this report is to summarise the key matters discussed by the Quality & Safety Committee at its meetings 2 nd May 2018. Areas covered at the 2 nd May meeting include: Commissioning Support Unit (CSU) Performance & Quality Report Summary London Central & West Unscheduled Care Collaborative (LCW) Provider Update & Patient led insight visit Enfield Referral Service (ERS) Quarterly Update Report Continuing Healthcare (CHC) Operating Procedure District Nursing Team Insight & Learning visit Magnolia Unit Insight & Learning visit Quality Strategy 2018/2021 Learning from the Liverpool Community Services Health Independent Review Report, Jan 2018 Quality and Safety Risk Register The Committee approved the following policies: CHC Operating Procedures Quality Strategy 2018/2021 Health, Safety & Wellbeing Strategy 2018-19 Personal Health Budgets Operational Policy CHC Support Tools Change Policy The Committee also received the following for information: Quality and Risk Sub-Group (Q&R) Minutes of the meeting on 4 April 2018 Quality Strategy 2018/2021 SUPPORTING PAPERS: None. RECOMMENDED ACTION: The Governing Body is asked to: a) Note the summary of the meetings held on 2 nd May 2018. b) Note the approved 2018/2021 Quality Strategy. 177 of 255

Objective(s) / Plans supported by this paper: All Enfield CCG objectives. Patient and Public Engagement (PPE): Quality & Safety Committee membership includes the lay member for Governance. Equality Impact Analysis: This is conducted in line with agenda items. Risks: As outlined in the CCG s assurance framework and risk register. Resource Implications: These have yet to be identified. Audit Trail: Minutes of the Quality & Safety Committee 178 of 255

Quality & Safety Committee Summary Report from meeting held on 2 nd May 2018 1. CSU Performance & Quality Report Summary The Committee received the CSU Performance & Quality Report Summary. The highlights are available in the Integrated Quality & Performance Report on the Governing Body agenda. 2. London Central & West Unscheduled Care Collaborative (LCW) Provider Update and Patient-led insight visit The Committee received an update on LCW quality and performance as well as the recent patient led insight visit attended by Enfield CCG. The highlights are available in the quality and safety exception report on the Governing Body agenda. The Committee noted a programme of commissioner led insight & learning visits for 2018/2019 has been agreed with LCW. 3. Enfield Referral Service (ERS) Quarterly Update Report Since 1 st January 2018, ERS are now processing urgent referrals. These are not triaged but are forwarded to the correct speciality on behalf of the General Practitioners. ERS collects information from each referral onto the Docman database and this information is used by the QIPP (Quality, Innovation, Productivity and Prevention) team and Commissioners to inform pathway development and commissioning decisions. Temporary bank staff are helping the team with its workload and to address the pressure from the introduction of the new Docman electronic referral management system. 4. Continuing Healthcare (CHC) Operating Procedure The Committee approved the CHC Operational Policy which was revised for two reasons: Firstly, the service operates differently from the policy and to bring the new policy in line with the new Continuing Healthcare National Framework 2018 which becomes operational from October 2018. Secondly, the policy had a commissioning 10% cap on domiciliary packages against a nursing home fee which was deemed unlawful by Equality and Human Rights Commission in March. We committed to changing this policy and publishing the new policy by May 2018. This policy supersedes the previous CHC policy. 5. District Nursing Team Insight & Learning visit The District Nursing Insight visit took place on 5 th February 2018. The Committee noted that this was a very well attended visit with the majority of the senior District Nursing team present and participative. The team s commitment to prioritise patient care and to meeting patient needs despite present challenges was a consistent theme during this visit. The dedication to ensure this service develops and remains relevant to the patient requirements was further exhibited in the teams inclusion of student District Nurses into this visit and discussion. There were positive ideas of how to support its staff and opportunities to develop the service. These range from formal Nurse Prescribing courses enhancing understanding of roles and responsibilities by shadowing commissioners. 179 of 255

The CCG made recommendations which have all been agreed with the provider and will be monitored at the Clinical Quality Review Group (CQRG) meeting. 6. Magnolia Unit Insight & Learning visit The Magnolia Unit insight visit took place on 5th February 2018.The Magnolia Unit is a 24hr nurse consultant led in patient service focused on preventing avoidable admission to acute hospital and rehabilitation, for those that cannot safely be looked after at home. The service is available to adults registered with an Enfield GP who are medically fit but require the support nursing, physiotherapy and occupational therapy staff. Magnolia Unit was last inspected by the Care Quality Commission (CQC) in November 2015; the report, published in March 2016, awarded the service a rating of Good for each of the inspection domains. The unit was bright and airy with many windows giving patients and carers a view of the surrounding land. The patient bays, side rooms and bathroom areas were clean and tidy. There were no obstacles in corridors and no fire hazards noted. There was a very pleasant, calm and friendly atmosphere; at the time of the visit there were patients attending a physiotherapy class, some in their rooms watching television or reading and one person in the day room reading. Patients interviewed were complimentary about the service. The reception staff were warm and welcoming; information on the unit and the service was clearly displayed in the reception area and corridors. Recommendations around recruitment will be monitored at the CQRG meeting. 7. Quality Strategy 2018/2021 Enfield CCG s Quality Strategy 2016-18 has reached its review point. The Committee approved the revised 2018/2021 Quality Strategy aimed to support the CCG through the next three years of continuous quality development until 2021. The strategy has been aligned to the North Central London (NCL) Sustainability and Transformation Plan (STP) arrangements and recent national drivers. The Strategy has also been aligned to the five CQC domains to facilitate and support the monitoring of our providers. The Strategy has also introduced a quality concerns escalation process which defines how we act when we identify a quality concern with one of our providers. This will ensure that we have an open and robust process for managing concerns and ensuring that all relevant authorities are informed in a timely manner. The strategy will be supported by a yearly implementation plan which will be monitored regularly at the Quality & Risk sub group. The Quality Strategy is available upon request from the CCG quality team. 8. Learning from the Liverpool Community Services Health Independent Review Report, Jan 2018 The Committee received a summary report following an independent review into the widespread failings by Liverpool Community Health published in February 2018. The review conducted by Dr Bill Kirkup CBE, commissioned by NHS Improvement, looked into the issues at Liverpool Community Health NHS Trust from November 2010 to December 2014. The report outlined how cost improvement programmes imposed by the trust in a bid to gain foundation trust status put the safety of patients at risk, and that a culture of bullying meant that staff were scared to speak up or that incidents were ignored or not escalated. The review found that the external overview of the trust failed to 180 of 255

identify the services problems for at least four years, and concluded that earlier intervention would have reduced the avoidable harm that occurred to patients and staff across the trust. It also looked at the oversight of the Trust by the NHS Trust Development Authority, NHS England and Commissioners. Dr Kirkup made a series of recommendations for NHS Improvement, the CQC, NHS England, the Department of Health and to the trusts currently providing services that used to be run by Liverpool Community Health NHS Trust. Liverpool Community Health NHS Trust was created in 2010 and services included adult care, child and adolescent care, community dentistry, prison healthcare and public health. The report is a review of the learnings and recommendations to provide assurance to the Quality & Safety Committee that the processes in place within ECCG would prevent these system failures within the CCG and an organisation in which it commissions services. This report was discussed at the April Barnet Enfield and Haringey Mental Health Trust (BEHMHT) CQRG. BEHMHT confirmed that they are reviewing the report with a view to presenting a response to their Trust Board and the CQRG. The Quality & Safety Committee requested an NCL approach to learning from this report to be discussed at the NCL Quality Directors meeting. 9. Quality and Safety Risk Register The Committee noted nine risks on the Quality and Safety risk register. Two risks from the quality and safety risk register were recommended for closure and transfer to the performance risk on the BAF: o o 236 : delays in treatment leading to poor patient experience and potential for clinical harm 295: Risk to patient safety and patient experience from exceeding expected standards for cancer waiting times for treatment at Royal Free London Hospital. The Committee agreed to continue to monitor these risks until the NCL governance arrangements for strategic risk reporting has been agreed. End of report 181 of 255

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MEETING: Governing Body Meeting in Public DATE: Wednesday 23 May 2018 TITLE: Audit Committee Report from Meeting held on 25 April 2018 LEAD GOVERNING Karen Trew, Lay Member for Audit and Governance BODY MEMBER: AUTHOR & POSITION: Brenda Thomas, Board Secretary CONTACT DETAILS: Summary: Brenda.Thomas1@nhs.net Agenda Item: 8.5 The purpose of this paper is to outline matters discussed by the Audit Committee at its meeting held on 25 April 2018. 25 April 2018 2017/18 Draft Annual Report and Accounts including Head of Internal Audit Opinion The Health and Social Care Act 2012 require CCGs to produce an Annual Report and Accounts for each financial year including an annual governance statement. CCGs are also required to submit the Annual Report and Accounts to NHS England, publish the report and hold an Annual General Meeting to present the report to the CCG membership and public. NHS England provided a template for CCGs to follow for 2017/18, which is largely unchanged from last year. The Committee spent significant amount of time thoroughly reviewing the draft CCG Annual Report for 2017/18 including the Sustainability Report, Annual Governance Statement, the Head of Internal Audit Opinion and the Statutory Accounts Template 2017/18. The summary of the timetable for the production of the Annual Report and Account was noted and further comments on the draft were requested by 4 May, ahead of the papers being circulated to the Audit Committee for its meeting on 23 May 2018 and submission to NHS England on 30 May 2018. The draft Head of Internal Audit Opinion noted that the CCG has an adequate and effective framework for risk management, governance and internal control. However, further enhancements to the framework of risk management, governance and internal control to ensure that it remains adequate and effective have been identified. Internal Audit Plan 2018/19 The Committee reviewed the 2018/19 Internal Audit Plan, noting that an NCL approach has been taken in developing the Plan. The Plan would be signed off at the NCL Audit Committee in Common meeting in July albeit recognising some of the field work would have commenced. Internal Audit Progress Report for Enfield CCG The Committee was pleased to note that overall, good progress has been made since the last report, especially with primary care delegated commissioning part II, for which controls have been strengthened during the course of the year. 183 of 255

The following reviews have been finalised: CSU Contract Monitoring; Primary Care Delegated Commissioning Part I; Conflicts of Interest; Provider Contract Management; Board Assurance Framework and Risk Management; Financial Reporting and Governance; QIPP and Sustainability; and Primary Care Delegated Commissioning Part II. The draft report for the Governance Review has been issued, which concludes the 2017/18 Internal Audit Plan. Internal Audit Progress Report for North East London Commissioning Support Unit Since the last meeting, the final report for the Information Governance review have been issued and no substantial issues were identified for Enfield CCG. The following reviews are in progress Data Quality and Performance Management; Data Protection Act. The Committee noted that the draft 2018/19 Commissioning Support Unit Audit Plan would be discussed and signed off at the NCL Audit Committee in Common in July. Quarterly and Annual Conflict of Interest return to NHS England The Committee noted that the quarter four and annual Conflicts of Interest return were completed in line with the other four NCL CCGs for consistency and was submitted to NHS England against the required deadline. 23 May 2018 A verbal update will be provided for the Committee meeting held on 23 May 2018. Supporting Papers: None Recommended action: The Governing Body is asked to note the contents of the report. Objective(s) / Plans supported by this paper: This report supports all of the CCG s strategic objectives. Audit Trail: N/A Patient & Public Involvement (PPI): N/A Equality Impact Assessment: N/A Risks: N/A Resource Implications: N/A Next Steps: None 184 of 255

MEETING: Governing Body Meeting in Public DATE Wednesday 23 rd May 2018 TITLE: Board Assurance Framework & Corporate Risk Register LEAD BOARD MEMBER Deborah McBeal, Deputy Chief Officer & Director of Primary Care Commissioning AUTHOR: Andrew Spicer, NCL Head of Governance and Risk CONTACT DETAILS: Andrew.spicer1@nhs.net SUMMARY: The Board Assurance Framework ( BAF ) captures the most serious risks identified as threatening the achievement of the CCG s strategic objectives. The BAF includes some NCL wide risks escalated from the NCL Joint Commissioning Committee which takes a wider pan-ncl perspective. These are clearly set out as risks from an NCL perspective. The Corporate Risk Register ( CRR ) captures the high level risks identified as threatening the achievement of the CCG s objectives with a current risk score of 8 or higher. This report provides a summary of the BAF and Corporate Risk Register via a risk tracker and risk map for the BAF. The full BAF and Corporate Risk Register are available upon request from the Board Secretary. Number of risks There are 12 risks on the BAF. Six are from a Local perspective with one new risk. Seven risks are from an NCL perspective. Key Highlights- Local Perspective Agenda Item: 9.1 Risk 401- Failure to deliver the In Year Control Total and Risk 346- Failure to maintain long-term financial sustainability: The CCG reported a deficit of 3.4m against a control total of 2.1m, an adverse variance of 5.5m. This variance was largely driven by Acute over performance, QIPP under delivery and significant cost growth in Continuing Healthcare and prescribing cost pressure arising from No Cheaper Supply Obtainable ( NCSO ) Drugs. This deficit is added to the CCG s cumulative deficit taking it to 40.6m and thereby the CCG s ability to address long term financial sustainability. Both risks will be discussed further at the next F&P Committee. In the NCL footprint Camden and Islington CCGs met their control total whereas Barnet and Haringey CCGs did not. The finance team are focussing on plans for the CCG meeting its 2018-19 control total and long term financial sustainability. Risk 343 - Performance and quality risk arising from non-delivery of NHS constitutional standards: An updated Remedial Action Plan was received from Royal Free London on recovery of their Referral To Treatment position in March 2018. The remedial action plan is being monitored through contract meetings. New Risk Risk 435 - Increase in number of children waiting more than 13 weeks for an initial assessment for CAMHs: This risk has been escalated from the Corporate Risk Register to the BAF. There are 102 children waiting over 13 weeks for an initial assessment for CAMHS at BEH Mental Health Trust. The CCG has put into place a recovery plan and provided additional funding to address this issue. 185 of 255

The risk has been reassessed and escalated to the BAF for oversight whilst the recovery plan is taking effect and to demonstrate that the risk is being managed. Closed Risk Risk 400 - Risk arising from the mobilisation of the STP plan. This risk has been closed as it is being monitored through risk NCL 1 - Delivery of the Transformation Agenda (Threat) on the NCL Risk Register. NCL Joint Commissioning Committee Risk Register The NCL Joint Commissioning Committee ( NCL JCC ) risk register has 7 risks with a current risk score of 15 or higher and therefore are reporting them to the Governing Body to ensure visibility and oversight. These risks are from a pan NCL perspective and therefore there is some overlap with Enfield CCG only risks. Key Highlights JCC 1 - Delivery of Cancer 62-day waiting time standard (Threat): NCL as a system delivered the standard in December 2017 but additional work is required for this to be sustainable. However, the individual recovery plan from UCLH defers their recovery of the standard from March 2018 to June 2018. Internal pathways are expected to be compliant in April 2018. JCC 10 - Mobilisation of STP and QIPP plans (Threat): The in-housing of functions from NEL CSU into the CCGs is underway. This will provide greater support and capacity to deliver STP interventions. However, additional capacity is needed to progress the work on alternative contract forms. JCC 11 - Managing Acute Contracts within Contract Baselines (Threat): Signed contracts with acute providers in place for 2017/18 and 2018/19 and contracts include marginal rate payments/deductions for variances from plan and 3% growth. This is higher than historic growth trends. System intentions have been issued to providers. NCL Primary Care Co-Commissioning Risk Register The NCL Primary Care Co-Commissioning Committee in Common ( NCL PCC ) risk register has 1 risk with a residual risk score of 15 or higher and therefore this risk is being reported to the Governing Body to ensure visibility and oversight. Risks from the NCL PCC can be from either a local perspective or a pan NCL perspective depending on the risk. Risk 18 - Primary Care Support England (Threat): The NHS England primary care support functions provided by NHS England and contracted to Capita have been significantly underperforming. This has led to a disruption in GP business continuity and potential cost pressures to CCGs. This risk is primarily managed by NHS England. NHS England meet with Capita regularly to try to resolve the issues and the NCL CCGs raise issues with NHS England at London primary care meetings. NCL Risk Register A new NCL Risk Register has been developed which captures the key pan NCL risks that are not captured by our other risk registers. The NCL Risk Register contains ten risks which include NCL and STP risks. The NCL Risk Register will be reviewed regularly by the NCL Senior Management Team, the STP PMO and the assurance process will be overseen by the NCL audit committees. Key Highlights NCL 4 - Failure to Effectively Engage with Patients and the Public (Threat): A new Head of Communications for the STP has been recruited and will start in May 2018. NCL 8 - Recruitment and Retention a High Performing Workforce (Threat): The NCL HR team has been fully recruited to with all team members being in place by end of June 2018. Recruitment for the Organisational Development roles is under way. 186 of 255

