AGENDA - City and Hackney CCG Us/Board... · c. Matters arising . Clare Highton Papers 2a, 2b & 2c...

Chair: Dr Clare Highton Chief Officer: Paul Haigh

NHS City and Hackney Clinical Commissioning Group (CCG) Board Friday 31 October 2014, 1400 – 1600

Room TBC, Tomlinson Centre, Queensbridge Road, London, E8 3ND

AGENDA Chair: Dr Clare Highton Agenda Items

Led by & Appendix number

Timing

1. Welcome, introductions and declarations of Interests

Clare Highton Verbal

1400-1405 (5 mins)

2. CCG Committee business: a. Minutes of the last meeting; b. Register of Interests; c. Matters arising.

Clare Highton Papers 2a, 2b & 2c Pages 3-18

1405-1410 (5 mins)

3. Questions from the public Clare Highton Verbal

1410-1420 (10 mins)

CLINICAL STRATEGY (FOR DECISION) 4. 2015/16 Plan on a Page update Clare Highton

Paper 4 Pages 19-30

1420-1435 (15 mins)

5. CCG Non Recurrent Investment Prioritisation

Clare Highton Papers 5a & 5b Pages 31-72

1435-1455 (20 mins)

6. Commissioning of Community Health Services

Clare Highton Paper 6 Pages 73-74

1455-1515 (20 mins)

PERFORMANCE 7. CCG Finance update:

Building Familial Resilience through Family Mental Health Workers contract waiver.

Philippa Lowe Paper 7a & 7b Pages 75-88

1515-1525 (10 mins)

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8. CCG Contracts Committee update Paul Haigh Paper 8 Pages 89-93

1525-1535 (10 mins)

FOR INFORMATION 9. 2013/14 CCG Audit Committee annual

report Mariette Davis Paper 9 Pages 94-104

1535-1545 (10 mins)

10. NHS England Quarter 1 2014/15 CCG Assurance Report


1545-1550 (5 mins)

11. Reports from Subcommittees of the Board: Key issues from subcommittees.

Clare Highton Papers 11a & 11b Pages 110-112

1550-1555 (5 mins)

12. Friday 28 November 2014 draft CCG Board agenda


1555-1600 (5 mins)

13. Any Other Business Clare Highton Verbal

1600-1605 (5 mins)

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MINUTES OF THE NHS CITY AND HACKNEY COMMISSIONING GROUP BOARD

HELD ON FRIDAY 26 SEPTEMBER 2014

AT TOMLINSON CENTRE, QUEENSBRIDGE ROAD, LONDON, E8 3ND

PRESENT: Dr Clare Highton (CCG Chair)

Dr Haren Patel (CCG Clinical Vice Chair) Dr Gary Marlowe (CCG Board GP) Catherine Macadam (CCG Lay Member for Public and Patient Involvement) Mariette Davis (CCG Lay Member for Governance) Jaime Bishop (CCG Associate Lay Member) Christine Blanshard (CCG Board Consultant) Siobhan Clarke (CCG Board Nurse) Paul Haigh (CCG Chief Officer) Philippa Lowe (CCG Chief Financial Officer)

IN ATTENDANCE: Dianne Barham (Hackney HealthWatch) Sam Mauger (City of London HealthWatch)

Richard Quinton (Interim Director of Commissioning, Barts Health Clinical Commissioning Collaborative) for agenda item 2

Steve Ryan (Medical Director, Barts Health) for agenda items 2 & 8 Paul Jenkins (Tavistock & Portman Chief Executive) for agenda item 6 Done Neame (CSU Director of Communications)

Mark Scott (CCG Urgent Care Programme Director) for agenda item 6 Jenny Singleton (CCG Head of Quality) for agenda item Karl Thompson (CCG Head of Corporate Services) Matthew Knell (CCG Business Co-ordinator)

APOLOGIES: Honor Rhodes (CCG Associate Lay Member)

Emma Craig (Hackney HealthWatch) Dr Penny Bevan (LBH & CoL Director of Public Health)

Agenda Item 1 – Welcome, introductions and declarations of Interests The CCG Chair, Dr Clare Highton (CH) welcomed members to the September 2014 meeting of the NHS City and Hackney Clinical Commissioning Group (CCG) Board, highlighting that Catherine Macadam (CM) was joining the Board for the first time as the new Lay Member for Public and Patient Involvement (PPI) and that Jaime Bishop (JB) was now an Associate Lay Member. Apologies had been received from Honor Rhodes, Penny Bevan and Emma Craig, with Hackney Healthwatch represented by Dianne Barham (DB) at the meeting. The GPs present at the meeting, CH, Haran Patel (HP) and Gary Marlowe (GM) all declared interests in agenda item 12 and the payments to GP practices that would be

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covered. It was agreed that they would not take part in any Board decision needed under the relating to the conflict. Agenda Item 2 – Barts Health Steve Ryan (SR), Medical Director at Barts Health and Richard Quinton (RQ), Interim Director of Commissioning for the Barts Health Clinical Commissioning Collaborative joined the Board for this agenda item. CH reminded the Board that they had received and discussed a Barts Health specific quality report in July 2014, following which a letter summarising the CCGs concerns was sent to Barts. This letter, included in Board papers also invited SR to make a presentation to the CCG and discuss the concerns. SR drew the Boards attention to the circulated presentation and summarised its contents, noting that Barts was aware of issues and actively working to address them, with timelines and action plans in place to address them. Steps had been taken and actions completed already, for instance in the centralisation of support services from the clinical academic groups (CAGs). SR continued to outline how the Trust is looking at the patient experience to improve management processes, improving communications with GPs with regards to referral to transfer (RTT), increasing theatre capacity, clinics and analysing onward referral processes to ensure an efficient, effective system. SR confirmed that medium and long term plans are in place to address concerns, although noted that the October 2014 target would be slipping to around January 2015. SR moved on to inform the Board that all 52 week wait patients from Hackney have dates for appointments now. SR also confirmed that Barts Health mortality measures are all good, amongst the best in the country, although recognised that never event rates were a concern. SR noted that many of the never events had been de-escalated and that the high reporting levels were a good measure and that Barts was within the national reference range. RQ updated the Board on the role of the Waltham Forest, East London and the City (WELC) Commissioning Collaborative, noting that he works on behalf of the local CCGs with Barts, recently concentrating on RTT, cancer and 52 week waits. RQ reminded the Board that a formal contract notice had been issued earlier in the year, starting a formal process of action plan productions. Processes were in place at Barts to improve performance and were monitored via fortnightly tracking meetings. RQ confirmed that the expected improvements from the February 2014 action plan had not been forthcoming, but a new position was being drawn up and agreed and would be available shortly. RQ continued to detail that Barts have a new Director team in place to deliver action plans and that January or February 2014 would be the new target for improvements to be in place. RQ also noted that local CCGs had agreed to increase the staffing level of the Commissioning Collaborative, which should help supporting and monitoring Barts Health performance. HP asked whether Barts are aware of the internal communication issues that are affecting patient care and impacting outside the organisation, detailing specific cases he had heard

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of with regards to multi-disciplinary team discussions not being communicated to oncologists or dental clinicians. Mariette Davis (MD) asked for further details on the administration issues encountered at Barts Health and what needed to be in place to resolve them. MD continued to ask whether the contract query notice had made an impact and asked what staff morale was like, following a recent review indicating poor measures in this area within the Trust. Christine Blanshard (CB) questioned the geographic spread of services and sites across Barts Health, asking whether centralisation could help address any issues. CB noted that there appeared to be reports of different practices in place at different sites and asked whether there was a consistent approach to surgical safety across the Trust. Dianne Barham (DB) noted that most patient complaints regarding Barts Health are about communications, transport and system issues, while the actual care is often complimented. DB also highlighted that patients often report a culture within the Trusts staff of blaming problems on the ‘system’ or understaffing. DB noted that some form of easily accessible dashboard system to help monitor improvements in these areas at the Trust would be very useful. Sam Mauger (SM) agreed with DB, supporting that patients were reporting muddled appointments and that there was a general lack of confidence in the Trust. GM noted that as the Planned Care Clinical Lead, he had significant worries regarding the Trusts cancer two week waits as well as experiences with his own patients breaching referral targets with no communications from the Trust. GM added that his practice often has to dedicate their own staff to chasing Trust communications, something that is not encountered with any other Trust. GM detailed another patient case where a patient was passed back to the GP with no communication or contact for a catheter removal. GM asked that recovery and action plans are closely monitored across the Trust and at individual sites. Jenny Singleton (JS) asked whether Barts Health had concerns regarding the sustainability of their actions plans, noting that historically agreed plans between the Trust and commissioners have slipped several times. The CCG’s quality report indicates a loss of faith in Trust systems by its staff, who appear to be resorting to producing their own procedures, causing differences in working practices across sites. Cynthia White (CW), present at the Board meeting as a member of the public, noted that the Older People’s Reference Group (ORPG) have been compiling experiences of patients encountering systemic issues and getting lost in bureaucracy. CW asked for more patient consultation and an approach of ‘you said, we did’ to be adopted by the Trust in addressing issues. CW continued that she had recently come across a case of a patient left standing at the Patient Advice Liaison Service (PALS) desk in a dressing gown for 30 minutes before being addressed. CW continued to outline the difficulties patients encounter in getting medication, issues with unsafe discharges and lack of communications, including one

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recent case where a patient was discharged and advised to eat anything by their Barts Health nurse, against the consultant’s advice. SR responded to the Boards questions, noting that several overarching themes were present in the feedback. SR noted that staff morale was a known issue, with the Care Quality Commission (CQC) flagging bullying as a concern in their recent review. The Trust commissioned an independent report on this area, which will report publically shortly. SR recognised that staff morale is broadly low, with huge savings required across the Trust and consequent pressures across all areas of the organisation. SR highlighted that the monthly staff survey Barts conducts is showing improvements in recent months, particularly in the children’s and emergency care teams. Staff morale is being addressed by ensuring excellent leadership is in place and that staff are supported. SR continued to outline the steps in place at Barts to address internal systems, including the programme of work underway to develop new IT systems at Whipps Cross, which will be rolled out across all Barts sites to provide a consistent system. SR recognised that there are delays in dealing with patient complaints, which management have highlighted and prioritised. SR noted that Barts are looking at putting in place a more supportive complaint process, where the formal complaint route isn’t the first form of redress and talking and learning is given more emphasis. SR confirmed that the Trust doesn’t have money to throw at the issues present across the Trust and that all costs must be met with savings, however costs should be recouped by the Trust taking a more proactive approach. SR confirmed that Barts is also looking at working closer with GPs to support keeping patients in the community under the care of their GP, rather than in the outpatients department (OPD). SR also confirmed how important the patient voice is to Barts and that the management team is always open to patient views and meeting with patients to take on board patient views. Siobhan Clarke (SC) asked whether the current issues were the result of the organisation having grown too large after the merger of Trusts, with the reports of processes failing and lack of engagement potential symptoms. CB thanked SR for his responses and asked that if Barts know the problems, do they know the solutions and how to implement them. SR responded that strong leadership is in place, with 40 clinical directors in post leading specific areas and stated that the issues being experienced are serious and are not being taken lightly, relating directly to patient safety and experience. SR continued that the task is large and challenging, particularly in the current NHS climate, which hadn’t been planned for at the time of the merger. SR noted that recruitment, retention and the London wide financial situation would all factor into the Trusts position. CH stated that the CCG was desperate to see improvements at Barts. In the meantime, the CCG has advised local GPs that patients need to be aware of the waiting time issues in order to provide them with the most informed choice. SR recognised waiting time issues in certain clinics. CH asked that the list of 52 week breaching patients be sent directly to

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those GP practices affected, noting that the CCG had been waiting 9 months for this action to be taken. SR confirmed that these details can be sent to secure nhs.net accounts as soon as possible. ACTION: Barts Health to communicate details of patients breaching the 52 week wait targets with the appropriate GP practices as soon as possible. The Chair thanked SR for his presentation and the Board agreed that whilst it had been helpful to hear direct from the Trust, the CCG continued to remain concerned about the quality of the administrative systems and support and the impact of these on patient care. Agenda Item 3 – CCG Committee business Paul Haigh (PH) updated the CCG Board that the first meeting of the cancer and cardiac change review group would be held shortly and that the Board would be updated in October 2014. CH flagged that there is currently a national accident and emergency (A&E) doctor shortage, which is affecting the Homerton University Hospital NHS Foundation Trust (HUHFT), with the Trust not being able to fill posts for the first time. The Board discussed how these positions could be made more attractive, noting that it is an unattractive job with unsociable hours for many. CH confirmed that Health Education England (HEE) is working in this area and trying to make the roles more appealing by changing the training requirements and programme, but that it is a hard sell to many clinicians. CH also highlighted that there are 450 unfilled GP positions nationally, with the profession becoming increasingly unattractive. The Board discussed what further steps HEE could take, including increasing training numbers and addressing shift patterns, while noting that no national body was effectively performing workforce planning currently. Agenda Item 4 – Questions from the public CW informed the Board that her a colleague had been in contact with NHS England (NHSE) regarding the cancer and cardiac change programme, expressing concerns over Barts Health ability to meet the service needs, considering its current issues. SR recognised that service changes are not without risk, but the new services will be centralised at St Bartholomew’s Hospital and the change programme is well underway towards making the service a success. A paper will be submitted to the Barts Health Board next week, which will include a revised timescale towards the service going live, which is now not expected to be in January 2015. SR continued to confirm that the cancer pathway changes will help, with more integration and consolidation of all cancer care, including specialist services. The changes will also free up capacity at other Trusts, allowing better care and efficient working. CH thanked both SR and CW for the update and reiterated that the CCG Board will be updated in October 2014 on this area.

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No further members of the public posed questions to the CCG Board. Agenda Item 5 – Quarterly Quality Report JS presented the quarterly quality report to the CCG Board, noting that this edition of the report contained the new ‘safer staffing’ data, along with new HealthWatch reports and the results of recent national clinical audits. JS summarised the safe staffing measures, which seeked to measure planned vs actual nurse staffing across services and wards, including that they revealed some specific areas of HUHFT that may require further attention, including the Mary Seacole Nursing Home. The Royal London Hospital at Barts Health also indicated low staffing levels in some areas. JS emphasised that this was the first return of this data, and potentially subject to data issues. JS highlighted that East London Foundation Trust (ELFT) had achieved perfect measures across its services. JS moved on to detail feedback from patient experience surveys, noting that food was reported to be poor at HUHFT, with no fresh fruit available. JS highlighted that Barts Health was found to have the most expensive food in London, although was still not received well by patients. JS detailed recent Duty of Candour reports from across the CCG’s practices, including a trend towards practices experiences issues with cancer referrals at Barts Health. SC asked if the safe staffing measures were reliable, considering the lack of proven benefit and need to use clinical staff time to produce national returns instead of patient care. SC added that as a measure alone, it may not be valuable, but when taken amongst other measures, could help highlight issues. CB agreed, adding that it was only a measure of planned nursing staffing levels against actual, which didn’t guarantee that the planned levels were safe. The measure also didn’t account for any handovers. JS supported SC and CB, stating that it was a measure that helped support gather a fuller picture of quality and that no single measure should be relied exclusively on. MD noted that pressure ulcers at Barts Health appeared to be high. CH agreed, noting that issues had been reported accessing pressure relieving mattresses. SR clarified that grade 3 and 4 pressure ulcer rates were reducing and that the Trust is addressing this area, with new training, processes and intensive interventions where needed. CW added that this measure was an indicator of poor care and SR agreed, noting that the Trust Board uses it as one of three top concerns, with root cause analysis’s conducted and learnt from. Philippa Lowe (PL) highlighted the improvements in the out of hours (OOH) service, but was concerned to note that the percentage of locum staff had been increasing recently, which could start to have a detrimental impact on A&E attendances. CH suggested that this likely due to the workforce issues discussed earlier in the meeting.

