Agenda Governing Body Board (Part 1) - Waltham Forest CCG · Sue Evans Ellie Ward (City of London)...

Agenda Governing Body Board (Part 1)

Date: 28 February 2018

Time: 12.00-14.00

Venue: Boardrooms A, B and C, Kirkdale House, Leytonstone, E11 1HP

Chair: Dr Anwar Khan

No Topic Action Required

Clinical Lead/Lead

Lead officer Time Page

1 General Business

1.1 Apologies & announcements To discuss Dr Anwar Khan

12.00

1.2 Declaration of Interest and Conflicts of Interest

To be noted All

12.05

1.3 Draft minutes from January’s Board

To approve 12.08

1.4 Matters Arising To discuss

12.15 1

1.5 Chair’s Report To receive

12.20 -

1.6 Accountable Officer’s Report

To receive Jane Milligan 12.25 3

1.7 Questions from Members of the Public

12.35 -

2 Governance

2.1 Joint Commissioning Committee Report

To receive Dr Anwar Khan Jane Milligan 12.45 4

3 Performance and Quality

3.1 Performance and Quality Report For discussion and approval

Dr Dinesh Kapoor Jane Mehta and Helen Davenport

13.05 28 & 49

No Topic Action Required

Clinical Lead/Lead

Lead officer Time Page

4 Finance & QIPP

4.1 Finance Report

To approve Henry Black 13.15 64

5 Health and Well-Being Strategy

No Papers

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Strategy and Planning

6.1 NEL Transformation (NEL Commissioning Alliance and East London Health & Care Partnership)

To review Jane Milligan 13.20 78

6.2 Planning for the future

To discuss Dr Anwar Khan Jane Mehta 13.30 87

7 For information

7.1 Minutes of the Audit Committee

Review hyperlink

Vineeta Manchanda

Henry Black 13.42 98

7.2 Minutes of the Performance & Quality Committee

Review hyperlink

Dr Dinesh Kapoor Helen Davenport

13.44 105

7.3 Minutes of the Planning & Innovation, Finance and QIPP Committee

Review hyperlink

Alan Wells Jane Mehta 13.46 118 & 124

7.4 Minutes of the IT Committee Review hyperlink

Dr Mayank Shah Henry Black 13.50 128

7.5 Minutes of the Primary Care Commissioning Committee

Review hyperlink

Alan Wells Jane Mehta 13.52 134

7.6 Minutes of the Patient Reference Group

Review hyperlink

Caroline White Helen Davenport

13.54 143

7.7 Actions from Leyton/Leytonstone, Chingford & Walthamstow Locality Meetings

Review hyperlink

All Clinical Directors

13.56 150

8 AOB

9 Forward Plan For discussion

All 152

Page 1 Action Log Waltham Forest CCG Governing Body Part 1 on 24 January 2018 including earlier Brought Forward Items 28 February 2018

Action log Waltham Forest CCG Governing Body Part 1 on 24 January 2018 including earlier Brought Forward Items Date: 24 January 2018

Time: 12-2pm

Minute No.

Action Lead/ Owner

Due Date

Status Status Approval

Date Completed

183/17 Revise the BAF risk description relating to the non-achievement of the CCG’s planned surplus target.

HB January 2018

Open Further clarification required

186/17 (i)

Prepare a report in relation to diabetes education uptake for Clinical Directors.

AK February 2018

Open AK liaising with JMe

01/18 AW/JMe to take forward the merger of the Planning and Innovation and Finance and QIPP Committees, write up a Terms of Reference and decide on attendance list.

AW/JMe March 2018

Open

02/18 The Governing Body requested that Clinical Forum is used to support some of the challenges facing Whipps Cross.

ALL Ongoing Open

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Page 2 Action Log Waltham Forest CCG Governing Body Part 1 on 24 January 2018 including earlier Brought Forward Items

Minute No.

Action Lead/ Owner

Due Date

Status Status Approval

Date Completed

03/18 Alan Gurney to attend the Whipps Cross Clinical Forum.

LT February 2018

Closed Added to membership 7/2/18

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Agenda item 1.6 – Accountable Officer’s Report North East London Commissioning Alliance We held a further session on 14 February to help establish the NEL Joint Commissioning Committee. Although we ran this as an OD session, part of the session was simulating a JCC considering a number of reports around the planning guidance, maternity and a risk register. The session went well and showed good participation from all members taking a NEL approach to issues (rather than more parochial stances) with a strong focus on improving services and outcomes and making a difference. It also highlighted a number of areas to improve on before the JCC goes live including the layout of the room, the overall format of papers and having sharper, more action focused reports that are presented jointly by the lead JCC member and officers. The stocktake of arrangements across NEL CCGs is coming to the end of Phase 1 and I will be discussing with the CCG Chairs the particular areas to focus on to improve collaboration across NEL. We continue to work on our recruitment and I hope that we will advertise the permanent MD roles by the end of February. I will be bring forward proposals for the Chief Financial Officer following further discussions with the CCG Chairs. I continue to get out and about meeting stakeholders and staff across North east London and I see this as a key part of my role. In the last few weeks I have met with LMC chairs and attended the ONEL Joint Overview and Scrutiny Committee. I have now met with a number of the PE groups and we are looking to form a network for PPE leads across NEL to learn from each other and spread good practice. With the planning guidance being published I have also attended workshops for the STP leads across London to consider the implications for London and how it can help promote our ambitions around integrated care partnerships. I also attended the ONEL Joint Overview and Scrutiny committee. I continue to meet with staff and by mid-April I will have attended all CCGs staff awaydays.

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Item 2.1

Title of report NEL CCGs Commissioning Arrangements

From Dr Anwar Khan, Chair, Waltham Forest CCG

Author Alan Steward, System OD and Transition SRO, BHR CCGs

Purpose of report

The report asks the NHS Waltham Forest CCG Governing Body to support proposals for new commissioning and governance arrangements across North East London. It builds on the updates provided at each Governing Body. This paper:

• Advises the governing body of the membership and leadership of the shadow Joint Commissioning Committee (JCC).

• Sets out the proposed arrangements for establishing the Joint Commissioning Committee including the Scheme of Reservation and Delegation.

• Sets out the constitutional changes required by NEL CCGs to establish the JCC and ensure it operates effectively.

Changes/additions/amendments to paper as a result of discussions held at WF Committees

This paper has not been to any previous committees in Waltham Forest CCG.

Recommendations

The Governing Body is asked to:

1. Note the membership and leadership of the Joint Commissioning Committee 2. Review and approve the Scheme of Reservation and Delegation for the Joint Commissioning

Committee 3. Approve the proposed constitutional changes for consultation with member practices.

Impact on patients & carers

The development of the new commissioning arrangements will have a positive impact on patients and carers in Waltham Forest. By working collaboratively, the 7 CCGs in NEL, through a single accountable officer will align key strategies, undertake commissioning once for NEL where it benefits local people, reduce local assurance requirements and access additional transformation funding to further develop local services.

Risk implications

Agreeing the recommendations of this report will assist the CCG to deliver on its priorities and mitigate the risks by contributing to:

• An aligned commissioning strategy to improve health outcomes and support the long term viability of local NHS providers.

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NEL CCGs Commissioning Arrangements

• Delivering financial sustainability against a backdrop of increasing demand. The appointment of an AO (combined with the role of STP lead) is key to securing the transfer and application of transformation funds to North East London.

• Preparing for the delegation of specialist commissioning to NEL. • Increased focus on developing local integrated commissioning and accountable care systems.

Financial implications

There is a commitment that the proposed changes will be cost neutral across NEL and CCGs. Equality analysis

This document relates to all Waltham Forest residents in the 9 protected characteristics that are covered by the Equality Act 2010 and our Equality Duties. The proposals described in this paper will enable the development of Integrated Care Systems across North East London and will therefore potentially allow providers and commissioners to work together to develop a set of agreed outcomes to improve the health and well-being of their population and in particular target those groups that have traditionally been disadvantaged. The Integrated Care System provides the opportunity to address many of the challenges consistently identified as key barriers to better services including ‘hand offs’ between providers and improving the complete patient journey.

The devolvement of specialised commissioning will further strengthen the ability of commissioners to join up services and address the key health challenges for local people.

Future specific service changes will be subject to an equalities impact assessment.

Business Intelligence Source

Not applicable

Other committees/groups, including the CCG Reference Group and Rapid Feedback Group

There has been no presentation of this paper at any previous meeting for Waltham Forest CCG. However, this paper is the product of joint working across the 7 CCGs, specifically:

1. The seven NEL CCG Chairs, meeting together as a Steering Group. The recommendations have been informed and agreed by the chairs;

2. A governance workstream, led by the NHS WEL CCG Deputy Chair, with support from the NEL CCGs governance leads.

3. It builds on the previous GB reports on the new commissioning arrangements.

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Introduction and Purpose

1. This report updates all North east London (NEL) CCG Governing Bodies on the establishment of the new commissioning arrangements. It builds on the previous Governing Body reports and discussions at Board Development sessions and the shadow meetings of the Joint Commissioning Committee. The paper recommends that GBs agree formally to establish the Joint Commissioning Committee and move to consult with member practices to amend CCG constitutions to allow these changes.

2. These new arrangements are vital to deliver North east London’s:

• Strategic alignment with the NHS Five Year Forward View and in particular the commitment to develop Accountable Care Systems (ACS)

• Sustainability for the whole system including providers, commissioners and partners • Improvements in outcomes, quality and performance and reducing variation across

North east London. North East London Commissioning Arrangements

Governance 3. The proposed new commissioning arrangements require robust North east London

governance. This is being driven through a wider group of CCG lay members and partners. Through a number of engagement sessions the proposals have been developed to provide the further detail needed to recommend the required NEL CCG governance and any changes. These are how the Joint Commissioning Committee will be established and work with the seven CCG Governing Bodies and sets out how decision making will happen. It is recognised that the future Integrated Care System will require integrated commissioning arrangements with Councils. The Joint Commissioning Committee membership includes non-voting local authority representation. The membership of the JCC is set out below.

CCG Chair Lay Member LA Rep

Barking & Dagenham

Kash Pandya (acting Chair until elections complete)

Kash Pandya Mark Tyson

Havering Dr Atul Aggarwal Richard Coleman Mark Ansell Redbridge Dr Anil Mehta Khalil Ali Adrian Loades City & Hackney Dr Clare Highton.

Mark Ricketts (new Chair from 1 April 2018)

Sue Evans Ellie Ward (City of London) Gareth Wall (Hackney)

Waltham Forest Dr Anwar Khan Alan Wells Linzi Roberts-Egan Newham Dr Prakash Chandra Andrea Lippett Grainne Siggins Tower Hamlets Dr Sam Everington Noah Curthoys Denise Radley

Recruitment of the Nurse and secondary care consultant will commence in March.

4. At the December GB meeting, the Terms of Reference of the Joint Commissioning

Committee were agreed to operate in shadow form through to March 2018. The JCC has met twice in shadow form. Firstly with all Chairs and Lay Members to focus on the key elements where further clarity and develop a joint understanding of the role and responsibilities of the JCC. The second meeting included the proposed CCG members of the JCC (Chair and Lay Member) and included a session in shadow form to look at the requirements needed to have an effective JCC before it goes live in April 2018. The final terms of reference will be submitted to GBs in March to allow an April go-live. This will reflect the lessons learned from the shadow sessions.

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Leadership of Joint Commissioning Committee 5. A part of establishing the NELCA Joint Commissioning Committee and under its

Shadow Terms of Reference agreed at all GBs in December 2017, three leadership positions were agreed. These are: 1. Chair to be selected and elected by the CCG Chairs only 2. Deputy-Chair to be selected by the Chair from the CCG chairs. 3. Vice Chair must be a Lay Member to chair any meetings or undertake any other

duties where the Chair / Deputy has a COI or a perceived COI. The Vice Chair is to be selected and elected by the Lay Members alone.

6. The CCG Chairs and Single Accountable Officer agreed the job description for the Chair

of the JCC and this is attached at Appendix A.

7. Nominations were invited from the shadow JCC members with provision to run a ballot should there be more than one nomination for each position. Only one nomination was received for the Chair and Vice-Chair and subject to ratification at the JCC’s first formal meeting, these will be agreed. The Chair will be Dr Anwar Khan and the Vice Chair will be Kash Pandya. Dr Khan has selected Dr Prakash Chandra to be his deputy through to the end of his term as a CCG Chair (June 18). From July 18, he has selected Dr Anil Mehta to be his deputy.

Constitutional Changes 8. To establish the new joint commissioning arrangements requires changes to some CCG

constitutions. The changes required to each CCG constitution to enable the Joint Commissioning Committee and the Single Accountable Officer to operate within the framework agreed by the seven CCGs are set out below. The proposed changes reflect the advice given by each Governing Body when making the original decision to increase collaborative working in 2017 plus the advice received from the solicitors Capsticks and Beachcroft.

9. CCG GBs will then need to consult with member practices to approve the changes. In

so doing the previous legal advice provided by legal representatives has been taken into account. As this will require constitutional changes we have also taken the opportunity to reflect the latest Conflict of Interest guidance and update the Primary Care Commissioning Committee’s terms of reference where relevant as this does not apply to all CCGs. There will also be a proposed terms of reference for Committees in Common. This is a matter of good governance to ensure that there is a common understanding of how Committees in Common will function in North East London. The section will also deal with voting and with the process to elect a Chair.

10. Scheme of Reservation and Delegation (App B) sets out the services and functions that

the NEL CCG Governing Bodies wish to delegate to the newly established Joint Commissioning Committee. These align to the outline scheme of delegation proposed in the September 2017 Governing Body report.

Single Accountable Officer / Managing Director 11. The existing Constitutions allow the CCG to share staff with other CCGs for delivering

commissioning functions in the section “Joint commissioning arrangements with other Clinical Commissioning Groups”. These clauses do not extend to allow the joint appointment of a single Accountable Officer for the seven CCGs as membership of the Governing Body and responsibility of non-commissioning functions are outside their remit.

12. The ability of the single Accountable Officer to attend all the meetings of the seven member Councils, Governing Bodies and their committees will be challenging. It is

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inevitable that a number of management techniques will need to be used to allow the normal operating of the governance functions for the CCGs. In most cases careful integrated planning between the Governing Body secretaries will be sufficient and easily undertaken within the existing Constitution powers. There are however three techniques that require amendments to the Constitution: • Deputisation for Joint Appointments • Joint Commissioning Committee • Committees in Common

13. It is expected that the management of the CCGs’ functions will be split between those that could benefit from an economy of scale and therefore be handled at a NEL CCG level, whereas other functions remain best managed by a local CCG team. Senior managers would be required to lead both the NEL teams and the local teams. The Managing Director from each of the CCGs would be nominated as a deputy for the Accountable Officer and provide the necessary cover at a Governing Body / Committee meeting. There are a number of advantages of having a named deputy in each CCG, rather than appointing an additional local senior CCG manager to the Governing Body. These advantages are: • The existing balance of clinical/non-clinical membership remains unchanged. • The Accountable Officer continues to retain the accountability and consistency of the

input to decision-making from the staff. • It is considerably easier to maintain the quorum for governing body / committee

meetings.

14. As a result of the newly created Managing Director post, the CCG constitutions will be amended to reflect the respective responsibilities of the Accountable Officer and Managing Director including financial thresholds. It is proposed to move to a standard form across NEL that sets out the responsibilities at each level.

Joint Commissioning Committee 15. The NEL CCGs have agreed to set up a Joint Commissioning Committee (JCC) to

enable collaborative commissioning for the whole of North East London.

16. The CCG Constitution template has a section titled: “Joint commissioning arrangements with other Clinical Commissioning Groups”. This is present in all NEL CCG constitutions. The provisions of this section should be sufficient to enable each CCG to establish a JCC and committees in common. However for some CCGs, it is necessary to name them in the main body of the constitutions as a generic new committee clause is absent. Since it is likely that the JCC will be making significant strategic decisions, it would be good practice to add the JCC to the list of Governing Body committees in the main body of all NEL CCG Constitutions.

17. All seven CCG constitutions must specify how the governance of the JCC operates and what functions have been delegated to it. This information is recorded in the Constitution appendices: “Scheme of Reservation and Delegation” and referenced in the JCC’s “Terms of Reference”.

18. The attachments for the Scheme of Reservation and Delegation (SORD), Joint Commissioning Committee (App B), sets out the key function of the Joint Commissioning Committee to provide assurance that there will be no duplication with CCG Boards. The SORD JCC will be reviewed towards the end of 2018/19 to ensure that it reflects accurately the role of the Committee.

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Committees in Common 19. The Joint Commissioning Committee has a number of limitations and in order for the

Single Accountable Officer to work effectively across North East London, the Constitutions need to add a greater degree of collaborative flexibility. This can be achieved through the use of “Committees in Common” arrangement.

20. A “Committees in Common” arrangement is where the same committee from more than one CCG meets at the same time, same place with the same agenda and makes the same decisions.

21. The limitations of the Joint Commissioning Committee are: • Legally, it can only consider commissioning functions. • To be quorate it must have all CCGs present. This makes it difficult to decide upon

matters that involve only six or fewer CCGs. • It is unable to include other CCGs in its decision making on an ad hoc basis.

22. By contract the “Committees in Common” arrangement may:

• Consider any function or use any power delegated by the Governing Body to the specific committee that is meeting in common.

• Set up an arrangement of any two or more CCG committees as required by the matter to be decided upon;

• Invite the same committees from non-NEL CCGs to join a “Committees in Common” arrangement as required by the matter to be discussed.

23. Technically, there is no requirement for any change of an individual CCG Constitution to enable the use of the “Committees in Common” arrangement. In its purist form, each of the same committees hold their meeting at the same time in the same place with the same agenda and each has its own set of minutes.

24. However there are some practical details that make the use of the purist form of “Committees in Common” impractical. These are: • A meeting is not effective if it has more than one chairperson and especially if there

are seven chair persons. • A meeting is not effective if there is a very large number of members present. • A meeting is not effective if there are more than one sets of Terms of Reference. • A meeting is not effective if the Governing Body has a perception that there is a

majority vote that overrules its committee’s decision.

25. A solution to these shortfalls is to provide in the CCG Constitution enabling clauses. These give consent / encouragement to the CCG’s Committees to work collaboratively with the same committee in other CCGs. It also provides an addendum to all CCG committee Terms of Reference setting out how the “Committees in Common” meeting will be conducted.

26. The detailed recommendations for change to constitutions are set out below. 27. Recommendation 1: The following clause is added to the NEL CCG Constitutions at the

section listed below the text:

X.X Joint Appointments with other Organisations The CCG may make joint appointments including joint appointments with other CCGs. Any such joint appointments will be supported by a memorandum of understanding between the organisations that are party to these joint appointments.

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Where a Joint Appointment is made, the appointee may choose a named deputy in each of the CCGs. The named deputy must be agreed by the chair of the Governing Body.

CCG Insertion Point Barking & Dagenham CCG:

After 7.9 (Deputy clause only)

City & Hackney CCG: After 7.4 (nb 7.14 covers is a different issue) Havering CCG: After 7.9 (Deputy clause only) Newham CCG: After 7.3 (Except first sentence.) Redbridge CCG: After 7.9 (Deputy clause only) Tower Hamlets CCG: After 6.5 Waltham Forest: After 7.9 (Deputy clause only)

28. Recommendation 2: The following line is added to the NEL CCG Constitutions, where

appropriate, at the section listed below the text: Heading Number Current Joint Arrangements Sub- Heading No. Joint Commissioning Committee The Joint Commissioning Committee has been established to include the seven North East London CCGs. The committee will exercise such commissioning powers as are delegated to it by the Governing Body and set out in the Scheme of Reservation and Delegation approved by the Governing Body. Any decision must be made unanimously (as described by the Committee Terms of Reference) with the other partner CCGs listed in the Terms of Reference. CCG Insertion Point Barking & Dagenham CCG:

After 6.6.11.8 becomes 6.6.12

City & Hackney CCG: After 7.6.1 becomes 7.6A (or 7.7 with all future paragraphs increased by one)

Havering CCG: After 6.6.11.8 becomes 6.6.12 Newham CCG: After 6.7.11 becomes 6.8 Redbridge CCG: After 6.7.11.8 becomes 6.7.12 Tower Hamlets CCG: Replace whole of section 6.7.12 and replace 6.7.12 with

“Not Used” Waltham Forest: After 6.5.4d New Heading 6.5.4e

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29. Recommendation 3: The following line is added to the NEL CCG Constitutions “Scheme of Reservation and Delegation” at the section listed below the text using one of the formats:

Policy Area Decision Joint

Commissioning Committee

COMMISSIONING & CONTRACTING FOR CLINICAL SERVICES

The committee will exercise such delegated powers as are transferred to it by the Governing Body and set out In the Terms of Reference approved by the Governing Body. Any decision must be made unanimously (as described by the Committee Terms of Reference) with the other partner CCGs listed in the Terms of Reference.

30. Recommendation 4: The JCC Terms of Reference with its Schedules and Annex are

added as an appendix to each of the NEL CCG Constitutions. 31. Recommendation 5: The following paragraph is added to the NEL CCG Constitutions,

where appropriate, at the section listed below the text: • Committees in Common Arrangement

All Governing Body Committees may meet with similar committees of other CCGs, using the “Committees in Common” arrangement, where the committee chair considers there is a value of working collaboratively on one or more specific issues. When the Committee Chair chooses to meet using a “Committees in Common” arrangement, the additional Terms of Reference for “Committees in Common” will be applied to the usual Committee’s Terms of Reference.

32. Recommendation 6: The Terms of Reference Addendum for the use of a “Committees

in Common” meeting arrangement (Appendix B) is added as an appendix to each of the NEL CCG Constitutions.

33. Recommendation 7: The following clauses add the requirement for a Conflict of Interest

Guardian to the Constitution.

The CCG shall appoint a Conflict of Interest Guardian who will normally be the Audit Committee Chair and whose responsibilities shall be to: a) Act as a conduit for GP practice staff, members of the public and healthcare

professionals who have any concerns with regards to conflicts of interest; b) Be a safe point of contact for employees or workers of the CCG to raise any

concerns in relation to this policy; c) Support the rigorous application of conflict of interest principles and policies; d) Provide independent advice and judgment where there is any doubt about how to

apply conflicts of interest policies and principles in an individual situation; e) Provide advice on minimising the risks of conflicts of interest.

34. Recommendation 8: To approve for recommendation to member practices the draft

CCG constitution that sets out all the changes required.

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Next Steps

35. To ensure that the North east London commissioning arrangements are implemented formally from 1 April 2018, the following next steps are proposed. • CCG GBs undertake consultation with member practices to approve the

constitutional changes • JCC continues to meet in shadow form with lessons learnt being submitted to CCGs

in March for final proposals. • Recruitment commences on the vacant JCC positions of nurse and secondary care

consultant Appendices Appendix A – JCC Chair of Chairs JD Appendix B – Scheme of Reservation and Delegation Appendix C – Addendum for Committees in Common Appendix D – Addendum for Primary Care Committees

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Appendix A NEL Chair of Chairs of Joint Commissioning Committee

Job Description

Job purpose The Chair of Chairs will be responsible for leading the NEL Joint Commissioning Committee (JCC) and the collective commissioning arrangements in the ELHCP. This will involve providing strategic direction, leadership and influence, clinical engagement, financial management and service redesign and development. An overview of NEL clinical areas will be required to influence and deliver the NEL commissioning strategy initiatives with NEL CCG chairs and wider clinical leaders. The Chair of Chairs must: • Lead the NEL JCC to:

• drive improvements in health outcomes and experience of care for local people and reduce variation in quality and services in NEL

• drive sustainability for NEL commissioners, providers and partners • align and deliver the NHS Five Year Forward View and develop accountable care systems • ensure that services commissioned by the NEL JCC align with those commissioned locally so that

a coherent clinical strategy is in place

• Engage with NEL CCG Chairs and other clinical leaders and organisations to deliver the priorities set out in the NEL Commissioning Plan and ensure effective CCG and clinical participation to accelerate the improvements in health services.