NCL 9 - Delivering Financial Balance Across NCL CCGs (Threat): 2018-19 budget planning is underway and QIPP plans will be implemented throughout the year. Corporate Risk Register There are 15 risks on the Corporate Risk Register ( CRR ). There are no new risks. Five risks have reduced below the Current Risk Score of 8 and have been deescalated to the Directorate Risk Registers. Two risks have been closed. One risk has been escalated to the BAF as reported above. Key Highlights Risk 342 - Risk to the delivery of Primary Care Transformation Programme: The Federation is implementing Phase I of the Enfield Single Offer and the CCG is in the process of commissioning Phase II and Phase III services around the Care Closer to Home Agenda. The Federation has worked hard to engage with all 48 member practices. However, the Federation is still developing and will need further sustainability in order to offer a robust response to service development and delivery. Risk 465 - Personal Health Budgets (PHB) concern regarding safety of commissioned care meeting patient health needs: The CCG has extended the current provider s contract for 6 months whilst the CCG secures a new service provider to manage the interface between the CCG and people receiving Personal Health Budgets. Risk reduced from 12 to an 8. Risks Deescalated to the Directorate Risk Registers The following risks have a current risk score of 6 which is below the level required for the CRR. Risk 13 - Failure to comply with the CCG's Policy and statutory guidance on Conflicts of Interest (COI) could result in potential for legal challenge to Commissioning decisions, reputational damage and potential conflicts of interest in commissioning decisions. The CCG has processes in place for managing its conflicts of interest and therefore this risk has been reduced from 8 to 6. It will be monitored by the NCL Corporate Services Directorate. Risk 34 - Mental Health Commissioning: Risk of financial exposure to high cost of out of area placements. Lack of appropriate community based facilities resulting in patients being inpatients for some years: Systems and processes in place for review of patients so risk now reduced to moderate risk. Risk reduced from 9 to 6. Risk 59 - Backlog of processing referrals within Enfield's Referral Service arising from the installation of new Personal Computers in Enfield CCG alongside the introduction of community clinics have resulted in a backlog of processing referrals: Staffing levels are returning to normal but there are still two staff members on long term sick leave. Staff are working at weekends to help manage the backlog. Risk is holding steady at 6. Risk 397 - PMS Reviews will impact core PMS funding which may impact on the delivery of patient services and destabilisation of practices: All new PMS contracts have been sent to practices and the Commissioning Intentions have been sent to all GMS and APMS practices. The CCG had an engagement meeting, with all practices invited, on the 8th May 2018. The aim is for all practices to sign by 31st May 2018 with new PMS contracts backdated to start on the 1st April 2018. The risk has reduced from 10 to 6. Risk 430 - Risk of not finding appropriate accommodation within the timescales to relocate ECCG: The CCG has agreed a five year lease for Holbrook House with a two year break clause. Risk reduced from 8 to 6 and the risk will be closed. Closed Risks Risk 463 - Inability of NMUH to deliver an effective Dermatology Service: This risk has been successfully avoided and no longer exists as NMUH has confirmed they want to keep the contract whilst the CCG is reviewing its procurement options. Risk 430 - as the update above. 187 of 255

SUPPORTING PAPERS: BAF Risk Tracker BAF Risk Heat Map NCL Joint Committee Risk Register NCL Risk Register Risk Scoring Key Corporate Risk Register Tracker RECOMMENDED ACTION: The Governing Body is asked to review the risks and provide feedback on the updated BAF. Objective(s) / Plans supported by this paper: The BAF and Corporate Risk Register applies to all plans related to services commissioned by the CCG Patient and Public Involvement (PPI): Enfield CCG aims to involve patients and the public in implementing its corporate objectives Equality Impact Analysis: This report was written in accordance with the provisions of the Equality Act 2010. Risks: The BAF report assists the Governing Body to provide oversight and scrutiny of the key risks facing the organisation. Resource Implications: Updating of the BAF is the responsibility of each risk owner and their respective directorates. The NCL Governance Team helps to support this by providing monitoring, guidance and advice. Audit Trail: The BAF was last reviewed by the Governing Body on 21 st May 2018. Risks are kept under review by committees of the Governing Body and risk owners. 188 of 255

2017/18 Q1 Q2 Q3 Q4 Risk ID Risk description APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR MAY Progress Target Risk Rating 343 346 Performance & quality risk arising from non delivery of NHS constitutional standards arising from provider Cancer & A&E underperformance (RFL & NMUH). Update: An updated Remedial Action Plan received from Royal Free London on recovery of their Referral To Treatment position in March 2018. The remedial action plan is being monitored through contract meetings Failure to maintain long-term financial sustainability. Update: The CCG reported a deficit of 3.4m against a control total of 2.1m, an adverse variance of 5.5m. This deficit is added to the CCG s cumulative deficit taking it to 40.6m and thereby the CCG s ability to address long term financial sustainability. This risk will be discussed further at the next F&P Committee meeting. The finance team are focussing on plans for the CCG meeting its 2018-19 control total and long term financial sustainability. 16 16 16 16 16 16 16 16 16 16 16 16 16 10 16 16 16 16 16 16 16 16 16 16 16 16 16 12 347 Failure to ensure a safe and high quality service is commissioned from and delivered by our providers. (Quality and safety concerns at the NMUH Emergency department, BEHMHT rated as requires improvement by the CQC in 2018) Update: The CCG continues to work with providers to ensure safe and high quality services. 16 16 16 16 16 16 16 16 16 16 16 16 16 12 401 Failure to deliver the In year control total Update: This risk has materialised. The CCG reported a deficit of 3.4m against a control total of 2.1m, an adverse variance of 5.5m. This variance was largely driven by Acute over performance, QIPP under delivery and significant cost growth in Continuing Healthcare and prescribing cost pressure arising from No Cheaper Supply Obtainable ( NCSO ) Drugs. 8 8 16 16 16 20 20 20 20 20 20 20 20 12 435 Increase in number of children waiting more than 13 weeks for an initial assessment for CAMHs Update: There are 102 children waiting over 13 weeks for an initial assessment for CAMHS at BEH Mental Health Trust. The CCG has put into place a recovery plan and provided additional funding to address this issue. The risk has been reassessed and escalated to the BAF for oversight whilst the recovery plan is taking effect and to demonstrate that the risk is being managed. 8 8 8 8 8 8 8 8 8 8 8 8 12 189 of 255

2017/18 Q1 Q2 Q3 Q4 Risk ID Risk description APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR MAY Progress Target Risk Rating 436 Risks associated with aligning the STP, Operating Plan, QIPP Plans and Contracts Update: The CCG continues to work on aligning and delivering QIPP. Concerns remain around a number of QIPP schemes where the STP are responsible and present the CCG with uncertainty and lack of control around delivery. There is also current uncertainty around 18/19 QIPP target due to failure to agree QIPP in Acute contracts. 16 16 16 16 16 16 16 16 16 16 16 16 16 12 190 of 255

Appendix 1c: Enfield CCG Board Assurance Framework New Risk Map (NB: Now 12-25) (See Risk Tracker for full risk description) 5 Risk 401 4 Risk 435 Risk 343 Risk 347 Risk 346 Risk 436 Likelihood 3 2 1 1 2 3 4 5 Consequence 191 of 255

North Central London CCG Risk Register as at April 2018 ID Director Objective Risk Controls in place Evidence of Controls Overall Strength of Controls in Place Rating (Current) Likelihood (Current) Consequence Risk level (Current) Controls Needed Evidence of Controls Needed Actions Action Completion Date Update on Actions Likelihood (Target) Consequence (Target) Rating (Target) Risk level (Target) RISKS FROM THE NCL JOINT COMMISSIONING COMMITTEE JCC 1 Paul Sinden, NCL Director of Performance and Acute Commissioning 62 Days Waiting Time Standard is Met Delivery of Cancer 62-day waiting time standard (Threat) Cause: There may be insufficient capacity within the system, and inefficiencies along pathways in particular for inter-provider transfers. Effect: There is a risk that the system may be unable to cope with the level of demand and has limited resilience to unexpected events. Impact: This may result in people not receiving treatment within 62 days with potential adverse impact on their health outcome. C1. North Central London ('NCL') cancer governance arrangements established to cover both performance and transformation. C2. Improvement trajectory agreed with NHS England and NHS Improvement. C3. Remedial Action Plans in place with providers that are not meeting the 62 day standard. Updated plan received from Royal Free London. C4. 38 day transfer protocol in place for inter-provider transfers from district general hospitals to tertiary services with the 38 day standard compatible with treatment commencing within 62 days. C5. Trajectory agreed with providers to meet the 38-day standard for transfers of care C6. Recovery plan received from UCLH, with overall compliance by June 2018 and compliance on internal pathways by April 2018 C1. Meeting papers and notes. C2. Plans and trajectories in place with providers to allow NCL to meet the standard overall. Backlog analysis indicates reduction towards sustainable level. Progress most marked at Royal Free London in October and November. C3. Plans. C4. Transfer protocol document. C5. Provider trajectories C6. Provider recovery plan Average 4 4 16 Very High CN1. Arrangement to be put into place to ensure all providers are abiding by the inter-provider transfer protocol. CN2. Individual providers to resolve internal pathway issues to ensure they meet the 62 day target. CN3. Backlog reduction by providers to level consistent with delivery of the waiting time standard. CN1. Improvements delivered inline with agreed trajectories and contained in reports. CN2. Improvements delivered inline with agreed trajectories and contained in reports. CN3. Analysis agreed with NHS Improvement indicates maximum backlog level to deliver the standard A1. Continue to work with providers on delivering the trajectories. A2. Continue to work with providers to ensure sustainable delivery and includes work through the cancer vanguard. A3. NCL recovery of the 62 day standard by December 2017. A4. UCLH recovery of the 62 day standard by end of March 2018 and is consistent with system recovery by December 2017. Updated recovery plan required from the Trust. A1. 30.06.2018 A2. 30.06.2018 A3. 30.06.2018 A4. 30.06.2018 A1. Provider meetings continue on a fortnightly basis on recovering the trajectories. A2. Cancer vanguard meetings in place with provider and commissioner representation which meet monthly. A3. NCL delivered the standard in December 2017 but further work is required for sustainability. This work is being undertaken and is reflected in action A4. A4. UCLH recovery plan received but defers recovery to June 2018 from expected recovery by March 2018. Internal pathways are expected to be compliant by April 2018. 3 4 12 High JCC 10 Paul Sinden, NCL Director of Performance and Acute Commissioning Effective mobilisation of Sustainability and Transformati on (STP) plans and CCG QIPP plans to ensure contracts remain within resource envelopes Mobilisation of STP and QIPP plans (Threat) Cause: if we do not ensure that STP and QIPP plans are delivered in accordance with planning assumptions Effect: There is a risk that contracts will not be delivered within resource envelopes for 2017/18 Impact: This may result in delays to service changes, higher contract baselines for 2018/19 than anticipated in financial plans for CCGs, and a wider system financial gap. C1. Signed contracts in place for 2017/18 and 2018/19 C2. Contract frameworks in place with each provider including Local Delivery Teams to support the STP C3. In-year contract variances subject to marginal rates rather than full tariff adjustments C4. Collaborative arrangements in place through Finance and Activity Modelling (FAM) Group as part of STP governance framework C5. Sustainability and Transformation Plan governance and supporting work streams with commissioner and provider membership in place C6. Development of schemes for 2018/19 underway. Project initiation documents shared with providers for planned care, care closer to home, and urgent and emergency care C1. Signed contracts C2. Meeting minutes and papers C3. Signed contracts C4. Meeting minutes and papers C5. Meeting papers C6. Meeting papers and project initiation documents Average 4 4 16 Very High CN1. CCG and CSU redirection of CN1. Realigned CCG and CSU capacity to support mobilisation of STP teams for contract frameworks interventions that release resources to support CN2. Collaborative work with the STP providers to realign system incentives, CN2. Proposals for alternative and contract form, to support STP contract form delivery A1. Finalise proposals to A1. 01.07.2018. increase support for STP work A2. 01.07.2018 streams A2. Progress the work of the acute contract modelling group to consider alternative contract forms A1. In-housing of NELCSU to provide greater support and capacity for delivery of STP interventions is underway. A2. Work is progressing but needs additional capacity to put into place shadow proposals for 2018-19. 4 3 12 High JCC11 Paul Sinden, NCL Director of Performance and Acute Commissioning Management of acute contracts to ensure contracts are delivered within contact baselines (CCG resource envelopes) Managing acute contracts within contract baselines (Threat) Cause: if expenditure on acute contracts exceeds planned contract baselines Effect: There is a risk that CCGs will not meet their financial duties and/or investment is withheld to support delivery of the Sustainability and Transformation Plan Impact: This may result in delays to investing in primary care and community capacity and perpetuate the risk over performance on acute hospital contracts C1. Signed contracts in place for 2017/18 and 2018/19 C2. Contracts include marginal rate payments/deductions for variances from plan and 3% growth (higher than historic growth trends) C3. Contract management framework in place with providers C4. Issue of contract notices in line with contact provisions C5.. Mobilisation of STP and QIPP plans (see JCC10) C6. North Central London Finance and Activity Modelling (FAM) Group, with commissioner and provider membership. that oversees system financial position C7. Work on alternative contract forms to support the Sustainability and Transformation Plan (STP) through the Acute Contract Modelling Group (with commissioner and provider membership) C8. Quarter one reconciliation agreed with providers as a precursor to establishing the opening contract baseline for 2018/19 C9. Agreement of treatment of disputed items with Royal Free London in 2017/18 reached C1. Signed contracts C2. Signed contracts C3. Meeting minutes and papers C4. Contract documentation and correspondence including remedial action plans C5. See JCC10 C6. Meeting minutes and papers C7. Meeting minutes and papers C8. Meeting minutes and papers Average 4 4 16 Very high CN1. Development of system intentions for 2018/19 CN2. Develop proposals to realign system incentives including new contract forms for hospital contracts CN1. CCG system leadership for commissioning. Contract requirement to signal major contact/service changes CN2. Proposals for realigning system incentives. A1. Develop and sign-off system intentions for 2018/19 A2. Develop, in co-production, with providers, proposals for alternative contract forms for hospital providers A3. Development of planning assumptions for 2018/19 with providers. A1. 30.09.2017 A2. 01.07.2018 A3. 23.03.2018 A1. Action completed. System intentions issued to providers. A2. Consideration of models used elsewhere - Aligned Incentive Contract in Bolton; Accountable Care models. Work has commenced on this and is continuing. A3. Planning assumptions are being developed through STP finance meetings following publication of national planning guidance. 4 3 12 High 192 of 255