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SM reported that City of London HealthWatch had recently met with ELFT and had been impressed by the clear leadership team and strong values across the organisation. Recent staff survey results had placed them in the top five Trusts in the country and this was being witnessed by patients, who had reported good experiences as well. CH agreed, thanking ELFT for their good work. Agenda Item 6 – Implementing Practice Based integrated care Paul Jenkins (PJ) and Mark Scott (MS) joined the Board to present the latest integrated care proposals. PJ confirmed that he is chairing the One Hackney working group of providers working together to deliver better integrated care across organisational boundaries. MS briefed the Board that the first phase of the programme would be targeted at the 1700 most vulnerable City and Hackney patients and be patient centred and steered, aiming to better co-ordinate care across providers and meet patients’ needs and crisis’s better. PJ confirmed that the providers would have access to the resources needed to effectively troubleshoot and solve patient’s issues and that benchmarking metrics and being developed and agreed to ensure the services are high quality and commitments being met. The paper outlined the investment proposed across the One Hackney provider community to meet the CCGs service specification and the implementation of these and their impact on the agreed metrics would be monitored by the Better Care Fund (BCF) Board. The funding to deliver the programme was now £2.89 million plus a performance payment to be split equally between the current year and next. CH thanked PJ and MS for their work in this area, noting that it’s a very different way of doing NHS business, which will now include local authority social services and local voluntary sector groups for full integration of services. CH reminded the Board that there was little evidence that this work would reduce admissions, but would provide higher quality care for patients. CH confirmed that the Board was being asked that the higher investment level be agreed. CB asked if the stretch targets are enough, noting that the key performance indicators (KPIs) for December 2014 looked ambitious, while the June 2015 were not significantly higher. PJ responded that the One Hackney are in uncharted waters here and that lessons will be taken on board as work progresses. The team is taking a cautious approach to start with. PH agreed, advising the Board that this area has been debated and that the swift mobilisation and staff recruitment needs to be taken into account. SC asked how the performance bonus will be distributed across providers. PJ responded that the performance metric split is covered in the memorandum of understanding (MOU) between providers and that they will be taking a collective approach. MS added that the London School of Economics (LSE) and University College London (UCL) have been engaged to evaluate the programme of work and report to the CCG. MD thanked the team for the update, noting that it sounds a positive step. CH thanked the provider community for their work in this area. GM added that the Board needed to accept that the programme may not work or deliver the desired results or money,

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recognising that this was new territory for the NHS and that the bringing together of providers in this fashion was a big new step. CH agreed, noting that the role of HealthWatch in monitoring patient outcomes and feedback would be significant. The metrics underpinning the performance monitoring were based on the national BCF guidance. SM asked if City of London patients were catered to by the programme and how cross boundary issues with Islington or Tower Hamlets would be dealt with. MS responded that the City and Hackney practice in the City would have embedded care navigators to assist City of London patients in accessing care. PJ added that cross border issues are always a concern and that while no easy solutions exist, visibility and consideration with appropriate resource available were vital. DECISION: The Board noted the One Hackney programme of work and agreed the investment package and contractual arrangements as outlined in papers. Agenda Item 7 – Patient and Public Participation Annual Report and Innovation Fund update CM updated the CCG Board, informing that the Public and Patient Involvement (PPI) annual report was now ready for approval and that the PPI team were proud of the achievements and work outlined in it. CM continued to brief the Board on the progress of the innovation fund, noting that most of the grants had been awarded to voluntary organisations, with 60 total applications – which would have needed three times the funding available to fund them all. The Board discussed the fund, noting that there was useful learning for the future. PH noted that any unsuccessful innovation fund bids were welcome to utilise the non-recurrent funding route instead if they so wished and CH thanked everyone involved in the process for their work. DB asked whether the team had a plan to report back to the public on their achievements and feedback on what had been asked of them through the year. CH responded that this was the plan for the November 2014 public event, which will be run in a ‘you asked, we did’ format and the public asked ‘what’s next?’. JB added that the patient voice has noticeably changed CCG decision through the year and that the process will be finessed through the year. CH supported JB, adding that the CCG has also worked closely with the local Health Oversight and Scrutiny Committee (OSC) and Health and Wellbeing Boards. CA stated that clear information aimed at patients and local clinicians on why PPI is vital and constructive will also help. CW thanked the CCG for its efforts in the PPI arena, noting that the commitment has noticeably helped, although reaching the socially isolated is more of a challenge. CH agreed, stating that health advocacy is a vast, mostly unexplored field. JB informed the Board that all 43 City and Hackney practices had signed up for the PPI direct enhanced service (DES) with NHSE again this year, despite the issues encountered with the service last year. GM supported this statement, noting that the criteria had proved impossible to meet and expressed hope that NHSE guidance would be cleared this year.

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Agenda Item 8 – Transforming Services, Changing Lives Case for Change Don Neame (DN), CSU Director of Communications joined the Board to present the circulated presentation. DN summarised the review programme, which had been running for several months, concentrating on Barts Health and Barking, Havering and Redbridge Trusts. The formal feedback period was now winding down and an initial report would be published soon. The initial views expressed to date were that patient experience and focus, integrated pathways and economies of scale were vital to the future of services. SR informed the Board that he had been involved in the process and that it was important to note that the review had taken the approach to never do anything in isolation, the review team had no plan at the start of the review and learnt from engagement. The next phase will be a design phase, looking at producing better pathways of care that are sustainable and affordable. The Board noted that any results of the review needed to tie into primary care, integrated care and public health services. PH added that City and Hackney CCG was not a full member of the review group, but that the Board needed to understand the results and be clear on what impacts may be locally. NHSE were keen to see an overarching North East London group formed to oversee changes, although the CCG were happy to participate, it was felt that any decision making which could impact on City and Hackney patients needed to be retained by the CCG Board to ensure strong local debate. GM thanked everyone involved for the update, noting that it was helpful to hear confirmation that the review was not about hospital reconfiguration. He moved on to express concern that the review may result in more work being pushed to primary care, which is not resourced to deal with it and that the suggested changes may mean sidelining the role of the district general hospital in favour of centralised specialist services. SR responded that the review was pathway centred, and that it made clinical sense for, for instance, cardiac or stroke patients to be cared for in centres of excellence. Barts Health needs to shed 200 beds to reach affordability and integrated care plans with Tower Hamlets, Newham and Waltham Forest is vital to achieving that. SR emphasised that patients have the answers to how care should be organised. GM noted that the UK already has the second lowest ratio of beds to population in Europe and that care needed to be taken to ensure patients are seen in the most appropriate environment. DB stated that the focus on patients and people was vital and that they should be steering the pathways. There was a danger of pigeon holing patients into unsuitable pathways without proper engagement. SR agreed, recognising the dangers of medicalising patients. CA asked where the solutions will come from and where any final decision will be made. DN responded that the review so far has been to assess the needs and interest in change across the area, while the next steps will be dedicated to the production of options for change based on the feedback received. Any decisions will be sought in July 2015. CH

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added that the changes would primarily affect Tower Hamlets, Waltham Forest, Newham and Barts Health, while any City and Hackney changes should only be peripheral and knock on – the CCG is not the primary commissioner involved. However any changes which impacted on City and Hackney patients would need full debate with the CCG Board. Agenda Item 9 – Better Care Fund MS briefed the Board on the revision and submission of a new BCF plan, which is now being assessed by NHSE. The new fund totals £21 million from the CCG, alongside funding from the London Borough of Hackney (LBH) and will support two year contracts from April 2015 for those services indicated in the circulated papers. The CCG Board, Clinical Executive Committee (CEC) and LBH Cabinet will receive periodic updates on the performance of the BCF. PL noted that national allocations have only been granted for 2014/15 and 2015/16 so far, with no word on 2016/17 or beyond as of yet. There is a risk that the Board should be aware of that those allocations change in future years, affecting the BCF, therefore the two year contracts starting in 2015/16 must have a break clause in the event the funding allocation for BCF changes. CH noted that the CCG has gone against national guidance to commit to a 2% reduction in admissions under the terms of the fund – the national recommendation was 3.5%. CH continued that the CCG was already high performing in this area and did not want to commit to an impossible target while already running a highly efficient system. The Board supported this approach, noting that safety and clinical quality were more important and shouldn’t be risked, while being aware that this commitment may be questioned by NHSE. Agenda Item 10 – Board Assurance Framework PL presented the Board Assurance Framework (BAF) to the Board, noting that it has been extensively discussed and cleared for discussion at the Board by the Audit Committee (AC), although it should be noted that the document will remain a work in progress due to its nature and will develop over time. PL confirmed that Baker Tilly, the internal auditors had also been closely engaged through development and their advice had been helpful. MD agreed with PL, noting that the BAF was an important tool to help the Board hear of CCG work and inform on key risks and how they are being managed. The AC will continue to use the BAF, report to the Board and provide assurance that the BAF is being actioned appropriately across the CCG to enable delivery of the CCG’s main objectives. The Board discussed the BAF, suggesting that the quarterly quality report be added to page 224 and SC thanked the team for the work, finding it very helpful. PL informed the Board that a development session concentrating on risk, the BAF and risk appetite was being planned for the near future.

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Agenda Item 11 – Review of CCG Board and subcommittee TORs PH briefed the Board on the papers circulated in advance of the meeting and the Board discussed the revised terms of reference (TORs), noting that they were sensible and an improvement on the current arrangements. The Board thanked JB for his time served as Lay Member as PPI. CW asked if the ORPG should be indicated as a member of the PPI Committee and Karl Thompson (KT) responded that this would be checked and amended. ACTION: ORPG membership of the PPI Committee to be checked and amended on the PPI Committee TOR. The Board agreed to adopt all of the TORs. DECISION: CCG Board agreed to adopt TORs as presented and discussed. Agenda Item 12 – CCG Finance update PL drew the Board’s attention to the circulated paper, noting that no major financial risks had been encountered since the previous meeting. Activity remained broadly in line with planned levels and the CCG was underspending against its plan primarily due to slippage in the investments of non-recurrent funds, running costs and the release of contingencies that had been set aside before contracts with providers had been signed. The current forecast underspend was £5 million, but there was a risk this would grow if investments slipped further. PL confirmed that heads of terms (HOTs) had now been agreed with HUHFT and a full contract was expected to be ready for signature shortly. PL outlined the few issues currently in play, that NHS Property Services were seeking a meeting to discuss potential double charging of property costs 2013/14 and an increase in charges for 2014/15 that was not expected. Funding for GP IT would remain challenging in future years after NHSE had removed half of the funding, however, transition funding had been secured from NHSE for 2014/15 to address IT issues, but this was for the current year only. PL continued to inform the Board that while the PCT had made a provision for all potential legacy continuing healthcare (CHC) claims dating back before March 2013, NHSE were now seeking contributions towards a national pooled insurance fund. Contributions towards that fund were not based on the size of legacy claims and disregarded the legacy provision. The CCG was expected to contribute £1.3mm in 2014/15 and a further £0.8m in 2015/16. As this had been well managed by the PCT, the likely local claims were only £0.4m. PH briefed the Board that the CCG would shortly be discussing and deciding on further non recurrent bids for funding, having invited CCG Programme Boards, HUHFT, ELFT and other partner organisations to make evidenced bids. These would be submitted in a standard format to the Prioritisation Committee, which will assess them under a recognised

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framework to produce a prioritised list against the funds available. PH added that most bids received to date were addressing IT, waiting times and quality standards. Each bid would need to be accompanied by a service specification to allow for swift mobilisation of the service and agreed KPIs for implementation. PL raised that a waiver notice had been circulated with papers for the Bereavement Counselling Service provided by St Joseph’s Hospice and that it needed the Boards approval to proceed. The Board supported the waiver. DECISION: St Joseph’s Hospice Bereavement Counselling waiver accepted by the CCG Board. PL continued that the Board also had a number of documented payments to GP practices to consider and approve, noting that the Audit Committee had examined the payments and been assured that they were right and proper. PH added that these payments included the first payment to the GP Confederation and MD supported PL, confirming that the AC had been assured. DECISION: CCG Board approved payments to GP practices and the Confederation as indicated in circulated papers. Agenda Item 13 – NHSE Annual Assurance PH noted that the CCG had received its 2013/14 annual assurance letter from NHSE, distributed with Board papers for the Boards information. The Board thanked PH and the CCG team for the good work indicated in the letter. Agenda Item 14 – Reports from Subcommittees of the Board The Board accepted the reports from its sub-committees and noted the contents. Agenda Item 15 – Friday 31 October 2014 draft CCG Board agenda The Board noted the agenda of the following months meeting. Agenda Item 16 – Any Other Business CB raised that an external review of surgical site infection at HUHFT was underway and that the CCG may wish to secure a copy of the results for inclusion in the next quarterly quality report. CH agreed, noting that this area has also been discussed at the Planned Care Programme Board (PCPB) and Clinical Quality Review Meeting (CQRM). No further business was discussed.

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AGREED BY: AGREED ON:

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Action Assigned to Assigned from Assigned

date

Due date Update

Moorfields to be covered in the quarterly quality report from quarter 3

onwards.

Jenny Singleton CCG Board 25/07/2014 19/12/2014 TBC

CCG to consider inviting Moorfields to a future CCG Board meeting. Paul Haigh CCG Board 25/07/2014 19/12/2014 TBC

Barts Health to communicate details of patients breaching the 52 week

wait targets with the appropriate GP practices as soon as possible.

Barts Health CCG Board 26/09/2014 31/10/2014 TBC

2014/15 NHS City and Hackney CCG Board Action Tracker (OPEN)

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Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments

Dianne Barham 16/04/2013 Hackney Healthwatch Representative Urban Inclusion Community Director of Urban Inclusion Community

Dianne Barham 16/04/2013 Hackney Healthwatch Representative Healthwatch Tower Hamlets Chief Operating Officer of Healthwatch Tower

Hamlets

Dianne Barham 16/04/2013 Hackney Healthwatch Representative ELFT

Tower Hamlets CCG

Hackney and the City PCT

Undertaken research for ELFT, Tower Hamlets CCG,

Hackney and the City PCT.

Penny Bevan 28/05/2014 LBH Director of Public Health London Borough of Hackney Director of Public Health at the London Borough of

Hackney

Penny Bevan 28/05/2014 LBH Director of Public Health Postitive East Ex Chair of The Globe Centre, an HIV charity in

Tower Hamlets now called Positive East.

Christine Blanshard 28/09/2012 CCG Board Consultant Salisbury Hospital NHS Foundation Trust Medical Director at Salisbury Hospital NHS

Foundation Trust that does not hold any contracts

with the CCG.

Siobhan Clarke 20/06/2014 CCG Board Registered Nurse Your Healthcare CIC Managing Director at Your Healthcare CIC

Emma Craig 27/02/2014 Hackney Healthwatch Chair Women and Health Counselling Co-ordinator at this Camden based

charity

Mariette Davis 16/04/2013 CCG Board Governance Lay Member

Audit Committee Chair

Remuneration Committee Chair

Acanthus Advisers Private Equity Limited Acanthus Advisers Private Equity Limited, a

placement agency not operating in or with the NHS.

Paul Haigh 09/04/2014 CCG Chief Officer ELIC (East London Integrated Care) ELIC (East London Integrated Care) - dormant

practice based commissioning organisation which

has ceased operating and will close in 2014.

Paul Haigh 09/04/2014 CCG Chief Officer NHS England Partner - Helen Bullers is Regional Director of HR

and Organisational Development (London), NHS

England.

Clare Highton 18/04/2013 CCG Chair

Long Term Conditions Programme Board Clinical Lead GP

Childrens Programme Board GP

Lower Clapton Group Practice (CCG Member Practice) Principal Partner at Lower Clapton Group Practice,

our practice now provides a CCG Commissioned

community ENT clinic run by my GP partner Dominic

Roberts with our local ENT consultant. The practice

also employs 3 Heart Failure nurses and their HCA.

Lower Clapton is a research associate practice, so

does not hold grants but does participate in

research that is funded.

Clare Highton 18/04/2013 CCG Chair

Long Term Conditions Programme Board Clinical Lead GP

Childrens Programme Board GP

Tavistock and Portman NHS Trust Rob Senior, the Medical Director at the Tavistock

and Portman NHS Trust is my husband.

Philippa Lowe 12/05/2014 CCG Chief Financial Officer PIQAS Ltd Director at PIQAS Ltd, dormant company.

NHS City and Hackney Clinical Commissioning GroupRegister of Interests

Page 17 of 114

Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments

Philippa Lowe 12/05/2014 CCG Chief Financial Officer GreenSquare Group Group Audit Chair and Development Committee

member for GreenSquare Group, a group of

houseing associations. KPMG are internal audit

providers to the associations and external auditors

to the CCG. The group holds many contracts with

public and private sector bodies.

Catherine Macadam 04/09/2014 CCG Board Public and Patient Involvement Lay Member

Public and Patient Involvement Committee Chair

British Medical Association Member of the British Medical Association Patient

Liasison Group

Gary Marlowe 22/05/2014 CCG Board GP

Planned Care Programme Board Clinical Lead GP

De Beauvoir Surgery Partner at De Beauvoir Surgery

Sam Mauger 16/05/2014 City of London HealthWatch Chair Age Concern London Company Secretary, Age Concern London, a

company limited by guarentee.

Sam Mauger 16/05/2014 City of London HealthWatch Chair Age Concern London Trading Company Ltd Company Secretary, Age Concern London Trading

Company Ltd, a company limited by guarentee.

Sam Mauger 16/05/2014 City of London HealthWatch Chair Age Concern London Retail Company Ltd Company Secretary, Age Concern London Retail

Company Ltd, a company limited by guarentee.

Sam Mauger 16/05/2014 City of London HealthWatch Chair Age Concern City of London Chief Executive and Company Secretary, Age

Concern City of London, a company limited by

guarentee.

Sam Mauger 16/05/2014 City of London HealthWatch Chair Age England Association Director, Age England Association, a membership

body operating as a company limited by guarentee.

Sam Mauger 16/05/2014 City of London HealthWatch Chair Healthwatch City of London Chair and Director, Healthwatch City of London

Sam Mauger 16/05/2014 City of London HealthWatch Chair Westminster Arts Trustee and Director, Westminster Arts, a company

limited by guarentee.

Haren Patel 14/11/2013 CCG Clinical Vice Chair

Clinical Executive Committee Chair

Prescribing Programme Board Clinical Lead GP

Latimer PMS Plus Practice (CCG Member Practice) Senior Clinician and Management Lead for Project

and Intermediate/Secondary Mental Health Service

Provision. Interest in mental health services at the

Latimer PMS Plus Practice.