• Ensure that NEL has appropriate arrangements in place to exercise its delegated functions effectively,

efficiently and economically and in accordance with the principles of good governance. • Enable NEL to develop further its commissioning capability and track record of delivery.

• Work collaboratively with counterpart clinical leadership roles across London to support the devolution

agenda. Job role The Chair of Chairs of the NEL JCC will be NEL CCGs Clinical Leader and the role and responsibilities will include those as set out in Section X of NEL CCGs’ Memorandum of Understanding (MOU). The Chair of Chairs’ roles and responsibilities will also include:- • Leading the NEL JCC, ensuring it discharges its duties and responsibilities as set out in the NEL

CCGs’ MOU / Terms of Reference - in conjunction with the Single Accountable Officer and supported by the Director of Strategic Commissioning

• Ensuring proper constitutional and governance arrangements are in place and support the Single

Accountable Officer in upholding these • Work with the Vice Chair (Lay Member) to ensure any potential conflicts are managed

• Lead the building of the shared vision of the aims, values and culture of the NEL JCC taking account of

the views of local people and stakeholders • To act as ambassador and champion for NEL CCGs • Providing the support to foster the development of local accountable care systems, integrated

commissioning and provider collaboration

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• Engage actively with local people, clinicians and community representatives to shape NEL health

services by promoting co-design and collaboration between clinicians, practitioners and local people • Act as convener and champion for NEL and the NEL JCC at local, regional and national meetings and

events including regional assurance meetings with regulators • To lead the planning and delivery of opportunities to improve health outcomes across NEL by linking to

the NEL clinical senate and ensuring its plans are delivered

• To promote and champion with providers the delivery of high quality and cost effective services to improve health outcomes and satisfaction with local health and social care services

• To ensure transparency and personal accountability for all NEL JCC decisions including finance, quality and performance

• To communicate effectively with constituent CCGs and wider stakeholders to deliver the NEL JCC commissioning plan through co-design and collaboration

• To role model the values and ambitions of the NEL JCC • To lead the regular evaluation of the performance of the NEL JCC, its sub-committees and members

• To undertake the objective setting and appraisal with the SAO on behalf of all CCG chairs

• To ensure the effective flow of business between the NEL JCC and CCG Governing Bodies

• Establish the operating model for specialised and services commissioned by the NEL JCC.

Key Deliverables • Chair 80% of NEL JCC formal meetings • Prepare and deliver the Chair’s Annual Report on the NEL JCC business and achievements • To manage the NEL JCC business effectively and to the highest standards of governance particularly

around conflict of interest and confidentiality • Provide leadership, advice and guidance to NEL JCC members • Objective setting and appraisal for the SAO • Work with the SAO to ensure the NEL JCC is effective and set the objectives and undertake appraisals

of NEL JCC members • Support and encourage NEL JCC members to monitor, scrutinise and challenge on the business of the

NEL JCC

• To deliver its agreed strategic objectives, improved health outcomes; reduced health inequalities and improved quality and patient experience

• Engagement with clinical and practitioner leaders to promote collaboration and joint working

• Close and effective working with the local authority leaders (political and executive) on joint

commissioning and the integration of services • Foster and promote transparent accountability within NEL JCC member organisations, wider ELHCP

members and NHSE

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• Promote the sustainable, effective and efficient use of resources to deliver the NEL commissioning

strategy • Put a focus on local people at the heart of the NEL JCC and especially disadvantaged groups

This job description gives a general outline of the post and is not intended to be inflexible or a final list of duties. It may therefore be amended from time to time in consultation with the post holder. Tenure The appointment would be for 2 years. Remuneration The Chair of Chairs would be expected to undertake their duties within 1 session per week. This would be additional to any other duties they were required to carry out for their “home” CCG. Remuneration would be in line with their “home” CCG.

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Person Specification Criteria Essential Desirable Education and knowledge

• Knowledge of NHS Governance systems, codes of practice etc.

• Knowledge of establishing corporate structures and frameworks

Experience

• Chairing complex professional meetings at a senior level and ability to chair in an efficient manner

• Significant experience of working with boards • Experience in resolving transactional

conflicts to deliver both high quality services and the highest value for money for stakeholders

• Experience of working across agency and professional boundaries and collaborative and partnership working

• Experience of chairing a similar board

• Experience of chairing joint committees

• Experience of working with professionals and members of the public to improve services and create value for money for stakeholders

• Experience of managing strategic change in a political context

Skills

• Communication skills: interpersonal presenting, media relations, maintaining a positive public and professional profile.

• Ability to influence key stakeholders and decision makers in a multi-agency/partner environment.

• Assertive, Clear thinking and able to negotiate.

• Ability to generate and develop good working relations across partnership board member organisations at Board and senior management levels.

• Problem solving skills: Ability to identify issues and areas of risk and lead partners to effective resolution and decision.

• Chairing skills: Ability to organise, co-ordinate and follow through on key decisions, manage competing or differing views and positively challenge to achieve the desired outcome.

• Significant skills in negotiating to assist in managing and resolving conflict.

• Ability to recognise discrimination in its many forms and promote Equal Opportunities policies within the operation of the NEL JCC.

• Ability to ensure high standards of confidentiality in terms of individual cases and sensitive cross organisational matters.

• Enthusiasm, commitment and a determination to carry forward a complex agenda.

• Ability to enthuse and gain the commitment of others.

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Appendix B

Scheme of Reservation & Delegation (Functions related to NEL Commissioning arrangements)

This Scheme of Reservation & Delegation relates primarily to those functions considered as part of the North East London Commissioning arrangements and provides clarity on some of the other key issues to avoid any misunderstandings. It is not intended to be a comprehensive scheme relating to all CCG functions and responsibilities.

Delegation from Members Practice

CCG Board -

Services Functions Joint

Commissioning Committee -

Services

Functions

• Children’s services (NHS and joint)

• Business cases and service change requests

• Needs assessment and demand and capacity planning

• Procurement • Contracting and

contract management

• Joint work with LA • Setting outcomes for

providers • Outcome monitoring • Decommissioning

services • Consultation and

engagement – local people, members, local organisations (providers, councils, VCS)

• Specialised commissioning

• Business cases and service change requests

• Needs assessment and demand and capacity planning

• Contracting and contract management

• Joint work with LA • Setting outcomes for

providers • Outcome monitoring • Decommissioning

services • Consultation and

engagement – local people, members, local organisations (providers, councils, VCS) – done via local CCG arrangements

• Primary care development, contracting, prescribing

• LAS

• Termination of Pregnancy

• IUC

• Joint Commissioning with LA – Learning Disability / CHC / prevention / elderly / BCF

• Maternity Planning

17

Delegation from Members Practice

CCG Board -

Services Functions Joint

Commissioning Committee -

Services

Functions

• Community Services contracting

• Mental health (acute beds only)

• MH contracting – except inpatients

• NHSE assurance (except through exception done elsewhere eg A&E)

• Acute Commissioning and contracting (local)

• Approve ACS framework

• Borough workforce delivery

• Integrated Care Development

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2018/19 JOINT COMMISSIONING COMMITTEE – DETAILED SCHEME OF DELEGATION The Scheme of Delegation 2018-19 sets out those functions that are to be delegated by the CCGs to the JCC and those that are reserved for individual CCGs. It is intended to be reviewed in March 2019 at which time other functions may be delegated. As the experience of CCG Boards suggest there is unlikely to be many votes taken, in the unlikely event that there is, the Joint Commissioning Committee membership and voting system relies on all CCGs agreeing with a proposal for recommendations to be implemented. It is also the case that the subsidiarity principle applies and that the Joint Commissioning Committee will be dealing with matters that apply to all or most of the CCGs. The functions identified below emanate from previous discussions with Chairs and are reflected in the terms of reference of the JCC. There are also a series of corporate functions such as financial, quality and performance that would be core activity for any key commissioning body. Finally, it is the case that the scheme will need to be regularly reviewed to ensure that the JCC is considering issues that allow the Committee to fulfil its role. It is also a recognition that some issues will only become material once the Committee starts meeting formally. The Joint Commissioning Committee will have the following role for services and budgets delivered across NEL CCGs. With respect to the Sustainability and Transformation Plan (STP) • Operational responsibility for the work which needs to be undertaken to implement

the STP Strategy and Priorities from the commissioners perspective that impact on all seven CCGs and in so doing integrate into the STP process as the representative voice of NEL CCGs.

With respect to the commissioning of LAS, 111, and Specialised Services • Approve a common NEL wide Commissioning Strategy for these services • Approve needs assessment, demand management and capacity planning

assumptions • Approve a commissioning plan for each service • Approve arrangements for consultation and engagement with Patients, Providers,

Local Authorities and Members • Review and monitor recovery plans for pathways or contracts that are significantly

off track • Approve the decommissioning of delegated services • Approve the contracting approach with Providers and any contract management in

relation to those contracts • Approve financial contributions and incentive payments • Approve the business cases. With respect to Maternity Services • Approve Maternity Services Capacity Planning for NEL With respect to NHSE Assurance • Approve assurance process and approach with CCGs that feeds into the NHSE

assurance process.

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With respect to Infrastructure • Approve NEL Workforce strategy to support the commissioning and financial strategy

and monitor progress and implementation • Approve IT digital Strategy for NEL to support the commissioning and financial

strategy and monitor implementation • Approve Estates Strategy framework for NEL CCGs and monitor implementation of

the action plan

With respect to Financial Strategy • Approve JCC Financial Strategy and ensure alignment with the STP Financial

Strategy • Approve Provider Payment Mechanisms to replace Payment by Results • Approve revised payment mechanism strategy for acute services • To adopt risk sharing agreements for CCGs that take into account the services

commissioned locally and their effectiveness • Approve core financial processes, timetable and plans including operating financial

plans, CCG and STP Financial strategies and agreements, budget setting and risk assessment

• Monitor and oversee programme, administrative, collaborative (STP/TST etc.) and capital budgets and financial performance

• Review business cases and proposed procurement financial components for services within the remit of the JCC to ensure appropriate identification and management of financial risk (including QIPP schemes, Transformation schemes, investment proposals and funding bids)

• Identify and recommend allocation or reallocation of resources where appropriate for services within the remit of the JCC to improve performance or ad hoc performance and financial issues that may arise

• Review reporting arrangements to ensure these remain fit for purpose and appropriate to meet the JCC accountabilities and assurance in collaborative arrangements.

With respect to Quality and Performance • Continuous improvement in the quality of services commissioned on behalf of the

CCGs through the development of a common quality assurance and reporting framework and quality improvement strategy

For consideration in 2019/20 There are a number of other possible areas that could be included in the scheme of delegation but should be considered as part of the review for 2019/20. In particular: • Approve a Provider Commissioning Framework to align Acute Services across NEL • Approve an Alignment Framework for the development of Out of Hospital and

Primary Care at Scale • Approve needs assessment, demand and capacity planning, provider outcomes

and outcome monitoring for these strategies • Agree the contracting approach to acute and mental health providers • New and revised clinical pathways for services that impact upon all or most of the

CCGs It should be noted that local acute responsibilities will continue to stay with CCGs.

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NEL CCG Governance Recommendations vs9 Page 1

Appendix C

XXX CCG(Add name of CCG) Terms of Reference

Addendum for Committees in Common arrangement

Introduction 1. This Terms of Reference Addendum is to be added to the CCG’s Committee Terms of Reference,

when the Committee wishes to meet with other similar committees from other CCGs using the “Committee in Common” (CIC) meeting arrangement. The terms in this paper should be read in conjunction with the main Terms of Reference of the Committee wishing to use them.

2. The CCG has a number of established Governing Body Committees. The NEL CCG Governing Bodies have instructed that their Committees may meet using a CIC arrangement where the business is common to two or more CCGs. These additional Terms of Reference set out the special membership, remit, responsibilities and reporting arrangements of a meeting using the CIC arrangement and are incorporated into each Clinical Commissioning Group’s Constitution.

Purpose 3. The purpose of the Committee wishing to use the CIC meeting arrangement remains unchanged

from its Terms of Reference and the Scheme of Reservation and Delegation.

4. The CiC may consider any matter that is of interest to two or more CCGs.

5. The CiC has the same authority, as its constituent committees, to commission any reports or surveys it deems necessary to help fulfil its obligations.

Membership 6. The CiC membership is made up of:

• The participating CCG Committees (Voting)

Meetings 7. The CiC will adopt the Newham CCG Standing Orders relating to the conduct of meetings, agendas

and declaration of interest with the exception of the clauses in this addendum.

Meeting Chair 8. The CiC membership will appoint a CCG lay member to be the chair.

Frequency 9. The Committee Chairs will agree an annual schedule of meetings with the CiC meeting secretary.

The programme will be circulated to all CiC members.

Quoracy 10. Quorum for each of the participating committees will be the current quorum specified for each CCG

within their current terms of reference.

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Decision making 11. A decision made at a CIC meeting shall be binding on the constituent CCGs when the following

criteria have been met: • The decision is within the bounds of the CIC delegated functions; • Each CCG Committee has one vote; • A decision has been unanimously agreed.

Voting 12. Voting will be by consensus with the outcome clearly recorded in the minutes of each Committee.

13. Should the participating Committees have a differing view and decision, a vote will be taken with each CCG Committee having one vote. A record will be made in the minutes and the item deferred to the following meeting with advice sought from the participating CCG Chairs.

14. Should consensus still not be achieved at the next meeting, the decision made will represent that of each of the individual Committees. A record of the decisions will be added to the minutes and a notification made to each of the CCG Governing Bodies. For clarity, in this scenario the different decisions of each of the committees are not binding on the other participating CCG Governing Bodies.

In Attendance 15. The CiC Convenor will agree with the Committee Chairs the attendance of other individuals required

to enable effective decision-making.

16. Where individuals attend a CiC meeting, this will be noted as “in-attendance” in the minutes.

Conflicts of Interest 17. For clarity - The Conflicts of Interest policies of Newham CCG apply to the working of the CiC.

Reporting arrangements 18. The minutes of the CiC will consist of a set of identical minutes for each of the participating CCGs.

19. The minutes of each Committee will be reported to each of the participating Governing Bodies for information when agreed as accurate by the CiC. The individual CCG reporting arrangements to the Governing Body is set out in their Constitution.

20. The CiC will present an Annual Report to each Governing Body on the actions taken by the CiC to comply with its Terms of Reference.

Administration 21. Support for the CiC will be arranged by the Accountable Officer.

Review of Terms of Reference Addendum 22. The Committee will review this Terms of Reference Addendum annually at one of its meetings.

Changes in the Terms of Reference Addendum need to be approved by each Governing Body and reflected in each CCG’s Constitution.

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Appendix D

XXX CCG(Add name of CCG) Primary Care Commissioning Committee

Terms of Reference

1. Introduction 1.1. In accordance with its statutory powers under section 13Z of the National Health Service Act

2006, NHS England has delegated the exercise of the functions specified in Schedule 2 of the Delegation Agreements to these Terms of Reference to xxx CCG.

1.2. The CCG has established the Xxx CCG Primary Care Commissioning Committee (“Committee”). The Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers.

1.3. The ongoing relationship the Primary Care Commissioning Committee will have with NHS England will be revised on an ongoing basis, though this will be outlined in Schedule 4 of the Delegation Agreement.

1.4. It is a committee comprising representatives of the following organisations: • xxx CCG • NHS England • LB xxx • Local Medical Committee (LMC) • Healthwatch

2. Statutory Framework 2.1. NHS England has delegated to the CCG authority to exercise the primary care commissioning

functions set out in Schedule 2 of the Delegation Agreements in accordance with section 13Z of the NHS Act.

2.2. Arrangements made under section 13Z may be on such terms and conditions (including terms as to payment) as may be agreed between the NHS England Board and the CCG.

2.3. Arrangements made under section 13Z do not affect the liability of NHS England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including:

a) Management of conflicts of interest (section 14O);

b) Duty to promote the NHS Constitution (section 14P);

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c) Duty to exercise its functions effectively, efficiently and economically (section 14Q);

d) Duty as to improvement in quality of services (section 14R);

e) Duty in relation to quality of primary medical services (section 14S);

f) Duties as to reducing inequalities (section 14T);

g) Duty to promote the involvement of each patient (section 14U);

h) Duty as to patient choice (section 14V);

i) Duty as to promoting integration (section 14Z1);

j) Public involvement and consultation (section 14Z2).

2.4. The CCG will also need to specifically, in respect of the delegated functions from NHS England,

exercise those set out below: • Duty to have regard to impact on services in certain areas (section 13O); • Duty as respects variation in provision of health services (section 13P).

2.5. The Committee is established as a Committee of the Xxx CCG Governing Body in accordance with Schedule 1A of the “NHS Act”.

2.6. The members acknowledge that the Committee is subject to any directions made by NHS England or by the Secretary of State.

3. Role of the Committee 3.1. The Committee has been established in accordance with the above statutory provisions to

enable the members to make collective decisions on the review, planning and procurement of primary care services in Xxx, under delegated authority from NHS England.

3.2. In performing its role the Committee will exercise its management of the functions in accordance with the agreement entered into between NHS England and Xxx CCG, which will sit alongside the Delegation Agreement and terms of reference.

3.3. The functions of the Committee are undertaken in the context of a desire to promote increased co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

3.4. The role of the Committee shall be to carry out the functions relating to the commissioning of primary care services under section 83 of the NHS Act.

3.5. This includes the following: • GMS, PMS and APMS contracts (including the design of PMS and APMS contracts,

monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract);

• Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”);

• Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF);

• Decision making on whether to establish new GP practices in an area; • Approving practice mergers; and • Making decisions on ‘discretionary’ payment (e.g., returner/retainer schemes).

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3.6. The Committee will also carry out the following activities: a) To plan, including needs assessment, primary care services in Xxx; b) To undertake reviews of primary care services in Xxx; c) To co-ordinate a common approach to the commissioning of primary care services

generally; d) To manage the budget for commissioning of primary care services in Xxx.

3.7. The Committee is accountable for exercising the agreed delegated functions from NHS England; these functions operate at practice level and not at individual Primary Care Contractor level.

4. Geographical Coverage 4.1. The Committee will comprise of decisions relating to Primary Care in Xxx.

5. Membership 5.1. The Committee shall consist of:

• Chair – Lay Member • Lay member (Vice Chair) • Associate Lay Members X2 • Chief Accountable Officer • CCG Chair • Director of Primary Care Development • CCG Chief Finance Officer • Secondary Care consultant • General Practitioner (not within North East London) • Director of Commissioning & Planning (or equivalent) • Director of Quality & Performance (or equivalent)

Non Voting Members

• GP Locality Clinical Leads x3 Representatives • NHS England (London Regional Team) Representative • HealthWatch Representative • LMC Representative • Health & Wellbeing Board Representative

5.2. The Chair of the Committee shall be a CCG Lay Member and will be appointed at the first meeting of the Committee.

5.3. The Vice Chair of the Committee shall be a CCG Lay Member and will be appointed at the first meeting of the Committee.

5.4. The Committee may invite ad-hoc members to advise it on specific matters within its Terms of Reference from time to time as appropriate.

5.5. There will be an annual review of the Committee’s Membership and Terms of Reference to support it efficient functioning.

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6. Conflicts of Interest 6.1. Conflicts of Interests will be managed in accordance with the CCG‘s current policy; ‘Standards

of Business Conduct and Managing Conflicts of Interest Policy’.

6.2. Any conflicted Members may be required to leave the meeting for the relevant discussions, as appropriate under direction by the Chair.

7. Meetings and Voting 7.1. The Committee will operate in accordance with the CCG’s Standing Orders. The Business

Manager for Xxx CCG will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than 5 working days before the date of the meeting. When the Chair of the Committee deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as s/he shall specify.

7.2. Each member of the Committee shall have one vote. The Committee shall reach decisions by a simple majority of members present, but with the Chair having a second and deciding vote, if necessary. However, the aim of the Committee will be to achieve consensus by decision-making wherever possible.

7.3. The Chair shall determine if any conflicted member should leave the discussion or be excluded from the decision making process.

8. Quorum 8.1. The Committee will be quorate with 7 out of the 12 voting Members in attendance, with at

least one Lay Member Present who is not the Chair (but can include Associate Lay Members), and the Chief Accountable Officer or Chief Finance Officer in attendance.

9. Frequency of meetings 9.1. The Committee shall meet at least quarterly in public with the inclusion of ad hoc seminars

held in private for developmental purposes.

10. Meetings of the Committee 10.1. Meetings of the Committee shall:

a) be held in public, subject to the application of 31(b);

10.2. the Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.

10.3. Members of the Committee have a collective responsibility for the operation of the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view.

10.4. The Committee may delegate tasks to such individuals, sub-committees or individual members as it shall see fit, provided that any such delegations are consistent with the parties’ relevant governance arrangements, are recorded in a scheme of delegation, are governed by terms of reference as appropriate and reflect appropriate arrangements for the management of conflicts of interest..

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10.5. The Committee may call additional experts to attend meetings on an ad hoc basis to inform discussions.

10.6. Members of the Committee shall respect confidentiality requirements as set out in the CCG’s Constitution.

10.7. The Committee will present its minutes to the London Area Team of NHS England and the governing body of Xxx CCG for information, including the minutes of any sub-committees to which responsibilities are delegated under paragraph 34 above.

10.8. The CCG will also comply with any reporting requirements set out in its Constitution.

11. Decisions 11.1. The Committee will make decisions within the bounds of its remit.

11.2. The decisions of the Committee shall be binding on NHS England and Xxx CCG.

11.3. The Committee will produce an executive summary report which will be presented to the London Area Team of NHS England and the governing body of Xxx of the CCG.

12. Reporting 12.1. The Committee will report to the CCG Governing Body on the decisions made within the

bounds of its remit.

13. Immediate and urgent decisions 13.1. There may be instances when the Committee is required to make a decision in advance of the

regular full committee meetings in light of unforeseen circumstances. Depending on the urgency of the matter such decisions may need to be immediate (i.e. to be made in 24 hours) or urgent (i.e. to be made in timeframes longer than 24 hours but in advance of the next scheduled meeting).

13.2. The Director of Primary Care Development will decide when an immediate or urgent decision is required and will initiate the decision making process.

13.3. In the instances where an immediate decision is needed the Director of Primary Care Development will arrange a meeting with the Chair or Vice Chair (if Chair is not available) and the CCG Accountable Officer to take the decision. Such decisions will only be taken in exceptional circumstances, such as the need to close a practice due to clinical reasons or contractor death. Any immediate decisions taken under this procedure will be presented at the next Committee meeting.

13.4. In the instances when the Director of Primary Care Development deems it necessary to request an urgent decision the Chair will be contacted. The Chair or Vice Chair (if Chair not available) may deem it necessary to call a meeting at short notice outside the regular full committee meetings as set out in paragraph 27 above.

14. Review 14.1. It is envisaged that these Terms of Reference will be reviewed bi-annually in Year 1 and then

annually thereafter, reflecting experience of the Committee in fulfilling its functions. NHS England may also issue revised model terms of reference from time to time.

15. Primary Care Commissioning Committees in Common 15.1. The Primary Care Commissioning may meet as a “Committees in Common” with other CCGs

using additional terms as set out in the addendum.

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Page 1

Item 3.1a

Title of report Performance and Quality Report (CCG Scorecard)

From Jane Mehta, Interim Managing Director – WFCCG

Author Enrico Panizzo, Senior Commissioning Manager - WFCCG

Purpose of report

The purpose of this report is to inform the CCG Governing Body Committee of the CCG’s performance against the CCG Scorecard and other national performance and quality standards at the end of December 2017 (Month 9).

Summary of report

Currently, the CCG has assessed that 14 are low risk to delivery (52%) and should be achieved in 2017/18. Five indicators are medium risk (18%) and eight are considered high risk (30%). 17 indicators (65%) are meeting their targets on the latest performance data. High Risk Indicators

• Eight CCG targets are considered high risk to delivery in 17/18: Cervical Cancer Screening (6b); Diabetes Structured Education (7a); Renal (7b); CHC Assessments in 28 days (9a); E-referrals (10a); A&E performance at Whipps Cross (11a); Pressure ulcers at Whipps Cross (13b); and Delayed Transfers of Care (15a).