ID Director Objective Risk Controls in place Evidence of Controls JCC 13 Paul Sinden, NCL Director of Performance and Acute Commissioning Management of winter pressures to support recovery of A&E waiting time standard and protect capacity for delivery of cancer and referral-totreatment waiting time standards Ensuring that management of winter pressures supports recovery of waiting time standards for A&E and cancer and protects capacity for elective pathways (Threat) Cause: if we are unable to manage non-elective flows within planned hospital and community capacity to meet winter pressures Effect: There is a risk that patients may receive suboptimal care and long waiting times leading to the local system missing waiting time standards for A&E and referral-to-treatment. Historically capacity to meet cancer waiting time standards has been successfully ring-fenced. Impact: Patients may remain in inpatient placements longer than anticipated as community care packages are developed. C1. Establishment of A&E Delivery Boards with representation across health and care system C2. Establishment of NCL Urgent and Emergency Care (UEC) Board C3. STP work streams for urgent and emergency care established for long-term sustainability. C4. Winter plans for 2017/18 prepared by each A&E Delivery Board C5. Recovery plans submitted by each A&E Delivery Board to regain A&E four-hour waiting time standard C6. See JCC2 - recovery of A&E four-hour waiting time standard C7. Supplementary winter plans submitted by each A&E Delivery Board to NHS England and NHS Improvement in December 2017 C1. Meeting papers and minutes from A&E Delivery Boards C2. Meeting papers and minutes from UEC Board. C3. Work streams plans and QIPP monitoring reports C4. Plans submitted and reports/dashboards monitoring progress. C5. Plans submitted and reports/dashboards monitoring progress. C6. See JCC2 C7. Funding confirmation for priority supplementary schemes from NHS England Overall Strength of Controls in Place Average Rating (Current) Likelihood (Current) Consequence 4 5 20 Risk level (Current) Very high Controls Needed Evidence of Controls Needed Actions Action Completion Date Update on Actions CN1. Development of NCL-wide escalation process for winter 2017/18 CN2. NCL winter workshop on 27 September to align plans across A&E Delivery Boards. CN3. Development of further plans for winter 2017/18 to ensure resilience CN1. NCL wide escalation process; CN2. Notes of workshop; CN3. Plans. A1. Agree escalation process for NCL with NHS England and NHS Improvement A2. Hold winter workshop on 27 September A3. Identification of further recover plans through winter workshop and A&E Delivery Boards A4. Provider mutual aid plans developed for January 2018 to free up clinical time from elective care pathways to support emergency patient flows A5. Each A&E deliver board to complete an after action review process for winter 2017-18. A6. Plans for winter 2018-19 to be submitted to NHS England by end of April 2018. A1. 13.10.2017 A2. 30.11.2017 A3. 31.12.2017 A4. 31.01.2018 A5. 31.03.2018 A6. 30.04.2018. A1. Action completed. NCL approach to escalation agreed in principle with NHS England. All A&E Delivery Boards have agreed escalation protocols to respond to surges in pressure and/or demand A2. Action completed. Actions from winter workshop were actioned through A&E Delivery Boards A3. Additional plans submitted by A&E deliver boards in December 2017. A4. Action completed. A5. Work is progressing on this. A6. Work is progressing on this. Likelihood (Target) Consequence (Target) Rating (Target) 4 4 16 Risk level (Target) Very high JCC 14 Paul Sinden, NCL Director of Performance and Acute Commissioning Mobilising STP schemes that shifts activity away from acute providers in a way that allows those providers to release capacity and costs, and thereby reduce overall system costs STP and local plans target the shift of care from hospital into community settings, to reduce the overall system financial deficit this needs to be done in a way that allows hospital providers to reduce capacity and costs. This risk follows on from the initial risk of mobilising STP and local plans in JCC10 (Threat) Cause: if we are unable to shift care from hospital to community settings that allow providers to make a stepchange in capacity Effect: There is a risk that hospital providers are left with stranded costs and we do not reduce overall system costs Impact: STP and local interventions do not help reduce the system financial deficit in the anticipated way. C1. Signed contracts for 2017/18 and 2018/19 that include the impact of STP interventions C2. System intentions for 2018/19 that seek to align intentions across CCGS so we commission at scale C3. Agreement of approach to planning round for 2018/19 with providers through STP finance meetings. Contract baselines for 2018/19 to include the impact of STP interventions. C4. Work with providers on alternative contract forms to support STP delivery, with the work informed by provider cost profiles. C5. STP Finance meetings with commissioners and providers that has a common understanding of financial position in NCL system C6. STP interventions for 2018/19 developed and shared with providers C1. Contract documentation C2. NCL Systems Intentions letter C3. Meeting paper and notes. C4. Meeting papers and notes. C5. Meeting papers and notes C6. Meeting papers and project initiation documents. Average 4 4 16 Very high CN1. Development of STP work streams interventions plans for 2018/19 CN2. Agreement of contract baselines for 208/19 CN3. Development of alternative contract models and incentive systems CN1. Interventions impacts need to be planned and agreed for incorporation into contracts CN2. Signed contracts for 2017-19 require the negotiation of contact baselines for 2018/19 CN3. Alternative contract forms need to be shadow run in 2018/19 to be used in contracts from 2019/20 onwards A1. Work streams development of STP plans for 2018/19. A2. Agree option for setting contract baselines for 2018/19. A3. Negotiation of contract baselines for 2018/19 incorporating 2017/18 plan/outturn, growth and impact of interventions. A4. Agree models for alternative contract forms to be shadow run in 2018/19 A5. Create finance and activity schedules that support the shadow running od the alternative contract forms. A1. 30.11.2017 A2. 23.03.2018 A3. 23.03.2018 A4. 01.07.2018 A5. 01.07.2018 A1. Plans submitted to STP finance group in November 2017. A2. Options being refreshed following issue of national planning guidance. A3. Negotiations are underway with completion targeted in line with national timetable. A4. Work is progressing but needs additional capacity to put into place shadow proposals for 2018-19. A5. Open book approach to provider cost profiles agreed and work is underway to provide the information. 3 3 9 High JCC 18 Paul Sinden, NCL Director of Performance Reducing the system financial NCL is a system in deficit. One of the aims of our Sustainability and Transformation Plan is to deliver financial recovery and maintain and sustainable health and care system. The STP sets out the challenges to financial recovery from demographic and demand trends. (Threat) Cause: if our plans do not deliver financial balance Effect: There is a risk that additional savings plans will need to be developed that have a greater impact on service delivery and access than current plans, and the local system comes under greater scrutiny from regulators. C1. STP finance meeting established that has a common view of system deficit C2. Collaborative approach to contracting round for 2017/18 and 2018/19 C3. Work on alternative contract forms for future years to support cost reduction C4. Monthly reporting cycle and monitoring C5. Working groups established for areas of pressure and with scope for cost reduction - estates, continuing healthcare, demand management etc. C6. Iterative CCG QIPP plans C1. Meeting papers and minutes from STP Average finance group C2. Contract documentation; notes from STP finance group. C3. Notes from acute contract modelling group C4. Reports C5. Meeting notes C6. Reports. 4 5 20 Very CN1. Identify opportunities for yearend settlements with providers to allow planning certainty and focus on cost reduction CN2. Identification of further savings opportunities for the system CN3. Ensure mobilisation of STP and local interventions (see JCC 10) CN1. Quarter one reconciliation process. Both CCGs and providers under financial pressure CN2. CCG finance reports - risks outweigh opportunities in 2017/18 CN3. See JCC10 A1. Finalise quarter one reconciliation process to identify opportunities for yearend settlements A2. Continue to identify further savings opportunities A3. 2081/19 planning round to set contract baselines for 2018/19 A4. Greater alignment of CCG QIPP and provider cost improvement programmes (CIP) for 2018/19 A1. 31.01.2018 A2. 31.03.2018 A3. 23.03.2018 A4. 31.01.2018 A1. Action completed. A2. Work is on-going. Opportunities are being developed through STP finance group and locally by CCGs A3. Process for planning round agreed through STP finance group and work is on-going. A4. QIPP/CIP meeting held in January 2018. 4 4 16 Very 193 of 255

ID Director Objective Risk Controls in place Evidence of Controls JCC 18 Performance deficit in line and Acute with planning Impact: Delivery of our STP developments is slowed Commissioning assumptions down and impact reduced. Greater local resource is taken up with assurance processes Overall Strength of Controls in Place Rating (Current) Likelihood (Current) Consequence 4 5 20 Risk level (Current) high Controls Needed Evidence of Controls Needed Actions Action Completion Date Update on Actions Likelihood (Target) Consequence (Target) Rating (Target) 4 4 16 Risk level (Target) high JCC 20 18-week Paul Sinden, NCL Director of Performance and Acute Commissioning referral-totreatment waiting time standard is met Delivery of referral-to-treatment (RTT) waiting time standard (Threat) Cause: There may be insufficient capacity within the system, and inefficiencies along pathways. Effect: There is a risk that the system may be unable to cope with the level of demand and has limited resilience to unexpected events. Impact: This may result in people not receiving treatment within 18 weeks of referral from their GP with potential adverse impact on their health outcome. C1. Contract governance arrangements established to C1. Meeting papers and notes. cover performance. C2. Agreed remedial action plan C2. Remedial action plan agreed with UCLH. C3. STP Project Initiation Documents (PIDs) C3. Planned Care work stream considering demand C4. Draft remedial action plan management schemes to support RTT delivery including Clinical Advice and Navigation. C4. Remedial action plan received from Royal Free London but with recovery of the waiting time standard targeted by August 2018. CCGs and NHS Improvement are challenging the Trust for a faster recovery. Average 4 4 16 Very High CN1. Receipt of Royal Free London remedial action plan CN2. Build more effective early warning system for long waits CN3. Development of planned care initiatives in the STP to support delivery of elective pathways CN4. Agreement of contract terms including tariff for Clinical Advice and Navigation. CN5. Ensure payment for waiting list backlog consistent with marginal rates set in the contract CN6. Understand impact of winter planning mutual aid on elective waiting time performance CN1. Plan; CN2. Growth in long waits including waits over 52 weeks (for which clinical harm reviews are undertaken) CN3. STP service developments offset demographic growth CN4. Clinical Advice and Navigation requires a different tariff to outpatient referral CN5 Under performance in 2017/18 due to backlog recouped at marginal rate, pay for backlog clearance at marginal rate if falls into 2018/19 CN6. Trust plans to free-up clinical capacity from elective pathways to support winter pressures A1. Continue to work with UCLH and Royal Free London on delivery of remedial action plans A2. Continue to work with providers to ensure sustainable delivery including work through the STP A3. Develop activity plans for 2018/19 for sustainable delivery A4. Develop tariff arrangements for Clinical Advice and Navigation A1. 31.03.2018 A2. 30.11.2017 A3. 23.03.2018 A4. 23.03.2018. A1. Updated Remedial Action Plan received from Royal Free London in March 2018. Continuing to monitor remedial action plans through contract meetings. A2. Action completed. Development of planned care initiatives for 2018/19 are completed. A3. Development of activity plans for 2018/19 underway taking into account national planning guidance that waiting lists should be maintained at current levels as a minimum. A4. Draft tariff agreed by commissioners which will be shared with providers. 3 3 9 High 194 of 255