Honor Rhodes 11/05/2014 CCG Board Associate Lay Member

Individual Funding Request Panel member

Barton House Practice I, partner and one child are patients at Barton

House Practice (CCG Member Practice)

Lynn Strother 18/04/2013 City of London HealthWatch representative Age UK London The charities I am employed by – Age UK London

and The Greater London Forum for Older People are

funded by grants and donations.

Karl Thompson 19/09/2014 CCG Head of Corporate Services Nothing to declare Nothing to declare

Page 18 of 114

OUTLOOK FOR THE NEXT 5 YEARS

OUR PLANS

September 2014

Page 19 of 114

SUMMARY Our vision for the City and Hackney health economy is: • Patients in control of their health and wellbeing; • A joined-up system which is safe, affordable, of high quality, easy to access, saves patients’ time and improves patient experience; • Everyone working together to reduce health inequalities and premature mortality and improve patient outcomes; • Getting the best outcomes for every £ we invest through an equitable balance between good preventative services, strong primary and

community services and effective hospital and mental health services which are wrapped around patient needs; • Services working efficiently and effectively together to deliver patient and clinical outcomes and providers in financial balance.

Reduce premature mortality

Manage demand

Develop primary care and

community services

Safe high-quality

hospital services

Address mental health needs

Focusing on cardiovascular & respiratory diseases, people with mental health problems and people with cancer, commission our providers to deliver: • Earlier diagnosis and treatment; • Social prescribing and integrated preventative services; • Patients supported and empowered to embrace lifestyle changes which will impact on

their health. • Use the Better Care Fund to ensure services and providers are working in unison to

deliver patients’ care plans and the system-wide metrics we have set; • Commission better support and quality of life for people with long term conditions and

mental health problems; • Ensure practices have the capacity & time to support & care for people in the

community given the increasing demands they are facing. • Commission the GP Confederation to deliver population coverage, uniform high quality

standards & outcomes in primary care; • Commission One Hackney providers including the voluntary sector to join up their

services & work more closely with practices and patients & explore whether an Accountable Care Organisation would be a robust future delivery model;

• Ensure patients see primary care as their first port of call in and out of hours; • Maintain our demand management & audit work with Homerton to align clinical

behaviours. • Work with our partners to develop an integrated offer for early years which supports

everyone to get the best possible start in life. Support Homerton Hospital to deliver: • Strong 7 day DGH services, meeting fair, benchmarked performance standards and

achieving good outcomes; • Services aligned to patient pathways across primary care & specialist services,

ensuring minimal impact on local DGH services, patient access and outcomes from redesigned service models;

• Improved patient experience, satisfaction and information & join up our IT systems. • Commission access to fast professional care and support to maintain recovery and

independence; • Support primary care development and education to deliver more community based

provision and parity of esteem.

Overseen by: • Our CCG Board & 2 HWBBs debating &

making decisions which affect City & Hackney transparently & in public;

• Our Programme Boards working with patients & clinicians to affect change on the ground in line with our constitution;

• Closer collaboration with Public Health commissioners in the Local Authorities;

• Our providers working in unison under “One Hackney” aligning individual organisational and service responsibilities to deliver shared outcomes;

• Our clinical senate generating ideas & debating & influencing clinical behaviours;

• Co-commissioning with NHSE & other CCGs;

• Organisation leaders meeting & working together for the good of City & Hackney.

Measured by: • User, clinical & process outcomes for

each service, contributing to & delivering system outcomes;

• KPIs across aligned contracts & tracking system-wide changes in activity & spend;

• Financial balance maintained & all providers remain viable & without significant performance concerns.

1

2 4 3

5

BIG THEMES:

PLANS:

1 Page 20 of 114

• We are setting out the clinical ambitions we have to improve things for our patients in City & Hackney.

• We are not a financially challenged health economy and so we don’t need to develop heroic plans to balance our books.

• We face the same challenges though as everywhere else in the NHS with the prospect of little financial growth and possible changes in the future to how much money we receive for health services for our patients. The CCG is lucky to have sufficient financial headroom to make strategic investment to improve services and quality and test out whether what we are commissioning is really making a difference on the ground. This is a unique and highly privileged position which means we need to focus relentlessly with our patients, clinicians and stakeholders on where we need to improve things, how to do so, and ensure that we “think like a patient but act like a taxpayer”.

• We continue to liaise with other CCGs in North East London to ensure that we can understand the impact of any service changes that they are proposing for either our patients or on the Homerton Hospital.

• Having listened to our patients and our practices, looked at how we and our providers benchmark against elsewhere we have agreed 5 big themes that we want to tackle together.

INTRODUCTION

2 Page 21 of 114

Our plans fall into 5 areas • Reducing premature mortality • Managing demand • Developing primary and community services • Ensuring safe high quality hospital services • Addressing mental health needs

The following pages outline: • Why we need to address each of these • What we are going to do

BIG THEMES

3 Page 22 of 114

• We have worse premature mortality than London and the rest of England:

• CVD mortality rate locally is 89 deaths per 100,000 compared to 66 across England and cancer mortality rate is 142 deaths per 100,000 compared to 122 nationally.

• Life expectancy in males is 1.5 years lower in C&H than in England (with 4.4 years gap between the most and the least deprived in C&H).

• People with mental health problems die 20 years before the comparative population;

• Our patients have told us they want more support, help and education to manage their conditions;

• 62% of people locally feel supported to manage their LTC compared to 65% nationally and this has improved over the last year;

• We are in the top fifth for most measures of clinically effective management of LTC in London.

• We’ve heard from our patients that they want to be in control of their health and decisions about their health - so we are using our Innovation Fund to commission a range of new services suggested by our patients, including more peer support, education, advocacy and information and we have exciting plans to work with clinicians at Homerton to improve patient information and decision aids;

• We are working hard on parity of esteem – supporting our practices and providers to treat the whole person and address their physical health needs, not just their mental health problem.

• We have invested over £2m in a comprehensive programme to commission our GP practices via the Confederation to identify and diagnose patients at risk of diabetes, cardiovascular, respiratory or liver diseases and to initiate treatment and management;

• We have also commissioned our practices to offer an extended consultation on initial diagnosis and training our practice staff in improved consultation & care planning skills;

• We are commissioning a greater focus at Homerton Hospital on supporting and managing people with Long Term Conditions to join their work up with what our practices are doing– hospital staff reviewing care plans when people are in hospital, improving communication about changes to care plans, and linking up patients with community education and support

• We have invested a further £600k to extend our social prescribing scheme with the voluntary sector so that more GPs can refer patients to healthy living and wellbeing interventions in the community and our patients have better knowledge of the support available to them;

• The biggest impact on premature mortality will come from tackling poverty, increasing exercise and from reducing obesity, alcohol use and smoking. We are working with our Local Authority Public Health commissioners to join up plans to ensure that together we can have the biggest impact;

• We are working with our GPs to support earlier cancer diagnosis and access the range of advice and diagnostic services we commission – although the biggest impact on cancer mortality will be from the Local Authority’s work on stop smoking and encouraging patients with symptoms to contact their GP.

REDUCING PREMATURE MORTALITY

WHY? WHAT?

4 Page 23 of 114

We have increased our focus on emergency activity as we want people to be cared for safely at home wherever possible and the new Better Care Fund gives an added impetus to this. We appear to perform relatively well compared to London and the rest of England on the number of emergency admissions per 1000 people (on average 1750 emergency admissions per month). 20% of these admissions are in the over 75s and our rate of emergency admissions in the over 75s per 1000 people is greater than across London. Whilst we are ambitious to make improvements we don't believe there is scope to safely reduce these by more than about 2%. Although this initiative won't save us significant amounts of money we believe it will make a difference for our patients in the quality of care and services they receive and in minimising unnecessary hospital stays.

We are very conscious that demand to see GPs has doubled in the last fifteen years and we need to support practices to manage this alongside the increasing workload from more services and care outside hospital. Our main strategy is to ensure that practices have the capacity – both time and manpower – to care for people in the community and to offer a rapid response and consultation service when needed and that they are supported by a range of community services working together to help them • We are investing nearly £4m in practice based integrated care which commissions our practices to develop care

plans with our vulnerable and at risk patients, put these in place and undertake regular proactive home visits. This also funds more staff at Homerton, the Local Authority and in our other community and voluntary sector providers to ensure that they can wrap their staff and services around what our GPs are doing to ensure that strong clinically-led multidisciplinary teams are delivering the care plans set by our patients;

• We expect our plan to improve the quality of services in the community, reduce hospital emergency bed days, delayed discharges and readmissions & support more people to die in their own home if that is their wish;

• Our newly commissioned reablement and intermediate care service is starting which is a joint service between Homerton and social care and is aimed at providing one point of access and a rapid response to care for people safely in their homes

And we already have a wide range of commissioned services which are all focused on helping people to be cared for in their home environment. These will become the focus of our Better Care Fund. Our clinicians believe these new services will improve the quality of care for our patients but we are cautious about setting an ambitious target of how much hospital based activity they might save due to the limited evidence base for this. In association with our fellow commissioners of adult social care in our two Local Authorities we will use the Better Care Fund to support our providers to work together really effectively to care for as many people as possible in the community in line with their care plans, improve the hospital discharge experience and reduce any delays, and support more people to die outside a hospital setting if that is what they want Whilst the Better Care Fund has a national focus on adults, locally we are also looking at emergency admissions for children to Homerton and have commissioned an expansion to the children's community nursing team to support more children and their parents in the community and support earlier discharge. We also want to develop a programme with Homerton to look at whether their community services for children could do more to avoid hospital admissions and manage more children at home. Over the next year we will have a particular focus on asthma and on supporting our practices to identify children at risk so that they can put In place the necessary support and care plans.

MANAGING DEMAND

WHY? WHAT?

5 Page 24 of 114

As well as our work on emergency admissions we are maintaining our focus on the wider urgent care system for our patients, recognising that at the moment our A&E attendance rate is 10% higher than across London. We are fortunate that locally the Homerton delivers really strong A&E performance for sick people but we need to ensure we have a good wider urgent care system both in and out of hours which meets the needs of our patients and that our patients see primary care as their first point of contact for all non-emergency issues both in and out of hours.

Last year we commissioned our new out of hours GP service from a new local GP led social enterprise - CHUHSE - and already have seen 38% more people use the service. Over the next year: • We will be investing in our practices to extend their opening hours to improve GP access for our patients in an

attempt to discourage people from using A&E as their first port of call • We have also commissioned a new £600k service in conjunction with our GP Confederation and the London

Ambulance Service called Paradoc which ensures a GP and paramedic can respond to an urgent call, visit the individual and ensure that there is support and care available to keep them at home and avoid having to go to hospital. So far it has seen over 500 cases and only 14% of these ended up going to A&E;

• We have invested in an Observational Medical Unit at Homerton A&E to quickly treat patients referred by GPs with certain conditions and we are also commissioning a range of consultant advice lines and urgent clinics coupled with rapid access diagnostics so GPs can get a quick diagnosis and start treatment fast;

• All our practices work with Homerton and other partners to develop care plans with patients who frequently attend A&E;

• We are commissioning Homerton to help people who are using A&E and don’t have a GP to register with a local GP and have extended this service to Hackney Service Centre to encourage more local people to register with our GPs;

• We are commissioning Homerton to identify people attending A&E with mental health problems & develop care plans for them;

• We have commissioned our GP out of hours provider to have community nurses working alongside them to provide more holistic care for our patients overnight and at weekends;

• We are working with Homerton, London Ambulance Service and our GP Confederation to improve how information is shared about our patients’ care plans and ensure that emergency services follow these;

• We are investing in more services to make hospital discharge smoother & in more community services for people who are at the last stages of life;

• Our Urgent Care Programme Board is working with Homerton and our practices to think about how we could redesign the current Primary Urgent Care Centre (PUCC) service to better meet the urgent care needs of our patients

Now we have such a wide range of services in place our priorities are to make sure the services work together to address patient needs and link up with primary care, that patients can articulate what they want their care plans to look like and that we are supporting clinical behaviour which results in care for as many people as possible in the community.

OUR URGENT CARE SYSTEM

WHY? WHAT?

6 Page 25 of 114

Many people believe that the current model of primary care needs to change and adapt to better meet the needs of people in the 21st century. Locally we are fortunate to have a good range of well performing practices that have been commissioned to offer a range of extended services to support our patients and take forward our plans and they are now working together as a Confederation. However we aren't complacent. Our patients told us that they wanted a GP out of hours service they knew about and had confidence in - we addressed this and now have a new service run by local GPs. Our patients are telling us that they are struggling in some cases to get access to primary care and are going to A&E to seek help, even when their practice is open and that there are differences between what different practices offer.

Our 43 member practices have formed a GP Confederation which is a GP-led not for profit umbrella organisation, providing help and support to practices with the delivery of services and giving other local providers one organisation to talk to who can represent practices as we try to ensure the integration of local services. We now contract for additional services from our member practices via the GP Confederation – this means we just have one contract with one organisation that is responsible for supporting practices to ensure uniform high quality standards and outcomes and ensure population coverage – ie so that all our patients can access the services we are commissioning from primary care irrespective of which practice they are registered with. We are already commissioning the following new services from primary care: • Extended opening hours in response to patient feedback; • Duty doctor service to respond to urgent requests for support from patients and other providers; • Identification of vulnerable older people, development and agreement of care plans, proactive home visiting service; • Identification and early diagnosis of people at risk of coronary heart disease, respiratory disease and diabetes; • Access to support, advice and education for everyone with a long term condition and longer initial & care plan

review consultations; • Proactively reviewing & managing people with mental health problems; • Seeing each woman during her pregnancy and after delivery to ensure that her needs are being met; • Focusing on proactively reviewing all children with long term conditions and ensuring that care plans are in place

with a specific focus on the management of asthma and ensuring support is available to children and their families; • Ensuring high quality prescribing practice. To complement this and ensure integrated pathways and provision we hope we will be allowed to take formal responsibility for co-commissioning primary care with NHSE via our Health & Wellbeing Boards. Our GPs have also worked really hard over the last six years with consultants at Homerton Hospital to improve care for our patients, eliminate waste and make care as seamless as possible. We have low out patient referral rates and we will be maintaining this focus through our clinical leadership work with Homerton, our Planned Care Board and our consortia by developing more pathways, eliminating steps in the patient pathway which don’t deliver patient benefit and improving access to diagnostic investigations. Our 6 commissioning Consortia are the bedrock for how our GPs work together to discuss & develop primary care clinical behaviour & deliver education & support. Our local providers across the NHS and voluntary sector (including the GP Confederation) have also come together under the “One Hackney” umbrella to join up their services, work more closely with our practices and take collective responsibility for delivering specific outcomes. We are keen to explore with them whether this could develop into an Accountable Care Organisation to better coordinate care for our patients. We are starting some work with our partners over the next few months to develop an integrated service offer for vulnerable parents & children to ensure that we can identify their needs, wrap services around them to address their needs and get them the best possible start in life. Whilst we have spent a lot of time focusing on the needs of our elderly population we now need to address the needs of our growing young population.

DELIVERING PRIMARY & COMMUNITY SERVICES

WHY? WHAT?

7 Page 26 of 114

We want to make sure that the experience of our patients when they have to go into hospital is first class and that services are safe and of high quality. Most of our patients use Homerton Hospital and we are fortunate that it is efficient with good standards and outcomes. Patients have told us that they would like to see better join up between hospital services and primary care and a reduction in waste in hospital - wasted appointments where there isn't the information available to treat them, duplicate tests, poor communications. These issues seem to be more of a problem at non-local hospitals – particularly Barts Health where our GPs are also concerned about the delivery of some services. People are broadly complimentary about the services at the Homerton but feel that they have more to do around addressing feedback from patients and staff attitudes.

We will continue to work with Homerton to ensure that it stays a high performing organisation and that it can meet any new quality or performance standards which are introduced and can meet the challenges of ensuring great services seven days a week. The six main areas of work for us over the next year are: • Supporting the work which Homerton is doing to improve patient experience in some areas - particularly

care of the elderly and post natal care - and linking up with the views of our patient and public involvement groups, Healthwatch, our GPs and other stakeholders to ensure that concerns are being addressed and patient satisfaction and empowerment is core to how Homerton - and other providers - design and deliver their services;

• Ensuring hospital services abide by NICE standards and participate in national audits. We are also very active in supporting local joint clinical audits of our clinical pathways & clinical behaviour;

• Making sure that we are working with clinicians at the Homerton to monitor, investigate and learn the lessons from complaints, incidents, outbreaks of infection and any avoidable deaths;

• Working with our colleague CCGs to understand the implications of emerging models of specialist care commissioned by NHSE. We want to ensure that we have integrated pathways from presentation in primary care to hospital treatment and need to make sure that the NHSE reviews of specialist service provision across London do not worsen access, outcomes or quality for our patients nor destabilise any local services and pathways;.

• Ensuring that we continue to have strong local pathways for people with cardiac and cancer diseases which link in with the new specialist centres being developed at Barts Health and UCLH;

• Understanding the plans of our fellow CCGs to improve the quality of services across Barts Health and the implications of any changes for both City and Hackney patients and for the Homerton.

SAFE HIGH QUALITY HOSPITAL SERVICES

WHY? WHAT?