Based on the latest data the CCG does not expect to meet these targets for 2017/18. However, it is important to note that all but three indicators have shown improvement in 2017/18. Home Births (4), Cervical (6b), CHC (9a), Pressure Ulcers (13b) and Delayed Transfers of Care (15a) have all shown improvements in performance in 17/18. The most challenged CCG targets in 2017/18 have been:

• Diabetes (7a): The CCG continues to focus on patient engagement and referrals to both the face to face and the online training services. The CCG is also raising awareness with GPs. Structured Education is recommended for both new and existing diabetes patients. The CCG is renewing communications to GPs to emphasise that current diabetics are eligible for referral. There are approximately 16,000 diabetics within Waltham Forest.

• Renal target (7b): Performance is being investigated due to potential data errors from the

Barts Health submissions. The CCG is continuing to work with GPs to make referrals to the virtual clinic rather than to Whipps Cross outpatients. Presentations have been made at the locality meetings to support referrals and performance has improved in the latest month.

• A&E performance (11a): Performance is below the target, but showing improved performance

compared to last year. Recent improvement is attributed to improved bed availability, reduced numbers of patients with long lengths-of-stay, and the expansion of ambulatory care. Emergency Department attendances have not seen any increase in 17/18 and Delayed Transfers of Care are low compared to recent periods.

28

Performance and Quality Report (CCG Scorecard)

Other important updates include:

• CHC performance (9a): Performance against the 28 target has improved and the target was met in December. However, there remains a risk related to the proportion of CHC assessments completed out of hospital (in order to reduce potential delay to hospital discharge). This is an additional target that NHSE has asked CCGs to monitor in 2017/18. In Q4 55% of CHC assessments were completed in hospital against a national target of 15%. The CCG plans to meet this target by the end of the year and has increased the capacity of the community team.

• E-referrals’ (10a): Whilst performance is below target it was recognised at the start of the year that the national target was extremely challenging. WFCCG’s performance (52%) is above the London average performance (47%) and has improved from 46% at the start of the year.

Medium Risk Indicators Five targets are considered medium risk: IAPT access rate (2b); Home Births (4); Learning Disability Health Checks (5); GP FFT (14a); and Medically Optimised patients (15b). All of these targets are showing improved performance relative to last year. The CCG expects to meet some of these targets and all can be achieved with good performance in the last two months of 17/18.

• IAPT access rate (2b): NELFT achieved the access rate for Q3 but provisional figures for January and February 2018 indicate that the target is at risk in Q4. The national performance target increases from 3.75% in Q3 to 4.2% in Q4. The CCG has funded additional activity from NELFT but figures show that referrals were 150 below the required level in January. The CCG is investigating the actual performance data and reviewing this with NELFT at weekly meetings. Confirmed underperformance in Q4 will be raised with NELFT and the CCG will consider contractual options in response.

• GP FFT (14a): Note that data for November (66%) is substantially skewed by the submission of

1,346 records from one practice in that month. Excluding this data, which covers data for a substantial time period and which therefore distorts the true performance, yields a monthly performance of 80% for November and 86% YTD (versus a target of 85%).

Since November Home Births (4), COPD (7c), Palliative Care (8) and Patient Online (14b) are meeting their targets. The report outlines actions being taken for all medium and high-risk indicators. Other Updates: London Ambulance Service The London Ambulance Service implemented the Ambulance Response Programme (ARP) in November 2017. This replaced the national response time standards and put in place a new call prioritisation system which sets the standards for all 999 calls to ambulance services including those passed to ambulance services via 111. The new national standards were established under an initiative called the Ambulance Response Programme (ARP) led by NHS England. The aim of ARP is to ensure that the sickest patients receive the fastest response and all patients get the best response allocated to them first time. As part of the new system call handlers will be given more time to assess the caller’s symptoms and this is expected to ensure better identification of the sickest patients.

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LAS pan-London performance is shown in the table below. Performance on Category 1 calls (life threatening calls) was close to the new standards. National Standards were achieved across Cat 1, Cat 2 and Cat 4 90th centile for M8. LAS are currently running in third position against Cat 1 performance against the 8 national ambulance Trusts currently reporting under ARP.

CCG-level reporting is currently unavailable. There remains a risk for WFCCG as performance in the borough has historically been significantly lower than the London level. This will be monitored as soon as results are available. The ARP is expected to have a beneficial impact on patients as it improves the prioritisation of calls and ensures good response times for the sickest patients. LAS are working with commissioners to review and design the appropriate suite of reports to capture the new range of metrics.

Recommendations for Governing Body

The Governing Body is asked to review the report and the identified areas of risk and make any recommendations for further investigation and assurance, and also to make any possible suggestions for potential improvement activities that might mitigate areas of underperformance.


The CCG is not meeting several performance targets, including the 4hr waiting time target for A&E at Whipps Cross Hospital. The report details the actions being taken by the CCG and by providers to address these and other areas of under-performance. The Scorecard is the principal tool for the CCG to ensure it is reporting on the impact of the CCG’s work programmes for 2017/18 in terms of improved patient care and outcomes. The report supports the delivery of improved care by providing a process for recording progress each month and highlighting any risks to delivery, so that these risks can be appropriately mitigated by the CCG.

Risk implications

Failure to ensure that there are improvements to the quality and performance of services commissioned may result in a failure to manage and mitigate risks with potential harm to patients and reputational damage to the CCG.


Failure to meet NHS Constitution standards or CCG Local Priorities may affect the size of the Quality Premium, an additional incentive payment made to CCG to meet national quality targets. The COPD Spirometry target (7c) was chosen as the local indicator for the CCG Quality Premium in 2017/18. This target is currently being met.

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CHC assessments being completed within 28 days (9a) is also part of the Quality Premium assessment. The CCG is currently meeting part of this target (assessments being completed in 28 days), but not the element about assessments being completed out of hospital.

Equality analysis

The report has considered the CCG’s equality duty and where relevant has identified relevant actions which address any likely impact on equality and human rights.


An earlier version of this report was presented to the Performance and Quality Committee.

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February 2017

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Page 2

1. Scorecard Aims and Objectives NHS Waltham Forest Clinical Commissioning Group (WFCCG) has developed the Scorecard to report progress against key performance and quality targets in 2017/18.

The Scorecard has been designed around the CCG workstreams as identified in the CCG Business Grid (Appendix A). In order to create the Scorecard each CCG workstream lead was asked to develop a maximum of two indicators and targets that reflect the key goals for that programme. These goals have been developed in collaboration with the relevant Clinical Director and/or Clinical Leads. The Scorecard has also been signed-off by the Performance and Quality Committee (April 2017) and approved by the Governing Body.

The intention of the Scorecard is to identify specific measurable indicators that can be used to demonstrate improvements in patient care and outcomes over the course of the year. Where it has not been possible to measure health outcomes on a regular basis, indicators have been chosen that most closely reflect the work being undertaken by the CCG workstreams to influence improvements in outcomes.

The Scorecard reflects Waltham Forest priorities and objectives and enables the CCG to measure the effectiveness of its plans. Where relevant, the Scorecard has used existing national indicators and targets. National targets have also been chosen where the CCG was not meeting key targets at the end of 2016/17. Scorecard targets have been aligned with the levels of ambition set out in the CCG Operating Plan and Quality Premium submissions to simplify reporting processes.

The CCG performance reporting process focuses on the latest performance information, progress made in the past month, the identification of any risks to delivery, and actions being taken to resolve underperformance or mitigate adverse impact. Whilst the reporting process will focus on performance of the Scorecard indicators, the intention is also to capture the key elements of the wider work being undertaken within each workstream, to the extent that this supports making a difference for the residents of Waltham Forest.

The monthly reporting process will also be used to report by exception on the CCG’s performance against national performance and quality targets not covered by the Scorecard so that the CCG is aware of any risks to the local population. This exception reporting includes the NHS Constitution standards and the CCG requirements outlined in the 2017/18 Operating Plan guidance.

2. Scorecard risk assessment Performance on the CCG Scorecard is RAG rated on the basis of the following thresholds:

• Green: performance is meeting target level or is on trajectory to meet target level by expected date

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Page 3

• Amber: performance is below target/trajectory but has demonstrated improvement from baseline • Red: performance has not improved from baseline

In addition to the RAG rating described above the forecast delivery of each target is risk assessed. This risk assessment considers any risks to delivery, under-performance to date and the scale of the required improvement trajectory.

3. 2016/17 CCG Scorecard Performance The main risks to the performance against targets are outlined below along with planned mitigations.

1a Emergency admissions for high risk cohort

Risk: Low

The CCG met its targets for reducing emergency admissions from the high-risk cohort in 2015/16 (19% reduction) and 2016/17 (10% reduction). Emergency admissions at Whipps Cross overall fell by 4% in 2016/17. The target for 2017/18 is a further 10% reduction from the high-risk cohort. Monitoring figures for April – November show a reduction in 342 admissions from the high risk cohort (13% reduction). This level of improvement has decreased in the last four months and this is being investigated in relation to an overall increase in emergency admissions since August. This effect is due to changes in counting and coding of activity (and the classification of Ambulatory Care Patients) and is not related to actual changes in the numbers of patients that need to be admitted at Whipps Cross. The CCG expects to meet this target in 2017/18.

1b Emergency admissions from care homes

Risk: Low

In 2015/16 the total number of ambulance conveyances from care homes increased by 7%. In 2016/17 the CCG commissioned a pilot to give 12 homes enhanced support from a GP. The aim was to reduce hospital admissions by 25% for this cohort of homes. The homes reduced non-elective admissions by 36% and ambulance conveyances reduced by 11%. As a result, enhanced support has continued in three nursing homes with a focus on training care home staff and annual medical assessments on all residents. As the numbers are relatively small this figure is expected to be volatile month on month. YTD there has been a 14% reduction in emergency admission from across the three nursing homes in Waltham Forest. There were 17 admissions recorded in December but this remains lower than the 18 recorded in December 2016/17. The CCG expects to meet this target in 2017/18.

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Page 4

2a Improving Access to Psychological Therapies (IAPT) Recovery Rate

Risk: Low

The target relates to the effectiveness of the IAPT service commissioned from NELFT and measures the proportion of patients that are considered to move into recovery. A person is considered to have moved into recovery if after treatment they score below the clinical threshold for depression and anxiety. Performance can be affected if the overall case-mix of patients entering treatment changes in severity. Performance in December was 51%. An action plan has been agreed and the service will be closely monitored to ensure that the performance meets its target. The CCG is monitoring the effects of expanding the IAPT service might have on the recovery rate. The CCG expects to meet this target in 2017/18.

2b Improving Access to Psychological Therapies (IAPT) Access Rate

Risk: Medium

The target measures the number of people entering the IAPT service against the estimated local population of people with anxiety or depression that would benefit from the service (29,903, based on the Adult Psychiatric Morbidity Survey). To meet the target 16.8% of this population (5,024 new individuals) need to have started treatment by the end of the year. December performance was below target by 84 referrals. However Q3 performance overall was 3.9% against a target of 3.75%. There has been an increase in new referrals as a result of recent GP visits conducted by the GP lead. It has been agreed with NELFT that they will achieve an effective rate of 15% for the first 9 months of the year (3.75% per quarter) before moving up to 16.8% (4.2% per quarter) in Q4. The increase in rate required in Q4 remains a risk. NELFT have an action plan in place and the service is looking at increasing referrals from parents and self-referrals. A new phone system has been put in place so that patients receive call-backs. NELFT report that they have identified appropriate staff to meet this requirement.

• An action plan is in place and is being monitored on a weekly basis to ensure the Q4 performance target is met. • Underperformance in Q4 may trigger a formal contract performance notice against NELFT.

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2c Early Intervention in Psychosis

Risk: Low

The access and waiting time standard for early intervention in psychosis (EIP) services was introduced in 2016/17 and requires that more than 50% of people experiencing first episode psychosis will be treated with a NICE-approved care package within two weeks of referral. The CCG has set a stretch target with NELFT at 66%. November performance was 100%. The CCG expects to meet this target in 2017/18.

3 Children’s Dietetics Waiting Times

Risk: Low

The CCG invested in an expansion of the children’s dietetics service in 2016/17. This service sees children with swallowing difficulties, high level intolerances, home enteral feeding, and severe jaundice. The target is for urgent cases to be seen in two weeks and routine referrals to be seen in 18 weeks. In December performance was 100%. The target has been met for the last six months. The CCG expects to meet this target in 2017/18.

4 Home Births

Risk: Medium

This is a new target for the CCG (replacing the early booking target that was met for the previous two years). The CCG has set the target for increasing the availability of home births, which expands the choice of birth options for women and is expected to impact on measures of experience and satisfaction with maternity services, which has been highlighted as an area for improvement in patient surveys for north east London. The CCG has supported the availability of home births through investment in the Neighbourhood Midwives project. Performance in October was 4%, above the target of 2.5%. This represents 6 home births completed by Neighbourhood Midwives (compared to 3 the previous month) and 11 completed by Barts (compared to 5 the previous month). The home birth team at Whipps has been reinstated, however home births managed by Whipps are below the 2016/17 levels of an average of seven per month. WX have made progress seeing more patients in the midwife-led birthing unit at Whipps (and fewer in the obstetric unit).

• Overall there has been improvement in the number of home births but the target is considered medium risk as there is limited flexibility to increase home births within the year. Neighbourhood Midwives expect to see an increase in activity over the next couple of month.

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5 Learning Disability Health Checks

Risk: Medium

The CCG met its target for learning disability health checks in 2016/17 and has increased the target from 50% to 55% in 2017/18. Performance in November was above the planned trajectory. A revised action plan is being monitored at the Learning Disability Health Transformation Board. This indicator is assessed as medium risk as the trajectory assumed a large increase in activity at the end of the year (from November onwards).

6a CCG GP Referral to Treatment (62 Days) Performance

Risk: Low

The target measures the proportion of people with cancer who start treatment within 62 days of their referral from GP. Performance for 2016/17 was 84.5%, just below the 85% target. Performance was 86% in November, above the target of 85%. Barts achieved 86%. WFCCG had breaches in Upper Gastrointestinal (2), Head and Neck (1) and Gynaecology (1).

6b Cervical Cancer Screening

Risk: High

In 2017/18 the CCG has switched the data source from Health Analytics to Open Exeter in response to overwhelming feedback from the clinical leads, GPs and practice managers that they felt cervical cancer screening performance is better reflected by the Open Exeter data. This is a manual submission each month done by practices. Data is available 6 months in arrears and the reported performance is therefore showing the position six months previous. The performance measures the proportion of women who have had a screen within the last 3.5 years for those aged 25 to 49 and within the last 5.5 years for those aged 50 to 64. Performance in February (reflecting the July 2017 position) was 68% against a target of 71%. There has been an improvement in performance in the last five months. In December the CCG commissioned a calling service to follow-up women eligible for screening at targeted GP practices. The CCG is also working on raising public engagement and community activities.

• A business case has been approved for £35k to support a calling service to remind eligible women to uptake screening, alongside community engagement and communications.

• 10 practices with low screening rates were sent emails inviting them to participate in the calling project. Six practices have accepted. Calls have started from six practices. 582 calls have been made up to the start of January with 94 appointments booked. The CCG is monitoring the conversion of calls to bookings and will be collecting data on DNA rates.

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• The service aims to call 2,000 patients between November and April with a target of 400 additional screening appointments • Practice level data has been shared with localities • A list of stakeholder groups in place for community engagement has been developed with this work starting in November. • Funding related to the calling service are limited to the end of March 2018 • The possibility of additional STP money for early diagnosis is being explored

7a Diabetes Structured Education

Risk: High

The target aims to increase the number of people being referred to structured education. There are approximately sixteen thousand people with diabetes in Waltham Forest and 100 new diabetes are diagnosed per month. Referrals to structured education can come from newly diagnosed or from known patients. Patients can access face to face structured education through NELFT. In 2017/18 the CCG has also provided the option to access an online version of this programme. This is being delivered by Changing Health. There have been 495 referrals year-to-date to structured education against a plan of 977. The new online service provided by Changing Health has been in place since May 2017. Presentations were made at an education event on 18 May and to GP localities in July. A total of 160 referrals to Changing Health have been completed YTD (500 licenses have been bought for the year). 53 were completed in August, but these have reduced to 12 (Sept), 9 (Oct) and 29 in November. The increase in August has been attributed to the first round of reminder text messages sent out to patients at pilot practices and this is being followed-up. A tool has been developed to identify potential eligible referrals who are then be contacted by text message.

• Five GP practices are in the pilot and the aim is keep focusing on the larger practices. • Patients can now self-register for the course. This is being promoted on Facebook and through other channels including GP

practice websites. • Practices are being asked to prioritise the utilisation of SMS texts to promote this service to appropriate patients. • The CCG Clinical Lead is promoting the course. • The CCG has engaged through the practice nurse forum and with community pharmacy to promote the course.

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7b Renal – Reduced Outpatient Appointments

Risk: High

The target is to reduce the number of renal outpatient appointments. The project is to introduce a collaborative virtual Chronic Kidney Disease (CKD) clinic & Referral Management System between Waltham Forest primary care and Bart’s Health NHS Trust, providing a more responsive service to CKD patients. The number of first outpatient attendances at Barts nephrology was 24 in December, above the target of 21. This figure includes consultant to consultant referrals which cannot be made to the virtual clinic (unless by being referred back to the GP). Previous figures have included some virtual clinic appointments which appear to be resolved in the latest month and this is being checked with the trust.

Actions include:

• All EMIS practices are now registered with the service (final practice registered w/c 6 November) • GP referrals are being investigated by the clinical lead as some GPs continue to refer direct to WX • CCG leads are going to all the locality meetings, the consultants from Barts will also be present to promote the service and

give guidance to the GPs to encourage referrals • The CCG is sending out information on behalf of the clinical lead to all practices, reminding them about the process for

referral to the virtual CKD clinic • The CCG is exploring whether more granular relevant data can be extracted from the Barts records (that excludes specialist

clinics that are captured in the CCG data but not impacted by the project) to demonstrate the impact of the project

7c COPD – Post Bronchodilator Spirometry

Risk: Low

The target is to increase the number of COPD patients that have confirmation of diagnosis through Bronchodilator Spirometry within twelve months of diagnosis. Improved diagnosis should support identifying patients for appropriate ongoing management. Performance is measured against the cohort of patients diagnosed with COPD in 2015/16 and is expected to improve over the course of the year towards the target. The target has been achieved.

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8 Patients on the Palliative Care Register

Risk: Low

This indicator measures the number of patients registered on end of life care register, which means those identified early as approaching the end of life. Improved identification of patients at the end of life supports improved care planning and can support patients dying in their preferred place of death. January performance was 622 (above target). The CCG is focusing on the identification of patients through the use of the Electronic Frailty Index and through ensuring CHC fast track patients are added to the list. A CCG volunteer has visited practices and using Health Analytics to identify patients classified as severe frailty (score above .39) with the recommendation that all these patients are reviewed with the potential for them to be added to the end of life register. The CCG expects to meet this target in 2017/18.

9a Continuing Healthcare Eligibility Assessments (28 days)

Risk: High

This indicator is a national measure and a component of the CCG Quality Premium for 2017/18. The proportion of people who completed a community CHC assessment in 28 days was 86% in December against a target of 80%. There was one breach which was jointly attributed to between social worker delays and family reasons. A social worker has been recruited to support this process and this has had a positive impact on the figures.

• A dedicated social worker has been agreed to support the CHC process. • The CCG has agreed investment from winter funds to support additional capacity linked to the programme of work shifting

CHC assessments from the hospital to the community (see below). These posts were recruited in October. • NELFT processes are being reviewed to ensure that these do not impact on waits, for example notification of families.

Out of Hospital CHC Assessments (Quality Premium target):

NHS England introduced a target for 2017/18 measuring the proportion of people who have their CHC assessment completed out of hospital. The national target is that no more than 15% should be completed in hospital. This reflects the objective of ensuring that discharge arrangements should not be delayed by assessments of ongoing needs or responsibility for funding. In Q1 2017/18 the CCG performance was 76% of CHC assessments completed within hospital. In Q2 this figure improved to 55% and in Q3 performance was 43%.

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This is above the CCG plan but does not meet the NHSE requirements. The CCG has developed a plan that would ensure we meet the national target by February 2018 and this has been agreed with NHS England. Additional CHC assessment capacity for the community has been funded out of Operational Resilience and recruitment to the community CHC nursing team has been completed. A new process is being developed with LBWF and being implemented with Whipps Cross discharge team. The project should support the reduction in number of medically optimised patients at Whipps Cross. Whilst the CCG does not expect to meet the QP target for the full year 17/18 it does expect to be compliant by February 2018. Internal processes for weekly performance reporting have been established.

9b Personal Health Budgets

Risk: Low

The indicator measures the number of new people receiving a Personal Health Budget in Waltham Forest and reflects the CCG operating plan target of 150 by the end of the year. Performance in December was 55. The CCG is developing proposals for ensuring groups of patients have access to PHBs in 2017/18. A project to support children and adults with learning disabilities or autism to access “challenging behaviour support” is in the process of being developed and expected to have impact on the figures from January. The CCG expects to meet this target in 2017/18.

10 RTT incomplete pathway performance

Risk: Low

The CCG is currently meeting the national target with performance of 95% in November 2017. However, the reported CCG performance does not include figures for Barts Health as these are not being reported nationally. Figures reported directly from the trust show that WFCCG performance at Barts Health was 81% at the end of December. This is the equivalent to 3,119 patients waiting over 18 weeks and includes 24 patients with waits over 52 weeks. The Barts specialities the account for a significant proportion of long waits are Trauma and Orthopaedics, Ophthalmology and General Surgery. The focus of Barts Health in 2016/17 has been to improve the data quality of 18 week reporting, complete the legacy validation of 69,831 pathways, and develop an accurate 18 week Business As Usual (BAU) Patient Tracking List (PTL). The Trust trajectory assumes that 52 week waits are reduced to nil in all specialities apart from T&O and oral surgery by December 2017, with these specialities clearing 52 week waits by the end of March 2018. Barts have reported that they do not expect to meet the December deadline. Barts are planning to resume national reporting by March/April 2018. Barts expect to resume national reporting in April 2018.

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10a E-Referrals

Risk: Medium

In 2017/18 there is a national target to increase the use of the e-referral booking system so that 80% of first outpatient referrals are done via the e-referral system by the end of the year. A key element of this target is ensuring that there are available appointments for GP referrals. Performance is calculated as a proportion of all hospital outpatient activity. Performance in January was 51%. The indicator is assessed as high risk as the national target is 80%. WFCCG performance is above the London level. Barts needs to work on the directory of services to make appointments accessible and this is being managed as part of the outpatients work led by TST. Currently 86% of specialities are available for e-referral and 100% are planned to be available by the end of the year. Performance is variable between practices with some achieving the 80% target. Support is available for GPs if they cannot access services.

11a A&E 4hr all types performance at Whipps Cross

Risk: High

The CCG and Barts Health have developed an improvement plan that assumes that Whipps Cross achieve 93.19% (and Barts Health achieves 95%) by March 2018. The key elements of the plan focus on improved staffing in the emergency department, improved flow through the hospital, improved discharge, and engaging the “hearts and minds” of staff with the improvement plan. The CCG has put in place a number of demand management programmes to support performance in 2017/18 including investment in GP with specialist interest in paediatrics in the Urgent Care Centre and expansion of the Rapid Response Service to deliver IV antibiotics. The CCG has also invested in the Discharge to Assess programme to support discharges. Emergency admissions reduced by 4% in 2016/17 and have continued to fall in 2017/18. Whipps Cross performance for January was 88% against a trajectory of 90%. This was an improvement compared to the previous month and last year. The improvement has been linked to an increase in beds at Whipps Cross, the expansion of Ambulatory Care and the impact of the PERFORM programme that aims to increase the number of discharges. Performance remains volatile day-to-day in response to changes in staffing, bed pressures and hospital flow. The CCG and the wider system have agreed an updated improvement plan covering hospital and out of hospital actions. Key actions include the implementation of the SAFER patient discharge bundle, increasing the number of early discharges, improving the recruitment to medical and nursing posts, and supporting discharge from the hospital to community and social care for patients with ongoing care requirements. The plan was approved by the Performance and Quality Committee in July 2017 and is being monitored at the Urgent Care Working Group. The CCG has agreed a list of winter investment plans that includes enhancement of the UCC, improvements to streaming and extending the discharge to assess programme.