NCL Risk Register April 2018 ID Director Objective Risk Controls in place Evidence of Controls Overall Strength of Controls in Place Rating (Current) Likelihood Consequence Risk level (Current) Controls Needed Evidence of Controls Needed Actions Action Completion Date Update on Actions Risk level (Target) Rating (Target) Likelihood (Target) Consequence NCL Risk Register Delivery of the Transformation Agenda (Threat) C1. Clinical leaders are in place across workstreams; C1. Terms of reference and project documentation; Average CN1. On-going work to link to new CCG operating models is in progress. CN1. Papers, Standing Operating Procedures; A1. Continue to work with CCGs on linking CCG operating models to STP A1. 14.02.2019 A1. Alignment on QIPP is completed. C2. NCL wide Health and Care Cabinet established to oversee plans; C2. Papers; CN2. Scope and develop provider focussed efficiency workplan; CN2. Provider focussed delivery plan; plans. A2. 01.04.2018; Alignment on risk management is Cause: If the STP does not have sufficient clinican and political C3. Recruitment to STP programme team is in progress; C3. Job adverts and employment contracts; CN3. Complete recruitment to STP programme team. CN3. Employment contracts; A2. Scope and develop provider focussed efficiency workplan; A3. 01.09.2018; underway; support and suitable capacity and resources C4. QIPP Planning processes in NCL aligned with STP; C4. Finance reports, CCG QIPP plans. CN4. Strengthen Health and Care Cabinet and link back to partner CN4. Refreshed Terms of Reference and communications plans; A3. Complete recruitment to STP programme team; A4. 30.05.2018; A2. SRO appointed and areas of C5. On-going senior enagement with local councillors and with the C5. Meeting papers. organisations CN5. Benefit tracker. A4. Revise terms of reference for Health and Care Cabinet; A5. 30.05.2018; scoping chosen; Effect: There is a risk that the STP will not deliver the expect Joint Health and Overview Scrutiny Committee C6. Terms of reference and meeting papers. CN5. Improve tracking of benefits across programmes. A5. Develop communications plan; A6. 30.05.2018 A3. 80% posts recruited to NCL 1 Successful financial or quality benefits and that services are not appropriately Will Huxter, NCL delivery of the integrated Director of STP Strategy transformation Impact: This may result in a system wide financial deficit and agenda deterioration in clinical quality which will negatively impact on patient care and reputational damage. C6. STP programme infrastructure in place including programme C7. Programme delivery plans, notes and minutes from meetings; board with senior representation from parter organisations and a C8. Governing Body papers; sector wide finance group; C9. Business case and project plan papers; C7. Robust planning process in place including regular reviews with C10. Employment contracts; NHS England and NHS Improvement; C11. Documents and papers. C8. Commissioning intentions; 4 3 12 High A6. Develop new programme highlight reports containing benefits tracker. substantively; A4. Terms of reference under review; A5. Communication manager recruitment in progress; A6. A review of this is in progress. 4 2 8 High C9. Service business cases and project plans; C10. CCG commissioning teams and Provider teams in place; C11. Clinically led STP delivery plans in place. Sustainability of Fragile Services (Threat) C1. NCL Joint Commissioning Committee in place which considers C1. Terms of reference and committee papers; Average CN1. Strengthened oversight of totality of provider contracts: CN1. Completed register of contracts, named leads; A1. Development of contract registers A1. 30.06.2018 A1. CCGs developing contract registers issues of system stability; C2. Minutes and notes of programme board meetings; CN2. Centrally held registers of contracts in each CCG; CN2. Completed register of contracts; A2 Identification of fragile services A2. 30.09.2018 and identifying small contracts rolled Cause: If the STP does not recognise the need for system stability C2. Relevant STP programme boards feed into service plans where C3. Stuffing structure and employment contracts; CN3. Overview of fragile services CN3. Notice from providers on service cessation for unsustainable forward year-on-year NCL 2 across services and providers appropriate; Paul Sinden, C3. CCGs have commissioning teams in place; Director of Maintaining Effect: There is a risk that smaller and fragile services become C4. Governing Bodies focus on issues when they arise; Performance System Stability unsustainable C5. CCG commissioning intentions; and Acute C6. Commissioners feed into development of workstream plans. Commissioning Impact: This may result in disruption to patient services and system C4. Governing Body and committee meeting papers and minutes; C5. Document; C6. Minutes and notes of programme board meetings. 3 3 9 High services. A2. STP planned care workstream identifying fragile and at-risk services in providers 3 2 6 Moderate instability. Failure to Develop an Effective STP Estates Strategy C1. STP Estates Board established; C1. Terms of Reference, meeting papers and notes; Average CN1. Develop STP estates strategy CN1. Estates Strategy paper; A1. Develop draft STP estates strategy for engagement with key A1. 30.07.2018; A1. Initial draft NCL estates workbook C2. STP SRO appointed; C2. Papers and notes of meeting; CN2. Ensure appropriate link between STP Estates Board and NCL CCG CN2. Governance chart, Governing Body papers and reports. partners; A2. 31.03.2018 completed system engagement Cause: If the STP partners do not develop an effective estates C3. Working with STP partners, regulators and the London Estates C3. E-mails, papers and notes. Governing Bodies. A2. Establish appropriate governance arrangements for the STP Estates underway with next draft due 7.2018 strategy for the STP which takes into account the resources within Board to understand the key objectives. Board A2. Strategy outlines proposed Terms the system and the current limitations of national legislation of Reference and governance. Effect: There is a risk that the Estates Strategy does not deliver the NCL 3 Development of most effective use of resources and impacts on services and staff Simon Goodwin, an Effective STP NCL CCGs CFO Estates Strategy Impact: This may result in wasted resources, opportunity costs, reputational damage and difficulties in recruiting and retaining high 3 3 9 High 3 2 6 Moderate quality staff. Failure to Effectively Engage with Patients and the Public (Threat) C1. STP governance structure which includes significant clinical and C1. STP plan; Average CN1. Recruit to Head of STP Communications role; CN1. Employment contract; A1. Recruit Head of STP Communications A1. 01.09.2018; A1. A1. Head of Ccomms due to start public oversight; C2. Papers and minutes of meetings; CN2. STP communications and engagement plan; CN2. Finalised STP communications and engagement plan. A2. Draft STP Communcations and Engagement Plan. A2. 30.05.2018 in May 2018; Cause: If the STP partner organisations do not effectively engage C2. Health and Well Being Boards; C3. Papers and minutes of meetings; A2. This will begin once the Head of with patients and the public as part of the STP process C3. Joint Health Overview and Scritiny Committee; C4. Papers and minutes of meetings; STP Communications is in role. C4. CCG Governing Bodies; C5. Papers and minutes of meetings; Effect: There is a risk that the STP process is not properly C5. Provder Board of Directors and Council of Governors where C6. Papers and minutes of meetings; NCL 4 Helen Pettersen, Effective NCL CCGs Engagement Accountable with Patients Officer and the Public understood by patients, the public and their representatives causing appropriate; them to disengage C6. Local Councils and Councillors; C7. NCL Advisory Board including councillors, Healthwarch and the Impact: This may result in service design not taking proper account Chairs of STP partner organisations; of the needs of local people, reputational damage and a blcokage to C8. Health and Care Cabinet with extensive clinical leadership; C7. Papers and minutes of meetings; C8. Papers and minutes of meetings; C9. Contracts of employment, meeting papers and notes; C10. Employment contracts. 4 3 12 High 4 2 8 High integrated services. C9. CCGs and Providers have their own communications and engagement teams and local patient and public engagement mechanisms and meetings; C10. Named Communications Lead in each CCG. Purdah Period and the Impact of Local Elections (Threat) C1. Continued work with the Joint Health Oversight and Scrutiny C1. Papers and minutes of meetings; Average CN1. An STP induction programme CN1. Register of attendance, induction pack; A1. Create STP indiction pack; A1. 03.05.2018; A1. Action in progress; Committee; C2. Papers and minutes of meetings; CN2. Ensure clearer narrative between STP programmes and postive CN2. Communications; A2. Develop KPIs for workstreams which demonstrate positive impact A2. 03.05.2018; A2. Action in progress; Cause: If there is an inability for decision making at the local C2. Continue to work with local authroity partner organisations; C3. Papers and minutes of meetings; impact on local people; CN3. STP Communications and Engagement Plan document; on local people; A3. 30.05.2018; A3. This in being developed; Councils due to the Purdah period or if there is signficant change of C3. Continue to work with and strengthen relationships with local C4. Papers and minutes of meetings, communications, e-mails. CN3. STP Communications and Engagement Plan; CN4. E-mails and correspondence; A3. Draft STP Communcations and Engagement Plan; A4. 04.05.2018 A4. This will be completed after the policial leadership and direction of travel due to local council councillors; CN4. Quickly build relationships with new local councillors; CN5. E-mails, correspondence and papers. A4. Identify and make contact with new councillors after local elections results of the local elections are elections in 2018 C4. Continue to effectively engage. CN5. Involve existing and new local councillors in on-going development in 2018; announced. NCL 5 Helen Pettersen, Achievement of Effect: This is a risk that the Council cannot make key decisons as an NCL CCGs STP Year 2 STP partner organisation and/or that a change in personnel and Accountable Objectives policy within one of more local councils Officer 4 3 12 High of STP. 3 3 9 High Impact: This may result in a delay in the implemntation of the STP workstreams and/or the need to develop and strengthen new relationships to preservice continuity of delivery. Lack of Clarity on STP and NCL CCG Governance Arrangements C1. STP Head of Programme Management in place; C1. Employment contract; Average CN1. STP Communications and Engagement Plan; CN1. STP Communications and Engagement Plan document; A1. Draft STP Communcations and Engagement Plan; A1. 30.05.2018; A1. This is being developed; (Threat) C2. Interim NCL Head of Governance and Risk in place for the NCL C2. Employment contract; CN2. Recruit to Head of STP Communications role; CN2. Employment contract; A2. Recruit Head of STP Communications; A2. 01.09.2018; A2. Head of Communications due to CCGs; C3. STP Plan, structure chart and papers and minutes of meetings; CN3. A document clearly outlining STP governance and how it links with CN3. Governance document. A3. Create document setting out STP governance and how its links with A3. 30.04.2018 start in May 2018; Cause: If there is a lack of clarity on STP and NCL CCGs' governance C3. STP governance structure in place; C4. Governance documentation, structure charts, papers and STP partners' governance structures; CN4. Contracts of employment. STP partner organisations' governance structures. A4. 30.06.2018 A3. This work is due to begin. arrangements; C4. CCG and Provider organisations' governance structures in place; minutes of meetings; CN4. Recruitment to all governance and Board Secretary posts on NCL A4. Complete recruitment to NCL CCG Corporate Services governance A4. Board Secretaries recruitment C5. STP website containing STP structure and minutes of STP C5. Webiste; CCG Corporate Services structure. roles. completed. Interim NCL Risk Manager Effect: There is a risk of confusions as to where decisions are made Programme Delivery Board and Health and Care Cabinet meetings; C6. Document. is in role and interviews are being held NCL 6 Will Huxter, NCL Ensuring and that decisions are not made in the correctly or at all C6. STP governance handbook in place. CCG Director of Effective Strategy Decision Making Impact: This may result in decision freeze or in decisions being made ultra vires which may result in signficant delay in delivering 3 3 9 High for interim Governance Lead. 2 2 4 Moderate integrated services due to an inability to act or legal challenge. 195 of 255

NCL 7 Failure to Deliver the Digital Agenda Across the STP (Threat) C1. Ditigal Programme Board in place; C1. Terms of Reference, meeting papers; Average CN1. STP Digital Strategy; CN1. Digital Strategy paper; A1. Develop Digital Strategy; A1. 30.03.2019; A1. This work is due to begin; C2. Digital road map between STP partner organisations; C2. Terms of Reference, meeting papers; CN2. Clear digital governance structure; CN2. Digital governance structure paper; A2. Continue to develop HIE and PHM Delivery Plan; A2. 30.05.2018; A2. This work is being developed; Cause: If the STP partners do not deliver the digaital agenda across C3. NCL IG Group in place; C3. Terms of Reference, meeting papers; CN3. Clear differentiation between commissioner and provider digital CN3. Agreement between STP partner orgsnisations showing clear A3. Develop Digital governance structure; A3. 30.05.2018; A3. This work is being developed; the STP; C4. Health Information Exchange ('HIE') delivery plan and Population C4. Papers; roles and responsibilities. responsibilities. A4. Develop agreement between STP partners on responsibilities; A4. 01.06.2018; A4. This work is due to begin; Health Management ('PHM') delivery plan being developed; C5. Minutes from February 2018 STP Delivery Board. A5. HIE and PHM delivery plan to be presented to May 2018 STP A5. 30.05.2018 A5. PHM delivery plan is being Effect: There is a risk that the STP partners will not be able to deliver C5. Priorities for 2018-19 agreed with SRO being Health Information Delivery Board. drafted. the Five Year Forward View and the underlying digital infrastructure Exchange ('HIE') and population health management. Will Huxter, NCL Delivery of the CCG Director of STP Digital Strategy Agenda such as integrated ditigal care records and will be unable to deliver the required QIPP savings Impact: This may result in a negative impact on investments across 4 3 12 High 3 2 6 Moderate the STP partners, a negaitve impact on the quality of patient care, reputational damage and an inability to meet the required national targets. Recruitment and Retention a High Performing Workforce (Threat) C1. STP is developing priorities for key clinical and staff providing C1. Papers; Strong CN1. Develop NCL Organisational Development strategy; CN1. NCL Organisational Development strategy document; A1. Develop NCL Organisational Development strategy; A1. 30.08.2018; A1. This work is due to begin; care; C2. Employment contracts; CN2. Develop specific workforce strategy/plans for each CCG which CN2. Strategy/plan documents; A2. Develop specific workforce strategies/plans for each CCG; A2. 30.08.2018; A2. This work is due to begin; Cause: If the NCL CCGs are unable to recruit and retain a high C2. NCL CCG wide Senior Management Team in post; C3. Employment contracts; includes talent management and succession planning; CN3. Strategic plan document; A3. Develop organisational development strategic plan; A3. 30.08.2018; A3. This work is due to begin; performing workforce; C3. Chief Operating Officer for each CCG in post; C4. Job adverts, employment contracts; CN3. Develop organisational development strategic plan; CN4. Equality, Diversity and Inclusion Strategy document; A4. Develop Equality, Diversity and Inclusion Strategy for 2018-19 ; A4. 30.05.2018; A4. This was is being developed; C4. Chief Operating Officers are recruiting to vacant posts on the C5. Papers, communications; CN4. Develop Equality, Diversity and Inclusion Strategy for 2018-19 ; CN5. Employment contract. A5. Continue to recruit to HR and Organisational Developlment roles. A5. 28.04.2018 A5. The HR team has been fully Effect: The NCL CCGs will be unable to deliver their stategic establishment; C6. Papers; CN5. Complete HR recruitment. recruited to with all team members objectives and operational goals; C5. NCL SMT are fostering a culture of openness and transparency; C7. Results paper and plans; being in place by end of June 2018. C6. Executive leadership development is under way; C8. Employment contracts; Recruitment for the Organisational NCL 8 Ian Porter, NCL Recruit and CCG Director of Retain a High Corporatre Performing Servces Workforce Impact: This may result in a negivtive impact on the delivery of CCG C7. NHS Staff Survey and acting on the results; C9. Job adverts and Job Descriptions; workstreams, integrated care and patient services. C8. NCL HR Team to support the NCL SMT and CCG Chief Operating C10. Policy documents; Officers; C11. Papers, communications; C9. Recruiting to NCL HR roles; C12. Meeting papers and notes; C10. NCL wide HR policies; C13. Papers. 3 2 6 Moderate Development roles is under way. 2 1 2 Low C11. Increased focus on Organisational Development; C12. HR and OD groups operating locally in some CCGs and are being developed for all CCGs; C13, Equality, Diversity and Inclusion work is being developed across NCL; Delivering Financial Balance Across NCL CCGs (Threat) C1. Each CCG has QIPP schemes in place and delivery plans; C1. QIPP plans and papers; Average CN1. Develop and implement a 2018-19 budget to offset potential CN1. Agreed budgets and papers; A1. Develop and agree the 2018-19 budgets; A1. 30.04.2018; A1. 2018-19 budget planning is C2. QIPP planning and delivery is overseen and scrutinised by C2. Governing Body and committee papers and minutes; unmitigated financial risks within each CCG; CN2. In year QIPP moniroing reports. A2. Implent 2018-19 QIPP plans. A2. 31.03.2019 underway; Cause: If the five CCGs in North Central London fail to deliver their Governing Bodies and relevant committees; C3. Meeting papers, minutes and notes; CN2. Implement 2018-19 QIPP plans. A2. This will start at the beginning of QIPP targets and achieve financial balance by the end of the financial C3. NCL Senior Management Team are QIPP focussed; C4. Contracts of employment; the 2018-19 financial year. year C4. QIPP managers are in role; C5. Review outcomes document; C5. Deloitte review of QIPP completed; C6. STP QIPP plans, meeting notes and minutes; Effect: There is a risk that the NCL CCGs will fails to meet the C6. CCGs working with providers through the STP to deliver QIPP C7. Contracts with providers; NCL 9 Achiement of collective NHS England control total. Simon Goodwin, Finance Balance NCL CCGs CFO Across NCL CCGs Impact: This may result in one or more CCGs being placed under legal directions or special measures, destbilisation of one or more savings; C7. Contractual levers and sanctions; C8. Addtional strategic QIPP capacity in place; C9. Single NCL CFO in place; C8. Contract for services; C9. Employment contract; C10. Plans; C11. Papers; 4 5 20 Veery High 4 3 12 High CCGs, a negative impact on the local health economy and loss of C10. Financial planning undertaken at NCL level using consistent C12. Papers and minutes of meetings. influence of quality of patient care. methology; C11. NCL finance leads meet on a monthly basis; C12. CCG Finance and Performance Committees (and equivalent) CSU In-Housing of Services (Threat) C1. Senior Management Team with a high degree of experience and C1. Employment contracts. Strong CN1. Business case for NHS England to be developed. CN1. Business case a formal part of process to in-house CSU services; A1. Continue to implement the project plan; A1. 01.07.2018 A1. Weekly project team meetings are expertise in CSU contracting. C2. Service Agreement. CN2. Business case to be approved by NHS England. CN2. Approval from NHS England required before HR consultation A2. Draft the business case for NHS England; A2. 28.02. 2018 held and going to plan; Cause: If we do not manage the in-housing of the contract team from C2. Programme Director in place; C3. Minutes and papers of meetings. CN3. HR engagement process; process can begin. A3. Present the business case to NHS England; A3. 30.04.2018 A2. Draft business case circulated; NELCSU successfully C3. Working Group in place with Governing Body oversight; Successful inhousing of the C4. Project Plan in place. Effect: There is a risk that business continuity is disrupted which may C5. Contingency for additional support if needed. multidisciplinary Paul Sinden, have a significant negative impact on services, staffing, C6. Signed SLA in place for 2017/18 and 2018/19 as a baseline NCL Director of organisational stability, finance, performance, and contract delivery. contract team NCL 10 Performance from North East and Acute Impact: This may result in a reduction in contract delivery. an London Commissioning increase in costs, downturn in performance, reputational damage Commissioning and a potential negative impact on patient services. Support Unit C4. Project plan document. C5. WAP Process. C6. Signed service level agreement 4 2 8 High CN4. Communications and engagement plan. A4. Develop supporting HR engagement process to start on approval of A4. 30.04.2018 business case by NHS England; A5. 30.04.2018 A5. Development of communications and engagement plan to support the HR process; A6. Continue to refine stranded costs included by NELCSU in the business case. A3. Business case is on track for submission by revised target date; A4. Development of HR process underway; A5. Plan in development; A6. Negotiations overseen by weekly project group meeting. 1 2 2 Low (NELCSU) 196 of 255