8 Page 27 of 114

Our population have high mental health needs: • 50% of all women and 25% of

all men are affected by depression at some point in their lives;

• 4-5% of people have a diagnosable personality disorder;

• People with schizophrenia are likely to die 15-25 years earlier than others;

• Dementia affects 5% of all over 65s and 10-20% of the over 80s.

We spend more money on mental health services than elsewhere in England and so we need to ensure that every £ is really addressing the mental health needs of our patients and really improving outcomes.

• We have commissioned a new service at Homerton to ensure a rapid assessment of people with mental health problems in the hospital wards and in A&E and to help support safe and rapid discharge;

• As part of our work on parity of esteem, we have also transferred the management of some patients with mental health problems to primary care. Our clinicians have now agreed to take a further step - discharging more patients over the next twelve months and reinvesting the savings in an extended primary care mental health service to help manage patients in the community;

• We are commissioning our practices to ensure they have the skills, capacity & time to provide the support that people with mental health problems need in the community;

• We are working with our Local Authority Public Health commissioners to align the health and wellbeing and prevention services they commission with our CCG plans;

• We are investing in community provision for dementia sufferers and their carers and are commissioning all our providers to increase the rate of diagnosis of dementia and ensure that advice and support is available to people diagnosed and their carers;

• We are investing in a training programme for community staff to recognise the symptoms of psychosis in order to enable swifter referrals;

• We will make sure that every patient with mental health problems has a recovery plan which has an introduction to benefits and employment support;

• We are continuing to commission shorter waiting times for psychological therapy assessment and treatment services and will commission an extended range of interventions.

• We have recently published a Joint Framework for CAMHS services to improve outcomes and promote early interventions;

• We are commissioning an extended mental health service to meet the needs of patients admitted to Homerton with mental health problems and those who attend A&E.

• We are expanding the popular service we commission with the Tavistock & Portman to support people with unexplained medical symptoms& complex medical problems which have underlying mental health issues.

ADDRESSING MENTAL HEALTH NEEDS

WHY? WHAT?

9 Page 28 of 114

Our patient and public involvement groups who work with our practices and with our Programme Boards are an incredibly rich source of useful and powerful information about what we need to change and why. We also spend a lot of time listening to the views of our 43 GP practices - they are in direct contact with our patients every day, work with local services and have a great understanding of what's actually happening "on the ground".

So we are making lots of other changes - which don't fit neatly into the other headings but are just as important if we are to meet our vision of making a difference for our patients. We are: • Developing a new pathway for the antenatal care of vulnerable women and working with fellow

commissioners and partners to develop an improved offer for our 0-5 year olds. • Improving the way that wound dressings for our patients are provided and managed in the

community and developing a new service for lymphpoedema. We think there is a lot of waste and duplication in the current dressings service which isn't as responsive to the needs of our patients as it ought to be;

• Commissioning a better spread and availability of diagnostic tests for patients in the community - blood tests, spirometry, ECG and anticoagulation amongst others;

• Commissioning a new community based service to test people for glaucoma and monitor the results which should result in fewer trips to hospital for check ups;

• Improving the way that people with pain and those needing joint surgery are cared for and treated - we think we could really streamline the pathway and better join up services so our patients don't need as many trips to hospital, provide much better information to our patients, and improve overall quality and satisfaction;

RESPONDING TO OTHER THINGS WE HAVE BEEN TOLD

WHY? WHAT?

10 Page 29 of 114

• Our plan maintains our 2013/14 £27.2m roll forward as headroom through the next 5 years; • We will use our strategic investment reserves and internal resources non-recurrently to

invest in change where it will deliver patient benefit for City & Hackney; these reserves also maintain our recurrent headroom against risk;

• All investment proposals are considered by our Prioritisation and Investment Sub-Committee using a prioritisation framework;

• Where evaluation shows that our new investment has delivered the improvements we expect and is sustainable, we will fund the services recurrently;

• Our plan supports the continued viability of our main providers Homerton, ELFT, CHUHSE and GP Confederation;

• We base all our decisions on evidence base and benchmarks, in line with our constitution, and our plans are grounded in clinical reality and making a difference on the ground and are all clinically led & supported – therefore we have not made heroic assumptions and our QIPP plans are cautious and deliverable;

• Our plan allows for headroom to cover downside risks such as funding formula change, demographic change and activity risk and we are full members of a risk share agreement with other East London CCGs – Waltham Forest, Newham and Tower Hamlets;

• We will continue to lobby with our partners for a fairer funding formula that reflects deprivation and meets the needs of an inner urban population.

FINANCIAL STRATEGY

11 Page 30 of 114

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NON RECURRENT INVESTMENT

REPORT TO OCTOBER BOARD

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BACKGROUND• 54 proposals for non recurrent investment have

been submitted by Programme Boards;• Proposals from providers have been reviewed by the

relevant Programme Boards and all proposals have been shared with member practices and PPI representatives to ensure input;

• 23 of the proposals have been reviewed by the Chair, Chief Officer and Chief Financial Officer and have been approved for mobilisation subject to their sign off of the service specification:• These are listed below.

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• The Prioritisation Sub Committee meets on 31 October to consider the remaining 31 bids• Summaries of each bid are in the following presentation.

• A number of the bids require further consultation with members and PPI to finalise the service specifications;

• Those specifications which propose contracts with practices as the providers/GP Confederation will be subject to added scrutiny by the CCG Contracts Sub Committee.

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• We will report verbally to the Board on the outcome of the Prioritisation Sub Committee;

• As previously the Board will be asked to delegate final sign off of service specifications to the Chair, Chief Officer and Chief Financial Officer:• Once done contracts will be entered into with providers.

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As a result of the number of investment plans:• We are utilising some short term additional

management capacity to support finalisation of service specifications and ensure rapid mobilisation of the services;

• We are developing a specification for evaluation as we recognise that for a number of the schemes we will need to review their impact in 2015 to determine future contracting arrangements.

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Name Summary & Next steps Source Value

Paediatric Audiology Room (with sound proof booth)

Childrens PB to lead on contracting following discussion with CFO HUHFT £70,000

First Steps (Early Intervention Children’s Psychology Service) –reducing current waits -

MH Programme Board to agree service spec and monitor contract/plan HUHFT £100,000

Raise awareness & management of hypoglycaemia amongst Health Care Professional

Project to raise awareness of the management of hypoglycaemia amongst patients and healthcare professional by creation and dissemination of educational materials (brief training DVD to play in waiting areas etc; drop in training for staff; credit card size information cards for patients and one for healthcare professionals).Plan to be signed off by PPI Committee

Long Term Conditions

£9,200

Pilot project to determine whether it is possible to alter the engagement of hard to reach communities

Pilot project to determine whether it is possible to increase the engagement with health services of “hard to reach” individuals with diabetes. The project will employ additional lay educators to identify and work with relevant patients to establish effective models of service delivery. Plan to be signed off by PPI Committee


£108,500

Pilot project is to determine whether the embedding of Psychological support for patient within The Hackney Diabetes Service can improve outcomes

Pilot project to determine whether embedding additional psychological support for young adults and adolescents with diabetes within the Hackney Diabetes Service can increase engagement and improve health outcomes.


£50,000

Approved for mobilisation subject to service specification sign off

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CIDC- Warwick Course A project to up-skill professional staff working in diabetes care to run the accredited Certificate in Diabetes Care (Warwick) course locally. This would improve access for local health care professionals and increase their knowledge and skills in relation to diabetes management.


£70,000

High Risk Diabetic Foot Co-ordinator

Pilot project to facilitate more efficient and timely management of people with complex, high risk and diabetic foot disease in line with NICE guidance. The aim of this trial is to assess the impact of the podiatric high-risk foot coordinator role on length of stay, rate of re-admission and bed cost.


£80,000

One year pilot rapid access specialist Atrial Fibrillation clinic

Develop and consult on pathway before implementation Long Term Conditions

£75,000

Continue funding for community based cardiac rehabilitation for lower risk patients


£76,000

Primary care outreach –COPD

Extra capacity for the ACERS team to support primary care staff to increase competence in identification/diagnosis/management of COPD; to identify undiagnosed or misdiagnosed COPD; to ensure quality of diagnostic spirometrycarried out in primary care.LTC to consider whether LTC contract needs changing to ensure practice engagementConsult members on model


£45,000


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VOICES survey Funding to use the validated VOICES survey to assess the quality of care delivered to people in the last three months of their lives. Project plan to be agreed by PPI Committee


£42,000

MSLC Development Programme

Engaging a third sector provider to support and strengthen the Maternity Services Liaison committee (MSLC). Improving engagement with users to promote services and encourage feedback on quality by commissioning a provider that will implement an operational framework for engaging members and providing feedback to providers and CCG. Establishing a programme of public consultation on maternity services.Plan to be shared with PPI Committee

Maternity £25,000

Mothers Champion Volunteer Programme

Piloting Mothers Health Champion project to test impact of culturally similar volunteers in improving uptake of healthy choices, early antenatal booking and care uptake and engagement with health child programme (particularly immunisation schedule). - Plan to be shared with PPI Committee and NHSE as main commissioner of chp

Maternity £49,000

Children’s User Engagement Committee

Engagement of a 3rd sector organisation to support a Children’s Voices Forum to bring together young people, parents and carers with providers of services and health commissioners to hear the experience and priorities of families, to better inform how we continue to improve services. Supporting families in decision making and express their views when funding decisions are made.Agree plan with PPI Committee

Children £25,000


Page 39 of 114


Children feedback tool Interactive feedback tool to enable parents and children to give real time feedback on services in urgent care outpatients and the communityAgree plan with PPI Committee

Children £25,000

Personal Health budget for children

Engage a third party to work with families whose children have very complex needs to agree how we can support families to receive money directly / via a third party for paying for care that meets their child’s needs.as a personal health budget. This will give the family more choice, flexibility and control over what will have the greatest impactAgree spec and plan with PPI Committee

Children £60,000

Choices’ vulnerable adults project

A project to empower vulnerable 14-19 year olds in Hackney to make more positive and informed decisions about their health,and provide them with the emotional and practical support that they need to access mainstream services and to transition to mainstream services.Agree spec and plan with PPI Committee

Children £22,000

Additional A&E capacity These new schemes have been worked up in collaboration with the Urgent Care Board and the Trust. These four key posts would add necessary capacity in the A&E department particularly during the overnight periods where the trust has struggled to maintain its 4 hour target and when there is typically fewer senior staff to attend to injuries or other conditions that require senior clinical input. The proposal is to continue to fund these posts beyond March 2015 for a further year as in the last 2 years it has been noted that A&E activity has maintained its winter peaks into April-June dropping only slightly in Jul and Aug and then returning to the upward trend from Sept onwards.

Urgent Care £675,000


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Ward Transfer Nurse TBC Urgent Care £27,000

A&E Porter TBC Urgent Care £19,000

Additional Registrar in the evening

TBC Urgent Care £115,000

Emergency Nurse Practitioner (ENP) overnight

TBC Urgent Care £64,000

Innovation Fund Following on from the Innovation Fund 2014 we propose the following three areas to be considered for non-recurrent investment for the total value of £667,508. This investment would be used towards (1) increasing the funding for existing services by 15% to meet the initial funding request, (2) Extending the funding to additional Innovation Fund bids that met the criteria and (3) Re-running the Innovation Fund process in 2015.

(1) And (2) to mobilise nowPlan/process for 2015 Fund (3) to come to Clinical Exec

Public and Patient Involvement

£667,508


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Prioritisation and Investments

HUHFT, BCF & CCG Programme Board Proposals

Page 42 of 114

Reference Title Source Value

NR1 Pathology – achieving ‘excellence’ in our quality management system (QMS) HUHFT / PlannedCare

£250,000

Summary

This is to resource additional staff costs to enable skilled existing staff to be released to deliver on the requirements of the QMS.

Feedback from Members and Public

Supported by Planned Care Programme Board. Local robust pathology department is the backbone to effective primary and secondary care management of health conditions across all programme boards.

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NR2 Pharmacy Quality Improvement Programme HUHFT / Prescribing

£150,000

Summary


Page 44 of 114


NR3 Training to Support Values and Culture Change HUHFT / Public &Patient Involvement

£206,050

Summary

This improvement programme is essential to deliver better patient experience at the Homerton Hospital. Inpatient surveys and Cancer Patient Experience surveys continue to perform poorly at the Homerton and this programme seeks to support the staff groups as central to achieving change.


The PPI Committee has been actively involve in shaping and monitoring the Homerton Patient Experience strategy. The Committee will require a regular update on the delivery and impact of this scheme as part of any agreement to commit the additional resources.

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NR4 Supported technology solution – patient experience feedback HUHFT / Public &Patient Involvement

£312,600

Summary

This is a scheme to provide technical equipment and a coordinator post to increase patient feedback on services at the Homerton and improving scores on key patient experience scores.


This scheme is supported along with a commitment from the Homerton team to actively involve local residents and PPI reps/committeemembers as potential volunteers in the scheme.

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NR5 Management system for supporting a comprehensive library of patient information available at the point of patient contact and compliant with the NHS information standard

HUHFT / Public & Patient Involvement

£220,000

Summary

• Investment for developing, tracking, updating and making accessible patient information in appropriate format and presenting this information in a standardised way, offering alternative formats where necessary (braille, audio, easy-read)

• Offering access to specific patient information through the external facing HUHFT intranet as well as external website in a printable and accessible format

• Involving staff as well as patients in developing this approach to ensure information meets national standards and is of use to patients ensuring links to organisations such as British Heart Foundation etc.


This scheme is supported though will require active participation from patient representatives in the choice of patient information as well as models of best practice. This will be underpinned by a philosophy of patients feeling in control of decisions about their care.

The PPI Committee requests continued oversight and input to all the schemes relevant to its role during further design and implementation phases.

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NR6 Waiting Time Reduction HUHFT / Planned Care

£1,100,000

Summary

This scheme is to fund additional capacity to clear a backlog of waiting lists of patients and reduce overall waiting times within a number of clinical specialities at the Homerton.


The Planned Care Programme Board has asked for revisions to the proposed scheme to ensure that patient volumes within each speciality are clearly agreed and commissioned at agreed prices. The Board agrees in principle to reducing waiting times for patients though seeks to have clearly understood parameters to this and agreed plans for sustainable changes to pathways in order to avoid future build up of current problems. It is proposed to agree this funding in principle and that the more detailed PID submission will be specifically agreed with oversight from the CCG Chief Financial Officer and Head of Contracting.

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NR7 Quality Improvement Programme HUHFT / Jenny Singleton

£1,000,000

Summary

2 year proposal with 300k for Y1 and 700k Y2. The programme has three stages with Y1: STAGE 1) data collection to provide real time quality & effectiveness dashboards owned by clinical directorates linking Ward to Board; STAGE 2) best practice and priority development with PPI and lead orgs in improvement techniques (ie.UCLP) to design 6 new pathways; Y2 STAGE 3) 6 transformational improvement programmes to deliver enhanced recovery and/or ambulatory care.

Investment would pay for Y1: improvement practitioners – in-house/consultancy/fixed term contracts – and review of best practice & evidence; Y2 co-ordination and programme management. Evidence cited about successful quality improvement pathway development is mostly collaboratives. No breakdown on costs for Y1&2 ie posts or outcomes. Lead @ HuH has good track record in this area.


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NR8 Premises Assurance HUHFT £1,450,000

Summary


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NR9 Electronic City & Hackney Care Record HUHFT £2,000,000

Summary


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NR10 Enhanced IT – mobile working in the community HUHFT £245,000

Summary


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NR11 One Hackney Project Management and evaluation Integrated Care £353,229

Summary

Practice-based integrated care is a key programme for delivering integrated care across City and Hackney. It involves a new way of working for all commissioning and provider organisations and will be a flagship project for the newly formed Better Care Fund Programme BoardThis PID will ensure there is programme management support for the provider group to deliver the One Hackney programme, to be provided by the GP Confederation. It is also for an evaluation of this programme. This will consist of an analysis of the benefits of the interventions in order to assess whether there has been any impact on patient outcomes, what the cost effectiveness of the programme is or the reasons behind non-achievement of predicted benefits/outcomes. The CCG will draw up a specification related to this evaluation. There is a current overall specification for the One Hackney Programme.


There has been extensive consultation with members and the public – Healthwatch have formally fed into the One Hackney provider board (Summer 2014), the model has been discussed at PPI groups (Spring 2014) and the BCF Programme board PPI representatives. It has also been presented at CCF.

At the CCG board (Sept) and at other fora it has been explicitly mentioned that there should be evaluation built into this programme from the outset.

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NR12 Increasing social care support in the community, delivering the Hackney DTOC challenge

Integrated Care £4,015,000

Summary

This bid is to support the Hackney DTOC Challenge. Hackney has historically had a persistent problem with delayed discharge and the performance last year was particularly unsatisfactory. The current position in Hackney is improving, however, the council would like to contribute to a step change in the DTOC figures. Therefore, the London Borough of Hackney (LBH) is signing up reducing DTOC (social care delayed transfers) figure from 4.5 to 3.4 (England average) by December 2015 and then reducing this figure further to 2.4 (CIPFA average) by March 2016. This bid is for a £4 million investment for a range of initiatives that will contribute to increasing social care support in the community so that it contributes to delivering the Hackney DTOC challenge.