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11b Urgent Care Centre Utilisation

Risk: Low

This is a new target for 2017/18 and measures the proportion of patients that attend the Whipps Cross A&E and are seen and treated in the Urgent Care Centre. An increase of the proportion of patients treated in the UCC should support a reduction in attendances in the Emergency Department. In 2016/17 the performance was 30% and the CCG has set a target for 2017/18 of 33%. In order to support this target the CCG has invested in a GP with specialist interest in paediatrics in the UCC from June. A pathway for patients with suspected DVT to be assessed in the UCC has also been developed and implemented in June. The UCC is also starting to see mental health patients and work with the psychiatric liaison service. Performance in December was 41%, above the target of 33%. The UCC saw a significant increase in activity in December. The CCG is investigating whether this was the result of improved streaming and UCC capacity (supported by Winter funding) or whether there was an increase in primary care attendances. The CCG expects to meet this target in 2017/18.

12 Antibiotic prescribing in primary care

Risk: Low

This indicator aims to reduce inappropriate antibiotic prescribing for urinary tract infections in primary care. Evidence shows that the use of inappropriate antibiotics can result in relapsing infections. This indicator aims to increase the appropriate use of nitrofurantoin as 1st line choice for the empirical management of UTI and support a reduction in inappropriate prescribing of trimethoprim which is reported to have a significantly higher rate of non-susceptibility in ‘at risk’ groups. Data for October shows that the CCG is on target for both antibiotic targets. The CCG expects to meet this target in 2017/18.

13a Improvement in Whipps Cross A&E FFT response rate

Risk: Low

In 2017/18 the CCG is focusing on improving the response rate for the Friends and Family Test in A&E to ensure there is robust data for measurement and making improvements. In October the rate increased to 16%. Whipps Cross piloted a method of texting the survey to

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patients in October. Data was not available in November and this is expected to be linked to a change in provider for the surveys as Whipps Cross. The CCG expects to meet this target in 2017/18.

13b Pressure Ulcers at Whipps Cross

Risk: High

This is a new Scorecard indicator. The CCG is targeting a reduction in the number of serious (grade 3 or 4) pressure ulcers at Whipps Cross. In November there were nine reported pressure ulcers at WX (grade 3). The CCG continues to investigate incidents of pressure ulcers and is following up the results of a recent deep dive, including potential links to the Emergency Department and care homes. An observation of Ambulance handovers at Whipps indicates that there is further work to be done to safeguard against pressure ulcers within the Emergency Department. Peer review at Whipps Cross has shown good standards of SSKIN assessment. A pressure ulcer strategy task and finish group is being established to oversee this work.

14a General Practice FFT score

Risk: Medium

The CCG continues to target increased response rates and performance on the GP Friends and Family Test.

• The CCG did not meet this target in November due to the very large number of submissions from one practice (this data clearly covered a number of years).

• If this one submission is excluded then the CCG remains on track to meet the FFT target with YTD performance of 86%. • The indicator is rated medium risk due to the variation in performance and the lack of improvement in 2016/17. Practices that

are not submitting data are to be reviewed at the Primary Care Committee.

14b Patient Online Usage

Risk: Low

This indicator measures the proportion of the registered population who have received online login details, gone home and activated this so that they can view their patient record online, order prescription online or book GP appointments online. This target has been met for 2017/18.

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15a Delayed Transfers of Care

Risk: Medium

The target measures the number of patients that are classified as Delayed Transfers of Care (DTOC) at Whipps Cross as a proportion of their total bed base. The patient is classified as ready for transfer when a clinical decision has been made that the patient is ready, a multi-disciplinary team decision has made and the patient is safe to transfer. There was a significant improvement in performance (a reduction of approximately 50%) in 2016/17 in part as a result of daily system-wide phone calls implemented by the CCG and the Integrated Discharge Team. Performance has improved in the last three months and the target was met in November and December.

15b Medically Optimised

Risk: Medium

The target measures the number of medically optimised patients at Whipps Cross awaiting discharge. The figures are related to the DTOCs (above) but the classification is based on medical assessment. The CCG Out-of-Hospital Pathways programme of work will support a system approach to reducing the number of patient’s deemed medically optimised awaiting discharge on the Whipps Cross Hospital site. The target was met in December. Actions to improve performance include the expansion of discharge to assess and the implementation of a process of “discharge without prejudice” whereby patients awaiting funding assessments are discharged prior to the completion of the funding determination, with an agreement with the LBWF on the refunding of costs following the assessment. This process is currently being tested with the process being finalised by the end of November. Other actions include improving process for ordering equipment and addressing delays due to housing.

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Appendices Appendix A Waltham Forest CCG Business Grid

46

# Indicator Description Lead CDR

E

D

A

M

B

E

R

T

A

R

G

E

T

Aim Baseline Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

YTD or latest

month

performance

TrendAssessed level of risk

(high, medium or low)

1a Integrated Care - Emergency admissionsReduce emergency admissions to hospital for the

20% of people at highest risk of admission4878 4877-4229 4228 4878 340 342 398 335 376 363 365 393 434 3346 Low Risk

1bIntegrated Care - Emergency admissions from targeted

nursing homes

Reduce emergency admissions for people living in

nursing homes *RAG yr on yr based196 195-177 176 196 19 14 13 7 14 14 22 9 17 129 Low Risk

IAPT recovery rate (NHS Digital)People successfully completing a course of

treatment and classed as ‘in recovery’ 50.01% N/A 50% 47.85% 52.00% 53.13%

IAPT recovery rate (NELFT NHSE London return)People successfully completing a course of

treatment and classed as ‘in recovery’ 49.99%

50%-

50.99%50% 55.70% 53.85% 43.52% 47.74% 56.25% 58.90% 54.46% 57.67% 47.80% 50.96% 52.60% Low Risk

IAPT access rate (NELFT NHSE London return)Percentage of people with anxiety and depression

accessing IAPT services15.00%

15.01%-

16.79%16.80% 15.33% 0.86% 1.41% 1.42% 1.17% 1.29% 1.18% 1.38% 1.55% 0.97% 11.24% Medium Risk

IAPT access rate (NHS Digital)Percentage of people with anxiety and depression

accessing IAPT services15.00%

15.01%-

16.79%16.80% 15.35% 1.39% 8.83%

2c Early Intervention in Psychosis Percentage of people experiencing first episode of

psychosis treated within two weeks

49.99%50.00%-

65.99%66% 70.16% 100.00% 66.67% 100.00% 75.00% 100.00% 100.00% 100.00% 100.00% 83.33% 92.59% Low Risk

3 Childrens dietetics waiting time

Children referred to dietetics service seen within

two weeks in urgent cases and in 18 weeks in non-

urgent cases

KH TM 75.00%75.01%-

94.99%95% 79% 88.24% 90.00% 91.43% 95.83% 100.00% 100.00% 96.30% 96.43% 100.00% 96.43% Low Risk

4 Home births Percentage of births that happened at home KH TM 1.65%1.66%-

2.49%2.5% 1.65% 1.53% 1.57% 2.30% 1.83% 2.04% 2.11% 4.03% 3.35% 2.34% Medium Risk

5 Learning Disability - Health Checks

Number of people aged over 14 on the learning

disabilities register who have had an annual learning

disabilities health check

KH RG 52%52.01%-

54.99%55% 52.00% 1.79% 3.76% 6.23% 9.14% 13.75% 15.97% 21.69% 30.06% 33.82% 33.82% Medium Risk

6a Cancer - urgent GP referrals

Percentage of people with suspected cancer (who

receive an urgent GP referral) who see a consultant

within two weeks and, if required, receive first

treatment within 62 days

84.46%84.47%-

84.99%85% 84.46% 93.55% 88.46% 68.33% 88.90% 84.21% 88.64% 90.91% 86.00% 84.85% 84.69% Low Risk

6b Cervical cancer screening uptakeWomen aged 25 to 64 who receive screening

cervical for cancer within appropriate timeframe67.93%

67.94%-

70.99%71.00% 67.94% 67.70% 67.65% 67.70% 67.55% 67.59% 67.74% 68.00% 68.03% 67.90% 68.07% 67.95% 67.95% High Risk

7a Diabetes: Sructured Education Referrals (cumulative)Number of people referred to diabetes structured

education courseLS 1215 1216-1464 1465 1215 86 148 214 282 366 409 445 495

23rd Feb-

17495 High Risk

7b Renal - first outpatient attendances at Barts nephrologyNumber of first outpatient attendances at Barts

nephrology department for Waltham Forest patientsCE 30 29-22 21 30 per month 23 23 34 50 26 34 36 41 24 32 High Risk

7c COPD - post bronchodilator spirometry

People newly diagnosed with Chronic Obstructive

Pulmonary Disease (COPD) receiving post

bronchodilator spirometry test.

AO 69.62%69.63%-

74.62%74.62% 69.62% 70.75% 71.70% 73.27% 73.27% 73.58% 73.58% 74.84% 75.47% 75.94% 75.94% ACHIEVED

8 Patients registered as palliative care (cumulative)

Patients registered on end of life care register, which

means those identified early as approaching the end

of life

JR MS 490 491-534 535 490 494 484 484 490 499 494 524 627 625 622 622 Low Risk

9a. CHC eligibility assessments within 28 days Continuing Healthcare eligibility assessments carried

out within 28 days ZM 67%

67.01% -

79.99%80% 67% 25.00% 47.37% 25.00% 55.56% 84.62% 57.14% 81.82% 70.00% 85.71% 58.33% High Risk

9b. Personal Health Budgets (cumulative)Number of people with Personal Health Budgets

KH 52 53-149 150 150 35 35 38 38 46 46 51 53 55 55 Low Risk

10 RTT incomplete pathway performancePercentage of people still within the 18-week

treatment targetLB DK 91.99% N/A 92% 93.85% 93.82% 94.56% 94.59% 93.87% 93.39% 93.17% 93.43% 94.57% 93.08% 93.08% Low Risk

10a e-ReferralsPercentage of outpatient hospital activity booked via

online electronic referral booking systemCE 45.83%

45.84%-

79.99%80.00% 45.83% 46.21% 47.06% 45.71% 48.53% 47.60% 48.11% 48.19% 47.54% 42.23% 51.34% 47.33% High Risk

11a A&E 4hr all types performance at Whipps CrossPercentage of people attending Whipps Cross A&E

seen within 4 hours84.39%

84.4% -

94.99%95% 84.39% 81.4% 82.3% 86.9% 89.4% 85.0% 82.9% 83.8% 85.5% 81.4% 88.2% 84.7% High Risk

11bProportion of A&E attendances that are treated in urgent

care

Proportion of patients attending A&E departments

at Whipps Cross seen in the Whipps Cross Urgent

Care Centre

30%30.01%-

32.99%33% 30% 34.50% 31.50% 30.90% 32.60% 33.60% 33.00% 34.20% 36.00% 41.00% 41.00% Low Risk

12 Trimethoprim items to nitrofurantoin items ratio

Reduce trimpethoprim antibiotics being prescribed

and increase prescribing of nitrofurantonin

antibiotics shown as a ratio

AO RG 1.5451.544 -

1.3921.391 1.545 1.387 1.368 1.33 1.23 1.12 1.02 0.92 0.78 0.92 Low Risk

HD

Integrated Care

End of life care

Mental Health

Children

Maternity

SA

Learning disability

Cancer

Long term conditions

MSNA

Waltham Forest CCG - 2017/18 Performance & Quality Scorecard

GF

NA

KA

RG

2a

2b

3.75%

41.00% 54.00%

3.70%

Integrated commissioning

Planned care

Urgent care

Prescribing

Quality & Safety

EP KA

47

# Indicator Description Lead CDR

E

D

A

M

B

E

R

T

A

R

G

E

T

Aim Baseline Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

YTD or latest

month

performance

TrendAssessed level of risk

(high, medium or low)

Waltham Forest CCG - 2017/18 Performance & Quality Scorecard

13a Improvement in Whipps Cross A&E FFT response rate

Percentage of people attending Whipps Cross A&E

who completed the friends and family test

questionnaire

1.23%1.24%-

9.99%10.00% 1.23% 2.19% 2.55% 2.96% 7.56% 12.25% 6.79% 15.82%

NOT

AVAILABLE15.56% 8.19% Low Risk

13b Pressure ulcers at Whipps Cross (Grade 3 and 4)

Number of people admitted at Whipps Cross who

have the most severe two categories of pressure

sores

6 5 4 5.25 per month 5 10 3 4 4 7 1 9 2 2 4.70 High Risk

14a General Practice FFT score

Percentage of people completing the friends and

family test questionnaire at their GP practice who

would recommend their practice to others

SYM 83.36%83.37%-

84.99%85% 83.36% 88.90% 85.60% 88.72% 89.25% 82.92% 88.30% 87.82% 65.81% 83.90% 80.98% Medium Risk

14b Patient online usage

Percentage of people who have completed their

online setup to be able to view their patient records

online, order prescriptions online or book GP

appointments online

HN 10.87%10.88%-

19.99%20.00% 10.87% 17.71% 17.97% 18.45% 18.94% 19.18% 19.77% 19.81% 20.13% 20.00% 20.00% Low Risk

15a Delayed Transfer of Care (Whipps Cross)Daily average percentage of beds used by patients

who could be discharged at Whipps Cross Hospital 2.51% N/A 2.50% 1.06% 4.42% 3.93% 4.38% 3.25% 2.24% 2.82% 2.54% 1.93% 2.26% 1.77% 3.02% High Risk

15b Medically optimised (Whipps Cross)

Daily average number of patients at Whipps Cross

Hospital classed as 'medically optimised,' which

means their health condition is controlled as well as

possible and they could potentially receive

treatment elsewhere or return home.

27.35 27.35-24.99 25 27.35 30.67 24.43 28.59 17.23 26.16 22.33 30.97 25.30 23.00 27.03 25.31 Medium Risk

HD

ZM HD

Primary Care

Discharge efficiency

MS

AW

48

Page 1

Item 3.1b

Title of report Monthly Quality Report

From Anne Walker, Deputy Nurse Director of Quality - WFCCG

Purpose of report

The purpose of the report is to inform the Governing Body of the quality provided to the patients of Waltham Forest at its Provider Organisations, indicating by exception where quality does not meet agreed targets.

Summary of report

Whipps Cross Hospital

* Please note that the Barts Health NHS Trust data was not available at the time of reporting

Friends and Family Test (FFT) response rate in the Emergency Department (ED) achieved 15% response rate in October, part of this can be attributed to the SMS trial that took place for one week in October.

4 overdue serious incidents

FFT target of 95% of patients who would recommend the service has not been achieved.

0 grade 4 pressure ulcers reported in October

1 grade 3 pressure ulcer reported in October, this is a decrease of 6 compared to the previous month.

3 mixed sex accommodation breaches were reported in October.

71% of complaints were responding to within the agreed timeframe in October, this is a decrease of 21% compared to the September figures.

Barts Health are currently procuring a new patient experience provider. The iWantGreatCare contract ends on 30 November and the new provider will need to be in place by 1 December. The CCG is awaiting confirmation of who the new provider will be.

0 Never Events reported in October

North East London Foundation Trust (NELFT)

0 serious incidents (SIs) overdue.

0 cases of clostridium difficile and MRSA reported.

Safeguarding Children's Level 2 and Life Support training, 85% target not achieved

0 complaints reported as being open for more than 90 days and 100% of complaints were responded to within the agreed timeframe.

Staff turnover 10% target not achieved, reaching 13.9% in November.

49

Monthly Quality Report

Page 2

Care Home Care Quality Commission (CQC) reports

CQC published reports on 5 residential homes in November 2017 4 of which were rated good overall. Kestrel House was rated requires improvement overall.

Clinical Quality Review Meeting (CQRM) NELFT

Topics discussed at the NELFT CQRM include, NELFT quality improvement plan, learning from serious incidents, health and safety report, information governance report and the annual patient safety report.

Recommendations for Governing Boddy

The Committee members are requested to

1. Approve the report


With appropriate quality and governance in place patient safety and experience should be wholly assured. Failure to provide quality care leads to increased risk to patient safety and patient harm, poor patient experience and health outcomes.

Risk implications

Failure of the Waltham Forest CCG not to incorporate the recommendations might lead to

• Patients not receiving expected quality of care which would lead to potential harm.

• Poor patient experience

• Inhibit WFCCG from achieving its corporate objectives.

• Reputational risk.


Funding services that are not high quality do not meet the needs of the patient is poor value for money and may result in additional funding pressures.

Equality analysis

The WFCCG is committed to fulfilling its obligations under the Equality Act 2010 and to ensure services commissioned by the WFCCG are non-discriminatory on the grounds of any protected characteristics.

The WFCCG will work with providers, service users and communities of interest to ensure that any issues relating to equality of service within this report are identified and addressed


Performance and Quality Committee

50

Quality Report

Quality Dashboard and Exception Report

January 2018

51

Executive Summary

January 2018

Quality Report

2

Whipps Cross Hospital * Please note that the Barts Health NHS Trust data was not available at the time of reportingFriends and Family Test (FFT) response rate in the Emergency Department (ED) achieved 15% response rate in October, part of this can be attributed to the SMS trial that took place for one week in October. 4 overdue serious incidents FFT target of 95% of patients who would recommend the service has not been achieved. 0 grade 4 pressure ulcer reported in October 1 grade 3 pressure ulcer reported in October, this is a decrease of 6 compared to the previous month. 3 mixed sex accommodation breaches were reported in October.71% of complaints were responding to within the agreed timeframe in October, this is a decrease of 21% compared to the September figures. Barts Health are currently procuring a new patient experience provider. The iWantGreatCare contract ends on 30 November and the new provider will need to be in place by 1 December. The CCG is awaiting confirmation of who the new provider will be. 0 Never Events reported in October

North East London Foundation Trust (NELFT)0 serious incidents (SIs) overdue.0 cases of clostridium difficile and MRSA reported. Safeguarding Children's Level 2 and Life Support training, 85% target not achieved0 complaints reported as being open for more than 90 days and 100% of complaints were responded to within the agreed timeframe. Staff turnover 10% target not achieved, reaching 13.9% in November.

Care Home Care Quality Commission (CQC) reportsCQC published reports on 5 residential homes in November 2017 4 of which were rated good overall. Kestrel House was rated requires improvement overall.

Clinical Quality Review Meeting (CQRM) NELFT Topics discussed at the NELFT CQRM include, NELFT quality improvement plan, learning from serious incidents, health and safety report, information governance report and the annual patient safety report.

52

Quality Dashboard Whipps Cross

January 2018Quality Report

3

* Trust wide

Domain Standard Trend Target Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Serious incidents reported by Whipps Cross 0 3 3 7 5 10 5 4 6

Serious incidents overdue 60 days STEIS reporting date 0 1 2 2 2 2 3 4 4

Never Events 0 1 0 0 0 0 1 0 0

Falls resulting in harm <=0 3 3 1 0 1 0 2

Pressure Ulcers - Grade 3 0 5 9 2 4 4 7 1

Pressure Ulcers - Grade 4 0 0 1 1 0 0 0 0

VTE Risk Assessments 95% 90% 90% 90% 98% 98% 98% 99%

C.Diff 2 3 2 2 4 2 1 1

Medication Errors: Potential SIs <=3 N/A N/A 0 0 0 1 0

MRSA 0 0 0 1 1 1 0 0

Supervision N/A N/A N/A N/A N/A N/A N/A

Safeguarding Adults Level 2 85% N/A 78% 84.84% N/A N/A N/A N/A

Mandatory and statutory Training - All 90% 89% 89% 89% 91% 91% 91% 91%

Sickness Absence Rate * <=3% 3.24% 3.75% 3.75% 3.82% 3.83% N/A N/A

Turnover rate * <=14% 13.60% 13.50% 12% 12.30% 12.30% 11.80% 12%

FFT respondents that would recommend - Inpatients 95% 92% 91% 92% 91% 92% 91% 93%

FFT respondents that would recommend - A&E 95% 87% 85% 92% 93% 91% 89% 91%

FFT respondents that would recommend - Maternity 95% 90% 94% 85% 92% 93% 91% 89%

FFT respondents that would recommend - Outpatients 95% 90% 92% 91% 93% 91% 93% 92%

FFT response rate - Inpatients 30% 26% 33% 40% 37% 42% 31% 40%

FFT response rate - A&E 20% 2% 3% 3% 8% 12% 7% 15%

FFT response rate - Maternity 15% 64% 25% 38% N/A N/A 12% 15%

NHS Staff Survey Results

Mixed Sex Accommodation Breaches 0 1 8 7 17 13 7 3

Complaints - numbers received 65 48 42 43 39 39 52 56

Complaints responded to within time scale 80% 66% 52% 58% 69% 49% 50% 71%

Writeen Complaints rate <=48.5 N/A N/A 60.7 53.4 52.8 N/A 72.2

Duty of Candour 100% 100% 100% 100% 100% 100% 100% N/A

Sepsis 6 antibiotic administration (60mins) >=90% N/A N/A N/A N/A N/A N/A 38.50%

SHMI 2016/17 100 101Effec

tiven

N/A

Safe

Resp

onsiv

e Ca

ring

101 100

Well

-led

53

Quality Dashboard – NELFT

January 2018

Quality Report

4

* Is for NELFT wide data ** Is for NELFT wide community mental health services

Domain Standard Trend Target Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Number of Serious Incidents since last report N/A 2 5 8 2 5 3 5 1

Number of SI investigation reports overdue (not received in the agreed time frame) 0 0 0 0 0 0 0 2 0

Pressure Ulcers - Grade 3 and above * N/A N/A N/A N/A N/A N/A N/A N/A

VTE Risk Assessments TBC N/A N/A N/A N/A N/A N/A N/A N/A

MRSA 0 0 0 0 0 0 0 0 0

C.Diff 0 0 0 0 0 0 0 0 0

Number of medication incidents N/A 6 6 8 6 3 12 4 8

Safeguarding Adults level 1 training 85% 87% 91% 92% 92% 91% 87% 90% 91%

Safeguarding Adults level 2 training 85% 88% 86% 87% 84% 84% 84% 87% 90%

Safeguarding Childrens level 1 training 85% 87% 90% 91% 93% 93% 91% 92% 91%



Infection Prevention and Control 85% 87% 88% 86% 86% 85% 84% 87% 87%

Life Support training 85% 85% 83% 84% 86% 85% 85% 83% 84%

% Staff Sickness 4% 3.02% 3.22% 3.61% 3.03% 3.18% 3.53% 4.32% N/A

% Staff Turnover (Rolling 12 months) 10% 15.40% 14.80% 15.10% 13.80% 13.70% 13.70% 13.70% 13.90%

FFT % that would recommend - Community Health * 96% 96% 96% 94% 95% 95% 97% 95% N/A

FFT % that would recommend - Mental Health * 89% 90% 89% 86% 87% 87% 94% 86% N/A

FFT number of responses - Community Health * N/A 760 961 855 833 872 848 661 N/A

FFT number of responses - Mental Health * N/A 286 397 353 439 417 392 415 N/A

Complaints - numbers received N/A 8 5 6 5 7 3 3 2

Complaints responded to within time scale 95% 100% 78% 100% 100% 100% 100% 100% 100%

Complaints - numbers open more than 90 days 0 0 1 1 0 0 0 0 0

Duty of Candour 100% N/A N/A N/A N/A N/A N/A N/A N/A

Effe

cti

CIDS Referral to Treatment Information

Data Completeness ** 50% 100% 100% 100% 100% 100% 100% 100% 100%

Well

Led

Safe

Ca

ring

Resp

onsiv

e

54

Exception Report – Whipps CrossIndicator Further Intelligence Action taken by CCG

Whipps CrossSerious Incidents (SI) overdue – 4 (November)

• Whipps Cross acknowledge capacity and capability of governance team to deliver timely closure.