Risk Scoring Key This document sets out the key scoring methodology for risks and risk management. 1. Overall Strength of Controls in Place There are four levels of effectiveness: Level Criteria Zero The controls have no effect on controlling the risk. Weak The controls have a 1-60% chance of successfully controlling the risk. Average The controls have a 61 79% chance of successfully controlling the risk Strong The controls have a 80%+ chance or higher of successfully controlling the risk 2. Risk Scoring This is separated into Consequence and Likelihood. Consequence Scale: Level of Impact on the Objective Descriptor of Level of Impact on the Objective Consequence the Objective 0-5% Very low impact Very Low 1 6-25% Low impact Low 2 26-50% Moderate impact Medium 3 51 75% High impact High 4 76%+ Very high impact Very High 5 Likelihood Scale: Level of Likelihood the Risk will Occur Descriptor of Level of Likelihood the Risk will Occur for Likelihood the Risk will Occur 0-5% Highly unlikely to Very Low 1 occur 6-25% Unlikely to occur Low 2 26-50% Fairly likely to occur Medium 3 51 75% More likely to occur High 4 than not 76%+ Almost certainly will Very High 5 occur Consequence Score Likelihood Score 197 of 255

3. Level of Risk and Priority Chart This chart shows the level of risk a risk represents and sets out the priority which should be given to each risk: LIKELIHOOD CONSEQUENCE Very (1) Low Low (2) Medium (3) High (4) Very High (5) 1 2 3 4 5 Very Low (1) 2 4 6 8 10 Low (2) 3 6 9 12 15 Medium (3) 4 8 12 16 20 High (4) 5 10 15 20 25 Very High (5) 1-3 4-6 8-12 15-25 Low Priority Moderate Priority High Priority Very High Priority 198 of 255

Appendix 2a: CRR Risk Tracker - 21 March 2018 2017/18 and 2018-19 Datix ID Risk description Key changes since last review Q1 Q2 Q3 Q4 Q1 APR MAY JUNE JUL AUG SEPT OCT NOV DEC JAN FEB MAR MAY Progress 5 CSU's inability to deliver key CCG functions in line with CCG performance and SLA arising from Capacity and capability of some CSU services. DMc 11/05/2018: Business Case to inform future inhouse services configuration is still under discussion with NHS England. Future update to be provided by NCL SMT Director of Performance, Planning and Primary Care to CCG Finance & Performance Committee. 8 8 8 8 8 8 8 8 8 8 8 8 8 53 Gaps in Complaints Service commissioned from NELCSU. AF 14/05/18: Current CSU complaints staff capability & performance issues being addressed by CSU AD for Patient Experience. To be kept under review 8 8 8 8 8 8 8 8 8 8 8 8 8 69 Inability of the CCG to report accurately and make effective decisions due to poor data quality following update of PAS system, delayed and/or incomplete information from Trusts and CSU data quality issues. AD 11/05/2018 - No change to risk score proposed. No 'new' data quality issues raised. Risk will be subject to review at next Finance Committee 8 8 8 8 8 8 8 8 8 8 8 8 8 236 Delays in treatment (RTT) leading to poor patient experience and potential for clinical harm. AF 11/05/2018: No change since last review 8 8 4 4 4 4 8 8 8 8 8 8 8 276 Risk to patient safety and patient experience arising from commissioned providers inability to meet performance targets on Healthcare Acquired Infections (HCAI). AF 11/05/2018: CCG will keep monitoring infection rates through CQRG and whenever is needed. 8 8 8 8 8 8 8 8 8 8 8 8 8 285 Lack of capacity within the CCG safeguarding team to deliver proactive safeguarding adults arrangements arising from a large (70+) number of Nursing and Residential homes in Enfield, the implications of the Care Act means the CCG is likely to require more internal resource to deliver its statutory duties. AF 02/05/18: Interim support has been extended. 8 8 8 8 8 8 8 8 8 8 8 8 8 295 Risk to patient safety and patient experience from exceeding expected standards for cancer waiting times for treatment at RFH. AF 11/05/2018: CCG will keep monitoring infection rates through CQRG and whenever is needed. 12 12 12 12 12 12 12 12 12 12 12 12 12 342 Risk to the delivery of Primary Care Transformation Programme DMc 11/05/2018 - The Federation is implementing Phase I of the Enfield Single Offer and the CCG is in the process of commissioning Phase II and Phase III services around the Care Closer to Home Agenda. The Federation has worked hard to engage with all 48 member practices. However, the Federation is still developing and will need further sustainability in order to offer a robust response to service development and delivery. 12 12 12 12 12 12 12 12 12 12 9 9 9 199 of 255

345 8.03.18 Enfield CCG had an interactive PPE event with local residents on 7 March 2018 which involved discussions on QIPP highlights for 2017/18 and areas to cover for 2018/19, primary care transformation achievements, care closer to homewhich services could ECCG commission to deliver in the community and a review of the iplato text message about primary care access. Risk that the CCG fails to demonstrate positive change on behalf of patients and residents in Enfield leading to stakeholder disillusionment, poor engagement and reputational damage.dmc 8 8 8 8 8 8 8 8 8 8 8 8 8 375 Risk of provider failure to maintain Safeguarding Children standards & reduce likelihood of harm to children & prevent system failures. AF 02/05/18: Quarter 3 report information was collated for Quality and Risk subcommittee in April 2018. 8 8 8 8 8 8 8 8 8 8 8 8 8 389 Insufficient community paediatrician capacity impacting on waiting times and other statutory duties VMc Risk 11/05/2018 No change since last review. A paper detailing impact and risks to go to the Clinical Commissioning Committee on the 30/05/2018 10 10 10 15 10 10 10 10 10 10 10 10 10 398 Access to CAMHS Tier 4 beds VMc 14/05/2018: No change since last review. 12 12 12 12 12 12 12 12 12 12 12 12 12 435 Increase in number of children waiting more than 13 weeks for an initial assessment for CAMHs. GMD 11/05/2018: There are 102 children waiting over 13 weeks for an initial assessment for CAMHS at BEH Mental Health Trust. The CCG has put into place a recovery plan and provided additional funding to address this issue. The risk has been escalated to the BAF for oversight whilst the recovery plan is taking effect and to demonstrate that the risk is being managed. 8 8 8 8 8 8 8 8 8 8 8 8 12 200 of 255

454 Lack of treatment options for children in the transforming care cohort, and commissioning capacity to implement guidance.vmc 11/05/2018 Additional capacity for the commissioning team being considered to support work on the Transforming Care agenda. other NCL commissioners interested in exploring the idea of a crisis/crash pad. 9 9 9 9 9 9 9 12 12 12 463 Risk to patient safety and experience due to notice given by NMUH Dermatology Contract. ME / RF 15/05/2018: This risk has been avoided and no longer exists as NMUH has confirmed they want to keep the contract whilst the CCG is reviewing its procurement options. The risk has been closed. 9 9 9 9 9 9 1 465 Personal Health Budgets (PHB) concern regarding safety of commissioned care meeting patient health needs. AF 11/05/2018: Current provider contract only extended for an additional 6 months. In the process of securing a new service provider to manage the interface between the CCG and people receiving Personal Health Budgets. 12 12 12 12 12 8 13 34 Failure to comply with the CCG's Policy and statutory guidance on Conflicts of Interest (COI) could result in potential for legal challenge to Commissioning decisions, reputational damage and potential conflicts of interest in commissioning decisions. NCL Director of Corporate Services. Mental Health Commissioning: Risk of financial exposure to high cost of out of area placements. Lack of appropriate community based facilities resulting in patients being inpatients for some years VMc 14/05/2018: Risk rating reviewed and reduced from 8 to 6. Removed from Corporate Risk Register to Directorate Risk Register. 14/05/2018: Systems and processes in place for review of patients so risk now reduced to moderate risk. Risk de-escalated from Corporate Risk Register to Directorate Risk Register. 12 12 12 12 12 12 12 12 12 12 12 8 6 9 9 9 9 9 9 9 9 9 9 9 9 6 59 397 Backlog of processing referrals within Enfield's Referral Service arising from the installation of new Personal Computers in Enfield CCG alongside the introduction of community clinics have resulted in a backlog of processing referrals. DMc PMS Reviews will impact core PMS funding which may impact on the delivery of patient services and destabilisation of practices. DMc 11/05/2018: Staffing levels are returning to normal but there are still two staff members on long term sick leave. Staff are working at weekends to help manage the backlog. 11/05/2018 - All new PMS contracts have been sent to practices and the Commissioning Intentions have been sent to all GMS and APMS practices. The CCG had an engagement meeting, with all practices invited, on the 8th May 2018. The aim is for all practices to sign by 31st May 2018 with new PMS contracts backdated to start on the 1st April 2018. 6 9 9 9 9 9 9 9 9 6 6 6 6 10 10 10 10 10 10 10 10 10 10 10 10 6 430 Risk of not finding appropriate accommodation within the timescales to relocate ECCG. DMc 16/05/18 : The CCG has agreed a five year lease for Holbrook House with a two year break clause. Risk reduced from 8 to 6 and the risk will be closed. 8 8 8 8 8 8 8 8 8 8 8 8 6 201 of 255

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MEETING: Governing Body Meeting in Public DATE: Wednesday 23 May 2018 TITLE: Agenda Item: 9.2 Delegation of Authority to the Audit Committee to approve the 2017/18 Annual Report and Accounts LEAD GOVERNING Deborah McBeal, Deputy Chief Officer and Director of Primary Care BODY MEMBER: AUTHOR & POSITION: Gail Hawksworth, Head of Communications and Engagement Enfield and Barnet CCGs CONTACT DETAILS: gailhawksworth@nhs.net Summary: 1.0 Requirement CCGs are legally required to publish an Annual Report and Accounts (ARA) document. NHS England has provided a template for CCGs to follow for 2017/18, which is largely unchanged from last year. We must submit, as a single document, a three part ARA: 1. The Performance Report, which must include an overview and a performance analysis. 2. The Accountability Report, which must include a Corporate Governance Report, Remuneration and Staff Report and a Parliamentary Accountability and Audit Report. 3. The Annual Accounts. 2.0 National and Local Timelines Date Actions April 2018 20 April Draft Annual Report to be ready for Audit Committee papers 20 April (noon) CCGs to submit: Draft annual report as approved by the Accountable Officer (and passed to appointed auditors for audit). A full copy of the draft Head of Internal Audit Opinion statement as issued by the CCG s internal auditors. To include a list of all audit reviews undertaken, and the level of assurance assigned to each review. Completed NAO disclosure checklist 2017/18 for draft submission 25 April Enfield CCG Audit Committee to review the draft Annual Report and send all changes to Head of Communications and Engagement by latest close of play on Friday 4 May 2018 203 of 255

May 2018 Friday 4 May Tuesday 8 May Enfield CCG s Audit Committee members to have sent their comments to Head of Communications and Engagement Comments to relevant leads for further review and updating of relevant sections. (Note: Monday 7 May is a Bank Holiday) 11 May All final comments received by Head of Communications and Engagement 18 May Final Annual Report and Accounts to be sent to Enfield CCG s Audit Committee 23 May Enfield CCG s Audit Committees sign off final Annual Report and Accounts (Note: Monday 28 May is a Bank holiday) Tuesday 29 May (noon) 30 May (5pm) CCGs to submit: Full audited and signed ARA, signed and dated by the Accountable Officer and appointed auditors, as one composite document. A full copy of the final Head of Internal Audit Opinion statement as issued by the CCG s internal auditors. Submitted a separate document. Summary version included in the ARA. Completed NAO disclosure checklist 2017/18 for final submission Regions to submit: Final assurance checklist as certified by the local Director of Commissioning Operations June 2018 By 15 June CCGs to publish their Annual Report and Accounts in full on their public website. September 2018 By 29 Sept CCGs should hold a public meeting at which their ARA should be presented. Member statement As part of our preparation and sign off of the annual report and accounts, whilst the Governing Body have delegated responsibility for the documentation to be signed off at the Audit Committee, each individual who is a member of the Governing Body at the time the Members Report is approved, is asked to confirm the following: so far as the member is aware, there is no relevant audit information of which the CCG s auditor is unaware that would be relevant for the purposes of their audit report the member has taken all the steps that they ought to have taken in order to make him or herself aware of any relevant audit information and to establish that the CCG s auditor is aware of it. Governing Body Members are asked to confirm they are happy to support this statement. 204 of 255

Supporting Papers: None. Recommended action: The Governing Body is asked to: DELEGATE authority for the approval of the final 2017/18 Annual Report and Accounts to the CCG Audit Committee; and NOTE Members response to the disclosure to Auditor s statement. Objective(s) / Plans supported by this paper: The Annual Report and Accounts applies to all Enfield CCG Objectives. Audit Trail: Summary timetable for the Annual Report and Accounts is given above. This information was presented to Directors on 20 February 2018 and then all information sent to relevant staff on 21 February 2018. The Engaging people and communities section of the Annual Report was sent to Patient and Public Engagement Committee s meeting on 3 May 2018 for noting. Patient & Public Involvement (PPI): Audit Committee membership includes lay members. The Patient and Public Engagement Committee also reports annually to the Audit Committee on its performance. Equality Impact Assessment: Not required. Risks: As outlined in the CCG s Board Assurance Framework and Risk Register. Resource Implications: None identified at present. 205 of 255

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MEETING: Governing Body Meeting in Public Agenda Item: 9.3 DATE: Wednesday 23 May 2018 TITLE: NCL Audit Committee in Common and Individual CCG s Audit Committees LEAD GOVERNING Karen Trew, Lay Member for Audit and Governance BODY MEMBER: AUTHOR & POSITION: Andrew Spicer, NCL Head of Governance and Risk CONTACT DETAILS: Andrew.spicer1@nhs.net Summary: This paper sets out revisions to the Terms of Reference for each CCG s audit committee and the NCL Audit Committee in Common. It also sets out the proposed membership and asks the Governing Body to approve these and delegate the power to appoint future members of the CCG s audit committee to the Chair of the Governing Body. Supporting Papers: 1. NCL Audit Committee in Common and Individual Audit Committees Terms of Reference. Recommended action: The Governing Body is asked to approve: 1. The amended Terms of Reference; 2. The membership of the CCG s audit committee; 3. The Chair and Vice Chair of the NCL Audit Committee in Common; 4. Delegation of the power to appoint members of the CCG s audit committee in line with the membership requirements set out in the Terms of Reference to the Chair of the Governing Body. Objective(s) / Plans supported by this paper: This report supports all of the CCG s strategic objectives. Audit Trail: This report builds on the work approved by Governing Bodies in November 2016 to support the development and delivery of their Sustainability and Transformation Plan and 207 of 255

integrated working arrangements. A report on the NCL Audit Committee in Common was presented to the Governing Bodies of Camden, Enfield, Haringey and Islington CCG in January 2018 and to the Barnet CCG Governing Body in March 2018. Patient & Public Involvement (PPI): This report is being presented to the Governing Bodies of the five CCGs in North Central London which include lay members and elected clinicians. In addition, the lay members for governance and audit in each of the five North Central London Clinical Commissioning Groups were consulted. Equality Impact Assessment: This report has been written in accordance with the provisions of the Equality Act 2010. Risks: This report helps to maximise the opportunities for strategic collaboration across the five North Central London Clinical Commissioning Groups and strengthens oversight and assurance of our internal control mechanisms. Resource Implications: This report if approved will: Reduce duplication of effort across the five North Central London Clinical Commissioning Groups; Reduce the amount of internal and external auditor resource needed to carry out effective scrutiny of our internal control mechanisms; Better deploy resources and increase expertise, effectiveness and learning through information, knowledge and skills sharing. Provide the flexibility to work together or individually when it best suits the needs of an effective audit function. Next Steps: If the recommendations in the report are approved the next step is to mobilise the NCL Audit Committee in Common with the first meeting due to take place in July2018. 208 of 255