This proposal has been worked up based on feedback from GP members, hospital clinicians and public/healthwatch regarding the discharge process and the availability and responsiveness of social care to enable a reduction in delayed transfer of care.

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NR13 Mare Street Hostel Hospital Discharge Service Integrated Care £150,000

Summary

The Hospital Discharge Service provided by St Mungo’s Broadway is an integrated health service based at Mare Street Hostel for Single Homeless people. The service offers a period of recuperation for homeless people who are discharged from acute hospitals alongside an assessment of unmet health needs and support to engage in planned healthcare. The service should have a significant impact on reducing unplanned attendances and reducing LOS for the cohort group, although a full evaluation will be brought to the BCF programme board. The service has been funded as a pilot with DoH pump-prime funding and this bid is for an extension of the funding until March 2015 to enable full health and social care evaluation.


This has been discussed at the inaugural better care fund programme board which had input from 3 patient reps. The BCF patient subgroup is still being set up so it could not be discussed there.

There has been a site visit and assessment by the BCF Frail Elders/Integrated Care GP Commissioner. If pilot continuation is continued, full engagement with practices and the public will take place on the potential long-term model.

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NR14 “Time to talk” – Extended Consultations for people with Long Term Conditions Long Term Conditions

£953,438

Summary

Is a 15 month pilot giving up to 19,000 patients who have three or more long term conditions the opportunity to have a half hour quality discussion with their GP or practice nurse talk about the things that matter to them the most, such as worries, depression, lifestyle, family issues, etc.


The idea behind this PID came from users, through research conducted as part of the Fund for Health, though consultation with the CCG’s PPI Committee specifically on what support people wanted to help manage their condition, and has the full endorsement of the LTC Board’s PPI rep.

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NR15 Care for those in last years of life – GP contract Long Term Conditions

£200,000

Summary

A extension to the FHV GP contract to ensure all patients in last years of life identified early, have a care plan and an advance care plan, care co-ordinated with other agencies and patients supported to die in their preferred place of death.


This has been discussed at the End of Life Care Board which has patient and voluntary sector representatives.

We will be seeking members views on the best way to ensure improved outcomes for patients and how to integrate this into similar services via the CCF/Consortia shortly.

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NR16 One City & Hackney Primary Care Mental Health Mental Health £987,000

Summary

An alliance between Confed, the VolSec network (and Family Action) and ELFT to drive increased integration and improved recovery and physical health outcomes for patients in primary care.


Flagged at the last CCF. Members were in favour of any initiatives which integrate services and standardise waiting times and recovery outcomes.

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NR17 One City & Hackney CAMHS Mental Health £400,000

Summary

An alliance between ELFT, Homerton and the voluntary sector to deliver improved CAMH outcomes with all providers using a common outcomes framework and delivering services within an integrated model. This will reduce wait times, increase throughput and improve experience and outcomes for families.



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NR18 One City & Hackney Dementia Mental Health £400,000

Summary

An alliance between ELFT, Homerton and the alzheimers society/others to improve care for recently diagnosed and existing patients including improved day opportunities. Including a single memory assessment service and seamless integrated care between ELFT, HUH and other partners.



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NR19 One City & Hackney Psychological Therapies Mental Health £500,000

Summary

An alliance between Tavi, ELFT, Homerton and the voluntary sector to increase access points to psychology therapies, reduce waiting times to 2 weeks for assessment and 4 weeks for treatment and provide a seamless stepped care model of psych therapies in the borough.



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NR20 Improved Voluntary Sector Treatment Provision Mental Health £TBC

Summary

Augmented Mental Health Network provision to support complex SMI patients recover and access mainstream community support. Working with Core Arts subcontracted by ELFT this additional support will ensure SMI patients can continue to access day opportunities to prevent relapse, reduce the need for specialist interventions and admissions.



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NR21 Breastfeeding Peer Support Maternity £128,045

Summary

Piloting breastfeeding support worker and peer support volunteers to increase rates of breastfeeding uptake and continuation at 6 weeks and beyond.


This project is endorsed by the MSLC and the delivery of breastfeeding support is a specific service development priority for them and their members (including local parents represented on the MSLC parent sub-group). Specifically users want more access to breastfeeding support and better coordination of the provision that is available.

In addition service users at the October 2014 Health Fund event recommended the development of breastfeeding support particularly regarding support for vulnerable women and their partners.

Feedback from GP members has not been formally collated at this stage but it is planned to be sought from the CCF and the proposal amended accordingly, should the prioritisation committee recommend the proposal.

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NR22 Targeted Antenatal Classes Maternity £60,000

Summary

Working with third sector providers and the Homerton to targeting antenatal classes for vulnerable woman, young woman, hard to reach communities and women with specific conditions.


This project is endorsed by MSLC and the delivery of targeted antenatal classes is a specific service development priority for them and its members (including local parents represented on the MSLC parent sub-group). The MSLC has noted in particular that:Users want to see increased provision for hard to reach groupsUsers want classes to be more relevant to the needs of local groups and communities Users want classes to be more interactiveUsers want more support throughout pregnancy

In addition service users at the October 2014 Health Fund event recommended the development of targeted antenatal groups. This was further endorsed by the Health Fund / Health Watch Turkish Children’s Centre (Minik Kardes) research project, which designed and piloted targeted antenatal classes for the significant Turkish community in Hackney, but which it cannot fund any further.

Feedback from GP members has not been formally collated at this stage but is planned to be sought from the CCF and the proposal amended accordingly, should the prioritisation committee recommend the proposal.Page 64 of 114


NR23 Obstetric Theatre Maternity £500,000

Summary

Bid to support the Homerton with the delivery of an improved care pathway for women entering the Homerton’s maternity service in the context of both emergency and elective C-section procedures.


The proposal is explicitly designed to address the current failings by creating an environment which is fit for purpose, complaint with all ventilation standards and as well-organised and welcoming as possible. Given the nature of the initiative no formal consultation with patients has occurred although extensive discussions have taken place with the Trust’s Obstetricians. Once completed, however, the Trust would seek to communicate the improvement in provision to Hackney women and also seek feedback from the FFT as well as GP members.

No formal consultation with members has occurred to date but upon recommendation by the Prioritisation Committee the proposal would be taken to members via the CCF for discussion and consideration.

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NR24 Epilepsy Service Children £85,000

Summary

Epilepsy nursing service to support interface between primary secondary and tertiary care this service will also support the transition of adolescents to Adult services.


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NR25 Interface Paediatrics Children £130,000

Summary

Consultant to support to support the integration of long term condition provision across primary community and secondary care.


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NR26 Reconfiguration of the Locomotor Pain Service Planned Care £333,037

Summary

A redesign of the pain management pathway to expand the psychosocial aspect of the service, increase provision of pain management programmes, provide a service for non-muscular-skeletal related pain and reduce emphasis on the medical management of chronic pain. It will deliver a single point of entry, clear referral guidance, 30% increase in multidisciplinary assessment, 60% of patients to access pain management programmes, reduction of tertiary referrals and spinal injection activity as well as reductions to A & E attendances for pain and outpatient appointments in the specialities of pain management, rheumatology and orthopaedics and reduce the activity of spinal injection procedures.


This was consulted on as a Planned Care Board priority with CCG members and the public as part of the development of 13/14 Commissioning Intentions. Patient feedback was that access to pain services was limited. Attendances for patients with chronic pain at GP practices are significant. Patients of the current pain service have been consulted as part of the service development proposal.

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NR27 Interim Tier 3 weight management programme Planned Care £120,596

Summary

Tier 3 weight management services are a pre-requisite in the NHSE eligibility criteria for Tier 4 surgical services. The proposal is for a 16-month, interim Tier 3 multidisciplinary weight management service. The service will measure both short and long term outcomes, including weight, physical measures, and quality of life. Each patient will receive an individualised programme consisting of regular group sessions and a maximum of 17 1:1 sessions with the physiotherapist, dietitian and clinical psychologist and two appointments with the Medical Consultant. The interim service has been commissioned to fill this gap so that patients who are sent to the Tier 4 provider, but rejected as they have not undergone Tier 3 services can be offered a course of treatment on the specialised weight management programme.


The views of patients who have used a previous pilot service have been considered as part of this proposal. The Planned Care Board have approved this scheme as patients who would benefit from and require from the service prior to bariatric surgery are currently being denied access.

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NR28 Clinical time for cancer Planned Care £TBC

Summary

This is a two fold scheme and the precise details are being developed. The first area will be to commission additional services from practices to increase screening uptake and deliver improved practice systems and audit processed to support early diagnosis work. The second element will commission extra ‘time to talk’ with GPs for patients with diagnosed cancer.


This proposal will be discussed in detail at November CEC after initial discussions at the October Programme Board. Patient views will be sought through patient groups and possibly facilitated by CNS staff. The PPI Committee will consider as part of its discussions of Commissioning Intentions at the October meeting.

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NR29 Extended Hours Urgent Care £410,422

Summary

The Extended Hours scheme was previously granted approval by the prioritisation committee in Feb 2014 for funding a pilot for 2 years. The original budget given for the contract was £300,000 per year. There have been challenges in getting the scheme off the ground these were linked to, delivering the model on a quadrant basis, GP capacity, tension between local scheme and national scheme. A new proposal is being worked up in collaboration with the GP confederation which will see the scheme be delivered on a practice basis, offering an additional 20176 appointments per year equitably across City and Hackney and which will see all practices sign-up to the national DES in order to qualify for the local scheme.


This scheme was proposed in response to a Health in Hackney Scrutiny committee in 2012/13. A large part of the review was to query why A&E attendances per 1000 population were higher in City and Hackney than London averages. It was concluded that more could be done to increase capacity in primary care given the number of A&E presentations that could be treated in community settings.

Given the public nature of the scrutiny review the extended hours proposal has therefore received significant feedback from a broad range of partners, stakeholders and public as well as patients representatives. A key feature of public responses was to ensure the equitability of available additional appointments, we believe this new proposal responds to those comments.

The proposal returned to the scrutiny review on 13 October 2014. Members of the committee responded positively to the proposal and looked forward to its launch.

The Urgent Care Board has considered this and the previous proposal at its meetings in March, July and September. Board members welcomed the scheme as part of the package of services designed to increase capacity in primary care and relieve pressures on A&E.Page 71 of 114


NR30 Improving access to community rehabilitation for clients with long term conditions

Better Care Fund £319,762

Summary

Specialist inter-disciplinary and uni-disciplinary rehabilitation to any client over the age of 18 with a physical or neurological impairment. ACRT provides assessment, re-assessment, therapy, advice, support. The service also offers advice and support to carers, family and friends of service users to maximise the function and wellbeing of ACRT clients. There are currently long waiting lists for this service (only 63% of patients are seen within 5 weeks). The funding will be to provide additional multidisciplinary staff to deliver the following waiting time standards. All non-urgent clients will be seen within 5 weeks. All urgent clients will be seen within 1 week.


This item will be covered by the BCF Programme board from October 14 onwards – it has previously been discussed at the LTC programme board, where feedback from long waits has been received and reviewed by clinicians and LTC patient representatives.

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COMMUNITY HEALTH SERVICES

FOR DECISIONOCTOBER 2014

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BACKGROUND• In April 2011 City & Hackney PCT transferred its community

provider services to Homerton University Hospitals NHS Foundation Trust under a Business Transfer Agreement.

• The contract value at the time of transfer was £46m however some commissioning responsibilities have since transferred to LBH, PHE and NHSE. The current CCG contract is due to expire on 31 March 2015.

• Very little work was undertaken at the time of transfer to the CCG about the activity or performance metrics to be delivered

• The value of the CCG contract for 2014/15 is £32m

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CCG COMMISSIONINGOver the last 2 years

• The CCG has developed One Hackney and a model for Practice Based Integrated Care (discussed at the September 2014 Board meeting) which seeks to expand and integrate a number of community services with other provider services to deliver care plans for our vulnerable patients

• This is currently mobilising and the impact of collective One Hackney provider services on the metrics and outcomes will not become clear until Spring/summer 2015

• Some services within the CHS Homerton contract will be commissioned via the Better Care Fund (BCF) from April 2015 via a 2 year contract, including Practice Based Integrated Care and piloting an alliance based contracting mechanism (as outlined to the last CCG Board meeting)

• The CCG agreed with Homerton Hospital as part of the 2014/15 contract to undertake a finance rebasing exercise for services commissioned via the CHS contract – this will be complete by end of 2014

• This is in order to recognise the full costs for each service including indirect costs and overheads and in recognition of changes made by the Trust to service provision over the last 3 years. This will ensure an agreed financial baseline for all services as some transfer to the BCF. The exercise will also address the true cost of services and ensure visibility the value for money test for the overheads within the contract.

• Programme Boards have been establishing key performance indicators and outcomes for each community health service and establishing systems to ensure these are reported as can be used to assess performance

• Programme Boards are also looking at how the community health services can integrate with other providers, including with primary care to help minimise Acute PbR spend

• As discussed in the past the CHS element of the Homerton contract is a reflection of the services which used to be provided by the PCT – there are a number of services provided in the community by Homerton which they were commissioned to provide prior to the transfer and are within the acute contract (eg Diabetes nursing, COPD community)

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RECOMMENDATION• Given that the BCF and One Hackney goes live in 2015 and are subject to 2 year contracts during which we will be

able to assess the impact of the services on metrics, outcomes and patient quality, it is recommended that the remaining services commissioned under the CHS contract are extended to March 2017.

• Allow the impact of the baseline costing to be assessed• Allow Programme Boards to continue to develop service specifications and metrics and better judge the

performance of the service• Allow the CCG and Trust to explore how some of the community and acute services could integrate further• Understand the impact of the BCF and One Hackney• Facilitate the investment in infrastructure eg IT and information systems to support integration.

• Furthermore • The NHS 5 year Forward look just published outlines some new organisational models for the provision of

services, and community based services in particular working alongside primary care. Local clinicians need some time to debate these and the appetite for pursuing the different options

• The CCG will be invited towards the end of 2014 to reapply to take on the commissioning of core primary care from April 2015 which will provide us with further opportunities to develop new integrated service models

• Against this national and local context the CCG Board is asked to endorse this approach assuming a satisfactory outcome to the rebasing exercise and unless a pressing clinical, patient or operational need arises to vary it for discrete services or condition specific areas.

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NHS CITY & HACKNEY CCG

BOARD MEETING

31 October 2014

FINANCE & ACTIVITY REPORT

Month 06 - 2014/15

NHS City & Hackney CCGPage 77 of 114

Contents

NHS City & Hackney CCG

Executive summary

Finance and activity dashboard & trend

Key risks narrative

Key risks, opportunities and assumptions underpinning year

end forecast

Running costs performance

Financial Statements

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Executive Summary A review of the month 6 financial position with month 5 activity was undertaken before compiling the

final month 6 and year end forecast position.

The month 6 position for the CCG improved to £7.3m surplus with a revised forecast year end surplus of

£33.1m (which is £5.9m better than planned).

The movement in-month was -£0.9m favourable, in the main, due to a +£0.6m net increase in cost

pressures across the Acute portfolio including Barts, offset by non-utilisation of Reserves totalling -£1.3m

and an additional -£0.2m underspend declared on running Costs.

The month 6 forecast outturn was risk assessed and the surplus position revised based on the half year

position. This position is now a fixed deliverable with NHS England.

The committed investment programme of £21m is a priority for 2014/15, with most of the spend falling

in the second half of the year. Investment delivery is therefore a key area of risk, and a judgement of what

can realistically be delivered was made in fixing the forecast outturn based on provider and internal

discussions. This is the biggest financial risk the CCG is facing as an under delivery will increase the

surplus which could be lost.

Delivery against the QIPP savings plan is progressing well with a year to date position of £2.63m against

a plan for the year of £5.4m equating to 49% delivery.

Homerton contract value has been finalised and Heads of Terms have now been signed.

The risk profile will be regularly reviewed against available headroom to cover the risks.

The Dashboard (page 4) highlights a GREEN RAG rating against all metrics.

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INCOME & EXPENDITURE MONTHLY ACTUAL YTD vs BUDGET EXPENDITURE YEAR END FORECAST v PLAN

TREND4795

ACUTE SPEND HUHT SPEND VARIANCE vs PLAN (%) ALL ACUTE SPEND VARIANCE vs PLAN (%) NCA SPEND VARIANCE vs PLAN (%)

TREND

QIPPPRESCRIBING

NON-ACUTE

-8442 Total of pre GW3 CRES ideas - valued at 35% which is the % required to be achieved of general CRES schemes

THIS IS THE ACHIEVEMENT OF YTD PLAN, UNDERLYING PERFORMANCE AND PROJECTED FORECAST.

THIS IS THE DELIVERY OF QIPP AGAINST THE PROFILED

ANNUAL PLAN. THE TREND REPRESENTS THE FULL YEAR

DELIVERY AGAINST TARGET WHICH WAS 43% (£0.8m) AHEAD

OF TARGET AT MONTH 6.

THIS IS THE SPEND ON PRESCRIBING BASED ON THE PPA

(PRESCRIPTION PRICING AUTHORITY) FORECAST VS ANNUAL

PLAN. M6 FORECAST IS BREAK-EVEN.

THIS IS THE SPEND ON MENTAL HEALTH, COMMUNITY

HEALTH & CONTINUING CARE VS ANNUAL PLAN. M6

FORECAST IS BREAK-EVEN.