• Medical Director leading improvement plan.• Trajectory for compliance has been produced• Plan for training in place for February 2018

• CPN (Contract Performance Notice) has been issued. Compliance with 90% of all reports closed within STEIS 60 day deadline will be delivered by end Quarter 1 2017/18, this was reviewed at the CQROA in August.

• This has not been achieved and has been added to the Service Delivery Improvement Plan (SDIP).

Emergency Department FFT response rate – 15% (October)

• 15% response rate was achieved in October, although non complaint with 20% trust target it is above the 10% CCG target on our dashboard.

• Patient Experience solution is out to tender, the new provider should be in place by 1 December 2017.

• Member of the WF CCG quality team attending compassionate care and patient experience meetings.

• ED FFT response rate indicator is on the WF CCG scorecard.

• Remedial Action Plan (RAP) closed due to vast improvement in response rates.

• Trial of texting the FFT question look place during the week commencing 23 October 2017

• CCG assessing risk relating to new solutions provider and will escalate if required.

Quality Report

January 2018 5

3% 8% 12% 7% 15%0%5%

10%15%20%

ED FFT response rate

2 2 3 4 40

5

July August Sept Oct Nov

Overdue Serious Incidents

55

Exception Report – Whipps Cross

January 2018

Quality Report

6

• Indicator • Further Intelligence • Action taken by CCG• Whipps Cross

• Complaints – 71% (October) • Complaints target of 80% of complaints responded to within 25 working days has not been achieved. Increased level of compliance in October achieving 71% compared to September where 50% was achieved.

• Contract Performance Notice issued.• The CPN was reviewed at the August CQROA,

Whipps Cross are to identify what resources are required to support requisite improvement.

• Whipps Cross have not identified the resource required, it has been closed as an action at the CQRM and Whipps Cross are to inform commissioners if they require further support.

• Non-achievement of CPN has been added to the SDIP (Service Delivery Improvement Plan).

• Thematic analysis of the increase in reportable complaints to be presented at the CQROA.

• Basic Life Support Training – 87% (September)

•

• Where it is marked 0 on the graph, CCG does not have the data

• Support requested from site leadership operational model (LOM) senior management teams to address.

• Use of enhanced advertising to improve attendance.

• Drop in sessions being held to improve access.

• Reviewed at CQROA.• Members of the CCG quality team attending the

compassionate care and patient experience meetings.

0%

82%

0%

82% 87%

0%20%40%60%80%

100%

Basic Life Support Training

58%69%

49% 50%71%

0%20%40%60%80%

Complaints

56


January 2018

Quality Report

7

Indicator Further Intelligence Action taken by CCG

Whipps CrossSafeguarding Adults Level 2 – 87% (September)

• Where it is marked 0 on the graph, CCG does not have the data

Non compliant with the trust target of 90%, although are complaint with the contractual target of 85%.

• Review at the monthly CQROA and KPI meetings.

• Remedial action plan received with an objective to be compliant by the end of quarter two 2017/18.

Grade 3 Pressure Ulcers – 1 (October) Target of 0 not been achieved during the financial year 2016.17 and 2017.18 thus far.

• Review at the monthly CQROA. • CCG established joint working with NELFT and

Whipps Cross and local authority through the pressure care task and finish group.

• Task and finish group established.• Members of the CCG quality team attending

the compassionate care and patient experience meetings.

Mixed Sex Accommodation Breaches – 3 (October)

Non compliant since January 2017. • Review at the monthly CQROA. • Visual observation during quality assurance

visits and discussion with patients and staff.• Requested CCG review of the Critical Care

Policy, commissioners are waiting to receive.

78% 85% 0 88% 87%0%

50%100%

Safeguarding Adults Level 2

2 4 47

102468

Grade 3 pressure ulcers

717

13 7 305

101520

Mixed Sex Accomodation Breaches

57

Exception Report - NELFT

January 2018

Quality Report

8

Exception Report – Whipps Cross Indicator Further Intelligence Action taken by CCG

Whipps CrossInfection Control Level 1 and 2 clinical staff – 77% (August)

• Where it is marked 0 on the graph, CCG do not have the data

• Non compliant with 90% target.

• Review at the monthly CQROA and KPI meetings.

Inpatients FFT % to recommend – 93% (October)

• Non achievement of trust target of 95%. • Member of quality team to attend the compassionate care and patient experience meetings

Safeguarding Children Level 3 training -88% (September)

• Where it is marked 0 on the graph, CCG do not have the data

• Non compliance with 90% target

• Review at CQROA meetings.

79%0

79% 77%

0%

50%

100%

April May June July August

Infection Control Training

88% 87%83%

88%

80%82%84%86%88%90%

Safeguarding Children Level 3

92% 91% 92% 91% 93%90%92%94%

Inpatient FFT

58

9

Indicator Further Intelligence Action taken by CCG

Whipps CrossED % to recommend – 91% (October) • Non compliant with trust target of 95%. • Member of quality team to attend the

compassionate care and patient experience meetings

• At the Barts Health KPI meeting the 95% target was discussed as this is felt to be an extremely challenging target. BH will review this.

Maternity % to recommend – 89% (October)

• Non compliant with trust target of 95%. • Member of quality team to attend the compassionate care and patient experience meetings


Outpatients % to recommend – 92% (October)

• Non compliant with the trust target of 95%. • Member of quality team to attend the compassionate care and patient experience meetings



Quality Report

January 2018

92% 93%91% 89% 91%

86%88%90%92%94%

ED FFT

85% 92% 93% 91% 89%80%85%90%95%

Maternity FFT

91%93%

91%93%

92%90%91%92%93%94%

Outpatient FFT

59

10

Exception Report - NELFTIndicator Further Intelligence Action taken by CCG

NELFTStaff Turnover –13.90% (November) The 10% target has not been achieved. Review at the monthly CQRM.

Safeguarding Children Level 2 – 79.60% (November)

Non compliant with 85% target since September 2017

Review at monthly CQRM.

Quality Report

January 2018

13.90%13.70% 13.70% 13.70%

13.90%

14%14%14%14%14%

Staff Turnover

87.6% 87.3%83.7% 80.80%79.60%

75.0%80.0%85.0%90.0%

Safeguarding Children Level 2

60

11

Exception Report - NELFTIndicator Further Intelligence Action taken by CCG

NELFTLife Support Training – 83% (November) Non compliant with 85% target since October

2017.Review at monthly CQRM.

Community Health FFT % to recommend – 95% (October)

96% target for percentage of patients to recommend the service not achieved.

Review at monthly CQRM.

Mental Health FFT % to recommend –86% (October)

Achieved 86% in October against a 89% target. Review at monthly CQRM.

Quality Report

January 2018

94% 95% 95%97%

95%92%94%96%98%

Community FFT % to recommend

86% 87% 87%94%

86%80%85%90%95%

Mental Health FFT % to recommend

86% 85% 85% 83% 83%80%82%84%86%88%

Life Support Training

61

Care Homes

During November 2017 CQC published reports on 5 residential homes. The table below shows the name of the homes, which locality they are in and their rating against the 5 CQC domains of care.

January 2018

Quality Report

12

Home Kestrel HouseResidential Mental Health Leytonstone

Carmen Lodge Residential Older PeopleLeytonstone

Homewards Ltd –20 Leonard RoadResidential Learning Disabilities Chingford

Outlook care –Summit road Residential Learning Disabilities Walthamstow

Ashbridge Lodge Residential Care Home Residential Learning Disabilities Leytonstone

Effective

Safe

Well-led

Caring

Responsive

Overall

Outstanding

Good

Requires improvement

Inadequate

Key

62

Clinical Quality Review Meeting Update NELFT – November 2017Item Update

NELFT Quality Improvement Plan • The CQC improvement team gave a presentation which described the journey of the project, the work that NELFT has achieved and gives insight a flavour of the mock inspection programme. This supported the requisite plans to ensure quality and compliance with the fundamental standards of care regulations.

• NELFT await 3 more core service reports which will be published on the CQC website in January.• Overall it is felt that there have been significant improvements across the services.

Organisational Data Quality Report • 1 red risk for turnover – however the vacancy rate is continuing to improve.• 4 amber risks related to: Safeguarding children level 2 at 81%, equates to 106 staff – aim to be compliant by end

Jan 2018; 2 related to mandatory training just below target, for Life Support and Fire; Completion of appraisals at 84.5%.

Learning – Serious Incidents, Serious Case Reviews, Domestic Homicide Reviews. Duty of Candour, Coroners (Complaints included)

• Themes across the investigations remains similar relating to areas below;• Recording next of kin/carers assessments, Clinical Risk Assessments, Working with GPs, Children and young

people’s evidence of learning• Kent and Essex there have been a number of unfortunate suicides of young people. • There had been peaks in unexpected deaths and suicides but these were evening out.• The Trust demonstrated learning from complaints including feedback and learning from coroners inquests.

Health and Safety Report • A legal update around manslaughter; Work on policies – making sure they are in date; Priorities include ligature risk assessments; Medical devices project shows excellent improvements on how the Trust are managing the procurement, ordering and training of medical devices; Constant review of the CAMHS system; Security management, proactivity and positivity with assisting with violence and aggression.

Information Governance Report • Quarterly update on information governance (IG) compliance demonstrating the progress towards maintaining level 2 and also maintaining compliance with version 14.1 of the IG toolkit.

• There have been no major IG breaches • General data protection regulations (GDPR) 12 recommendations have been reviewed and will go to the Board

to ensure compliance with the plans and actions by May 2018.

Annual Patient Survey • There were 2554 hours of individual involvement activities.• 112 people were involved which is an increase of 28 this year.• Engaging more with young people. • Received positive feedback from the CQC on patient experience.• As a Trust there are lots of activities and these are all paid activities. This is because the Trust value the

people who are involved.

Reports presented as part of Forward Planner

• Quality Account• Workforce Development Report

13Quality Report

January 201863

Purpose of report

To provide an update to the Governing Body covering the financial position of the CCG as at the end of

January 2018.

Changes/additions/amendments to paper as a result of discussions held at previous Committee

Not applicable.

Recommendations

The Governing Body is asked to approve this report.


None

Risk implications

There are financial risks inherent within the CCG’s 2017/18 QIPP programme, acute contract performance, continuing healthcare budgets and prescribing budget associated with national increases across a number of low stock medicines.


As a result of the information available to date the CCG is now projected to deliver an in year deficit of £1.5 million for 2017/18 against the plan of £0.3 million which is a deterioration of £1.7 million since M9. The CCG is reporting that we will maintain its running costs within the cap set by the Department of Health.

Equality analysis

Not relevant for this report.


Income and expenditure is reported from the CCG ledger and activity from provider SLAM (Service Level Agreement monitoring) returns held on the NELIE (North East London Information Exchange) database.


The Finance and QIPP Committee receives a more detailed report covering financial performance.

Item 4.1

Title of report Finance Report

From Henry Black, CFO – East London Health and Care Partnership (ELH&CP)

Author Ian Clay, Deputy CFO - WFCCG

64

Finance Report

Update regarding the financial position of the CCG as at the end of January 2018.

65

Finance Report

Page ii

Contents 1 Introduction 1

2 CCG summary income and expenditure position 1

2.1 Key headlines for M10 2

3 Commissioning expenditure 2

3.1 Barts Health contract 4

3.2 Associate acute contracts 5

3.3 Non Acute 6

3.4 Prescribing 6

4 Other financial risks and mitigations 6

5 QIPP 7

6 Balance sheet, cash management and PSPP 8

7 Conclusion and recommendation 8

Appendix A Detailed income and expenditure position 9

Appendix B Detailed QIPP performance 10

Appendix C Statement of financial position (balance sheet) 11

66

Finance Report

Page 1

1 Introduction The purpose of this report is to update the Governing Body on the financial position as at the end of January (Month 10) and provide projections of income and expenditure to year end. The report goes on to describe any key variances to the commissioning budget and identifies potential further financial risks and mitigating actions.

The Governing Body is asked to note that CCG’s have been instructed by NHSE to move to reporting in year surplus rather than total surplus within our reporting in order to be consistent with provider reporting. This requires that we exclude the return of the prior year surplus from our headline reporting and changes our planning surplus for 2017/18 to £0.27 million. This represents the in year movement from our 2016/17 outturn of £8.76 million and the 2017/18 opening plan of £9.03 million. At month 7, the CCG agreed to increase its in year planned surplus to £0.37 million to help partially offset a deterioration within the BHR CCGs.

Financial pressures have meant that at month 10 we reverted to the original control total of £0.27 million and in addition are now reporting an in year deficit of £1.46 million. This follows discussions with NHSE regarding the treatment of pressures on non-stock medicines where the full overspend has been included in the Month 10 forecast. However, it is expected that this will revert to plan at Month 12 when the currently uncommitted non-recurrent headroom of £1.7m is released. It should be noted that there remain significant risks to the achievement of this position which will be outlined later within the report.

2 CCG summary income and expenditure position A detailed budget position is attached at Appendix A and a summary position is shown in the following table:

Annual Budget

Year to Date Forecast Outturn M10

(surplus)/deficit (surplus)/deficit £’000 £’000 £’000

Barts Health 136,485 4,005 4,806

Other Acute 66,370 1,368 1,641

Mental Health 34,249 26 421

Other Non-Acute 62,999 463 (33)

Prescribing 34,986 (107) (128)

Delegated Primary Care 38,753 (1,063) 0

Corporate 10,198 (46) (55)

Sub-Total 384,040 4,646 6,652

CCG Reserves 5,265 (4,646) (5,189)

TOTAL EXPENDITURE 395,902 0 0

TOTAL INCOME 396,172 0 0

NET CCG POSITION (270) 0 1,463

67

Finance Report

Page 2

2.1 Key Headlines for M10 to note are:

• The CCG is reporting breakeven against our plan year to date (YTD) and is now forecasting to deliver a deficit of £1.46 million at year end after the application of all reserves and excluding the impact of the return of prior year surplus. At month 9 we had forecast to deliver a control total surplus of £0.37 million which generated a small contribution to offsetting financial pressures within the BHR health economy.

• The deterioration in the forecast position in M10 reflects national tariff pressures on non-stock medicines. The CCG expects an improvement at M12 when the non-recurrent headroom of £1.7 million is released.

• In line with planning guidance for 2017/18 at M10 there have been no commitments made against the £1.7 million non-recurrent headroom reserve (0.5 percent). We are investing the other 0.5 percent of headroom reserve non-recurrently during 2017/18.

• Barts have submitted SLAM data for M9 and based on freeze data for April to November and December flex data we are now projecting a £4.8 million deficit against plan at year end. This is a deterioration of £1.1 million over the position reported last month and will be covered later in the report.

• Based on M9 SLAM data submitted by other NHS and independent sector providers we are reporting a projected £1.6 million year end risk reflecting material variances at a number of Trusts. Further details are provided within the report.

• We are seeing a significant increase in the flow of patients to mental health services outside of North East London. This has resulted in a £0.3 million projected pressure at M10.

• Projected performance against our £14.2 million 2017/18 QIPP plan is reported within Appendix B. At M10 we are now projecting that savings of £13.5 million will be achieved or 95 percent of plan.

• We have received actual prescribing data up to November 2017 and have used this to extrapolate 2017/18 costs up to M10 on the basis of the average daily prescribing costs over the last 6 months which results in a small surplus year to date against the QIPP adjusted plan.

• Performance against the delegated primary care budget is shown separately within Appendix A. We are projecting a breakeven position against the £38.8 million budget.

3 Commissioning expenditure At month 10 the CCG is reporting a £4.6 million deficit position against commissioning budgets and a projected deficit of £6.7 million at year end. This deficit is covered by full application of the contingency and all other reserves.

The following graphs show changes in activity over the period from April 2016 to December 2017 for accident and emergency attendances, outpatient first attendances and births broken down by activity at Barts and all other providers along with the total.

68

Finance Report

Page 3

Attendances at accident and emergency departments have been increasing slightly over the same 21 month period.

1000

3000

5000

7000

9000

A&E Barts and Associates

Barts Grand total AssociatesLinear (Barts) Linear (Grand total) Linear (Associates)

010002000300040005000600070008000

FA Outpatient GP referral activity - Barts & Associates

Barts Grand total Associates

Linear (Barts) Linear (Grand total) Linear (Associates)

050

100150200250300350400450

Deliveries

Barts Grand total AssociatesLinear (Barts) Linear (Grand total) Linear (Associates)

69

Finance Report

Page 4

Total outpatient first attendance data recorded on the SUS system can be used as a proxy for GP referrals and the graph again shows that activity has been relatively flat over this 21 month period although there has been a spike in October which follows a similar pattern to that seen in 2016/17.

Birth numbers are subject to monthly fluctuations however overall numbers have been relatively stable over the 21 month period from April 2016.

Key commissioning variances and projected risks are as follows:

3.1 Barts Health contract • Barts have submitted SLAM data for M9 and the level of uncoded activity has continued to reduce.

Based on data, we are now projecting a £4.8 million deficit against plan at year end which is a further deterioration of £1.1 million from last month’s forecast. A summary showing all of the adjustments made to the headline M9 claim extrapolated for the full year is contained within the following table:

• The table details the value of the adjustments which have been made reflecting a risk assessment of the challenges which have been made to the Trust and the negotiations around reaching

M10 Reporting Upside Base Case Downside FOT M9 Change£'000 £'000 £'000 £'000 £'000

Extrapolated FOT from M9 SLAM 150,545 150,545 150,545 149,579 966

Readmissions Penalty (at plan) (1,756) (1,756) (1,756) (1,756) 0Emergency Threshold (1,639) (1,490) (1,341) (1,359) (131)Impact of Productivity Metrics (890) (809) (728) (893) 84Penalties (105) (95) (86) (100) 5Counting and Coding (1,137) (989) (841) (939) (50)Agreed Automated Claims (397) (361) (325) (288) (73)Patient Transport (517) (517) (517) (450) (67)Projected Claims and Adjustments (6,208) (5,817) (5,285) (5,575) (242)

Sub-Total 137,896 138,712 139,667 138,219 492

CQUIN @ 74 percent 1,935 1,946 1,959 1,940 6

CQUIN STP 0.5 percent 633 633 633 0 633

Estimated Total Contract Claim 140,463 141,291 142,259 140,159 1,131Source of FundsContract Value 136,485 136,485 136,485 136,485 0Total Source of Funds 136,485 136,485 136,485 136,485 0

Total Forecast Risk 3,978 4,806 5,774 3,674 1,131

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settlement on Q1 and Q2 claims. As can be seen from the table, there are both upside and downside risks associated with the above projection and the scale of the range at M10 is £1.8 million. The CCGs and Trust have closed all disputes related to Q1 except for two – Newham University Hospital maternity and high cost drugs – worth £1.3 million across the contract. Escalation to lead Chief Officers has failed to resolve these issues which may now require mediation. The CCGs and Barts Chief Officers have agreed to work towards a full year negotiated settlement over the next few weeks.

• M8 freeze data has been supplied and continues to show a reduction in elective pathways during the period up until November which was to be expected as a result of the cyber-attack earlier in the year. The Trust believes this will be recovered later in the year with a resultant increase in costs although this would, in part be dependent upon bed availability over the winter period. December’s flex data shows no increase in elective activity and the extrapolated total claim reported based on M9 SLAM data remains unchanged from M8.

• The M9 claim includes a number of significant variances against plan that when extrapolated and subsequently adjusted to reflect the potential outcome of challenges result in the projected deficit against plan detailed above. These are as follows:

o £5.4 million adjusted claim relating to non-electives ordinary, short stay and same day admissions which represents a 14.2% projected variance against plan. Analysis undertaken indicates that £1.8 million relates to activity while £3.6 million is price related and has been formally challenged with the trust. The trust has now adjusted their claim to reflect the correct local tariff for ambulatory care activity at Whipps Cross Hospital although the activity is still being recorded as an emergency admission. In addition, a jointly commissioned review of non-elective readmissions has identified a significant number of cases whereby activity has been incorrectly attributed as an emergency admission such as regular renal day attenders. Corrective action is being discussed with the trust regarding 2017/18 claims and how this affects activity planning for 2018/19.

o £1.3 million adjusted claim relating to accident and emergency. In the main, this reflects a delay in transferring minor injury activity into the urgent care centre in line with our plan. In addition we are seeing a year on year increase in the average tariff claim from the Trust which is being investigated through an independent review process.

3.2 Associate acute contracts Based on M9 SLAM data received from other providers we are projecting a full year risk of £1.6 million year which is a deterioration of £0.4 million over the position reported last month. Reasons for this movement are as follows:

• £0.1 million additional costs projected across the portfolio of non NHS contracts associated with additional elective activity undertaken.

• £0.3 million additional costs projected on the urgent care centre contract related to non-recurrent set up costs negotiated with the provider.

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3.3 Non Acute • We are currently projecting a £1.1 million risk across our adult and children’s continuing care

budgets based on the volume and cost of clients currently within the system. Work is ongoing with the CHC contracting team to understand this risk but we are seeing an increased volume of very high cost packages of care. The CCG will be directly managing this function from April 2018 with a view to delivering both operational and efficiency improvements across the CHC function.

• We are projecting a financial pressure of £0.3 million associated with increased flows of patients to mental health services outside of North East London.

• These risks are currently being offset by investment slippage across a range of community services contracts of £0.4 million and underperformance of £0.5 million across a number of cost and volume contracts.

3.4 Prescribing • We are projecting a £0.1 million surplus at M10 against the total prescribing budget based on

extrapolating actual prescribing data covering the 8 month period from April 2017 to November 2017 for a full year and then adjusting for the delivery of phased QIPP savings of £1.0 million. This position includes the impact associated with the very high cost of some anti-psychotic drugs due to the unavailability of the usual generic options which is a national and has been recognised by NHSE as requiring relaxation in in year business rules as covered within the risks and mitigations outlined below.

4 Other financial risks and mitigations Other financial risks faced by the CCG and mitigations are:

• The 2017/18 budget assumes successful delivery of the £14.2 million QIPP programme and the

latest risk assessment of the overall programme will be provided later in the report.

• At M10 the £1.7 million contingency reserve has been fully applied in full within our projected outturn so no further mitigation is available to cover additional risks.

• In line with business rules the CCG is holding non recurrent headroom of £1.7 million. We expect to release this at M12 to offset the national drug tariff pressures covered under prescribing.

• As at M10 the acute risk reserve totals £1.8 million and this has been fully applied to offset risks within our commissioning budgets.

• The CCG is currently in negotiation with NHS Property Services around the level of invoicing being received in relation to property voids within Waltham Forest which are significantly higher than our plan. Based on progress made to date our total risk has reduced to £0.4 million from £0.9 million reported last month.

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• There is currently a national issue regarding the very high cost of some anti-psychotic drugs due to the unavailability of the usual generic options. Based on currently available data the impact for WFCCG has now been estimated to be £1.4 million. In addition, we are expecting to receive income from NHSE of £0.3 million associated with in year changes to how the benefits of category M drug tariff adjustments have been distributed. NHSE have confirmed that the validated impact from these 2 changes will be excluded when monitoring CCG’s adherence to 2017/18 control totals.

• The following table shows the level of retained reserves which are available to manage in year risk. The table shows that we now hold no unapplied reserves to mitigate further deterioration in our position.

5 QIPP Appendix B shows the latest detailed risk assessment of the CCG’s £14.2 million QIPP plan which underpins our 2017/18 budget along with a projection of the level of QIPP which will be achieved at year end. The risk assessment is summarised in the following table.

Plan Value £m

Current Assessment

Previous Assessment

Red 0.7 5% 6%

Amber 6.5 46% 73%

Green 7.0 49% 21%

Total 14.2 100% 100%

We are currently projecting to achieve savings of £13.5 million which represents slippage of £0.6 million against plan. The assessment has improved since last month reflecting the net impact from a further delay in implementing the revised pathway for undertaking minor injury assessment and treatment within

FOT M10 M10Applied Unapplied

£'000 £'000

Surplus/(Deficit) before application of reserves (6,652)

Non Recurrent Headroom 0 1,733Contingency 1,733 0Balance Sheet Review 1,452 0Acute Reserve 1,844 0Specific Investments 160 0

(1,463) 1,733

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the Urgent Care Centre and additional income secured as a result of the national GP business rates review exercise.