NCL Audit Committee in Common and Individual CCG s Audit Committees Agenda Item: 9.3 Introduction This paper sets out revisions to the Terms of Reference for each CCG s audit committee and the NCL Audit Committee in Common. It also sets out the proposed membership and asks the Governing Body to approve these and delegate the power to appoint future members of the audit committee to the Chair of the Governing Body. Background In January and March 2018 the Governing Bodies of the five North Central London Clinical Commissioning Groups approved the harmonisation of their audit committee s Terms of Reference, approved the formation of an audit committee in common known as the NCL Audit Committee in Common, and approved Terms of Reference for each. However, membership of these committees had not been agreed and lay members requested some additional amendments to the Terms of Reference to strengthen the quorum requirements and clarify the importance of individual audit committees in terms of accountabilities. Terms of Reference The revised Terms of Reference contain the following amendments: Paragraph Amendment Reason 1.3, 5.1, 6.1, 7.1, 8.1, 9.1, 10.1, 10.2, 11.1, 11.2, 11.3 12.1, 13.1, 13.3 Minor amendments to wording. To emphasise the importance of individual audit committees and their accountabilities. 14.4 Inclusion of a paragraph setting out that the lay member for audit and governance from another NCL CCG will be appointed to the audit committee on a non-remunerated basis. 17.1, 17.2 Amended the quorum requirements so that at least one member of the audit committee must be from the respective CCG for a meeting to be quorate. 18.1, 18.2 Minor amendments to simplify the drafting. 31.2 Minor amendment so Terms of Reference are reviewed annually. To clarify to basis on which the lay member for audit and governance from another CCG is appointed onto the audit committee. This removes any risk of an audit committee being quorate without a member of the respective CCG being present. To make the Terms of Reference easier to read. To increase committee effectiveness and ensure ease of operations. Membership Under the agreed Terms of Reference the membership of each CCG s audit committee comprises of three people who are: 209 of 255

The CCG s Governing Body lay member for audit and governance; A Governing Body lay member for audit and governance from another NCL Clinical Commissioning Group; An additional member who is either: o A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or o A second Governing Body lay member for audit and governance from another NCL Clinical Commissioning Group who is a different person that that referred to above. In this regard the Governing Body is asked to formally appoint their members of their audit committee. The proposed membership of each audit committee is as follows: CCG CCG s Lay Member A Lay Member for Additional Member for Audit and Audit and Governance Governance from another NCL CCG Barnet Dominic Tkaczyk Karen Trew Ian Bretman Camden Richard Strang Dominic Tkaczyk TBC Enfield Karen Trew Adam Sharples TBC Haringey Adam Sharples Lucy De Groot TBC Islington Lucy De Groot Richard Strang TBC Governing Bodies are not asked to approve the membership of other CCG s audit committees. Chair and Vice Chair of the NCL Audit Committee in Common The Chair and Vice Chair of the NCL Audit Committee in Common are important as they act as convenors of the meeting and help ensure meetings run smoothly. The Chair and Vice Chair only have voting rights on the individual audit committees that they are appointed to. It is proposed that the Chair and Vice Chair of the NCL Audit Committee in Common are: Name Role CCG Adam Sharples Chair Haringey Dominic Tkaczyk Vice Chair Barnet The NCL Audit Committee in Common will review the Chairing arrangements after 12 months. When CCG audit committees meet individually the Chair shall be the Lay Member for Audit and Governance from that respective CCG. Delegation to the Governing Body Chair It is a requirement that the members of the audit committee are formally appointed by the Governing Body as set out above. To maximise operational flexibility, effectiveness and preserve current practices whilst ensuring that our governance processes remain robust Governing Bodies are requested to 210 of 255

delegate to the Chair of the Governing Body the power to appoint future members of the CCG s audit committee in line with the membership requirements set out in the Terms of Reference. Recommendations The Governing Body is asked to approve: The amended Terms of Reference; The membership of the CCG s audit committee; The Chair and Vice Chair of the NCL Audit Committee in Common; Delegation of the power to appoint members of the CCG s audit committee in line with the membership requirements set out in the Terms of Reference to the Chair of the Governing Body. 211 of 255

NCL Audit Committee in Common and Individual Audit Committees Terms of Reference 1. Introduction 1.1 The Governing Bodies of the five Clinical Commissioning Groups in North Central London ( NCL ) have each established their own audit committees to critically review and report to their respective Governing Body on the relevance and robustness of the governance and assurance processes on which each relies. 1.2 The five NCL Clinical Commissioning Groups are: NHS Barnet Clinical Commissioning Group ( Barnet CCG ); NHS Camden Clinical Commissioning Group ( Camden CCG ); NHS Enfield Clinical Commissioning Group ( Enfield CCG ); NHS Haringey Clinical Commissioning Group ( Haringey CCG ); NHS Islington Clinical Commissioning Group ( Islington CCG ). 1.3 The NCL Clinical Commissioning Groups are working together to form and operate with a common set of controls. To support this and provide strengthened oversight the NCL Clinical Commissioning Groups have agreed to hold their audit committees together at the same time, in the same place, with a common agenda and a common chair as a committee in common. This is known as the NCL Audit Committee in Common. 1.4 The NCL Clinical Commissioning Groups have also agreed to retain the flexibility for their individual audit committees to meet by themselves where doing so best achieves an effective audit committee function. 1.5 These Terms of Reference set out the membership, remit, responsibilities and reporting arrangements of both the individual Clinical Commissioning Group ( CCG ) audit committees and the NCL Audit Committee in Common. 2. Committees in Common 2.1 The following committees form the NCL Audit Committee in Common: NHS Barnet CCG Audit Committee; NHS Camden CCG Audit Committee; NHS Enfield CCG Audit Committee; NHS Haringey CCG Audit Committee; NHS Islington CCG Audit Committee. 3. Statutory Framework 3.1 The four key statutory requirements for Clinical Commissioning Group audit committees are: Provision Section 14(M) of the NHS Act 2006 (as amended) Section 14(1) of the Clinical Commissioning Group Regulations 2012 Section 14(2) of the Clinical Commissioning Group Regulations 2012 Requirement A governing body of a clinical commissioning group must have an audit committee The audit committee of a CCG Governing Body must have a chair, to be appointed by the CCG for a term to be determined by the CCG The chair of the audit committee must be a lay person who has qualifications, exertise or 212 of 255

Section 7(3) of Schedule 1A to the NHS Act 2006 (as amended) experience such as to enable the person to express informed views about financial management and audit. CCG Constitutions may include provision for the audit committee to include individuals who are not members of the governing body. 3.2 The individual audit committees and the NCL Audit Committee in Common are established in line with legislation and with the Constitutions of each of the NCL Clinical Commissioning Groups. 4. Role of the Committee 4.1 The role of the individual audit committees and the NCL Audit Committee in Common is to carry out the duties listed in sections 5 to 13 below. These apply regardless of whether the individual audit committees are meeting by themselves or together as part of the NCL Audit Committee in Common. 5. Integrated Governance, Risk Management and Internal Control 5.1 Each CCG s audit committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the CCG s activities that supports the achievement of its objectives. 5.2 In particular the audit committee will review the adequacy and effectiveness of: All risk and control related disclosure statements (in particular the annual governance statement), together with any accompanying Head of Internal Audit Opinion, external audit opinion or other appropriate independent assurances; The underlying assurance processes that indicate the degree of achievement of the organisation s objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements; The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and any related reporting and self-certifications; The policies and procedures for all work related to counter fraud and security as required by NHS Counter Fraud Authority; The policies and procedures for managing conflicts of interest; The policies and procedures for managing gifts and hospitality. 5.3 In carrying out this work the audit committee will primarily utilise the work of internal audit, external audit and other assurance functions, but it will not be limited to these sources. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk management an internal control, together with an indication of their effectiveness. These will be evidenced through the audit committee s use of an effective assurance framework to guide its work and the audit and assurance functions that report to it. 5.4 As part of its integrated approach the audit committee will have effective relationships with other key Governing Body committees so that it underpins processes and linkages. However, these other committees must not usurp the audit committee s role. 6. Internal Audit 213 of 255

6.1 Each CCG s audit committee shall ensure that there is an effective internal audit function that meets the Public Sector Internal Audit Standards 2013 and provides appropriate independent assurance to the audit committee, NCL Accountable Officer and Governing Body. This will be achieved by: Considering the provision of the internal audit service and the costs involved; Reviewing and approving the audit strategy, annual internal audit plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation as identified in the assurance framework; Considering the major findings of internal audit work (and management s response), and ensuring co-ordination between the internal and external auditors to optimise the use of audit resources; Ensuring that the internal audit function is adequately resourced and has appropriate standing within the organisation; Monitoring the effectiveness of internal audit and carrying out an annual review. 7. External Audit 7.1 Each CCG s audit committee shall review and monitor the external auditors independence and objectivity and the effectiveness of the audit process. In particular, the audit committee will review the work and findings of the external auditors and consider the implications and management s responses to their work. This will be achieved by: Considering the appointment and performance of the external auditors; Discussing and agreeing with the external auditors before the audit commences the nature and scope of the audit as set out in the annual plan; Discussing with the external auditors their evaluation of audit risks and assessment of the organisation and the impact of the audit fee; Reviewing all external audit reports, including the report to those charged with governance (before its submission to the Governing Body as appropriate) and any work undertaken outside of the annual audit plan, together with the appropriateness of management responses; Ensuring that there is in place a clear policy for the engagement of external auditors to supply non-audit services. 8. Other Assurance Functions 8.1 Each CCG s audit committee shall review the findings of other significant assurance functions, both internal and external to the CCG, and consider the implications for the governance of the CCG. 8.2 These will include, but will not be limited to, any reviews by Department of Health arm s length bodies or regulators/inspectors (for example, the Care Quality Commission, NHS Litigation Authority etc) and professional bodies with responsibility for the performance of staff or functions (for example, Royal Colleges, accreditation bodies etc). 8.3 In addition, the audit committee will review the work of other committees within the CCG, whose work can provide relevant assurance to the audit committee s own areas of responsibility. 9. Counter fraud 9.1 Each CCG s audit committee shall satisfy itself that the organisation has adequate arrangements in place for counter fraud and security that meet NHS Counter Fraud Authority s standards and shall review the outcomes of work in these areas. This will be achieved by: Considering the provision of the counter fraud service and the costs involved; 214 of 255

Reviewing and approving the counter fraud strategy, annual internal audit plan and more detailed programme of work, ensuring that this is consistent with the needs of the organisation; Considering the major findings of internal audit work and management s response; Ensuring that the counter fraud function is adequately resourced and has appropriate standing within the organisation; Monitoring the effectiveness of counter fraud and carrying out an annual review. 10. Management 10.1 Each CCG s audit committee shall request and review reports, evidence and assurances from directors and managers on the overall arrangements for governance, risk management and internal control. 10.2 Each audit committee may also request specific reports from individual functions within the organisation. 11. Financial reporting 11.1 Each CCG s audit committee shall monitor the integrity of the financial statements of its organisation and any formal announcements relating to its financial performance. 11.2 Each audit committee should ensure that the systems for financial reporting to the Governing Body, including those of budgetary control, are subject to review as to the completeness and accuracy of the information provided. 11.3 Each audit committee shall review the annual report and financial statements focussing particularly on: The wording in the annual governance statement and other disclosures relevant to the terms of reference of the Committee; Changes in, and compliance with, accounting policies, practices and estimation techniques; Unadjusted misstatements in the financial statements; Significant judgments in preparation of the financial statements; Significant adjustments resulting from the audit; Letters of representation; Explanations for significant variances; Ease of understanding of the contents for patients and the public. 12. Whistleblowing 12.1 Each CCG s audit committee shall review the effectiveness of the arrangements in place for allowing staff to raise (in confidence) concerns about possible improprieties in financial, clinical or safety matters and ensure that any such concerns are investigated proportionately and independently. 13. Reporting 13.1 Each CCG s audit committee shall report to the Governing Body on how it discharges its responsibilities. 13.2 The minutes of the audit committee s meetings shall be formally recorded by the Secretariat and submitted to the Governing Body as required. The Chair of the Committee shall draw to 215 of 255

the attention of the Governing Body any issues that require disclosure to the full Governing Body, or require executive action. 13.3 Each audit committee will report to the Governing Body at least annually on its work in support of the annual governance statement, specifically commenting on: The fitness for purpose of the assurance framework; The completeness and embeddedness of risk management in the organisation; The integration of governance arrangements; The appropriateness of evidence that shows the organisation is fulfilling regulatory requirements relating to its existence as a functioning business; The robustness of the processes behind the quality accounts. 13.4 The annual report should also describe how the audit committee has fulfilled its terms of reference and give details of any significant issues that the audit committee considered in relation to the financial statements and how they were addressed. 14. Membership 14.1 When the audit committees are meeting as the NCL Audit Committee in Common or as individual audit committees the membership of each audit committee is as follows: The CCG s Governing Body lay member for audit and governance; A Governing Body lay member for audit and governance from another NCL Clinical Commissioning Group; An additional member who is either: o A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or o A second Governing Body lay member for audit and governance from another NCL Clinical Commissioning Group who is a different person that that referred to in the second bullet point of section 14.1 above. 14.2 The membership requirements are summarised in Schedule 2. 14.3 Audit committee members may nominate deputies to represent them in their absence and make decisions on their behalf. 14.4 The lay member or members for audit and governance from another NCL Clinical Commissioning Group referred to in the second and third bullet points of paragraph 14.1 above shall be appointed on a non-remunerated basis to the audit committee by the relevant CCG s Governing Body. 14.5 The list of voting members is contained in Schedule 1. 15. Attendance 15.1 The individual audit committees and the NCL Audit Committee in Common shall have the following non-voting attendees: NCL Chief Finance Officer or a nominated deputy; Head of Internal Audit and internal audit representatives; External audit representatives; Local Counter Fraud Specialists; A representative from the NCL Corporate Services Directorate; A representative from North and East London Commissioning Support Unit, as required; Other directors and/or managers as appropriate; 216 of 255