THIS IS THE ACUTE PERFORMANCE AGAINST PLAN. THE TREND REPRESENTS THE RAG RATED MONTH ON MONTH CHANGE.

£15m

£25m

£35m

£45m

£55m

£65m

1 2 3 4 5 6 7 8 9 10 11 12£328m

£333m

£338m

£343m

£348m

£353m

£358m

1 2 3 4 5 6 7 8 9 10 11 12

-30%

-20%

-10%

0%

10%

20%

30%1 2 3 4 5 6 7 8 9 10 11 12

-30%

-20%

-10%

0%

10%

20%

30%1 2 3 4 5 6 7 8 9 10 11 12

FINANCEDASHBOARD

QIPP PERFORMANCE vs PLAN

Sep

Jan

PRESCRIBING PERFORMANCE vs PLAN NON-ACUTE PERFORMANCE vs PLAN

-15%

-10%

-5%

0%

5%

10%

15%1 2 3 4 5 6 7 8 9 10 11 12

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Key Risks - Finance Key risks are quantified on Page 6 and are based on the main drivers behind the performance shown in the dashboard on Page 4.

The Finance & Performance Committee will review the month (M6) financial position on 29 October and any further issues will be reported to the Board.

The Month 6 acute position across the provider portfolio was varied with the gross overspend totalling £2.0m offset by the release of Acute Reserves, following contract

settlements, to deliver a favourable position of £0.1m

Barts Health year to date was £0.4m overspent. The year end forecast against a plan of £22.2m is an overspend of £0.8m and has worsened slightly since M5, and the

expectation is that the year to go run rate is expected to continue.

Homerton had a year to date spend of £50.5m which is in line with plan, as is the forecast year end. The impact of any cost pressures will be managed through regular contract

performance reviews.

UCLH and Whittington contracts have yet to be finalised by the lead CCGs and remain work in progress.

Programme Boards have now taken on lead responsibility from CSU for management of activity and quality and the Finance & Performance Committee will oversee this, with a

‘deep dive’ being undertaken monthly, with Programme Boards in rotation.

Actions:

Address and bring to a satisfactory conclusion contract negotiations with providers.

Review and challenge overspends across all applicable Acute providers

Non-Acute expenditure on Continuing Health Care (CHC) appears to have stabilised at month 6. Any cost pressures relating to new packages or existing client will continue to

be risk assessed and recognised accordingly. NHS England have notified CCG’s they are proceeding with a national ‘risk pool’ to cover legacy CHC claims. As potential historic

claims had been fully provided by the PCT, it will result in £1.4m additional payment in 2014/15 from the CCG allocation, which is £1m over the maximum local liability.

Prescribing expenditure in total was reported on plan. The overall position is also inclusive of known Category M cost pressures managed through the utilisation of reserves.

QIPP plans are delivering in line with profile and most schemes are low risk as they are embedded in agreed contracts.

The non-recurrent (NR) investment profile continues to be the biggest single risk to the CCG of delivering to the bottom line target. Discussions with Programme Boards and

providers resulted in a risk assessment which has been reflected in the declared forecast position. The Prioritisation and Investment Committee meets again on 31 October

2014 to consider further proposals, but balancing slippage, value for money, agreement of contracts, managing expectations, but not over committing ourselves in 2015/16

will be highly challenging over the remaining six months.

The CCG is still in discussion with NHS Property Services and Community Health Partnerships over property charges for subsidised rents and void spaces. Sums remain

disputed for 2013/14 and the CCG does not accept many of the charges levied for 2014/15.

Action:

Closely monitor and manage NR investments and reserves on a year to go basis.

Continue to review QIPP and investments on a year to go basis ensuring 100% delivery of QIPP as a minimum.

Conclude negotiations on property charges.

Page 81 of 114


CITY & HACKNEY CCG

Ref: Description Risk Opp £'000

Prob.% Adj. risk/opp

Recurring £'000

Adj. risk/opp

Non Recurring

£'000

(3,355) (29,777) MEMO Risk/Opp £'000

Opp 2014/15 0Forecast Outturn (33,132)

Risk 2014/15 0

0 M5 expectation is minimum on-plan delivery.

20 Risk Property Costs 1,400 50% 700 0 Risk identified 21/07/2014 and probable financial impact.

19 Opp QIPP Over Delivery (1,000) 0% 0

1,352 Continuing Healthcare Risk share agreed at M6 and paid.

18 Risk QIPP Under Delivery 1,700 0% 0 0 Potential under-delivery for schemes phased on a year to go basis.

17 Risk Risk share 1,352 100% 0

(27,249) 2013/14 Surplus will not be utilised in 2014/15 - C&H CCG will fund all deliverable from in-year budget allocation.

16 Opp 13/14 Disputed Items (10,000) 33% 0 (3,300)Gross risks including Mental health invoices £3.3m, Property charges £1.9m, CHS disputed invoices £2.8m provided for in 2013/14. Risk assessed and part released.

15 Opp Carry Forward (27,249) 100% 0

0 Agreed 2014/15 NR investment. Further prioritisation & Investment Committee meeting on 31/10/2014. Discussions with providers to manage potential slippage risk.

14 Opp Uncommitted NR Reserve (2,123) 0% 0 Uncommitted investment subject to successful business case approval. Further review at the prioritisation & Investment Committee meeting on 31/10/2014.

13 Opp Committed NR Strategic Reserve (18,785) 0% 0

0 Programme management underspend.

12 Risk Specialist Commissioning 500 0% 0 0 Potential exposure as coding methodology may evolve and misattributions.

11 Opp Non Acute (1,000) 51% (512)

(580) Further savings and net recovery of monies owed from Local Authority 2013/14.

10 Opp Running Costs (2,300) 91% (2,100) 0 Potential underspend reviewed and revised.

9 Opp Prescribing (800) 73% 0

0 Release of contingency following risk assessment of year to go NR investment.

8 Risk Continuing Healthcare 1,000 48% 477 0 Specific high cost patients identified and recognised.

7 Opp Contingency (3,814) 50% (1,920)

0 Release of reserve to offset activity pressures.

6 Risk NCA 1,000 0% 0 0 Uncertainty of costs but assumed as absorbed in available budget.

5 Opp Acute Reserve (4,104) 93% (3,810)

4 Opp Claims and Challenges Acute contracts (1,612) 37% (596) 0 Based on success rate of year to date challenges.

3 Risk Outer sector - Acute contracts 3,769 80% 3,014

2 Risk Barts contract performance 1,802 60% 1,081 0 Strong focus in reviewing and challenging over-performance and misattribution issues. Year to go run rate expected to erode.

0Estimated exposure across portfolio and includes cost pressure relating to a recent high cost patient and Maternity over performance at UCLH.

Summary and Progress Report on Financial Risksto 30 September 2014

Narrative

1 Risk HUH Acute contract 2,000 16% 311 0 HOT signed and contract conclusion signoff imminent.

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Running CostsPerformance on CCG Running Costs is shown below. The CCG is not permitted to exceed its allocated Running Cost Allowance, but is

permitted to allow any unspent balances to be used for Commissioning. A total allocation of £6.5m was made to the CCG and the CCG

planned to spend £5.9m with £0.6m (10%) being reallocated to Programme Costs to support commissioning of patient care.

The month 6 year to date position on Running Costs is an underspend of £0.5m due to staffing vacancies and non-pay areas. The

forecast outturn is an underspend of £2.1m.

Total Planned Spend

CSU Planned Spend

CCG Planned Spend

Monthly Running Costs vs. Plan

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Key Risks - ActivityThe key trends and risks are reviewed by Programme Boards and the Finance and Performance Committee. The

financial impact of activity risks is covered below and the activity trends on page 9.

Homerton – the contract value is £100.9m (including CQUIN). This contract is currently performing in line with plan. The CCG has a number of investments in out of hospital services, the impact of which are not reflected in the activity plan with the Trust; the impacts will be evaluated of each of these initiatives as they get fully up and running.

Barts –the contract value is £22m. At month 6 there is a £0.4m overspend with a forecast overspend of £0.8m. The year to go spend has been assessed and the run rate is expected to continue with cost pressures on adult critical care and excess bed days having been recognised. The small sleep apnoea QIPP is unlikely to deliver a reduction in high cost devices in this financial year, but is likely to succeed in 2015/16. As the Governing Body is aware, the CCG has written to GPs following the Duty of Candour report highlighting Bart’s management and administration problems and consequent potential clinical safety risks concerns, for GPs to consider alternative referral choices. The CCG has written to the lead CCG for the Barts contract offering some one off financial support funding to help address this critical issue.

Moorfields – The M6 position declared was £0.4m overspent with a forecast overspend of £0.8m driven in the main by a specific high cost drug (Lucentis) used in the treatment of macular degeneration and other eye conditions.

UCLH – The lead CCG and NELCSU are still in contract negotiation with this provider, which includes the CCG as an associate. The month 6 position was £0.6m overspent with a forecast overspend of £1.2m in the main due to critical care and increase shift of maternity activity from other providers to UCLH.

Whittington – The lead CCG and NELCSU are still in contract negotiation with this provider, which includes the CCG as an associate. The month 6 position is showing a very small overspend for the year to date with a forecast overspend of £0.1m. The situation with this contract is fluid as the Whittington is pushing the CCG to accept a block contract at a higher value than is currently justified.

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ACUTE ACTIVITY

PLANNED CARE ACTIVITY ALL PLANNED ADMISSIONS VARIANCE vs PLAN (%) ALL OUTPATIENT VARIANCE vs PLAN (%)

TREND

URGENT CARE ACTIVITY ALL A&E ACTIVITY vs PLAN (%) ALL ADMISSIONS vs PLAN (%) HUHT ADMISSIONS vs PLAN (%)

TREND

THIS IS THE ACUTE ACTIVITY PERFORMANCE AGAINST PLAN. THE TREND REPRESENTS THE RAG RATED MONTH ON MONTH CHANGE.

THIS IS THE ACUTE ACTIVITY PERFORMANCE AGAINST PLAN. THE TREND REPRESENTS THE RAG RATED MONTH ON MONTH CHANGE.

ACTIVITYDASHBOARD

-20%

-10%

0%

10%

20%

30%

40%1 2 3 4 5 6 7 8 9 10 11 12

-20%

-10%

0%

10%

20%

30%

40%1 2 3 4 5 6 7 8 9 10 11 12

-20%

-10%

0%

10%

20%

30%

40%1 2 3 4 5 6 7 8 9 10 11 12

-20%

-10%

0%

10%

20%

30%

40%1 2 3 4 5 6 7 8 9 10 11 12

-20%

-10%

0%

10%

20%

30%

40%1 2 3 4 5 6 7 8 9 10 11 12

Note – Activity reductions in latest month appear correct, but are being fully validated.

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Financial Statements - 1


INCOME & EXPENDITURE ACCOUNTAnnual Budget

£’000

YTD Budget

£’000

YTD

Actual

£’000

YTD

(Under)/Over

spend

£’000

Forecast

Actual

£’000

Forecast

(Under)/Overs

pend

£’000

Improvement/

Deterioration

vs Month 5

Improvement/

Deterioration

vs Month 5

£'000

In Sector Acute Trusts 124,757 61,442 61,841 399 125,557 800 410

Out of Sector Acute Trusts 40,193 19,956 21,531 1,576 43,208 3,015 496

Other Acute 8,070 3,930 1,894 (2,036) 8,070 0 2,909

Subtotal Acute 173,020 85,327 85,266 (61) 176,835 3,815 3,815

Mental Health 45,141 22,320 22,320 0 45,141 0 0

Community Health 35,961 17,724 17,724 0 35,961 0 0

Other Non Acute 19,563 9,657 9,603 (54) 19,528 (35) 22

Subtotal Non Acute 100,664 49,701 49,647 (54) 100,630 (34) 22

Prescribing 29,771 14,857 14,277 (580) 29,191 (580) 0

Other Primary Care Services 9,267 4,179 4,175 (4) 9,261 (6) (50)

Subtotal Primary Care 39,038 19,037 18,453 (584) 38,452 (586) (50)

NHS Property Services 748 119 119 0 748 (0) 0

Reserves 34,607 7,103 1,004 (6,098) 27,580 (7,027) (4,065)

QIPP 0 0 0 0 0 0 0

TOTAL CSU 348,077 161,286 154,489 (6,797) 344,245 (3,832) (278)

Corporate 5,920 2,128 1,643 (485) 3,820 (2,100) (800)

TOTAL CORPORATE 5,920 2,128 1,643 (485) 3,820 (2,100) (800)

GRAND TOTAL 353,997 163,414 156,131 (7,282) 348,065 (5,932) (1,078)

TOTAL RESOURCE LIMIT (381,197) (163,414) (163,414) 0 (381,197) 0 0

(SURPLUS)/DEFICIT (27,200) 0 (7,282) (7,282) (33,132) (5,932) (1,078)

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KEY BALANCE SHEET INDICATORS

Compliance with Public Sector Payment Performance Target 92.9%

Financial Statements - 2

The cash balance as at close of September was £2.5m. Cash drawdown was increased to £28m in September to allow for payment of 2013/14 over-performance invoices.

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City & Hackney Clinical Commissioning Group Request for Waiver of Standing Orders

SECTION 3: INFORMATION TO SUPPORT WAIVER REQUEST

Please answer the following questions:

Is this a Revenue Purchase? Yes No

Is this a Capital Purchase? (Note: Capital is defined a non-revenue items over £5,000) Yes No

If a Capital Purchase, has the potential for leasing been explored? Yes No

Does more than one company provide these goods or services? Yes No

If this request is to waive formal tendering, have competitive quotes been obtained? Yes No [Please insert comments in support of the Waiver request.]

SECTION 1: NOTES 1.1 This form is to be completed in all circumstances where the competitive quotation/tendering procedures required under the Trust’s

Standing Orders are to be waived. 1.2 All sections of the form must be completed in full by the Procurement Manager and/or requisitioning officer before submitting for

approval to an authorising officer. 1.3 The authorised waiver form should be forwarded to the Procurement Manager to review and enable the order to be raised.

SECTION 4: SUBMISSION OF WAIVER REQUEST (DIRECTOR) Request submitted by: [PRINT NAME] Signature: Friday, 24 October 2014

SECTION 5: APPROVAL OF WAIVER REQUEST (CHIEF OPERATING OFFICER) Request approved by: Designation: Chief Operating Officer Signature: Date:

FOR INTERNAL USE ONLY Requisition Number: Purchase Order Number: Requisition Date:

This service will be a pilot provision of a Tier 1/ 2 Mental Health Service with a family emphasis closely linked to the current social prescribing work provided by Family Action. It will be attached to existing Young Hackney Units in Secondary schools across Hackney. The intended service is for children who present with less serious emotional issues within the school system. Family Action is extremely well placed to deliver this pilot provision as they already have the required infrastructure for this pilot (GP Practices in Hackney and local authority) setup and running for other, highly successful innovative projects such as Social Prescribing which this service is intended to augment. Family Action has not only years of experience operating within the local area, but also in delivering this specific family support model which promotes joined up, holistic support for families. The provider is also able to demonstrate they have built up a high level of trust within the Hackney community which assists greatly in determining whether or not the model being piloted will work well for children and families in this area. The Family Action pilot will be in place for 12 months. 6 months in, there will be a review process, at which point we will seek to amend the specification to incorporate learning from the pilot, and start a full procurement process in line with competition regulation to award the remaining 1 year contract to the successful provider. Homerton First Steps is an alternative provider in Hackney, also well placed to deliver this pilot provision but is currently operating at maximum capacity and therefore unable to engage in this pilot.

David Maher

……………………………...

……………………………...

SECTION 2: DETAILS OF REQUEST

Mental Health Programme Board

David Maher

£500,702

£500,702

London Borough of Hackney (LBH) and Family Action

Description of goods or services

required:

Requisitioning Officer:

Supplier:

Department:

Net Value VAT Total Value

Purchase Value:

Building Familial Resilience through Family Mental Health Workers

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CONTRACTS SUB COMMITTEE

MEETING ON 24 OCTOBER 2014RECOMMENDATIONS TO CCG BOARD

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ROLE OF SUB COMMITTEEAs the Sub Committee will be scrutinising and agreeing all service specifications for contracts with the GP Confederation/practices as providers, they felt it may be more appropriate for the SC to also assess all payment recommendations from Programme Boards and recommend these to the CCG Board• At present this function rests with the Audit Committee• The Audit Committee Chair has agreed informally to this switch of responsibility• The Audit Committee will still have a key role in assuring the CCG Board of the

CCG’s systems and process for payment recommendations from Programme Boards to the Contracts SC and the mitigation of conflicts of interest

• If the CCG Board approves this switch the revised terms of reference for both SCs will come to the next Board for agreement

• The CCG Board is asked to agree this change

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GP CONFEDERATIONThe Sub Committee considered the due diligence of the GP ConfederationThe Sub Committee recommends to the CCG Board that subject to• the registration of the Confederation as a CIC appears on the CIC Regulator website;

• a heads of terms and agreement across the CCG, NHS England and the Confederation to enter into a formal contract and a timeline to achieve this;

• The Confederation articulating the individual Board leadership roles in relation to clinical governance, information governance and safeguarding and other responsibilities

• Receipt of an organisational development plan and timelines for development of Confederation policies and procedures and recruitment to the Clinical Board positions.