NHSE recognise the importance of QIPP for both in year financial performance and to the development of robust 2018/19 finance and capacity plans. As was reported previously, NHSE commissioned work to review 2018/19 QIPP plans and the results were incorporated within the initial draft 2018/19 budget plan submitted to the Committee.

NHSE have now commissioned a further phase of this work which will be focused on providing support to CCGs regarding specific elements of their 2018/19 plans where additional capacity would prove helpful. Requests for support are invited for submission by 22nd February covering the following areas of support:

• Clinical expertise • Benchmarking and analytics support • Financial analysis and modelling • PMO/Project management and delivery expertise

The CCG will be submitting a proposal to access additional external capacity covering support with development of detailed plans and broader PMO support for the overall 2018/19 QIPP plan. In addition, the ELHCP are considering how to use further support across key system-wide QIPP programmes.

6 Balance sheet, cash management and performance against public sector payment policy (PSPP)

Details of the CCG’s closing statement of financial performance or balance sheet along with comparable figures at M9 are shown within Appendix C.

The CCG had drawn down cash totalling £301.6 million at the end of M10 from the government banking service and had cash holdings of £0.4 million as at the end of January which is approximately 1.6 percent of the cash drawn down in the month. Cash management rules require that we minimise the level of cash held at month end to at no more than 1.25 percent and we have therefore failed to meet this measure for January.

The CCG, in common with all public sector bodies, is mandated to pay suppliers within 30 days from submission of a valid invoice. As at the end of January the CCG’s cumulative performance was measured at 99.5 percent (based on the value of invoices paid) and 95.9 percent (based on volume of invoices paid).

7 Conclusion and recommendation The Governing Body is asked to approve this report.

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Appendices A. Detailed income and expenditure position

Budget Actual Variance Budget Forecast Variance£'000 £'000 £'000 £'000 £'000 £'000

Confirmed (329,874) (329,874) 0 (396,172) (396,172) 0

Acute SLA's 157,840 162,306 4,466 189,408 194,796 5,388SLA Exclusions and Other Acute 11,206 12,113 907 13,447 14,506 1,059

Acute & Integrated Care Total 169,046 174,419 5,373 202,855 209,302 6,447

Mental Health 29,224 29,250 26 34,333 34,753 421Learning Disabilities 5,048 5,111 64 6,057 6,134 76Continuing Care 12,003 12,908 905 14,465 15,489 1,024Community Services 28,441 28,079 (362) 34,130 33,695 (435)Programme Spend on Additional Activities 8,222 8,069 (153) 10,392 9,682 (710)CSS Services 3,723 3,732 9 4,468 4,479 11Prescribing 29,155 29,048 (107) 34,986 34,857 (128)Co-Commissioning 32,428 31,365 (1,063) 38,753 38,753 0

Non Acute Total 148,244 147,563 (682) 177,583 177,843 260

Total Commissioning Expenditure 317,290 321,981 4,691 380,439 387,146 6,707

Running Costs - Admin 5,222 5,223 0 6,267 6,267 0Running Costs - Programme 1,319 1,330 10 1,583 1,596 12Transformation Costs Programme 600 578 (22) 720 693 (27)

Operating Costs Total 7,142 7,130 (12) 8,570 8,556 (15)

GP IT 1,082 1,040 (42) 1,298 1,248 (50)Programme Corporate Costs Total 1,082 1,040 (42) 1,298 1,248 (50)

Premises - Void Costs 275 283 8 330 340 10Estates Costs Total 275 283 8 330 340 10

Contingency (0.5%) 1,444 0 (1,444) 1,733 0 (1,733)Headroom Reserve 0 0 0 1,733 1,733 (0)Recurrent Investments 1,283 1,151 (131) 1,539 1,379 (160)Other Reserves 1,134 (1,936) (3,070) 260 (2,766) (3,026)

Reserves and Contingencies Total 3,861 (785) (4,646) 5,265 346 (4,919)

Total Expenditure 329,649 329,649 (0) 395,902 397,635 1,733

In Year Surplus / (Deficit) 225 225 0 270 (1,463) (1,733)

Memorandum £'000Historic Surplus 8,760Total In Year Plus Prior Year Surplus 9,030

YTD Full YearSummary Position

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B. Detailed QIPP performance

2017/18 QIPP PLANHeading Proposed Project Planned Gross

Savings £MForecast Gross

Savings £MRISK

Assessment

Scaling Up Integrated Care Phase 4Phase 5 - Social PrescribingCare Homes Support ProgrammeSelf CareHigh Intensity UserNeuro and Complex Cases NavigationDischarge to Assess PathwayAmbulatory CareTraige and Home VisitingDiagnostics and Minor InjuriesSpecialist Paediatric Advice in UCCDVT Pathway

Continuing Health Care CHC Proposals £0.30 £0.20Development of Primary Care Model by NELFTOther schemes currently in development and potential decommissioning

MSK Pathway ProcurementOpthalmalogy Pathway ProcurementRenal Pathway PilotGynaecology PathwayHeart Failure ServicesGP Direct Access MRI ProtocolReducing Unneccesary TestingBarts Gain Share on Biosimilars £0.23 £0.10Medicines Optimisation and OPAT £1.00 £1.20All Acute ProvidersNELFTProcedures of Limited Clinical ValueOliver Road ClosureAll other non acute providers

Corporate Reduce Property Voids £0.25 £0.25

Additional QIPP Contract Review Process £0.87 £0.87

£14.17 £13.46

Integrated care

Urgent and Ambulatory Care

Mental Health

Planned Care - Sustainable Hospitals

£0.78

£3.21

Tran

sfor

mat

ion

Medicines Management

£2.55

£1.06

£3.23

Tran

sact

ual

Productivity & Contract Efficiencies

£2.99

£3.17

£1.10

£2.42

£1.84

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C. Statement of financial position (balance sheet)

NHS Waltham Forest CCGStatement of Financial Position As at 31 January 2018

Mar 2017 Jan 2018Change

YTD vs Year End

£000 £000 £000

- NHS receivables: Revenue 1,575 776 (799) - NHS prepayments 1,023 2,375 1,352 - NHS accrued income 591 24 (567) - Non-NHS and Other WGA receivables: Revenue 241 2 (239) - Non-NHS and Other WGA prepayments 339 681 343 - Non-NHS and Other WGA accrued income 180 200 20 - VAT 163 196 34 - Other receivables and accruals - 67 67 Cash & Cash Equivalents 19 21 1 Total Current Assets 4,131 4,343 212

Total Assets 4,131 4,343 212

Current LiabilitiesTrade & Other Payables: - NHS payables: Revenue (3,771) (6,199) (2,427) - NHS accruals (4,024) (6,079) (2,055) - NHS deferred income (25) - 25 - Non-NHS and Other WGA payables: Revenue (3,387) (2,581) 806 - Non-NHS and Other WGA accruals (13,980) (8,009) 5,971 - Social security costs (58) (63) (5) - Tax (64) (65) (1) - Other payables and accruals (546) (3,109) (2,563) Total Current Liabilities (25,855) (26,105) (250)

Total Assets less Current Liabilities (21,724) (21,762) (38)

Total Assets Employed (21,724) (21,762) (38)

Financed by Taxpayers’ Equity:General Fund (21,724) (21,762) (38) Total Taxpayers’ Equity (21,724) (21,762) (38)

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Item 6.1

Title of report East London Health Care Partnership: Update

From Jane Milligan, Single Accountable Officer - Waltham Forest CCG

Author Alan Steward, System OD and Transition SRO - BHR CCGs

Purpose of report

The report updates the NHS Waltham Forest CCG Board on the progress made by the East London Health and Social Care Partnership (ELHCP) to deliver the NEL Sustainability and Transformation Plan.

It briefly sets out:

• the proposed changes to the governance arrangements to enhance the effectiveness of the ELHCP and ensure it can drive the changes required to improve services and health outcomes

• the latest summary of progress on the main transformation programmes delivered through the ELHCP

• the work of the Clinical Senate • the bid for Local Health and Care Record Exemplars • the review of ELHCP organisational development • the main communication and engagement developments in the last quarter.

Changes/additions/amendments to paper as a result of discussions held at WF Committees

This paper has not been to any previous committees in Waltham Forest CCG.

Recommendations

The Governing Body is asked to:

1. Note the report.


Ensuring equity of health and wellbeing outcomes.

By working through the ELHCP all parts of the system can develop a coherent and integrated approach to ensure improved services and health outcomes for local people. It also supports the delivery of effective Integrated Care Systems. Strengthened collaborative arrangements at NEL enable greater resources to focus on local integrated health and social care.

Risk implications

The ELHCP programme helps the CCG to deliver on its priorities and mitigate the risks by contributing to:

• Aligning NEL health and care partners to improve health outcomes and improve services.

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• Delivering financial sustainability for commissioners and providers against a backdrop of increasing demand;

• Increased focus on developing local integrated care systems.


There are no financial implications of this paper.

Equality analysis

This document relates to all Waltham Forest residents in the 9 protected characteristics that are covered by the Equality Act 2010 and our Equality Duties. Specific service changes resulting from the ELHCP programmes will be subject to equalities impact assessments.


Not applicable


There has been no presentation of this paper at any previous meeting for Waltham Forest CCG.

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Report 1. The East London Health and Care Partnership (ELHCP) brings together the 12 local NHS

organisations (commissioners and providers) and eight local councils to improve health and care services and outcomes. It takes the lead around the NEL Sustainability and Transformation Plan (STP). This report sets out: • the proposed changes to the governance arrangements to enhance the effectiveness of the

ELHCP and ensure it can drive the changes required to improve services and health outcomes • the latest summary of progress on the main transformation programmes delivered through the

ELHCP • the work of the Clinical Senate • the bid for Local Health and Care Record Exemplars • the review of ELHCP organisational development • the main communication and engagement developments in the last quarter.

2. It is intended to provide an update on the ELHCP at each meeting of the CCG GB.

ELHCP Governance 3. The ELHCP has been operating for over 12 months bringing together commissioners, providers and

other partners including local councils and the voluntary and community sector. Over the last two quarters (and emphasised in the new planning guidance issued by NHSE), it is timely to review the ELHCP governance. This is driven by two elements, the focus on developing and accelerating integrated care partnerships (formerly accountable care systems) and the establishment of the NEL Commissioning Alliance and the appointment of a Single Accountable Officer.

4. In January both the ELHCP Board and Executive agreed to:

• strengthen the Partnership Executive so that it meets monthly and is composed of the Chief Executives and other senior leaders from across NEL including all major providers, CCGs, primary care, local councils and the Clinical Senate. The CCGs are represented on the Executive through the Single Accountable Officer and the NELCA Chair of Chairs (Dr Anwar Khan)

• change the Board to a NEL Assembly that meets every 3 months with a range of stakeholders. This will take a themed approach to each meeting with an overall focus on health and wellbeing, prevention and self-care. It will provide strategic advice to the Executive as it looks to deliver the key ambitions and transformation set out in the STP.

5. Further work was requested to define more closely the links between the ELHCP Executive and the

three System Delivery Boards established to deliver the local integrated care partnerships and around the relationship and reporting to regulators (assurance). Future ELHCP updates will ensure CCG GBs are updated on the progress being made.

6. The ELHCP has also started a review of the current NEL Sustainability and Transformation Plan.

This is to take account of the updates to the Five Year Forward View, the latest Planning Guidance issued by NHSE and the formation of the NEL Commissioning Alliance. This will set out the key decisions and deliverables for 2018/19. An update will be provided to the next GB meeting on the outcomes of the refresh.

Delivery of the NEL Sustainability and Transformation Plan (STP) 7. The ELHCP drives the transformation programmes within the NEL Sustainability and Transformation

Plan. A monthly summary that sets out the progress, key delivery risks and any mitigating action is attached at Appendix A.

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8. Key progress areas to note are: • Primary Care: A common provider development framework has now been established. The

framework has 5 key elements that help move the federations in the 7 CCG areas along their development journey, developing clear system plans to ensure each is moving towards our aspirations and goals.

• UEC: The IUC 111 and Clinical Assessment Service (CAS) has now been awarded to LAS. The CAS service will enable patients to receive fast efficient clinical advice, with improved onward referral pathways, reducing the number of steps in key pathways into pharmacy, primary care, UTC, social care and mental health.

• Cancer: Focus on achieving and maintaining cancer waiting time targets. Preliminary figures on 12 January 2018, show that the system will remain above trajectory for those treated in December. Focus of the NEL 62 day group remains on delivery, achieved through working with providers in NEL and NCL such as UCLH, sharing learning across the system and carrying out root cause analysis (RCA) to prevent re-occurrence of problems and with the support of the regional cancer delivery board.

• Mental Health: ELHCP Mental Health workstream's Delivery Group 2 'Improving Access and Quality' has prioritised IAPT service transformation across East London to ensure all CCGs can improve and maintain their services and support delivery of IAPT access standards.

Clinical Senate 9. The Clinical Senate is developing its 2018/19 priorities and it is currently focusing on 4 areas:

• at the January meeting it was agreed to prioritise a systematic NEL approach to Outpatients transformation and a delivery plan will be presented to the April JCC outlining the Senate’s recommendations for implementation. This priority was supported by the ELHCP Executive and Board.

• the February meeting reached agreement on the clinical model for mental health support to primary care and agreed that a local mental health network be established to develop the delivery plan.

• a survey is being undertaken of views on the Senate’s role and its operating model and this will be discussed in March with recommendations to come to the ELHCP Executive for agreement.

• the forward business plan for the senate is under development and should be available by March. This will focus on those areas which the Senate wants to prioritise this year and the frame for their work and also those STP programme areas where there is a need for debate about the clinical model.

Digital: Local Health and Care Record Exemplars 10. NHS England (NHSE) is about to launch a call for proposals for up to five Local Health and Care

Record Exemplars (LHCREs) programmes that can ‘raise the bar’ in how the NHS, and its partners, share data to help deliver better care for our citizens. Each exemplar will be granted £7.5m available from 18/19 to 19/20 for each locality – matched with local investment and resource to implement and roll out their exemplar programme. Up to 5 of these will be awarded nationally. The LHCREs will show how data can be shared appropriately, and for what purposes, across venues of care within localities at scale and adhering to secure, robust and transparent information governance frameworks. They will demonstrate practical approaches to continuous patient, professional and public engagement and show how appropriate and compliant data sharing directly improves the quality and efficiency of care while reducing health care inequalities.

11. North east London is further ahead with this work compared to other areas across the country, with

significant and ongoing work on the eLPR (east London Patient Record) and Discovery/Population Health programmes. Following discussion with NHSE, it is now confirmed that north east London (ELHCP Informatics Group) will lead on the development of this pan London proposal in collaboration with the full London system. Active discussions are underway with the five London

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STPs to seek support for and frame the bid. It is anticipated that the NHSE call will be launched towards the end of February 2018 with a six-week timeline for submission and a decision on the successful LHCRE bids by the end of April 2018.

12. The ELHCP Board supported both a NEL bid and that NEL is leading the bid for London. Individual

CCGs are being engaged and the programme is being discussed in more detail at the next NEL Informatics Steering Group on 6 March 2018.

Organisational Development 13. Alongside the refresh of the Sustainability and Transformation Plan, a review of the ELHCP

organisational development strategy and plan is underway. It will build on the early successes of the programme in securing support from Staff College to support medicines optimisation, end of life care and diabetes work and with the Dartmouth Institute to support Integrated Care Partnerships. This will be integrated into the enabler workstream around workforce and seek to link together the organisational development needed to deliver the STP priorities in 18/19 and beyond.

Communication and Engagement 14. The ELHCP undertakes communication and engagement across NEL on some areas of the STP. In

the last quarter, the Partnership’s external website www.eastlondonhcp.nhs.uk has been rebuilt with an improved structure to bring it in line with industry standards. One of the site’s new features is a section devoted to health and care workforce recruitment and retention. This is work in progress but a preview is available at http://elhcpcareers.speedwaystaging.co.uk/.

15. There is a significant focus on improving recruitment and retention as one of the key enablers for the STP. The maternity transformation workstream is running a campaign to attract more midwives – Careers are born in east London - that is being launched at the end of February. There is also support to the primary care quality improvement programme to promote the significant improvements in primary care since the launch of the programme and there is a stakeholder event for the digital workstream on 21 February, focusing on shared patient records and telehealth.

16. Finally, a report on the successful ELHCP Health and Housing Conference last October has now been published on the Partnership website. The key findings will be taken into account in the refresh of the STP.

82

http://www.eastlondonhcp.nhs.uk/

http://elhcpcareers.speedwaystaging.co.uk/

Transformation Highlight Report

North East London STPJanuary 2018

Mehreen Arshad

NCEL STP Aligned Lead

NHS England Newham

Barking and Dagenham

Havering

Redbridge

Tower Hamlets

City & Hackney

Appendix A

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2

The one accountable officer appointment by the seven CCG governing bodies has been completed, System winter resilience is underway in primary, community and secondary care; including the appointment of directors for winter, General Practice resilience planning and AEDB winter monitoring. Accountable Care Systems – development of the sub-systems and their relationship with North East London Commissioning Board to improve provider and commissioner relationships in system delivery NEL Joint Commissioning Committee agreed – go live April 2018

STP Headlines

Progress against national priority programmes

PRIMARY CARE

Established a provider development framework for at-scale primary care providers Clear action plans for developing increased workforce Developed NEL international GP recruitment bid

UEC

CANCER

MENTAL HEALTH

THEME Progress

Progressed against provider development frameworks for at-scale primary care providers

Meeting with CCGs and at-scale providers to ensure plans are in place for further improvements in preparation for 2018/19

Progress LAS mobilisation plan to meet Go Live date Roll out of 111 bookable appointments to GP Hubs TH and WF CCG Early adopter programme to book 111 appointments into NEL GP practices 111 MH Warm Transfer SOP to C&H/TH/WF being developed UTC Designation dates for other sites underway

Map screening uptake levels in NEL and conduct gap analysis on challenges within primary care in implementing cancer pathways

Increase % seen in week 1, aiming to reducing timelines towards day 28, in 2020 of informing of diagnosis and onward referral by day 38 where appropriate.

Baseline and bid for IPS schemes complete Development of comparative framework for IAPT services Engagement plan for review of psychosis pathways Learning and recommendations from Liverpool suicide prevention and others Improving access and quality, dementia, access standards and waiting times

Next Steps

Consistent CWT performance since compliance against the 62 day standard for Q3 Shared learning across system, all Root Cause Analysis to prevent recurrence of avoidable breaches Collaboration and pathway work across the NEL and NCL STP with particular reference to Prostate

IUC 111 and CAS awarded to London Ambulance Service with expected Go Live date Summer 2018 NHS Online commenced 18th January for BHR and WF CCG 111 Bookable appointments to GP Hubs in BHR operational 111 MH Warm Transfer SoP to MH BHR /WF services to be signed imminently UTC Designation sign off for Queens and KGH

Implemented governance framework for five workstreams: NEL wide suicide strategy; improving quality and access for IAPT – meeting future targets; demand and capacity: Develop effective psychosis pathway and review pathways for other conditions; Improve whole system outcomes - achieve physical health check targets; Commissioning and New Models of Care - align focus of commissioning and contracting to support new models of care

Risk / Issue Mitigation1 Quality standards: There is a risk that with the focus being on financial or performance

delivery, the quality and clinical standards will not be central to planning and approval of transformation plans. This could impact on the quality and clinical impact on patients

NHSI providing input to support the system to control this risk. New operating model for CCGs and systems will support monitoring and managing risk (set up of quality surveillance group) to look at quality outcomes

2 Programme Outcomes: There is a risk that there is variation across all services clinical standards for primary and community services. This will impact on the quality outcomes for the various populations NEL services delivery

The Clinical Senate is currently informed by variation benchmarking presenting from work streams, Right Care and annual contracting information. The development of a NEL wide quality group will support the monitoring of risk of variation, approval process of business cases and escalating severe variation risk

3 Although contracts have been agreed with all providers, there is a risk of a financial gap opening up if the transformation, QIPP and CIP schemes do not deliver and some are high risk.

Operational Delivery Group to review high risk CIP and QIPP to identify work stream level mitigation plans. Plan to develop joint approach to the identification and implementation of CIP and QIPP

4 Due to limited funding for initiatives, there is a risk of prioritisation from other parts of the system, including the potential knock on effect from any reductions in Local Authority funding

Confirm through next stage of ELHCP design and Operating Framework

5 There is a risk that there is insufficient programme resource to deliver the ELHCP programmes Funding proposal developed and potential sharing of programme funding. Recruitment of central PMO roles, possibility of secondments. Review of programme structure underway

STP Risks / Issues

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3

Full year extrapolation forecasting at £260m deficit. At month 8 the reported full year forecast was £94.9m. Financial strategy: The ELHCP Payment Development Steering Group reviewed and summarised feedback on the Payment Reform consultation. The reform will help develop payment to support health and care objectives in NEL.

Engagement with stakeholder has helped identify perceptions of stakeholders, emerging principles, and areas that need further research. Next steps are to collaborate and shape upcoming discussions of the ELHCP working towards our aim of better serving our population.

Enabler Headlines

Risk / Issue Mitigation

1Finance: There is a risk of £165.05m within the full year forecast position. This is particularly the case for Barts and BHRUT who are currently forecasting significant improvements in their positions in comparison to their YTD deficits. This £165m risk relates to significant back-loading of efficiency plans across both commissioner and provider plans.

The main contributors to the system deficit position are Barts Health and BHRUT. Both organisations are currently in discussions with regulators with a view to improving their forecast position.

2Estates: The size of East London Health and Care Partnership/ NEL footprint means there is a risk that the capacity to manage the population growth is at stake. This will make it difficult to implement the necessary change programmes (particularly Whipps Cross proposals).

1. Development of estates strategy and function should be in place particularly for Whipps Cross2. All organisations need to demonstrate adherence to the estates strategy3. Securing funding to implement the strategy is essential for successful implementation4. An agreed Memorandum of Understanding should be circulated across all organisation with a NEL wide estates function.

Enabler Risks / Issues

Progress against Enabler Programmes

THEME Progress Next Steps

FINANCE

WORKFORCE

DIGITAL

ESTATE

Month 8 Contract Triangulation gap £31m and £41m forecast. Month 8 System gap excluding triangulation gap £147.3m and £173.3m including triangulation. Forecast full year deficit at month 8 excluding triangulation was £53.2m and £94.9m including triangulation.

Month 8 year to date forecast is £173.3m deficit. Refresh control total tool for month 8 Successful bids for maternity and CYP Transformation funding and National Mental Health winter funding

Well-established shared record system in INEL eLPR used in the Newham UCC to view GP records, and in the pilots that are underway to test new ways of

working in Outpatients Discovery programme receiving data from Homerton, Barts Health and the majority of GPs, combined to give a

single view of the patient record

Next Gateway requires London partners to complete a robust London Capital Plan by end of this FY, consolidation of STP Plans, working at a centralised capital total requirement for NEL and an agreed prioritisation matrix to be able to ranked different projects

Draft ELHCP Estates Strategy – to be signed off by the STP Executive committee Agreed Asset Management and Utilisation Strategy across ELHCP including void liability for the commissioners Progressing with the Back office consolidation strategy including all providers and commissioners – linked to

Productivity work stream

LWAB established and HEE resource provided New Role Development – including funding for MAs, PAs, NA System level interventions including a review to inform system level response and apprenticeships strategy GP International Recruitment Programme Primary care modelling and enabler programme implemented

Payment reform consultations responses review. Refresh control total tool for month 9 Develop financial model to evidence the potential additional staffing

requirements or not of implementing continuity of care model.