Representatives from other organisations, as required. 15.2 The NCL Accountable Officer will be invited to attend an audit committee meeting at least once per year to discuss the process for assurance that supports the annual governance statement and the annual report and accounts. 15.3 The individual audit committees and/or the NCL Audit Committee in Common may meet privately with the internal and external auditors at their absolute discretion. 15.4 Non-voting attendees may nominate deputies to represent them in their absence. 15.5 The individual audit committees and/or the NCL Audit Committee in Common may call additional experts to attend meetings on a case by case basis to inform discussion. 15.6 The individual audit committees and/or the NCL Audit Committee in Common may invite or allow additional people to attend meetings as attendees. Attendees may present at meetings and contribute to the relevant discussions but are not allowed to participate in any formal vote. 15.7 The individual audit committees and/or the NCL Audit Committee in Common may invite or allow people to attend meetings as observers. Observers may not present at meetings, contribute to any discussion or participate in any formal vote. 15.8 The list of non-voting attendees is contained in Schedule 1. 16. Chair and Vice Chair 16.1 The NCL Clinical Commissioning Groups Governing Bodies have agreed that the Chair and Vice Chair of the audit committee shall vary depending on whether the audit committees are meeting as the NCL Audit Committee in Common or individually by themselves. 16.2 When the audit committees are meeting as the NCL Audit Committee in Common the Chair of the NCL Audit Committee in Common shall be a lay member for audit and governance from either Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG or Islington CCG. 16.3 When the audit committees are meeting as the NCL Audit Committee in Common the Vice Chair of the NCL Audit Committee in Common shall be a lay member for audit and governance from either Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG or Islington CCG. 16.4 The Chair and the Vice Chair of the NCL Audit Committee in Common shall be from different CCGs. 16.5 The Chair and Vice Chair of the NCL Audit Committee in Common shall be appointed upon the agreement of each of the audit committees comprising the NCL Audit Committee in Common. 16.6 When the audit committees are meeting individually by themselves the Chair shall be the lay member for audit and governance. The Vice Chair shall be another lay member. 16.7 The Chair and Vice Chair requirements are summarised in Schedule 2: 17. Quoracy 17.1 When the audit committees are meeting as the NCL Audit Committee in Common each audit committee comprising the NCL Audit Committee in Common must be quorate. Each audit committee is quorate when the following conditions are satisfied: 217 of 255

At least two members from the respective audit committee or their nominated deputies are present; and One of the two members present is from the audit committee s respective CCG. 17.2 When the audit committees are meeting individually by themselves for the meeting to be quorate the following conditions must be satisfied: At least two members or their nominated deputies must be present; and One of the two members present is from the audit committee respective CCG. 17.3 If the NCL Audit Committee in Common is not quorate the individual audit committees have the option of meeting as individual audit committees at their absolute discretion and as long as the quorum requirements contained in section 17.2 above are satisfied. The individual audit committees may decide to meet at the same time and in the same room as each other at their absolute discretion. 17.4 The quorum requirements are summarised in Schedule 2: 17.5 If any representative is conflicted on a particular item of business they will not count towards the quorum for that item of business. If this renders a meeting or part of a meeting inquorate a non-conflicted person may be temporarily appointed or co-opted to satisfy the quorum requirements. 18. Voting 18.1 Each CCG s audit committee shall vote and make decisions for their CCG only. A vote of one CCG s audit committee is not binding on another CCG s audit committee. 18.2 Each audit committee member shall have one vote with resolutions passing by simple majority. The lay member for audit and governance from the respective audit committee s own CCG or their nominated deputy shall have the casting vote on any resolution. 18.3 When the audit committees are meeting as the NCL Audit Committee in Common the Chair or Vice Chair of the NCL Audit Committee in Common may not participate in the vote of any individual audit committee unless he or she is a member of that audit committee. 18.4 The voting requirements are summarised in Schedule 2: 19. Decisions 19.1 The individual audit committees will make decisions within the bounds of their remit. 20. Authority and Access 20.1 The individual audit committees and the NCL Audit Committee in Common are Governing Body committees. They must act within the remit of these terms of reference and have no executive powers other than those specifically set out in these terms of reference. 20.2 The Head of Internal Audit, representatives of external audit and counter fraud specialists have a right of access to the Chair of the individual audit committees and the Chair of the NCL Audit Committee in Common. 20.3 The individual audit committees and the NCL Audit Committee in Common are authorised by the Governing Bodies to investigate any activity within these terms of reference. They are 218 of 255

authorised to seek any information they require from any employees or officers and all employees and officers are directed to co-operate with any request made in this regard. 20.4 The individual audit committees and the NCL Audit Committee in Common are authorised by the Governing Bodies to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if they consider this necessary. 21. Secretariat 21.1 The Secretariat to the Committee shall be provided by the NCL Corporate Services Directorate. 22. Frequency of Meetings 22.1 It is expected that the NCL Audit Committee shall meet four times per year. Whilst it is expected that most items of business are suitable for the NCL Audit Committee in Common there may be some items which are better suited to being presented to individual audit committees. Therefore, individual audit committees may meet as required. This is expected to be approximately once per year. 22.2 The NCL Audit Committee in Common and/or the individual audit committees may hold additional meetings as required. 23. Notice of Meetings 23.1 Notice of a meeting shall be sent to all members no less than 7 days in advance of the meeting. 23.2 The meeting shall contain the date, time and location of the meeting. 24. Agendas and Circulation of Papers 24.1 Before each meeting an agenda setting out the business of the meeting will be sent to every member no less than 7 days in advance of the meeting. 24.2 Before each meeting the papers of the meeting will be sent to every member no less than 7 days in advance of the meeting. 24.3 If a member wishes to include an item on the agenda they must notify the Chair via the Secretariat no later than 7 days prior to the meeting. The decision as to whether to include the agenda item is at the absolute discretion of the Chair. 25. Minutes and Reporting 25.1 The minutes of the proceedings of a meeting shall be prepared by the Secretariat and submitted for agreement at the following meeting. 25.2 Each individual CCG will comply with their own Governing Body s reporting requirements. 26. Conflicts of Interest 26.1 Conflicts of Interest shall be dealt with in accordance with the NCL Conflicts of Interest Policy and NHS England statutory guidance for managing conflicts of interest. The NCL Conflicts of Interest Policy is a master document containing the single conflicts of interest policy agreed 219 of 255

by each of the NCL CCGs together with a schedule setting out each CCG s local variations to that policy. 26.2 The individual audit committees and the NCL Audit Committee in Common shall have a Conflicts of Interest Register that will be presented as a standing item on the agenda. 27. Gifts and Hospitality 27.1 Gifts and Hospitality shall be dealt with in accordance with the NCL Conflicts of Interest Policy and NHS England statutory guidance for managing conflicts of interest. 27.2 The individual audit committees and the NCL Audit Committee in Common shall have a Gifts and Hospitality Register that will be presented as a standing item on the agenda. 28. Standards of Business Conduct 28.1 Members, attendees and/or observers must maintain the highest standards of personal conduct and in this regard must comply with: The law of England and Wales; The NHS Constitution; The Nolan Principles; The standards of behaviour set out in each NCL CCG Constitution; Any additional regulations or codes of practice relevant to the Committee. 29. Training and Information 29.1 It is the responsibility of each organisation referred to in section 1.3 above to ensure that their representatives are provided with appropriate training and information to allow them to exercise their responsibilities effectively. 30. Quick Reference Guide 30.1 A quick reference guide to the voting members, chair, vice chair, quoracy, voting methodology and casting votes of the individual audit committees and the NCL Audit Committee in Common can be found in Schedule 2. 31. Review of Terms of Reference 31.1 These Terms of Reference will be reviewed from time to time, reflecting experience of the individual audit committees and the NCL Audit Committee in Common in fulfilling its functions and the wider experience of CCGs in overseeing a common system of controls. 31.2 These Terms of Reference will be formally reviewed annually. These Terms of Reference may be changed or amended by mutual agreement of the individual audit committees and the NCL Audit Committee in Common and on being approved by each of the Governing Bodies of the NCL Clinical Commissioning Groups in accordance with their Constitutions. 220 of 255

Schedule 1 List of Members This schedule sets out the membership, attendees, Chair and Vice Chair of each individual audit committee and the NCL Audit Committee in Common. NCL Audit Committee in Common: The voting members of the NCL Audit Committee in Common are as follows: Committee Voting Members Name and Title Barnet CCG Audit Committee Barnet CCG Audit Committee Barnet CCG Audit Committee Lay member for audit and governance from Barnet CCG Lay member for audit and governance from another NCL Clinical Commissioning Group A person who is either: A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or A second lay member for audit and governance from another NCL Clinical Commissioning Group Dominic Tkaczyk Karen Trew Ian Bretman Camden CCG Audit Committee Camden CCG Audit Committee Camden CCG Audit Committee Lay member for audit and governance from Camden CCG Lay member for audit and governance from another NCL Clinical Commissioning Group A person who is either: A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or A second lay member for audit and governance from Richard Strang Dominic Tkaczyk 221 of 255

another NCL Clinical Commissioning Group Enfield CCG Audit Committee Enfield CCG Audit Committee Enfield CCG Audit Committee Lay member for audit and governance from Enfield CCG Lay member for audit and governance from another NCL Clinical Commissioning Group A person who is either: A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or A second lay member for audit and governance from another NCL Clinical Commissioning Group Karen Trew Adam Sharples Haringey CCG Audit Committee Haringey CCG Audit Committee Haringey CCG Audit Committee Lay member for audit and governance from Haringey CCG Lay member for audit and governance from another NCL Clinical Commissioning Group A person who is either: A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or A second lay member for audit and governance from another NCL Clinical Commissioning Group. Adam Sharples Lucy De Groot 222 of 255

Islington CCG Audit Committee Islington CCG Audit Committee Islington CCG Audit Committee Lay member for audit and governance from Islington CCG Lay member for audit and governance from another NCL Clinical Commissioning Group A person who is either: A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or A second lay member for audit and governance from another NCL Clinical Commissioning Group. Lucy De Groot Richard Strang Chair and Vice Chair of the NCL Audit Committee in Common Position Name and Title CCG Chair Adam Sharples Haringey Vice Chair Dominic Tkaczyk Barnet Individual Audit Committees: Barnet CCG Audit Committee The voting members of the Barnet CCG Audit Committee are as follows: Position Name Title Lay member for audit and Dominic Tkaczyk Governance from Barnet CCG Lay member for audit and Karen Trew governance from another NCL Clinical Commissioning Group A person who is either: A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the Ian Bretman 223 of 255

CCG Governing Body; or A second lay member for audit and governance from another NCL Clinical Commissioning Group Chair Lay Member for Audit and Governance at Barnet CCG Camden CCG Audit Committee The voting members of the Camden CCG Audit Committee are as follows: Position Name Title Lay member for audit and Richard Strang governance from Camden CCG Lay member for audit and Dominic Tkaczyk governance from another NCL Clinical Commissioning Group A person who is either: Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or A second lay member for audit and governance from another NCL Clinical Commissioning Group Chair Lay Member for Audit and Governance at Camden CCG Enfield CCG Audit Committee The voting members of the Enfield CCG Audit Committee are as follows: Position Name Title Lay member for audit and Karen Trew governance from Enfield CCG Lay member for audit and governance from another Adam Sharples 224 of 255

NCL Clinical Commissioning Group A person who is either: A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or A second lay member for audit and governance from another NCL Clinical Commissioning Group Chair Lay Member for Audit and Governance at Enfield CCG Haringey CCG Audit Committee The voting members of the Haringey CCG Audit Committee are as follows: Position Name Title Lay member for audit and Adam Sharples governance from Haringey CCG Lay member for audit and Lucy De Groot governance from another NCL Clinical Commissioning Group A person who is either: A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or A second lay member for audit and governance from another NCL Clinical Commissioning Group Chair Lay Member for Audit and Governance at Haringey CCG 225 of 255

Islington CCG Audit Committee The voting members of the Islington CCG Audit Committee are as follows: Position Name Title Lay member for audit and Lucy De Groot governance from Islington CCG Lay member for audit and Richard Strang governance from another NCL Clinical Commissioning Group A person who is either: A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or A second lay member for audit and governance from another NCL Clinical Commissioning Group Chair Lay Member for Audit and Governance at Islington CCG Attendees The non-voting attendees at the individual audit committees and the NCL Audit Committee in Common are: Position Name Title NCL Accountable Officer Ms Helen Pettersen NCL Accountable Officer NCL Chief Finance Officer Mr Simon Goodwin NCL Chief Finance Officer Head of Internal Audit and Mr Clive Makombera Internal Audit Representatives External Audit Representatives Local Counter Fraud Specialists A representative from the NCL Corporate Services Directorate A representative from North and East London 226 of 255

Commissioning Support Unit The roles referred to in the list of voting members and non-voting attendees above describe the members and non-voting attendees substantive roles and/or any successor equivalent roles only and not the individual title or titles of any member. Names and job titles are provided for information purposes only and may be updated as required without the need to formally amend the Terms of Reference. 227 of 255

Schedule 2 Quick Reference Guide No Meeting Voting Members Chair Vice Chair Quoracy Voting Methodology 1. Audit committee when meeting as part of the NCL Audit Committee in Common 2. Audit committee when meeting individually by itself and not as part of the NCL Audit Committee in Common. The Governing Body lay member for audit and governance. The lay Member for audit and governance from another NCL Clinical Commissioning Group A person who is either: A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or A second lay member for audit and governance from another NCL Clinical Commissioning Group. The lay member or members for audit and governance from another NCL Clinical Commissioning Group referred to above shall be appointed on a non-remunerated basis to the audit committee by the relevant CCG s Governing Body. The Governing Body lay member for audit and governance. The lay Member for audit and governance from another NCL Clinical Commissioning Group A person who is either: A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or A lay member for audit and governance from an NCL CCG The CCG s lay member for audit and governance A lay member for audit and governance from an NCL CCG but from a different CCG than the Chair Another member lay Two members from each of the five individual audit committees or their nominated deputies must be present. One member must be from the respective CCG. Each of the five individual audit committees must be present for the NCL Audit Committee in Common to be quorate. If the NCL Audit Committee in Common is not quorate the individual audit committees may decide to meet at the same time and in the same room as each other at their absolute discretion. Two members or their nominated deputies. One member must be from the respective CCG. Resolutions of each individual CCG s audit committee pass by simple majority. A vote of one CCG s audit committee is not binding on any other CCG s audit committee. Resolutions pass by simple majority. Casting Vote The audit committee lay member for audit and governance or their nominated deputy The audit committee Chair or their nominated deputy 228 of 255

A second lay member for audit and governance from another NCL Clinical Commissioning Group. The lay member or members for audit and governance from another NCL Clinical Commissioning Group referred to above shall be appointed on a non-remunerated basis to the audit committee by the relevant CCG s Governing Body. 229 of 255

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MEETING: Governing Body Meeting in Public DATE: Wednesday 23 May 2018 TITLE: Annual Report of the Use of the CCG Seal LEAD GOVERNING Dr Mo Abedi BODY MEMBER: Chair, Enfield CCG Governing Body AUTHOR & POSITION: Brenda Thomas, Board Secretary CONTACT DETAILS: Brenda.Thomas1@nhs.net Agenda Item: 9.4 Summary: The purpose of the report is to detail the use of the CCG Seal for the 2017/18 financial year. The Governing Body at its meeting on 24 January 2018, noted via the Chair s report that it will receive an annual report on the use of the CCG seal. Supporting Papers: None Recommended action: The Governing Body is asked to note the Annual Report of the use of the CCG Seal. Objective(s) / Plans supported by this paper: This report supports all of the CCG s strategic objectives. Audit Trail: None Patient & Public Involvement (PPI): N/A Equality Impact Assessment: N/A Risks: N/A Resource Implications: N/A Next Steps: None 231 of 255

1.0 INTRODUCTION ANNUAL REPORT ON THE USE OF CCG SEAL 1.1 Annex 3, Section 6 of the CCG s Constitution provides information in relation to the use of the CCG s Seal and authorisation of Documents. 1.2 Details of any sealing should be reported to the Governing Body in line with good governance principles. 1.3 The following individuals are authorised to authenticate the use of the Seal by their signature: a) the Chief Officer; b) the Chair of the Governing Body; and c) the Chief Finance Officer. 2.0 USE OF THE CCG SEAL 2.1 The table below details the use of the CCG Seal for 2017/18 SEAL REF. NUMBER DATE DESCRIPTION OF DOCUMENT BETWEEN SIGNATORIES 2017/18-01 20 December 2017 Holbrook House Lease Enfield CCG and HPUT A Limited & HPUT B Limited Simon Goodwin, Chief Finance Officer, NCL CCGs & John Wardell, Chief Operating Officer 3.0 RECOMMENDATION 3.1 The Governing Body is asked to note the use of the CCG Seal for the 2017/18 financial year. 232 of 255