• Satisfactory conclusion on the overhead charges and how the Confederation will deal with any shortfall in funding to ensure it has a financially viable business for the future.

The CCG Board should agree the switch of the service contract from CHUHSE to the GP ConfederationThe Board is asked to delegate final review of satisfactory completion of these conditions to the Chair of the Contracts SC and the Chief Financial Officer and to endorse the contract novation once met

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GP CONFEDERATIONThe Contracts Sub Committee reviewed the request from the GP Confederation for the CCG to contribute to the overheads of the organisationThe SC recognises the value of the Confederation but has asked them to reconsider their overhead requirements in the context of• Potential to share management functions with other providers,

specifically CHUHSE• Contributions from GP practicesThe SC will consider the revised request for overheads at its next meeting in December

The CCG Board is asked to note this

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SERVICE SPECIFICATIONSThe SC scrutinised the proposed 14/15 service specifications and payment schedules for • Vulnerable childrens service• Extended hoursAnd made a number of comments for Programme Boards to considerThe Programme Boards have been asked to submit revised specifications to the Sub Committee

The SC will •Consider all service specifications for further contracts with the GP Confederation (which are being considered at the Prioritisation SC) at its December meeting•Consider proposed service specifications for 2015/16 with the GP Confederation at its meeting in February

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Annual Report from the Audit Committee to the Governing Body

1 Introduction The Audit Committee is established under Governing Body delegation in accordance with the NHS City and Hackney CCG Constitution with approved terms of reference that are aligned with the Audit Committee Handbook 2005, published by the HFMA and Department of Health. Our terms of reference are included at Appendix A.

The Committee consists of three members of the Governing Body and has met on thirteen occasions during the 18 month period covered by the report, namely 1 April 2103 to 30 September 2014.

The Committee has discharged its responsibilities for scrutinising the risks and controls which affect all aspects of the organisation’s business.

2 Membership The Audit Committee consisted of the following:

2.1 Members

Name Role

Mariette Davis Lay Member for Governance and Chair Jaime Bishop Lay Member of Patient and Public Engagement ( 1 April 2013 to 31 August

2014) Catherine Macadam Lay Member of Patient and Public Engagement ( from 1 September 2014) Honor Rhodes Associate Lay Member

2.2 In attendance

Name Role Organisation

Philippa Lowe Chief Finance Officer NHS City and Hackney CCG Paul Haigh Accountable Officer NHS City and Hackney CCG Karl Thompson [ insert role] NHS City and Hackney CCG Matthew Knell Minute taker NHS Tower Hamlets CCG Paul Cuttle Audit Manager KPMG [John Alway] Local Counter Fraud Specialist Baker Tilly Business Services Limited [John Elbake] Internal Auditor Baker Tilly Business Services Limited [Mark Trevallion] Counter Fraud Manager Baker Tilly Business Services Limited Nick Atkinson Partner Baker Tilly Business Services Limited

2.3 Meeting schedule The Committee met three times on the following dates as a Shadow CCG Audit Committee: 14 December 2014, 25 February 2013 and 20 March 2013

The Committee met 12 times in the 18 month period on the following dates: 22 April 2013, 23 May 2013, 13 June 2013, 20 June 2013, 23 September 2013, 19 November 2013, 27 February 2014, 10 April 2014, 8 May 2014, 30 May 2014, 5 June 2014, 31 July 2104, 4 September 2014.

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The Committee was quorate at each meeting. Ahead of several formal meetings, a pre-meeting was held between Committee members, Internal Auditors and External Auditors to discuss key issues without Executive Management present.

3 Principal review areas This Annual Report is divided into sections reflecting the key duties of the Committee as set out in our Terms of Reference.

3.1 Governance, risk management and internal control 3.1.1 In advance of the Governing Body approval of the Annual Report and Accounts on 5 June 2014,

the Committee had reviewed relevant disclosure statements, in particular the Annual Governance Statement together with the Head of Internal Audit Opinion, external audit opinion and other appropriate independent assurances and considered that the Annual Governance Statement included within the CCG’s Annual Report was consistent with the Committee’s view on the CCG’s system of internal control. Accordingly the Committee supported the Governing Body’s approval of the Annual Governance Statement and voiced this support during the Governing Body meeting on 5 June 2014 when the Annual Governance Statement was considered for approval by the Governing Body.

3.1.2 The Committee has reviewed the developing Board Assurance Framework (BAF) on several occasions. It believes that the BAF and its use by the CCG has improved and developed during the period. The Committee is pleased that the BAF is now being used regularly by the Governing Body during Board meetings to provide assurance to the Governing Body. The Audit Committee will review the BAF at each of its own Committee meetings going forward and report back to the Governing Body on this review. The Audit Committee may decide to conduct deep dives into specific risks included in the BAF and it may use internal audit to carry out this work. The results of any deep dive will be fed back to the Audit Committee and then to the Board.

3.1.3 The Committee has reviewed the risk management framework, which is a policy document that describes how the CCG manages risk throughout the organisation. The Committee considers that the executive management is making good progress in embedding the risk management procedures throughout the whole organisation. Work needs to be done to ensure that risks to the CCG emanating within the CSU are adequately identified and managed.

3.1.4 The Committee noted waivers to the Prime Financial Policies or Standing Orders presented to the Committee by the Chief Finance Officer which had been signed by the Chief Finance Officer or Chief Officer.

3.1.5 In order to report issues clearly to the Governing Body so that they could be discussed and considered by the Governing Body during Board meetings, the Committee prepared a written ‘Key Messages report’ for the Governing Body after each of its meetings throughout the 18 Month period.

3.2 Internal Audit and Counter Fraud 3.2.1 Throughout the period, the Committee has worked effectively with internal audit to strengthen the

CCG’s internal control processes. The Committee has:

Reviewed and approved the internal audit strategy for both 2013-14 and 2014-15, and the more detailed programme of internal audit work covering systems and functions within the CCG. Other functions have been outsourced to the Commissioning Support Unit (CSU) and Share Business Services (SBS). The Audit Committee sought and received assurance that the internal audit function was adequately resourced and had appropriate standing within the CCG

With other Audit Chairs across North East London, established a Commissioning Support Unit (CSU) Assurance Committee comprising members (mainly the CFOs) from each CCG serviced by the North East London CSU to provide and manage the assurance process on those CCG functions outsourced to the CSU.

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Agreed terms of reference for the internal audit firm to gain independent assurance on the

system of internal control operating across CCG functions outsourced to the CSU.

Reviewed and approved the internal audit strategy and more detailed audit programme of internal audit work to be carried out on CSU systems for both 2013-14 and 2014-15.

Reviewed internal audit reports throughout the 18 month period covering both internal audit work carried out on the CCG and on the CSU (assurance work on the CSU post 1 April 2014) and considered their findings and recommendations. Ensured that management responded appropriately to the internal audit findings and followed up the implementation of those recommendations.

Reviewed and considered the CSU Assurance Committee minutes.

Reviewed the Annual Summary Report from the Internal Auditors and the Head of Internal Audit Opinion relating to the year ended 31 March 2014. The Audit Committee was assured that management within the CCG had responded to the internal audit reviews in an appropriate manner and that the Head of Internal Audit Opinion and the Annual Governance Statement (covering the period 1 April 2103 to 31 March 2014) reflected any major weaknesses in internal control. The only major weakness noted in the Head of Internal Audit Opinion was within the CSU, and related to the management of Continuing Health Care. Attention is being paid to this area of concern by the CCG Accountable Officer and the Chief Finance officer and the Audit Committee is monitoring progress towards improvement closely this 2014-15 financial year.

Reviewed the letter written in March 2013 from the then Audit Chair of the City and Hackney PCT, Kash Pandya, written to all CCG Chief Officers, CCG Audit Chairs and the CSU Managing Director requesting that CCG Audit Committee/CCG CFO work plans include the management of Information governance in 2013/14. City and Hackney CCG did this.

Requested, received and reviewed a full list of outstanding actions arising from the North East London and the City Cluster of PCTs 2012/13 Internal Audits, to ensure they were closed. City and Hackney CCG did this.

Reviewed and approved the counter fraud plans for 2013-14 and 2014-15 and considered reports covering counter fraud work carried out by the Local Counter Fraud Service for us. The Audit Committee has consistently raised a concern that there is no pro active counter fraud work carried out at the CSU. The CSU Assurance Committee has been asked to take up his matter with David Slegg - Director of Finance (London Region) – NHS England. I have raised this consistently with Audit Chairs across North east London and North Central London when we meet (which we do regularly as a group). This matter will be raised again through this forum with the Audit Chair of NHS England.

3.3 External Audit 3.3.1 The Committee reviewed and agreed the external auditor’s annual plan

3.3.2 The Committee reviewed and discussed with the external auditors their work in respect of the 2013-14 audit and reports prepared by them.

3.3.3 In particular, the Audit Committee reviewed all audit reports prepared by the external auditors, including their report to those charged with governance and agreed the annual audit letter before submission to the Governing Body

3.4 Management 3.4.1 The Committee has continually challenged the assurance process when appropriate and

has requested and received assurance from CCG management and other sources, both internally and externally, throughout the period.

3.4.2 This process has also included calling managers to account when considered necessary to obtain relevant assurance.

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3.4.3 The Committee works closely with the Accountable Officer and the Chief Financial Officer

to ensure that the assurance mechanism within the CCG is fully effective. Matters are raised with the CCG chair if considered necessary.

3.5 Financial reporting 3.5.1 The Committee, through internal audit, has ensured that the systems for financial reporting to the

Governing Body including those of budgetary control are subject to review as to completeness and accuracy of the information provided to the Governing Body.

3.5.2 The Committee reviewed the CCGs Annual Financial Statements for the year ended 31 March 2014, with the external auditors on 8 May 2014, 30 May 2014 and 5 June 2014, before submission to the Governing Body. Following agreement on disclosure of remuneration and pensions, the Audit Committee had no significant matters to draw to the attention of the Governing Body on the financial statements.

3.5.3 The Audit Committee reviewed and discussed, with the CCG Executive, the Letter of Representation relating to the Annual Financial Statements and provided by the Governing Body to the external auditors before the Governing Body signed it and returned it to the external auditors.

3.6 Management of potential conflicts of interest in contracts between the CCG and GPs 3.6.1 The Governing Body has developed and adopted processes to ensure that any contracts entered

into with GPs are procured in accordance with relevant legislation and regulations, are free from conflicts of interest and represent value for money.

3.6.2 As requested by the Governing Body , the Audit Committee has reviewed the processes followed by the executives and others involved with procurement of GP contracts has provided to the Governing Body independent assurance that the pre-agreed processes have been followed.

3.6.3 At the request of the Governing Body the Audit Committee has reviewed all requests for payments to be made under contracts between the CCG and GPs. The Audit Committee reviewed whether the control processes (established by the CCG to ensure that services had been properly delivered by the GPs under these contracts) had been followed in practice and reported to the Governing Body its findings. On a number of occasions the Audit Committee sought further information or clarification about payment recommendations from the Programme Boards. In these instances the Audit Committee recommended to the Governing Body that payments should be withheld until justified. The Audit Committee welcomes the appointment of an Independent GP adviser to the CCG. The Committee will avail itself of advice from the Independent GP when it considers this will be helpful to the Committee in the discharge of its responsibilities.

4 Review of the effectiveness and impact of the Audit Committee 4.1.1 The Committee has been active during the year in carrying out its duty in providing the Governing

Body with assurance (or not) that effective control arrangements are in place. Specifically, the Committee has:

Reviewed the CCG’s Constitution, including the standing orders, prime financial policies and scheme of delegation, and suggested improvements to the content and format

Reviewed the process by which internal control policies are developed and approved by the CCG. The Committee will continue to review the development of these processes.

Reviewed the Board Assurance Framework and Risk Management Strategy and has influenced the drafting and ongoing development of these

Encouraged the Governing Body to engage with the Board Assurance Framework process and recommended that the Board Assurance Framework be presented and be considered at every meeting of the Governing Body high up on the agenda

Reviewed its own compliance with the Audit Committee Handbook and has undertaken a self assessment. The results of this self assessment will be considered by Committee members and any improvements identified will be implemented.Reported during the year

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to the Governing Body, in writing, on all matters considered significant by the Audit Committee.

Reviewed it own terms of reference and suggested improvements to them to reflect the work actually done by the Audit Committee, approved by the Governing Body on 30 September 2014

The Internal Auditor presented a summary of the recommendations arising from a national review of CCG Audit Committees carried out by the Healthcare Financial Management Association (HFMA). The evidence showed that City and Hackney CCG Audit Committee was following best practice

5 Cost benefit analysis 5.1.1 The direct costs of the Committee comprise part of the costs of the three members. 5.1.2 It is not possible accurately to quantify the benefits of the work of the Committee during the 18

month period covered by this report and it is impossible to determine the financial impact of risks mitigated and costs avoided and the proportion of these that could be apportioned to the Committee. However, in relation to the work of the Committee, it is clear that that the Committee has had a positive impact on the CCG’s integrated governance and risk management systems and that the current and future costs associated with the loss of reputation has been mitigated as a result of the work performed by the Audit Committee.

6 Conclusion The Audit Committee considers that it has operated effectively during the 18 month period ended 30 September 2014, but welcomes feedback. The Chair of the Audit Committee would be grateful to receive feedback from all Governing Body members at any time.

Mariette Davis

Audit Committee Chair

Date: 26 October 2014

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Audit Committee Terms of Reference

Introduction

The requirement for Clinical Commissioning Groups (CCGs) to establish an Audit Committee is included in the Health and Social Care Act 2012. The Governing Body established this Committee of the Governing Body in its Constitution. Its role is to seek assurance that financial reporting and internal control principles are applied and to maintain an appropriate relationship with the organisation’s auditors, both internal and external. The Audit Committee offers scrutiny and advice to the Governing Body about the reliability and robustness of the CCG’s processes of internal control.

Aims and objectives

The duties of the Committee fall into the following main categories:

Governance, risk management and internal control

The 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 the organisation’s objectives;

In particular, the 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 statement, external audit opinion or other appropriate independent assurances, prior to endorsement by the Governing Body.

The underlying assurance processes that indicate the degree of achievement of strategic 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 related reporting and self-certification.

The policies and procedures for all work related to fraud and corruption.

The Committee will review any incident of fraud, corruption or possible breach of ethical standards, conflicts of interest or legal or statutory requirements that has been brought to its attention and could have a significant impact on the CCG’s financial accounts or reputation.

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The Committee will note waivers or breaches to the Prime Financial Policies or standing orders which have been signed by the Chief Finance Officer or Chief Officer.

In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions, but will not be limited to these sources. It will also seek reports and assurances from executives and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

This will be evidenced through the Committee’s use of an effective Assurance Framework to guide its work and that of the audit and assurance functions that report to it.

Internal audit

The Committee shall ensure that there is an effective internal audit function established by management, that meets Public Sector Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Chief Officer and the Governing Body;

This will be achieved by:

Consideration of the provision of the internal audit service, the cost of the audit and any questions of resignation and dismissal.

Review and approval of the internal audit strategy, operational 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 audit resources.

Ensuring that the internal audit function is adequately resourced and has appropriate standing within the organisation

An annual review of the effectiveness of internal audit.

External audit

The Committee shall review the work and findings of the appointed external auditors and consider the implications of, and management’s responses to, their work.

This will be achieved by:

Consideration of the appointment and performance of the external auditors, as far as the rules governing the appointment permit.

Discussion and agreement with the external auditors, before the audit commences, of the nature and scope of the audit as set out in the annual plan, and ensuring co-ordination, as appropriate, with other external auditors in the local health economy.

Discussion with the external auditors of their local evaluation of audit risks and assessment of the CCG and associated impact on the audit fee.

Review of all external audit reports, including the report to those charged with governance, agreement of the annual audit letter before submission to the Governing Body and any work undertaken outside the annual audit plan, together with the appropriateness of management responses.

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Other Assurance Functions

The Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and considering the implications for the governance of the CCG;

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.)

In addition, the Committee will review the work of other committees within the organisation whose work can provide relevant assurance to the Audit Committee’s own scope of work. In particular, this will include the Finance and Performance Committee

Counter fraud

The Committee shall satisfy itself that the organisation has adequate arrangements in place for countering fraud and shall review the outcomes of counter fraud work.

Management

The Committee shall request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control.

The Committee may also request specific reports from individual functions within the organisation as they may be appropriate to the overall arrangements

In particular, a separate record of matters discussed during suspension of standing orders shall be kept. These records shall be made available to the Governing Body’s Audit Committee for review of the reasonableness of the decision to suspend standing orders.

Financial Reporting

The Audit Committee shall monitor the integrity of the financial statements of the CCG and any formal announcements relating to the CCG’s financial performance.

The Committee should ensure that the systems for financial reporting to the Governing Body including those of budgetary control are subject to review as to completeness and accuracy of the information provided to the Governing Body.

The Audit Committee shall review the annual report and financial statements before submission to the Governing Body, focusing 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 mis-statements in the financial statements

Significant judgements in preparation of the financial statements

Significant adjustments resulting from the audit

Letter of representation

Qualitative aspects of financial reporting.