Expansion of the eLPR into BHR. BHRUT and Barking & Dagenham GPs have committed to connecting. Work underway with suppliers

Connection of eLPR to London Health and Care Information Exchange NELFT and LB Newham contributing data to eLPR City of London Corporation and LB Hackney connecting to eLPR

Finalise strategy and prioritisation list for London Plan Void management plan with action plan per building setting financial targets per

CCG for 17/18 Infrastructure Delivery Plan showing project interdependencies between systems

Require service location data from providers (Nov – Jan) Finalise asset database to allow for mapping (Jan – March) Estate Reconfiguration options explored

ELHCP wide development of apprenticeship plan Economic review of embedding the NA role across ELHCP

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4

Progress against STP local themes

AO and Commissioning

Landscape Arrangements

Operating model design in progress (proposal team of system leaders and corporate directors) Interim SMT posts established (MDs, Director of Strategic Commissioning) ELHCP Governance being amended to compliment and align System stakeholder session delivered in December 2017 Stocktake of CCG arrangements underway to identify opportunities for shared approaches and good practice

Development of ACSs

ACS plans have been developed on three footprints: BHR / WEL / C&H Governance structures developing over 18 months to support new vision, largely advisory however successful in

bringing partners together to explore new operating models Joint Commissioning arrangements and supporting governance have been established Contract payment mechanism under review following system consultation Detailed self assessment update was developed for STP SROs Workshop in January 2018

Contract Round

Barts and NELCA working to agree year end deal in 2 weeks and making progress on 2018/19 contract. Escalation for latter due this month.

BHRUT and NELCA agreeing scope of expert determination with a view to rapid conclusion via national regulators agreeing impact on 2018/19 as soon as possible. Intention is to minimise scope of national arbitration through engaging with Trust.

King George Hospital

Public statement with BHRUT/ELHCP and NHSI published Nov 17 and BHR Integrated Care Partnership Board updated on December 2017

STP letter on congruence of KGH SOC and WX SOC and alignment with out of hospital strategy submitted to NHSI in January 2018

THEME Progress

Detailed governance (and CCG constitutional changes) Substantive Recruitment of MDs and other Executive posts underway Formal JCC members in recruitment (Lay members and others) System stakeholder session planned for March 2018 to review and launch OD plan in delivery Jan – Mar (JCC and Executive sessions) Stocktake outcomes Phase 1 – Jan / Feb, Phase 2 to consider opportunities

Assessing London Devolution implications Developing NEL ACS strategic framework Clinical strategy development Provider alliance development and response to commissioning test areas Next steps on the STP/commissioning agenda and the ACS programme

STP has systems in place to meet deadline of 28th February. All other contracts expected to be achieved except for some risk on ELFT CHS.

Public statement published NHSI preparing approvals report with a view to submission to NHSI Resources Committee in February 2018

Submission of approvals report to NHSI Resources Committee in February 2018

Next Steps

Winter

All tranches of winter funding now received i.e. acute, mental health, 111 and UEC totalling £6,270,257. Tracking of scheme implementation and impact across all tranches of received funding is in progress and reported to NHSE/I as appropriate

Heightened daily focus and priority is managing pressures relating to increasing circulating flu as measured by confirmed cases in ITU/HDU, in other beds and number of daily newly diagnosed cases

Focus on Christmas and New Year wash up ensuring clarity on refining high impact interventions in and out of hospital to support delivery against Q4 STF i.e. performance and streaming.

Communications and Engagement

Established online information and resource centre for Partnership organisations – The Briefing Room Rebuilt Partnership external website for ease of use Organised Health & Housing conference to identify actions in relation to the wider determinants on health Produced simpler narrative on transformation programmes to explain what we are doing and what it means Produced initial Live & Work in East London brochure to support workforce recruitment and retention

Recruitment and retention campaigns for maternity and workforce programmes Campaign to support quality improvement in primary care Developing stakeholder relations with east London voluntary sector, Healthwatch,

local colleges and universities Continuing to build relationships with local authorities and encouraging

involvement in transformation programmes

Support Requirements

Support Request Action Required

1 At present the approach to the distribution of transformation funding is fragmented and not always best targeted at local priorities.

A more locally tailored and targeted approach of transformation funding enabling STPs to have greater influence on the process, aligned with prioritisation in line with London Devolution.

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Item 6.2

Title of report Planning for the Future

From Jane Mehta – Interim Managing Director - WFCCG

Author Jane Mehta – Interim Managing Director - WFCCG

Purpose of report

This paper outlines:

• The rationale for integrating our commissioning functions and the benefits of service integration.

• Seeks to summarise the various discussions we have been having in the last 12 months about the future direction of commissioning and provision within local health services and how this links with the national and East London health & care partnership (ELH&CP) proposals.

• Provides an update on the progress made to date in integrating commissioning and provider services in line with previous governing body recommendations.

• Makes recommendations on the key priorities and resource requirements for 2018/19 to support the integration programme.

Changes/additions/amendments to paper as a result of discussions held at previous Committee

None

Recommendations

The governing body is asked to: • Note the progress made over the past 6 months in supporting the system integration agenda.

• Discuss and agree the key priorities for 18/19 to realise the ambition of the newly established

integrated (accountable) care system(s) in Waltham Forest.

• Endorse in principle the formal establishment of a WX Alliance with our fellow commissioners and providers (working draft attached at appendix 1).

• Agree to ‘earmark’ for 2018/19 ongoing funding (£250,000) to support the alliance work programmes and agree that a detailed work-plan and associated resource allocation will be submitted to March Governing Body for approval.

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Planning for the Future

• Note that future Governing Body Development sessions will be exploring how Governing Body members and the CCG workforce will need to adapt and reprioritise their work programmes to deliver integrated system working.


It’s important we align our strategic work so that patients & carers see improvement in services and how they are delivered and are not inconvenienced by our approach to transformation.

Risk implications

N/A


The advent of integrated care systems and a systems approach to provider development is seen as one of the key ways in which to manage the increasing demand for health services and therefore health & social care budgets.

Equality analysis

None undertaken to date.


N/A


Various governing body meetings and development sessions during 2017/18, the Better Care Together Programme Board.

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Integrated (Accountable) Care Systems

1 Purpose NHS England have provided in their annual operating guidance further clarity on how they expect care systems to integrate over the next 12 months; a summary of which has been shared with governing body members. It is therefore timely for the governing body to receive a report to agree next steps on service integration in Waltham Forest, this paper outlines:

• The rationale for integrating our commissioning functions and the benefits of service integration.

• Seeks to summarise the various discussions we have been having in the last 12

months about the future direction of commissioning and provision within local health services and how this links with the national and East London health & care partnership (ELH&CP) proposals.

• Provides an update on the progress made to date in integrating commissioning and provider services in line with previous governing body recommendations.

• Makes recommendations on the key priorities and resource requirements for 2018/19 to support the integration programme.

2 Recommendations

• Note the progress made over the past 6 months in supporting the system integration agenda.

• Discuss and agree the key priorities for 18/19 to realise the ambition of the newly established integrated (accountable) care system(s) in Waltham Forest.

• Endorse in principle the formal establishment of a WX Alliance with our fellow commissioners and providers (working draft attached at appendix 1).

• Agree to ‘earmark’ for 2018/19 ongoing funding (£250,000) to support the alliance work programmes and agree that a detailed work-plan and associated resource allocation will be submitted to March Governing Body for approval.

• Note that future Governing Body Development sessions will be exploring how

Governing Body members and the CCG workforce will need to adapt and reprioritise their work programmes to deliver integrated system working.

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3 Rationale for better integrated services and establishment of accountable care system(s)

Our current system remains highly fragmented with different types of providers (primary, community, social care etc.) working to different priorities, using different systems, budgets and incentives. This all contributes to a fragmented and often confusing patient journey. We also know that providers suffer from a lack of skilled staff resulting in high agency spend at a time when funding is limited and while the needs of our population are growing. Like many deprived areas our population is transient and their expectations are changing, giving greater uncertainty to what’s needed in the future. Regulatory constraints from the centre also lead to a focus on meeting top-down targets rather than focusing on population outcomes. Furthermore, the current commissioning contract mechanisms are inflexible – making it difficult for us as commissioners to drive the change we want within an annual commissioning cycle. An integrated (accountable) care system, where a group of providers working to a single budget with a clear outcome based contract, can begin to address some of these issues.

• Integrated care systems aim to focus on long term health and care needs of the population. This means a system view of the services we provide with a focus on fewer outcome based targets and a focus on population health.

• In order to remove misaligned financial incentives there is requirement to introduce risk share arrangements between providers. The agreements between providers need to incentivise the movement of resources upstream to self-care and prevention to deliver improved population health outcomes and a movement away from episodic treatment of illness.

• We need a system where the benefits and needs of the population and patient are put ahead of organisations. Some of this work has begun at a national level with regulators looking at how they can hold systems rather than organisations to account. The local integrated care systems provide opportunity to blur provider boundaries, integrate services and allow free movement of workforce across traditional service boundaries to reduce duplication and deliver patient focussed care at the right time and right place.

4 National Context The issues we face in Waltham Forest and East London are shared across the country and therefore national policy changes are being introduced to support integration of services. The Five Year Forward View (5YFV) was launched at the end of 2014 and set out a new shared vision for the future of the NHS based around the new models of care vanguards. The 5YFV set the challenge for the NHS to come up with local solutions for sustainability and loosened the reigns more than previously possible. It was a significant move away from

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previous top-down changes (such as the establishment of CCGs), it suggested – over to you, work out the solutions that work best in your area. The latest operating guidance references integrated care systems based on sustainable transformation plan (STP) footprints which has a single budget for commissioners and providers. The integrated care systems can earn autonomy and will be assured at a system level rather than organisational level allowing systems to focus on the individual organisational level plans ensuring that they are aligned and together deliver system-wide priorities. A high level view of the of the 2018/19 planning guidance has been shared with members of the governing body; the fully refreshed guidance issued in February and the five year forward view can be found on NHS England website.

5 North East London context There are a number of things taking place at the North East London (NEL) level that will impact on our local work. The CCG has agreed to enter into more formal collaborative commissioning arrangements across north east London starting with the appointment of a single accountable officer, chief financial officer and director of strategic commissioning for the 7 CCGs. Although Waltham Forest remains the responsible statutory body some of the work we have done locally will now take place across a larger footprint. Recently a Joint Commissioning Committee (JCC) has been established where leadership of the 7 statutory CCGs can come together to agree on the common key areas of interest such as finance and performance issues where a collective view is beneficial. We are calling this arrangement the North east London commissioning alliance. One of the areas the NEL alliance is looking at is the structures that could be put in place to develop integrated care systems across their geography, aligned to the acute provider footprint, so this may mean you will see the term ACS or ICS associated with work aligned to Transforming Services Together and so on for other areas, such as Barking, Havering and Redbridge. Although not fully established yet, an ACS at TST level may focus on payments and outcomes and the things that need to be done once to enable Barts Health to participate in local integrated care partnerships. There is also a well-established north east London health & care partnership (ELH&CP) where providers and commissioners come together to discuss large strategic issues and manage the implementation of STP with a focus on achieving a system control total. The ELH&CP is still emerging but has an established board with an independent chair. In practical terms the STP has chosen certain areas to focus on where it makes sense to do so over a larger footprint – such as primary care quality improvement and financial sustainability. Both these groups will have key roles in developing an Integrated Care System across North East London.

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6 Local Context - WX Accountable Care system(s)

There is a recognition that the delivery of Integrated Care system objectives at an ELH&CP level will only be delivered through the re-design of community based and home based services in partnership with social care, voluntary, community sector and our citizens. The local borough partnerships therefore remain a fundamental building block of the integrated care systems. Over the last year, with the freedom and innovations that these recent developments have given and our strong history of integrated care work, the Governing Body and Senior Management Team (SMT) of the CCG have been thinking about how we should commission in the future. What has emerged is the concept of an integrated care system for the Whipps Cross Hospital footprint that has the potential to address some of the systemic challenges we face. We have decided to develop systems within systems and it seems that in breaking up the work we have been doing we have made more progress than by focusing on a single big change approach. In Waltham Forest we are already working on many of the building blocks that make up an ICS, commissioning based on outcomes (CHS/MH), and facilitating greater partnership working through commissioning (CHS/UC) and working collaboratively to change services rather than procuring them. In practical terms, ICSs can be established at different levels or ‘footprints’, based on where it makes sense for organisations to work together at a local level and where it makes sense for them to work together at a wider level. The level at which they are established will also define the priorities and their collective work. The advent of integrated care both in terms of the integration of commissioning functions with the local authority and the nascent provider networks means the continued blurring of the boundaries between commissioning and provider responsibilities of both CCG and our local authority partners.

7 Progress to date - Integrated Governance Arrangements & Provider Partnerships

If we are to deliver truly integrated services we need to establish an effective governance arrangement which ensures providers and commissioners are working to common goals and are clear about their responsibilities and accountabilities within the wider health and care system.

The CCG has been working with its partners to better join up its governance arrangements delivering incremental changes; more recently the governing body has supported a step change to deliver joined up decision making. This work is being overseen by the ‘Better Care

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Together Board’ (BCT) a partnership of local providers and commissioners, chaired by a clinical director.

The BCT Board is focussing on three key deliverables.

• Development of a strategic commissioning function across health and social care. • Reviewing our existing contracts and clustering them around key system

deliverables. • Working with our providers to set up provider partnerships to deliver the new

integrated care system contracts.

Aligned strategic commissioning function

System wide contracts focussed on key outcomes

Provider partnership(s) to deliver new ICS contract(s)

A summary of the progress made in each of these areas over the last 6 months is outlined below.

7.1 Strategic Commissioning function The Council and the Clinical Commissioning Group (CCG) are committed to improving the health and wellbeing of Waltham Forest residents. As an important early step, the Council and the CCG have agreed to establish an Integrated Strategic Commissioning Function (SCF). Developing an integrated commissioning function is essential first step towards achieving the Council’s and CCG’s aim to develop an Integrated Care system (ICS). The rationale and direction of travel was reviewed by CCG Board and the Council’s Cabinet in October 2017. To take this work forward, the Council and the CCG have agreed joint governance arrangements to oversee the creation of phase 1 of the Strategic Commissioning Function by 1st April 2017. The first phase is largely discovery and has been working with a number of key officers from both organisations to understand the various roles and functions that might ultimately form part of an integrated function. A report summarising the discovery phase of the work will be taken to the March governing body and cabinet. The following functions are currently being explored: commissioning, contracting, contract performance management; quality, safeguarding, procurement, business intelligence & transformation. The programme of work is being managed by a steering group comprising councillors, clinical directors, lay members and senior officers setting the direction, with an intensive work programme led by a working group comprising officers from both organisations and representing the areas of function being explored. The programme is looking at creating a joined budget in the region of £430m.

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7.2 Integrated Care System Contracts

Whilst closer working between commissioners and providers is essential the CCG still has a legal requirement to formally contract with providers for service provision and has to continue to manage conflicts of interest. There therefore remains a commissioner/ provider split but there is clear expectation that this boundary is ‘moved’ rather than ‘blurred’ and that future contracts cover a ‘system’ rather than individual services and are outcome focused allowing providers to work collectively to deliver improvements in the population health and wellbeing. The CCG has been working to develop its commissioning processes to allow greater alignment with other organisations and taking an outcomes approach rather than an input approach to how we plan and commission services. In practical terms this means we commission based on what’s important to our patients and service users, along with data to support that, as opposed to commissioning activity delivered by providers (e.g. number of appointments). The largest contract we’ve developed in this ‘outcomes based’ way, is the combined Community Health Service and Mental Health service contracts with NELFT that have now been combined and provided clear outcome measures. This allows our community and mental health provider more flexibility to integrate services around the user. More recently we have started to look at other system-wide contracts which would be jointly funded from our Waltham Forest health and care budgets. We now have four established work programmes to deliver ICS contracts for;

• End of Life Care – using an integrator mechanism to bring in transformation money • Urgent Care pathway – from A&E tonight home visiting • Care Closer to Home - health and care pathways and beds to support people in the

community as long as possible • Community and prevention – self-care and self-responsibility

7.3 Provider partnership

• Senior responsible officers (SROs) have been identified from our providers to lead the four integrated system programs. Whilst the programs are at various levels of development all the providers are committed to working together with voluntary sector, patient representatives and other key stakeholders to deliver the new system-wide contracts.

• There is a recognition that to work effectively as a system requires a different culture to breakdown some of the organisational and professional boundaries. The CCG has therefore provided some specific organisational development support to the programs through the Staff College, UCLPartners/ Dartmouth Institute and Social Finance. Each are working with a different programme but the lessons learned are being shared amongst the partners. In addition CCG staff have been ‘seconded’ to work alongside provider colleagues to support the transformation work.

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• The establishment of a GP federation in Waltham Forest will support the delivery of

primary care at scale and will also provide a single voice for primary care provision. The organisation is in fledging form but is receiving support to develop from a number of sources. The development resource includes CCG management support and a specific quality improvement programme provided by South Bank University.

• In order to develop GP federation capacity and resilience it is also exploring a closer partnership working with NELFT through the re-provision of the urgent treatment centre contract and joint working on primary care contracts.

• Better Care Together programme board (previously Better Care Fund) – This is the transformation board in Waltham Forest comprising representation from key providers, the third sector and commissioners from health & the local authority. It has to date delivered on a number of transformation projects which collectively form the basis for integrated care in Waltham Forest. These include the establishment of an integrated discharge team, the pilot of discharge to assess, gathering views on models for health and care hubs in the borough amongst others. It manages services amounting to approximately £20m.

• Whipps Cross hospital redevelopment programme – The programme established to work towards a redeveloped WXH site and the opportunity to develop buildings that are fit for a redesigned system with many providers working together to provide system pathways for citizens.

The governing body are asked to confirm that the above areas continue to be our focus and priority for integrated system working in 18/19 and note that quarterly reports will be provided from the better care together board outlining progress during the year.

7.4 Alliance Agreement

Much of the recent momentum has been delivered through some dedicated support provided by CCG and providers.

The CCG set aside £100,000 this financial year and also provided Terry Huff as a dedicated resource to work with providers and commissioners to coordinate efforts across the system. This support will cease on 31st March and if we are to maintain momentum we need a more formal governance arrangement and longer term funding stream with which to continue to develop and implement our local vision of accountable care.

The CCG has been working with its providers and partners to develop an alliance agreement.

The agreement outlines what the shared aims and goals of the partnership are, the governance arrangements required to deliver and the resource that each of the partners are being asked to contribute. A draft is attached which has been shared with our fellow alliance partners – Barts, NELFT, Local authority and Fednet.

A final draft will be shared with the Governing Body in March for formal agreement. Members of the governing body are invited to comment on the current draft.

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The key proposals of the agreement are;

Establishment of a joint board

This will build upon the current BCT Board which was originally established to support the joint commissioning arrangements between local authority and CCG. It will require formal reporting lines and delegated powers from each of the alliance organisation governing bodies. The membership will also be reviewed to include representatives from all the key system providers including WFGP Federation and also any associated members who are essential in delivery of the WX ACS but not yet committed to full membership of the alliance – For example Redbridge CCG, representatives of care homes and a patient voice.

Executive team and programme leads

This is currently being led by SROs within the providers and supported by CCG officers. The SRO’s will require some dedicated programme support in order to drive the change at pace; the CCG and partners are currently exploring how best this can be organised and provided.

Establishment of a senior joint leadership post;

The post will be hosted by one of the alliance partners but will be accountable to all partners and be responsible for delivering the accountable care programme. Supporting the establishment of ACS contracts and the provider partnership agreements required to deliver them.

The post will not have any direct responsibility in the establishment of the strategic commissioning function. Whilst there needs to be much closer working between commissioners and providers and a movement of the boundaries between the two so that commissioners take a more strategic population health view of the system there does need to remain a split between provider and commissioner to avoid conflicts, to hold system to account and to preserve patient choice as the provider boundaries become blurred.

8 CCG workforce implications

As outlined in the report a joined up system of care with greater integration of services has major implications for our providers as they form new partnerships. It will also have a major impact on the CCG and its commissioning role.

Much of our tactical commissioning function will need to transfer to the new provider partnerships as our contracts are focussed on more strategic health outcomes. This will give providers more freedom to innovate and organise and provide services that improve population health rather than focus on episodic care interventions – A move from treatment to prevention.

As we move our focus to prevention and creation of a health and wellbeing service the collaboration with our local authority partners will be invaluable. Our commissioning roles will need to be more aligned and this too will have an impact on both our staff and Governing Body as we share decision making.

The creation of a CCG management team across NEL will also have an impact on local decision making as we aim to develop common strategies and share good practice across NEL.

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We have previously discussed in GB development sessions the idea of our staff gradually moving into roles within the provider networks, possibly working across more than 1 CCG, and moving into an integrated commissioning function with local authority staff. We’ve also discussed the implications for the governing body and how our role as members needs to begin to change to mirror the changes in the system of which we are part. Two facilitated sessions for the governing body and separate workshops for staff have therefore been arranged to begin to explore the implications to both our GB members and staff. It is anticipated that these workshops will help shape a detailed report to our Governing Body in the spring outlining the changes the CCG needs to make to support integrated system working.

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Highlights [Audit Committee] [January 2018]

Item 7.1

Committee Minutes

Audit Committee - January 2018

From Vineeta Manchanda, Chair of the Committee - WFCCG

Key highlights

• Review of directorate risk registers and BAF reports

• Update against CCG’s mandatory training status as administered through the OLM system. Assurance sought on clarification of how both clinicians and Governing Body members are advised of the process by which to ensure their compliance with mandatory training requirements

• Update on the internal auditor activities including (i) 2017/18 Internal Audit Progress

Report, (ii) 2017/18 NEL CSU Progress and Quality Assurance Reports

• Presentation and approval of the draft External Audit plan, 2017/18

• Update on the findings from contract audit of CCG employees

• Presentation of Corporate Credit Card standing operating procedure

• Discussion in relation to sponsorship arrangements following publication of related BMJ article

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1

Minutes of the Waltham Forest Clinical Commissioning Group Audit Committee (Part 1)

Date: Wednesday 10 January 2018

Time: 10.30am –12.30pm Venue: Kirkdale House

Members Present Vineeta Manchanda (VM) Chair Rizwan Hasan (RH) Secondary Care Consultant Alan Wells (OBE) (AW) Lay Member, Governance In Attendance Les Borrett (LB) Director Financial Strategy Jane Mehta (JM) Interim Managing Director, WFCCG David Pearce (DP) Head of Governance Toyin Ajidele(TA) Training Manager Auditors Nick Atkinson (NA) RSM (Internal Audit) Gemma Higginson(GH) RSM (Local Counter Fraud Specialist) Neil Hewitson (NH) KPMG (External Audit) Jack Stapleton (JS) KPMG (External Audit)

Item

Action

1 Apologies and Announcements There were no recorded apologies.

NH introduced JS as the new manager representing KPMG in respect to WFCCG activities. LB advised that this would be his last attendance at the WFCCG Audit Committee as he was taking up new responsibilities in the wider NEL organisation.

2 Declarations of Interest VM In line with statutory guidance a declarations of interest checklist was

reviewed by the Chair ahead of the meeting in order to identify any conflicts / potential conflicts of interest relative to the meeting agenda. NA advised that RSM were in the process of a procurement process in respect to provision of services to the CCG and that oversight of the process was being provided through NEL CSU against which RSM had issued a partial assurance in relation to its procurement processes. VM noted the declaration and determined that no action was required in respect to the Audit Committee meeting.

3 Minutes of meeting held on 1 November 2017 VM The minutes for November 2017 were approved.

4 Matters Arising VM Mandatory Training:

TA provided a further update on the mandatory training status and drew attention to data quality issue concerns with the provider which was resulting in a lack of visibility of achieved compliance levels. JM requested that TM undertake manual checks to clarify the status. RH noted that the previous concerns raised in respect to the required mandatory training requirements and compliance levels achieved for Governing Body members and Clinicians which were also not being captured. VA requested that a further update be presented to the next Audit Committee, 7 March 2018.

TA

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2

Audit Committee Self - Assessment: The Audit Committees self -assessment of its activities for 2017/18 were agreed.