Agenda Item: 10.1 MEETING: Governing Body Meeting in Public DATE: Wednesday 23 May 2018 TITLE: NCL Sustainability and Transformation Plan: Progress Report LEAD GOVERNING Will Huxter, Director of Strategy NCL CCGs BODY MEMBER: AUTHOR & POSITION: Richard Dale, Head of Programme Management, NCL STP CONTACT DETAILS: Richard.dale@nhs.net Summary: The following paper outlines the progress of the Sustainability and Transformation Plan (STP) in 2017/18, the priorities for 2018/19 and the links to local delivery. The paper includes successes, ways of working as details on the plans that relate to three priority areas of the STP, Urgent and Emergency Care, Planned Care and Health and Care Close to Home. It also outlines the proactive approach the programme will take to engage with staff and public. Supporting Papers: Presentation: Programme update and next steps. Appendix 1: STP plan on a page. Recommended action: The Governing Body is asked to: Note the progress of the STP over the past six months; and Note and support the priorities for 2018/19. 233 of 255

Objective(s) / Plans supported by this paper: Delivery of the priorities set out in the STP workstreams. Audit Trail: Enfield CCG Governing Body Meeting on 22 November 2017. Patient & Public Involvement (PPI): N/A Equality Impact Assessment: N/A Risks: As highlighted in the report. Resource Implications: As highlighted in the report. 234 of 255

Agenda Item 10.1 Programme update and next steps STP successes, next steps, priorities and links to local delivery 23 May 2018 Richard Dale Head of Programme Management for the STP 235 of 255

Contents Section North London Partners context 3 Ambitions of the STP 4 Key successes in 2017/18 5 Ways of working: System wide working Clinical input and leadership Capacity to facilitate change Aligning with local QIPP plans Overview of plans impacting acute providers: NCL-wide priorities Urgent and Emergency care Planned Care Health and Care close to home Patient and staff voice: Principles agreed with JHOSC What do we mean by engagement (ladder of engagement) Taking a proactive approach to engagement Next steps for the Programme in 2018/19 20 236 of 255 Slide 6 7 9 10 11 12 13 14 17 18 19

North London Partners context: 237 of 255 3

Ambitions of the STP Improve the health of the local population Ambition for the STP is built on existing CCGs, Local Authorities and Providers values and strategy Maximise care out of hospital Reduce health inequalities A partnership of the NHS and local authorities, working together with the public and patients where it s the most efficient and effective way to deliver improvements. 238 of 255

Key successes in 2017/18 In 2017 we have worked with our partners to engage with the public and begin to implement shared plans across to deliver improvements to health and care and spend money wisely. Some highlights of this include: Making it possible for residents to access GP services 8am-8pm through extended access in April 2017 Following capital investment of 1million by Camden & Islington Foundation NHS Trust, we opened the Women s Psychiatric Intensive Care Unit on 13th November 2017. This will ensure that women that require intensive care in NCL are not placed out of area as a first response to their crisis and need for intensive care. One of the first areas nationally to launch the new integrated urgent care model. This includes: Mental Health patients can now ring 111, and be transferred directly transfer to crisis team for advice and support. Enables clinical staff to get through to a clinical expert for urgent advice and support by dialing the appropriate number. Successful bid for enhanced mental health liaison services in A&E at University College Hospital in 2017/18, and North Middlesex University Hospital in 2018/19; Launched a specialist Perinatal mental health service for mums across North Central London, following a successful first wave bid for national funding; Made it quicker and safer for patients to get home from hospital by agreeing standard ways of working and working more effectively with social care. 239 of 255

System wide working Focusing on outcomes for local population and wider system, not on individual organisations/institutions Co-designing services with patients, providers, clinicians, CCGs and Local Authorities. Speeding up local implementation and spread of good practice through fastest first principle NHS provider organisations agreeing joint programme of work on productivity, over and above individual organisation savings plans (e.g. patient transport, facilities) CCG Commissioner Leads co-ordinating the co-design of services for improved outcomes and system efficiencies e.g. Enfield CCG leading work on Commissioning - inc. Colorectal, Gynaecology, Consultant to Consultant referrals [part of POLCE], Integrated Urgent Care and Children s Admission Avoidance As the STP covers the whole of North Central London, lead responsibility for scrutiny of the STP overall sits with the Joint Health Overview and Scrutiny Committee; 240 of 255

Clinical input and leadership across North London Partners Fundamental to development and implementation of every aspect of the STP Clinical Input into each workstream essential and SRO leadership across NCL CCGs Challenge and assurance of STP initiatives via Health and Care Cabinet (NCL CCG chairs and medical directors) Health and Care Cabinet (HCC) (includes MDs of all Trusts plus CCG Chairs) have approved overarching strategic delivery plans from which these PIDs are derived Programme boards for each of the STP workstreams have also endorsed plans Looking at systematic approach to quality improvement across all of the STP, with initial focus on Health and Care closer to Home 241 of 255

Clinical and senior leadership in place across North London Partners Clinical workstreams NCL Health and Care Cabinet: Richard Jennings and Jo Sauvage STP Clinical Leads and Co-Chairs Health and care Children and Prevention Planned care Mental Health Maternity closer to home young people NCL Programme Board and Advisory Board Input and membership of clinical working groups from across NCL CCGs, Providers and LAs Cancer Urgent and Emergency Care North London Councils Adult Social Care group Social Care Clinical leads Dr Karen Sennett (Islington) Dr Tom Aslan (Camden) Dr Richard Jennings, (Whittington) Dr Debbie Frost (Barnet) Dr Katie Coleman, (Islington) Borough based leads for each CCG Dr Vincent Kirchner (C&I) Dr Jonathan Bindman (BEH) Dr Oliver Anglin (Camden) Professor Donald Peebles Mai Buckley (Royal Free) Professor Geoff Bellingan (UCLH) Dr Clare Stephens (Barnet) Dr Shakil Alam (Haringey) Dr Chris Laing (UCLH) Dr Alex Warner (Camden) SROs Dr Julie Billet (Camden and Islington) Prof. Marcel Levi (UCLH) Tony Hoolaghan (H&I) Paul Jenkins (TAVI) Charlotte Pomery (Haringey LA) Rachel Lissauer (Haringey) Kathy Pritchard Jones UCLH Sarah Mansuralli (Camden) Dawn Wakeling (Barnet) 242 of 255

Capacity to facilitate change Dedicated capacity now in place across majority of workstreams to facilitate working across partner organisations to deliver agreed STP initiatives. Workstream Programme lead Email Address Adult Social Care Richard Elphick Richard.Elphick@camden.gov.uk Cancer Nasar Turabi n.turabi@nhs.net Children and Young People Sam Rostom sam.rostom@nhs.net Digital Geraldine Wingfield-Hill Geraldine.wingfield-hill@nhs.net Estates Dianne MacDonald diane.macdonald3@nhs.net Health and Care Closer to Home Sarah McIlwaine sarah.mcilwaine@nhs.net Maternity Julie Juliff Julie.Juliff@nhs.net Mental Health Chris Dzikiti Christopher.Dzikiti@nhs.net Planned Care Donal Markey donal.markey@nhs.net Prevention Mubasshir Ajaz mubasshir.ajaz@islington.gov.uk Productivity Shahbaz Bhutta shahbaz.bhutta@nhs.net Orthopaedic review Anna Stewart anna.stewart3@nhs.net Urgent and Emergency Care Alex Faulkes alex.faulkes1@nhs.net Workforce TBC out to recruitment TBC 243 of 255

Aligning with local QIPP plans and focus on delivery 244 of 255 10

NCL wide priorities: Across NCL, the top schemes by value are shared across the four main acute providers. These are summarised below: Number of times scheme appears within top 15 Royal Workstream PID reference Free NMUH UCLH Whitt Total Planned Care PC14 POLCE 1 1 1 1 4 Planned Care PC15 Diagnostics - Pathology 1 1 1 1 4 UEC UEC08 Adult Admission Avoidance - Rapid Response Services 1 1 1 1 4 UEC UEC9 Ambulatory Care 1 1 1 1 4 UEC UEC05 Simplified Discharge 1 1 1 1 4 UEC UEC01 IUC 1 1 1 1 4 UEC UEC02 Last Phase of Life 1 1 1 1 4 Health and Care Closer to Home Various "HCCHXX" CHIN & QIST initaitives combined* 1 1 1 1 4 Planned Care PC3,4,5 MSK 1 1 1 1 4 UEC UEC04 Reducing NEL Admissions for Children 1 1 1 3 UEC UEC06 ED Front Door Streaming & Redirection 1 1 1 3 Planned Care PC08 Gastroenterology & Colorectal Surgery 1 1 2 Planned Care PC06 Clinical Advice and Navigation (CAN) 1 1 2 Planned Care PC 27,35, 55 Gynaecology 2 2 Planned Care PC29 Camden Clinical Assessment Service (CCAS) 1 1 Planned Care PC09 Urology 1 1 Health and Care Closer to Home HCCH21 Universal Offer Review 1 1 Planned Care PC01 Teledermatology 1 1 UEC UEC07 HIU / LAS - Frequent Attenders 1 1 Planned Care PC02 Dermatology - minor skin lesions 1 1 UEC HCCG06 Stroke Prevention 1 1 Planned Care HCCG27 STT Cancer Pathway 245 of 255 1 1 11

Urgent and Emergency care: overview Overview of plans Across the STP programme there are 4 key workstreams and PIDs that relate to these. 1: Integrated urgent care 2: Admission avoidance 3: Simplified Discharge 4: Last Phase of Life VISION To bring together and enhance current urgent care services which are outside of hospital, in order to create a single, unified urgent care service for NCL citizens To develop same day emergency care services in both acute and community settings to enable rapid assessment, diagnosis and treatment and hence avoiding the need for overnight stays in hospital To develop improved discharge processes to reduce delays in patients leaving hospital when they are medically stable To bring specialist advice to staff who are looking after patients in the last year of their lives, in order to ensure best possible care and support to patients and reduce inequalities of care provision IUC project has 3 PIDs: IUC ED Streaming & Redirection High Intensity Users Admission avoidance has 3 PIDs: Adult Admission avoidance Paeds Admission avoidance Ambulatory Emergency care 246 of 255 Simplified Discharge has 1 PIDs: Simplified Discharge (i.e. Discharge to assess) There is one PID for last phase of life

Planned care: overview Each of the NCL wide planned care workstreams has a design group with clinical reps from secondary and primary care. For example: Dermatology Design group is lead by Camden CCG, includes service managers & dermatologists from for main providers: Cate Orteu (RFH), Claire Martyn-Simmons (UCLH), Ioulios Palamaras (RFH), Ben Esdaile (Whit). These groups have used evidence based pathway redesign to agree areas of focus and outline plans. These groups will work with behaviour change methodology to develop and embed new ways of working. This is supported by patient engagement with GP input from all 5 CCGs across workstreams. List of the priority planned care PIDs POLCE Diagnostics - Pathology MSK Gastroenterology & Colorectal Surgery Clinical Advice and Navigation (CAN) Gynaecology Camden Clinical Assessment Service (CCAS) Urology Teledermatology Dermatology - minor skin lesions STT Cancer Pathway There are 11 priority areas that have material finance and activity impacts this year (listed in the table on the right). These have been developed though a range of methodologies including benchmarking with similar services, learning from pilots (both local and further a field) and building on CCG successes. In addition, we are also undertaking a review of 247 of 255 orthopaedic surgery across NCL.

Health and Care Closer to Home: overview Across the programme there are three key workstreams: For extended access there is a single NCL PID For integrated networks and quality improvement support team there is a PID for each CCG as the teams are borough based. 248 of 255

Taking forward Health and Care Closer to Home 249 of 255 15

Enfield: CHIN and QIST Status North West CHIN North East CHIN Enfield QIST CHIN AND QIST Clinical lead: Dr Alpesh Patel, Dr Anjum Iqbal Focus: Long Term Conditions Population: 77,440 Involving: 10 practices Operational since: April 2017 Road map: Currently only GP networks and community services Contract with: Federation Contract: NHS Standard Contract South East CHIN Clinical lead: Dr Ujjal Sarkar, Dr Chimere Aka Focus: Long Term Conditions Population: 79,809 Involving: 13 practices Operational since: April 2017 Road map: Currently only GP networks and community services Contract: NHS Standard Contract South West CHIN Clinical lead: Dr Alpesh Patel Focus: Diabetes Operational since: Feb 2018 Contract with: Federation Contract: Heads of Terms Clinical lead: Dr Donna Samuels, Dr Meeta Arora Focus: Long Term Conditions Population: 90,243 Involving: 16 practices Operational since: April 2017 Road map: Currently GP networks and community services Contract with: Federation Contract: NHS Standard Contract Clinical lead: Dr Vip Thiagarasah, Dr Sarit Ghosh Focus: Long Term Conditions Population: 75,655 Involving: 9 practices Operational since: April 2017 Road map: Currently only GP networks and community services Contract with: Federation Contract: NHS Standard Contract 250 of 255

Patient and staff voice Principles agreed with the Joint Health Oversight and Scrutiny Committee (JHOSC) for use across the programme: 251 of 255 17

What do we mean by engagement? Collaborating Partnering with stakeholders in decision-making, including development of alternatives Involving Working directly with stakeholders to ensure that their aspirations/concerns are understood and considered Consulting Asking stakeholders for feedback or advice on a particular issue(s) Informing Giving stakeholders information on an issue(s) 252 of 255 As part of planning for 2018/19 there is a refreshed approach being taken across the STP, aiming to maximise the proactive involvement of patients and public, at both a strategic programme level as well as individual project level. This will mean working effectively with patients and staff at different levels of engagement to ensure meaningful input in taking forward and developing our plans further. 18

Across the programme we want to be proactive in the approach to communications and engagement with staff and the public Compliance / threat-based approach Why we must engage Engagement of local people is a legal obligation The 2006 NHS Act, the 2012 Health and Social Care Act and the 1999 & 2000 Local Government Acts place statutory requirements on healthcare providers and commissioners, and local authority organisations to engage the public. Engage to avoid reputational damage Not communicating with and engaging the public and staff around the work of the STP increases the risk that what we are aiming to achieve is misunderstood, leading to reputational damage and opposition. 253 of 255 Why we should engage Engagement enables large scale change Large Scale Change (LCS) theory says taking a topdown approach that focuses on changing structures and processes will not achieve the scale, depth and pervasiveness of change that the system requires. For LSC to be successful and sustainable, key stakeholder groups need to be engaged so that they become part of a movement for change. Successful implementation requires behavioural changes on the part of staff and service users and this requires a step up in communications and engagement activity. Engagement helps us do the right things We cannot develop care coordinated and centred around the needs of patients and users without understanding what communities want and without our partners in local government. That is why we need robust local engagement plans as part of the STP process. NHSE - Engaging local people in STPs Similarly, as the people who deliver care, frontline health and social care staff have unparalleled insight into what works well within our current models of care and respective organisations and what needs to change. Harnessing their insights will help ensure that we focus on the right problems. Opportunity-based approach

Next steps for the Programme in 2018/19 Work with all our partners and public to design plans Ensure plans are clinically led and evidence based Communicate with our stakeholders and communities about the changes ahead Align our plans and ensure these contribute to financial sustainability Continuing to explore scope for NCL working and greater impact To underpin this, we will be doing more work on the underlying financial position of the NCL system, to inform and strengthen our approach to transformation for 18/19 and beyond 254 of 255