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Authority

The Committee is authorised by the Governing Body to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. The Committee is authorised by the Governing Body to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

Membership

Members

To maintain its independent assurance and scrutiny role, the committee will be made up of Lay Members of the CCG Governing Body:

Lay Member – lead for Governance – Chair

Lay Member - lead for Patient and Public Engagement

Associate Lay member

The Chair shall have recognised professional accountancy qualification

Attendance

The Chief Finance Officer and appropriate internal and external audit representatives shall normally attend meetings.

At least once a year the Committee should meet privately with the external and internal auditors.

The Chief Officer should be invited to attend and should discuss at least annually with the Audit Committee the process for assurance that supports the Annual Governance Statement or she should also attend when the Committee considers the draft internal audit plan and the annual accounts.

All other responsible executives can be invited to attend, particularly when the Committee is discussing areas of risk or operation that are the responsibility of that executive.

Note

The CCG chair of the Governing Body will not be a member of the Audit Committee to ensure appropriate scrutiny by the Committee.

Quorum

The Audit Committee will be considered quorate when 2 out of the three members are present. In the event of members not being able to attend the meeting will be rescheduled within 2 working weeks.

Frequency

The Committee will meet at least quarterly at appropriate intervals in the financial reporting and audit cycle and otherwise as required. The Chair can call a meeting of the Committee as and when required with at least three weeks’ notice.

Outside of the meeting the Chair will maintain a dialogue with the Chief Finance Officer

Reporting / Accountability

As a committee of the Governing Body, the committee shall produce a report of the key issues discussed to the Governing Body on its proceedings after each meeting on all matters within its duties and responsibilities.

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The committee shall make whatever recommendations to the Governing Body as it deems appropriate on any area within its remit

The Committee shall produce an Annual Report to the Governing Body of its activities.

Secretary Support

The Committee shall be supported administratively by the [Governance and Risk Manager – include Karl’s title] , whose duties in this respect will include:

Agreement of agendas and forward planner with Chair and attendees and collation of papers

Taking the minutes

Keeping a record of matters arising and issues to be carried forward

Advising the Committee on pertinent issues/areas

Enabling the development and training of Committee members

Maintaining a record of all Audit Committee documentation .All Committee papers and minutes will be stored on the CCG [ I ] drive under a separate file called Audit Committee.

The meeting is not open to the public.

Management of conflicts of interest

If any member has an interest, pecuniary or otherwise, in any matter and is present at the meeting at which the matter is under discussion, he/she will declare that interest as early as possible and shall not participate in the discussions.

The Chair will have the power to request that member to withdraw until consideration of the conflicted item has been completed

If the Chair has a conflict then an alternative Chairperson will be nominated from the membership of the committee by the other members

Management of potential conflicts of interest in contracts between the CCG and GPs

The Governing Body has developed and adopted processes to ensure that any contracts entered into with GPs are procured in accordance with relevant legislation and regulations, are free from conflicts of interest and represent value for money.

From time to time, the Governing Body has asked the Audit Committee to review the processes followed by the executives and others involved with procurement of GP contracts and to provide assurance that the pre-agreed processes have been followed.

The Governing Body has further the Audit Committee to review requests for payments to be made under the GP contracts that have been entered into by the CCG. The Audit Committee has been asked to review whether the control processes (established by the CCG to ensure that services have been properly delivered by the GPs under these contracts) have been followed in practice.

Review of Terms of Reference

The Committee terms of reference will be reviewed every 2 years unless required sooner.

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End

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City & Hackney CCG Assurance Report – Q1 (2014/2015)

Headline assessment: Assured with support

Focus

Assurance level

Particular achievements noted/examples of good practice

Issues identified

Any issues identified requiring further action and actions agreed

Domain 1 (in summary) – Assured The CCG has performed well against the key quality standards and therefore the level of risk associated with the CCG’s current performance is low. The CCG has strong quality improvement systems in place. The CCG has robust governance arrangements in place to monitor, review and challenge provider performance, supported by detailed improvement and action plans which are regularly monitored, reviewed and updated to ensure performance improvements remain on track. Domain 1 Are patients receiving clinically commissioned, high quality services?

Winterbourne View: City & Hackney CCG has strong processes and systems in place for the management and joint delivery of Winterbourne View Concordat requirements. The CCG works closely with the local authority, the Health and Well Being Board, service users and other key stakeholders to ensure all are actively involved in supporting people with challenging behaviour to live in the community. NHS England confirmed the headlines from the publication of provisional Q1 Winterbourne View management data which covers a number of key areas including the number of patients currently in inpatient care, whether they have been transferred, if there a planned date to transfer and how many had been admitted in the last quarter. For City & Hackney CCG the data indicates that the CCG is non-compliant against 4 out of the 6 priority actions. City and Hackney CCG and NHS England are reviewing the data. HCAI: In Q1 there were no assigned cases of MRSA. The CCG’s Q1 performance against the C diff standard is below their trajectory. All incidences are subject to

Quality at Barts Health: City & Hackney CCG has written a detailed letter expressing the concerns of the CCG Governing Body about the quality of services provided at the Trust. A response has been provided by the Clinical Chair of Tower Hamlets CCG which highlights the importance of holding Barts Health to account and using all available levers to stimulate performance improvement. NHS England has acknowledged the concerns raised by City & Hackney CCG and encouraged the CCG to use the established routes for managing quality concerns. A joint Barts Health/CCG quality conversation event is being held on 18 September.

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Focus

Assurance level


Issues identified


robust infection control procedures, with appropriate action plans in place. Infection control procedures and performance is discussed and reviewed regularly including in Clinical Quality Review Group meetings. The CCG has strong monitoring systems in place. MSA: At Trust level there were no breaches while at CCG level there were 7 breaches. The CCG continues to work closely with the CSU in the monitoring and management of MSA breaches.

Domain 2 (in summary) – Assured NHS England will undertake a deep dive into patient and public engagement with City & Hackney CCG to review the CCG’s current approach, level of activity and performance. The Patient and Public Engagement Team at NHS England is setting out a process for reviewing each CCG’s current approach and level of activity around patient and public engagement. NHS England will then provide individual advice around opportunities to further stretch local plans. The benefit of taking this domain out of the general assurance meeting framework means that NHS England will be able to review it in significantly more detail and tailor it to ensure it is relevant for each individual CCG. NHS England will engage with the CCG in relation to the scope and timing for the deep dive. Domain 2 Are patients and the public actively engaged and involved?

Domain 3 (in summary) - Assured Homerton achieved the 95% 4-hour standard in Q1, with performance at 95.4%. The CCG has performed well against the key NHS constitution standards (A&E, RTT and Cancer waits) following on from the good performance in 2013/14. Domain 3 Are CCG plans delivering better outcomes for patients?

RTT: Performance at the Homerton was above the RTT standards in Q1. CCG level performance was strong in relation to non-admitted but below the standard for admitted. Admitted – Apr (87.6%) / May (85.8%) / Jun (88.7%). Non-admitted – Apr (95.5%) / May (95.5%) / Jun (96.9%). Incompletes – Apr (92.2%) / May (92.4%) / Jun (93.1%). 52 + week waiters – Apr (8) / May (6) / Jun (1).

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Focus

Assurance level


Issues identified


Cancer Waits: At both Trust and CCG level performance against the Cancer waits standards was strong. At CCG level with the exception of the 31 day subsequent treatment and the 62 day wait standard, which were narrowly missed, all standards were met. CCG: 2WW – Apr (93.8%) / May (94.2%) / Jun (95.4%). 2WWB – Apr (94.3%) / May (93.3%) / Jun (96.5%). 31 day first – Apr (98.3%) / May (94.4%) / Jun (100%). 31 day sub treatment drug – Apr (93.3%) / May (100%) / Jun (100%). 31 day radiotherapy – Apr (95.2%) / May (100%) / Jun (95.7%). (62 day standard – Apr (84.8%) / May (78.8%) / Jun (87.9%). A&E: Homerton met the standard in Q1 with performance at 95.4%. The Trust is a strong performer against the A&E standard. The CCG has effective systems and strong governance arrangements in place which ensure a whole system approach to delivery of the A&E standard. Operational Resilience: NHS England confirmed that, following a joint NHS England and Monitor review of the System Resilience Group’s (SRG) 1st submission of its Operational Resilience Plan, it has been rated as ‘self-assured’. NHS England acknowledged the considerable work that had been undertaken in developing the plan. Financial Assurance: The CCG’s financial position is ahead of plan YTD and is forecast to deliver the year end financial plan.

Financial Assurance: There is an underspend on non-recurrent investment programme which could result in a significant increase in the 2014/15 surplus.

Financial Assurance: The CCG is carrying out monthly reviews of its financial position including review of the non-recurrent investment programme. Page 107 of 114

Focus

Assurance level


Issues identified


Domain 4 (in summary) - Assured City & Hackney CCG has strong governance and clear risk management processes in place, supported by an experienced team. Given the information already shared throughout the assurance process, the level of risk associated with the CCG’s current performance is low. NHS England is assured against this domain. Domain 4 Does the CCG have robust governance arrangements?

CCG Risk Register: City and Hackney CCG confirmed the key strategic risks to the CCG and confirmed that these are recorded on the CCG’s Board Assurance Framework (BAF).. The BAF is subject to close monitoring, review and challenge by the CCG’s Governing Body.

Domain 5 (in summary) – Assured with Support City & Hackney CCG has developed close working relationships with neighbouring CCGs and is contributing to the alignment of strategy goals across north east London. The CCG continues to engage with all stakeholders to explore further options to improve outcomes and ambitions. The CCG has demonstrated effective engagement with patients and the public which is used to influence planning, development and the commissioning of local services. The CCG needs to continue to work collaboratively with Barts Health and co-commissioning CCGs in addressing quality issues which impact on City & Hackney residents. Domain 5 Are CCGs working in partnership with others?

Strategic Plan: NHS England has provided feedback on progress with strategic planning across north east London. NHS England confirmed the need to agree a joint case for change and the work necessary to ensure the alignment of plans. NHS England confirmed that the WEL SPG and BHR SPG was working well with stakeholders to ensure appropriate levels of engagement and agree areas for joint strategic development.

Strategic Plan: City & Hackney CCG to continue to work with co-commissioning CCGs to influence the planning, development and alignment of joint strategic goals. City & Hackney CCG to continue to work collaboratively with Barts Health and co-commissioning CCGs to address quality issues.

Domain 6 (in summary) - Assured NHS England will undertake a deep dive into the leadership and organisational development with City & Hackney CCG to review the CCG’s current organisational development plan and to provide advice around opportunities for strengthening the plan. NHS England is setting out a process for reviewing each CCG’s organisational development plan so that it can provide advice around opportunities for strengthening the plan. The benefit of taking this domain out of the general assurance meeting framework means that NHS England will be able to review it in significantly more detail and tailor it to ensure it is relevant for each individual CCG. NHS England will engage with the CCG in relation to the scope and timing for the deep dive.

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Focus

Assurance level


Issues identified


Domain 6 Does the CCG have strong and robust leadership

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NHS City and Hackney Clinical Commissioning Group Finance & Performance

Committee (FPC)

Wednesday 24 September 2014 key issues M5 finance based on M4 activity report The Activity and Finance Report was summarised, including that at month 5 the year to date position for City & Hackney Clinical Commissioning Group (CCG) improved to £6.3m surplus, with an in-month favourable movement of £4.0m. This was due to a net £705k improvement in acute expenditure, and the non-utilisation of reserves totalling £3.3m. Whilst there has been some slippage on non-recurrent investment, the CCG remains wholly committed to delivering plan expectations on a year to go basis. The Homerton University Hospital Trust (HUHFT) Heads of Terms having been signed. The expectation is to have the full contract signed shortly. The M5 position and FOT was reported as breakeven. Barts Health (BH) – a contract has now been formally agreed. At M5 a £0.2m overspend was declared with a forecast out turn (FOT) overspend of £0.4m. City & Hackney CCG has also written to GPs regarding Barts’ management and administration situation resulting in clinical safety risks concerns. Moorfields – the M5 position declared was £0.2m overspent with an FOT overspend of £0.6m driven in the main by a specific high cost drug (Lucentis). Increased day case activity and QIPP where saving has not yet been realised both also contributed to this overspend. City & Hackney CCG supported by NELCSU is still in negotiation with University College London Hospital (UCLH). The M5 position declared was £0.5m overspent with an FOT overspend of £1.2m in the main due to critical care and increased shift of maternity activity from other providers to UCLH. City and Hackney CCG supported by NELCSU is still in negotiation with Whittington Health. The M5 position declared a small £39k overspend on a year to date and FOT basis. The QIPP M5 year to date position at £2.48m actual was £820k ahead of plan. The full year plan delivery of £5.42m is expected to be achieved as a minimum.

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NHS City and Hackney Clinical Commissioning Group Clinical Executive Committee

(CEC)

Wednesday 8 October 2014 key issues Children’s Board report to the Clinical Executive Committee The Children’s Programme Board (CPB) briefed the CEC on recent work and upcoming plans, including the launch of the vulnerable children’s contract had been delayed due to ongoing discussions with the GP Confederation. The contract will be started as soon as possible. Further work is underway to issue new guidance around children’s asthma, diabetes and epilepsy pathways and the CPB will continue to look at developing new children’s community health services and nurse specialist services as evidence supports them. A transition service to adult disability services was also planned for development, as well as the potential to help support children, carers and families more. The CEC was briefed on the incoming 2015 changes to the responsibilities for children’s service transferring to the local authorities and expressed a wish to move to a more integrated, ‘one stop shop’ style service for children. Maternity Board report to the Clinical Executive Committee The Maternity Programme Board (MPB) briefed the CEC on recent work and upcoming plans, including its commissioning intentions for 2015/16. The MPB remains focused on improving women’s experiences, noting that the friends and family test, effective triage and post natal care at HUHFT are priorities, along with continuity of care. The CEC discussed proposals around community midwifery, GP Confederation engagement and patient safety and the MPB asked for input on what specific areas to review for future proposals. The CEC highlighted that care for vulnerable women is an area of concern for many GPs, along with consistent communications across organisations involved in women’s care. Commissioning Intentions The CCG Programme Board’s consulted the CEC, seeking feedback on 2015/16 proposed commissioning intentions, concentrating on Mental Health and Prescribing and building on the previously discussed Children and Maternity proposals. The Mental Health Programme Board (MHPB) highlighted that work will continue to integrate services across organisation where appropriate and putting in place strengthened child to adult transition services. The Prescribing Programme Board (PPB) informed the CEC that priorities remain to support joint working between GPs and Pharmacists and the CEC discussed how to involve Pharmacists in the integrated care work programme. Prioritisation and Investment Programme Board Proposals

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The CEC was briefed on the headlines from those bids entering the latest round of CCG non recurrent funding prioritisation and asked for feedback on detailed specification via email. Draft Anticoagulation service specification The CEC was briefed on the development of a new anticoagulation service specification, noting that governance of this work would take place via the CCG Contracts Committee and an open marker procurement due to potential conflict of interest issues. The CEC recommended that the specification needed to be revisited in light of the move towards integrated care to ensure that it fits in with future services across the area. The PPB was also asked to consider addressing self-monitoring in the specification to cater to those patients wishing to take this up. Primary Care Quality dashboard The CEC was briefed on the development of the primary care quality dashboard, noting that it is aimed at providing a vital tool for supporting clinicians. The CEC noted that it would be further discussed at the Clinical Commissioning Forum (CCF). CCG Finance update The CEC was briefed that the CCGs underspend is increasing due to the slippage of non-recurrent investments and agreed provider contract values being agreed.

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NHS City and Hackney Clinical Commissioning Group (CCG) Board Friday 28 November 2014, 1400 – 1600

Room TBC, Tomlinson Centre, Queensbridge Road, London, E8 3ND

AGENDA Chair: Dr Clare Highton Agenda Items

Led by & Appendix number

Timing

1. Welcome, introductions and declarations of Interests

Clare Highton Verbal

1400-1405 (5 mins)

2. CCG Committee business: a. Minutes of the last meeting; b. Register of Interests; c. Matters arising.

Clare Highton Papers TBC Pages TBC

1405-1410 (5 mins)

3. Questions from the public Clare Highton Verbal

1410-1420 (10 mins)

CLINICAL STRATEGY (FOR DECISION) 4. 2015/16 Commissioning Intentions Clare Highton

Paper TBC Pages TBC

1420-1450 (30 mins)

5. Primary Care Commissioning Clare Highton Papers TBC Pages

1450-1510 (20 mins)

6. IFR policy review Clare Highton Paper TBC Pages TBC

1510-1520 (10 mins)

7. Specs and proposed procurement process and timescales for dressings store and glaucoma

Gary Marlow Paper TBC Pages TBC

1520-1530 (10 mins)

PERFORMANCE

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8. CCG Finance update Philippa Lowe Paper TBC Pages TBC

1530-1540 (10 mins)

9. Payments to practices as providers Catherine Macadam Paper TBC Pages TBC

1540-1550 (10 mins)

FOR INFORMATION 10. Reports from Subcommittees of the Board:

Key issues from subcommittees. Clare Highton Papers TBC Pages TBC

1550-1555 (5 mins)

11. Friday 19 December 2014 draft CCG Board agenda

Clare Highton Papers TBC Pages TBC

1555-1600 (5 mins)

12. Any Other Business Clare Highton Verbal

1600-1605 (5 mins)

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