5 Risk Management 1 DP Directorate Risk Registers

DP presented the Audit Committee with a summary update of the CCG’s directorate risk registers. DP advised that there are a total of 56 risks recorded on the directorate risk registers of which 9 risks had been escalated to the Board Assurance Framework. DP further advised the risk break down as:

• 5 red (extreme) rated risks • 37 amber (high) rated risks • 12 medium (yellow) rated risks • 2 low (green) rated risk

VM sought clarity in respect to the Care Home risk which was recorded as new risk on the Quality and Governance Directorate’s risk register.

The Audit Committee noted the update against the CCG’s directorate risk registers.

DP

6 Risk Management 2 DP Board Assurance Framework (BAF)

DP presented the Audit Committee with the latest draft BAF. DP advised that the BAF details as presented may change before final presentation to the CCG’s Governing Body at its meeting 24 January 2018. DP advised that at the end December 2017 there were 9 risks reported through to the BAF of which 4 risks are extreme (red) rated and 5 risks are high (orange) rated.

DP further advised that since the last report to the Audit Committee:

o There had been 2 new risks added to the BAF: - There is a risk of inadequate nursing standards and quality

management processes within a Care Home in Waltham Forest - There is a risk that a variation in the delivery of primary care

compromises patient safety, patient experience and the provision of quality of care, highlighted in the Integrated Assessment Framework (IAF) report.

LB sought clarity from NA in respect to the recording of primary care performance risks on the CCG’s BAF given that the primary care commissioning committee (PCCC) was not directly accountable for such performance issues. NA, supported by AW, confirmed that this was the case given that the PCCC was accountable for spending funds for which the CCG was accountable. The Audit Committee noted the update against the CCG’s Board Assurance Framework.

`

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3

7 External Audit JS presented the Audit Committee with the draft External Audit Plan for

2017/18. JS drew attention to the 2 key risk areas that the regulator required the external auditors to consider as part of their audit approach:

- Fraud risk from revenue recognition - Fraud risk from management override of controls

VM enquired if changes to accounting standards would impact the CCG. NH clarified that there would be no impact on the current year but there would be an impact on future years. The Audit Committee approved the report.

8 Internal Audit 1 NA CCG Internal Audit:

NA presented the Audit Committee with an update of the internal audit plan. NA advised that there were no issues relevant to the CCG noting that: Draft reports One report from the 2017/18 plan had been issued in draft since the last Audit Committee: • Board Assurance Framework and Risk Management Work in progress Two reviews were in progress relating to • Conflicts of Interest – quality assurance stage • Primary Care Delegated Commissioning – fieldwork stage CSU Quality Assurance: NA presented the Audit Committee with an update against the NEL CSU Quality Assurance Plan progress report. NA advised that since the last report to the Audit Committee there had been 1 audit completed:

• Procurement (all 12 CCGs) – PARTIAL ASSURANCE NA drew attention to the details in relation to the Procurement audit including the need for;

- Better definition required within the CSU’s service level agreements with CCGs

- Consistency of reporting in order to ensure alignment to agreed KPIs

- Clarification of authorisation levels NA noted that whilst not presenting major procurement related issues there would be a need for a reference to be made within the Head of internal Audit Opinion (HOIAO). NA further advised that due to a lack of response to a number of audit recommendations some issues had been escalated to the CSU senior management and that these were now being progressed.

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4

The Audit Committee noted the CCG internal audit report and noted the update against the CSU Quality Assurance Plan.

9 LCFS Report GH

GH presented the Audit Committee with a formal update of the progress against the LCFS Work Plan for 2017/18. GH drew attention to key actions completed to date, noting actions undertaken in respect to Governing Body training and work undertaken in regard to the CCG’s policies and procedures. VM sought confirmation of the CCG’s good assurance in respect to the management of counter fraud. GH assured VM and members of the Audit Committee that this was indeed the case. The Audit Committee noted the update against the LCFS Work Plan.

10 CCG Report (1) JM

Contract Audit of CCG employees: JM presented the Audit Committee with a summary of the outcome of a recent employment contract audit of the HR files for all 62 NHS Waltham Forest CCG employees. JM advised that audit was undertaken following a recent occurrence where one CCG employee had not had a contract of employment in place. JM further advised that the purpose of the audit was to ascertain the contractual documentation held on file for each employee and to detail the next steps that would be taken by the NEL CSU HR team for any employees who did not have a contract of employment on file. JM advised that the audit had identified that there were 2 employees who transferred from the PCT / CSU who did not have a full PCT/BSA contract of employment on file but did have an amendment to contract on file for their current role. JM noted that the issues relating to the 2 employees were being addressed and further noted the lessons learnt in respect to TUPE arrangements which may be applicable in future commissioning arrangements. The Audit Committee noted the report.

11 CCG Report (2) LB

Corporate Credit Card Standard Operating procedure (SOP) LB presented the Audit Committee with Corporate Credit Card SOP. LB advised that the procedure formalised the CCG approach for the use of the CCG Corporate Credit Card. LB drew attention to key areas of the SOP including; - When to use the Corporate Credit Card - How to use the Corporate Credit Card - Guidance for Internet purchases

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The Audit Committee noted the Corporate Credit Card SOP.

12 Draft Assurance Plan 2018/19 DP

DP presented the Audit Committee with draft assurance plan to support its activities during 2018/19. DP drew attention to; • The proposed details of the assurance plan • The specific areas of clarification in respect to the date of Final Accounts sign off • Areas in relation to CSU assurance and CCG Management Report assurance not being specifically factored into the overall schedule but would be reviewed as appropriate through the scheduled deep dive reviews. NA noted that issues relating to the CSU activities would be fed back into the CSU assurance plan via the internal audit QA process. VM noted that issues arising from deep dive reviews could be fed back into the internal audit process to ensure full discussion and exploration. The Audit Committee agreed the Assurance Plan for 2018/19.

13 Forward Planner

Noted

14 Private discussion between Audit Committee and Auditors

Not applicable on this occasion 15 AOB

Sponsorship: JM advised the Audit Committee of a recent BMJ article that had been published following an FOI request and which had identified WFCCG in respect to issues associated with sponsorship. JM further advised that the article had not provided any context and had excluded relevant facts. JM further advised that whilst the article had prompted some actions to be taken by the CCG (e.g. publication of details on the website) NHS England were content with the CCG’s response. JM further advised that future with CEPN would not include sponsorships and that the CCG’s position was that the issue was now closed. JM provided further details in relation to CEPN and the governance arrangements in place in regard to sponsorships. AW, supported by NA, noted that it would be beneficial to record greater details in respect to gifts and hospitalities on the gifts and hospitalities register. AW further noted that for future the Governing Body should be informed of sponsorship arrangements given the potential damage to the CCG’s reputation.

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Next Meeting Wednesday 7 March 2018 10:00 – 12:00, Kirkdale House Signed …………………………………………… Date ………………………….

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Highlights (Performance and Quality Committee) [January 2018]

Item 7.2

Committee Minutes

Performance and Quality Committee – January 2018

From Helen Davenport, Director of Nursing, Quality and Governance - WFCCG

Key Highlights Cancer Performance

1. October – All of the 8 national standards were achieved including the 62 day wait target.

2. Year to date all but 62-day wait - urgent GP referral are on track to achieve year end targets.

3. Cervical screening uptake shows slight drop in performance to 67.9% from 68.03%, 13 practices remain above the 71% target. 10 practices have additional patient call support.

4. £737,000 funding has been identified for early diagnosis to be shared across NEL for the 12 work streams, decision on final schedule of projects to be held.

5. Community engagement session identified a request for further information on the screening programme.

Patient Experience Report Barts Health

1. Currently awaiting confirmation of the new patient experience solution. 2. The 95% target for patients to recommend the service has not been achieved. 3. Friends and Family Test (FFT) response rates have increased compared to

September’s figures. Emergency Department achieved 11% response rate in October.

4. The 80% target for percentage of complaints responded to has not been achieved. A revised trajectory for compliance requested.

NELFT

1. November - 2 complaints were received and 100% of complaints were responded to within the agreed timeframe

2. Community services continue to achieve a higher percentage of patients that would recommend the service though the Friends and Family Test.

Primary Care

1. 85% target for percentage of patients to recommend their GP practice through the friends and family test was achieved.

GP Alerts

1. 34 alerts were received in November 2. The main theme for Barts Health NHS Trust GP alerts is communication issues, with

sub themes for delays in care, results not received, failure to provide fit note and inappropriate care.

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Monthly Quality Report Whipps Cross Hospital

1. Friends and Family Test response rate in the Emergency Department achieved 15% response rate in October.

2. 4 serious incidents were overdue. 3. 1 grade 3 pressure ulcer reported in October, a decrease of 6 compared to the

previous month. 4. 3 mixed sex accommodation breaches were reported in October relating to critical

care step down. 5. 71% of complaints were responded to within the agreed timeframe in October which

is a decrease of 21% from September. NELFT

1. Staff turnover 10% target was not achieved reaching 13.9% in November. Barts Health Quality Accounts Priority Area

1. Review of NELFT Quality Account Priority Area indicates that the 9 priorities linked to the Care Quality Commission domains have either been completed or are on track for delivery.

Heathlands Assurance Visits

1. Following receipt of intelligence of safeguarding alerts relating to resident continence care a joint quality assurance visit was conducted on 07 November 2017.

2. Identified that over the previous six month period a significant number of safeguarding alerts had been raised.

3. Quality and Safety Concerns weekly meetings and programme of quality visits established.

4. All safeguarding alerts to be reviewed by the Adult Social Care team.

Learning Disabilities Dashboard

1. 20.87% of health checks completed as of October 2017 and within year end trajectory.

2. All required adult care and treatment reviews completed. 3. 59 people were funded out of the NHS continuing Health Care learning disabilities

budget of which 74.5% have an active care plan. Annual Safeguarding Adults Report

1. The MARIC and MASH referral forms will be combined. 2. Specialist training being developed for 2018. 3. The committee noted that the safeguarding training strategy will be reviewed and

updated following the publication of the intercollegiate guidance from NHS England. 4. Priorities for 2017/18 include:

• Continue to support implementation of the Care Act 2014. • Ensure that lessons learned from safeguarding adult reviews and domestic

homicide reviews are considered and applied and embedded consistently.

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• Support and strengthen the internal audit processes to reflect the emerging local trends in adult protection and ensure that service response to needs are sensitive to these findings.

• Continue to actively contribute as a member of the Waltham Forest Safeguarding Adults Board.

• Support and monitor providers with the applications of Deprivation of Liberty • Ensure that services commissioned are effectively engaged in local

safeguarding forums. Integrated Safeguarding Children and Looked After Children Quarterly Report

1. Committee updated on the progress with initiatives to safeguard vulnerable children and promote health and wellbeing.

2. New e-learning Prevent Training package to be introduced via the OLM platform in quarter one. Expectation that all Waltham Forest CCG staff will be complaint by February 2018.

3. There were 2 child deaths during quarter 3 one of which was an unexpected death and has been reported as a serious incident.

4. London Borough of Waltham Forest is participating in the Home office Syrian resettlement refugee programme and has pledged to take 10 families. GP practices will not be assigned until it is confirmed which locality the families will be located in.

5. A LAC visioning led by the Health Strategic Partnership Board is scheduled for February.


1. There are currently 13 low risk, six medium risk and seven high risks. The seven targets considered high risk are:

• Cervical Cancer Screening • Diabetes Structured Education • Renal • CHC Assessments in 28 days • A&E performance at Whipps Cross • Pressure ulcers at Whipps Cross • Delayed Transfers of Care

2. Based on the latest data the CCG does not expect to meet the above targets for

2017/18. 3. In relation to diabetes the CCG continues to focus on patient engagement and

referrals to both the face to face and the online training. There were no items for escalation to the Governing Body

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Performance and Quality Committee Meeting Date: Wednesday 10 January 2018

Time: 9.45am – 12.15pm

Venue: Boardroom, Kirkdale House, Leytonstone

Chair: Attendees: Apologies:

Dr Dinesh Kapoor (DK) Dr Dinesh Kapoor DK Dr Ken Aswani KA Kay Saini KS Paul Smollen PS Enrico Panizzo EP Isabelle Davies-Tutt IDT Stephanie Good SG Carl Edmonds CE Kelvin Hankins KH Dr Tonia Myers TM Jonathan Cox JC Korkor Ceasar KC Mark McLaughlin MMcL Dr Mayank Shah MS Dr Sabeena Pheerunggee SP Anne Walker AW Les Borrett LB Dr Munesh Mistry MM Helen Davenport HD

Minutes 1. Welcome and apologies DK DK welcomed all and apologies received were noted.

The committee sent their deepest condolences to Anne Walker whose mother has passed away.

2. Declaration of interest register DK None 3. Minutes of last meeting Minutes were approved with a minor change to the Chair’s update. The notes read

ECG instead of ANG. 4.0 Actions outstanding from previous meeting / Matters Arising Action The action tracker was reviewed, outstanding actions were updated and actions completed were closed. It was identified that the committee was not quorate, the committee proceeded and all agenda items will be discussion however all reports cannot be approved, the committee will make a recommendation for reports to be approved which will be presented to the quorum members outside of the meeting.

5.0 Chair’s Report Briefing – Whipps Cross (WX) Clinical Forum Minutes

Chair

The Chair noted that the committee was not quorate due to the fact there were no CCG Executive directors present. It was therefore agreed that the reports would be approved virtually after the meeting. DK gave a brief report on the Whipps Cross Clinical Forum for January which was attended by the Renal Consultant at Whipps Cross. It was

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agreed that the uptake at the virtual clinic needed to be improved and that the consultants would provide advice and guidance to GPs with the service set up and ensure the service ran smoothly for all System One practices. Whipps Cross have also agreed to update at the locality meetings.

6.0 Cancer Performance

In October seven of the eight national standards achieved target including the 62 day wait target which achieved over 90%. There were only four 62 day breaches in October. All but one of the national standards are currently on track to achieve target, which is the 62 day wait from referral target. The CCG is aiming for cervical screening uptake of 71% based on practices’ recording of screening in Open Exeter. There was a slight drop in performance in December to 67.9% however thirteen practices remain above 71% with five practices whose screening uptake is between 69% and 71%. Following invitations sent on behalf of Dr Shah 10 practices accepted the offer of additional support to call patients and discuss screening. Calls have begun to take place and as of 22 December 582 calls to patients were made across six practices resulting in 94 appointments. Other than patients not wishing to discuss booking an appointment at the time of the call no significant matters have as yet been identified in the responses given by patients who declined to make a booking. The report noted that at one practice the number of appointments for smears are limited to three or four per day therefore even when a nurse appointment is available patients are unable to book a smear. TM requested that the CCG check if this is one practice or several. Action: SG to investigate how many GP practices operate a system limiting the number of smears per day. The committee noted that there have been delays regarding the CSU marketing team data. JC asked when the screening calls took place if they were aware of the age of the patient and if they had previously had a smear test. SG stated they knew the age but did not know if they had previously been screened and would find out. Action: SG to find out if screening calls hold information regarding whether a patient has been previously screened. SG updated the committee that 737k of funding had been identified for early diagnosis to be split across NEL for the 12 work streams. Currently unsure which CCG will lead for projects 18/19. A meeting has

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been scheduled for 21st February and the funding release decision will be made then. Action: SG to share plans for funding and Performance and Quality will continue to receive updates. Three community engagement activities were undertaken in November and December. One of the main findings was that relatives of the women in the target group were interested in hearing about the screening programme. This information will be used to inform further events. A workshop is soon to be confirmed for February with attendees from the Local Authority, patients and the public and providers. KC advised that there were some safeguarding events in February which could be linked into cervical screening. Action: SG/KC to pick up outside the meeting and discuss linking screening into safeguarding events. TM requested clarity on the number of smears opposed to the number of appointments as the data will look very different once DNAs are taken into account. Action: SG to separate the data recorded so the committee can look at the number of appointments against the number of smears. TM also asked if it would be possible to look into the possibility of smears taking place at Gynaecology appointments otherwise there is a missed opportunity for women to be screened. The committee confirmed that Whipps Cross did not currently run a smear clinic and neither did the Female Genital Mutilation Clinic. TM also thought the Ludwig Goodman Centre could be used for screening. Action: SG to look into possibility of using gynaecology appointments to screen women as well as use of the Ludwig Goodman Centre in Newham and the FGM clinic. SG stated that they are trying to link in with cervical screening awareness week and requested Public Health support which JC agreed. The Committee recommends the report for approval

7.0 Quality Patient Experience Report

Barts Health Commissioners are currently awaiting confirmation from the trust as to who the new patient experience solution will be. Once confirmed an

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update will be included in the report for Performance and Quality Committee. 95% target for percentage of patients to recommend the service has not been achieved. FFT response rates have increase compared to September’s figures where there was a slight decrease. ED achieved 11% response rate in October. The 80% target for percentage of complaints responded to within the agreed timeframe has not been achieved. Commissioners have asked for a revised trajectory that identifies resources required. NELFT Two complaints were received in November 100% of complaints were responded to within the agreed timeframe Community services continue to achieve a higher percentage of patients that would recommend the service through the Friends and Family Test. Primary Care 85% target for percentage of patients to recommend their GP practice through the friends and family test was achieved. GP Alerts 34 alerts were received in November The main theme for Barts Health NHS Trust GP alerts is communication issues, with sub themes for delays in care, results not received, failure to provide fit note and inappropriate care. One complaint was received in November for Waltham Forest CCG in relation to a patient raising concerns around the change in location of the phlebotomy clinic. The CCG responded in liaison with NELFT. The CCG have still not been informed who new contract holder will be. IDT will update once known. TM requested that the CCG look into appointment booking for phlebotomy as it was reported that there were no appointments available online for several weeks. Action: KH agreed to monitor availability for phlebotomy as part of contracting. TM also requested that DK look into Domiciliary Phlebotomy how GPs can access T-Quest form for domiciliary phlebotomy. Action: DK to pick up outside meeting and feedback to TM on how a T-Quest form can be actioned for domiciliary phlebotomy.

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The Committee recommends the report for approval Monthly Quality Report The committee were requested to note that the Barts Health NHS Trust data was not available at the time of the report. Whipps Cross Hospital

• Friends and Family Test response rate in the Emergency Department achieved 15% response rate in October.

• There were four overdue serious incidents • There was one grade 3 pressure ulcer reported in October, this

is a decrease of 6 compared to the previous month. • 3 mixed sex accommodation breaches were reported in October • 71% of complaints were responded to within the agreed

timeframe in October which is a decrease of 21% from September.

NELFT Staff turnover 10% target was not achieved reaching 13.9% in November. The Committee recommends the report for approval. Quality Account Priority Areas – Progress Report – NELFT Each year NHS Foundation Trusts are required to prepare a quality account to reflect on the previous year’s practice and to set out their key quality objectives for the year ahead. For 2017/18 NELFT aligned the 9 quality account priorities to the Care Quality Commission domains. All goals and actions have either been completed or are on track for delivery. TM noted that GPs do not use the GP alert system for NELFT in the same way they do for Barts Health. The committee noted that mental health services seldom have GP alerts and that it was important that primary care was happy with the service provided by NELFT. The committee were requested to note the report for information. Heathlands Assurance Visits PS requested the committee note for information an update on Heathlands. NHS Waltham Forest Clinical Commissioning Group received intelligence that seven safeguarding alerts had been raised on one shift at Heathlands Care Home relating to resident continence care. As a result a quality assurance visit was conducted at Heathlands Care Home on 7 November 2017 in partnership with the London Borough of Waltham Forest. That assurance visit noted a number of significant

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areas of concern in particular that over the previous six month period a total of 27 safeguarding alerts had been raised.

On the 21 November 2017 a meeting was held with Waltham Forest CCG, LBWF and Heathlands Operational team on the concerns raised in the assurance visit and the level of safeguarding alerts. London Borough Waltham Forest Adult Social Care team identified that Heathlands Care Home had 52 safeguarding alerts over the previous six month period, far significant that previously known. At the meeting a number of themes were identified based on the safeguarding alerts and the areas of concerns noted in the assurance visit.

It was decided that Heathlands Care Home over the course of the next few weeks would receive a number of unannounced joint Waltham Forest CCG and London Borough Waltham Forest assurance visits. In addition a weekly Quality and Performance meeting would be held between Heathlands Care Home, Waltham Forest CCG and London Borough Waltham Forest, led by the CCG. Heathlands Care Home would develop a proactive action plan based on the trends and themes on the recommendations of the assurance visits then develop operational pathways to improve standards. The weekly Quality and Performance meetings would review the action plan to ensure progress was being made.

In addition the Adult Social Care team would investigate all safeguarding alerts and provide an update on each investigation at the weekly meeting.

Weekly quality assurance visits will continue at Heathlands Care Home that focus of the thematic areas in order to assist the home with monitoring against the action plan. The committee will be kept up to date of any further issues and progress.

Learning Disabilities Dashboard KH updated on the committee on the learning disabilities and CHC dashboard. As of October 2017 the percentage of completed health checks was 20.87%. This is in line with the expected trajectory as many of the checks are completed in the latter part of the financial year. All required adult CTRs have been completed and there is one CETR due to be undertaken in January 2018. Between June 2017 and January 2018 a consultation on a joint Learning Disability vision took place. The feedback from the consultation is currently being analysed and adjustments to the draft will

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subsequently be made. This will then be reviewed by the Joint Strategic Commissioning Committee in late January and will agree changes, timescales and responsibilities. As of the end of December 2017 59 people were funded out of the NHS continuing health care learning disability budget. This includes two new patients who became eligible in December 2017. Of the current 59 patients only 74.50% have an active care plan. The previous care plan was deemed not fit for purpose and a new care plan template has been put in place. Currently 50.84% of patients have had their reviews done have their care plans on the new template. The service has been asked to produce an action plan, which will be monitored by the contracting team. KH requested that the committee note that as of January 2017 Waltham Forest are the only CCG in North East London to no longer have a patient in hospital longer than five years. KH confirmed that Mile End host specialist services for eye health. TM requested that a list of specialities was pulled together into one database for reference for GPs including eye health and oral health and for this to be sent out in the GP newsletter. Action: Primary Care to pull together a list of specialist care services for Learning Disabilities and Communications to send out via the GP newsletter. The Committee recommends the report for approval Annual Safeguarding Adults Report The report updated the committee on the national and local safeguarding adult’s duties and requirements, and existing plans to meet these. Priorities for 2017/18 include:

• Support the implementation of the Care Act 2014. • Ensure that lessons learned from safeguarding adult reviews

and domestic homicide reviews are considered and applied and embedded consistently.

• Support and strengthen the internal audit processes to reflect the emerging local trends in adult protection and ensure that service response to needs are sensitive to these findings.

• Continue to actively contribute as a member of the Waltham Forest Safeguarding Adults Board.

• Support and monitor providers with the applications of Deprivation of Liberty

• Ensure that services commissioned are effectively engaged in local safeguarding forums.

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The committee noted that the safeguarding training strategy will be reviewed and updated following the publication of the intercollegiate guidance from NHS England. TM stated that the training provided for GPs on safeguarding was excellent however it would help if there could be a session that was broader and covered all topics rather than separate sessions concentrated on more specialist topics. KC confirmed that specialist training was in the pipeline for 2018. The committee also noted that due to issues with using the incorrect referral forms for MARIC and MASH a pilot will be run which will incorporate both referral forms into one. This will be reviewed at the end of the pilot with the idea of rolling it out permanently if successful. The Committee recommends the report for approval Integrated Quarterly Report for Safeguarding Children and LAC The committee were updated on the progress with initiatives undertaken with the health economy to safeguard vulnerable children and promote the health and wellbeing of LAC. Key highlights:

• Work is ongoing to improve reporting on training compliance with a new e-learning Prevent Training package to be introduced via the OLM platform in quarter one.

• Dates for three further prevent mop-up sessions will be circulated for quarter 4 with the expectation that all Waltham Forest CCG staff will be compliant by February 2018.

• There were two child deaths during quarter 3 one of which was an unexpected death and has been reported as a serious incident.

• London Borough of Waltham Forest is participating in the Home Office Syrian resettlement refugee programme and has pledged to take 10 families. GP practices will not be assigned until it is confirmed which locality the families will be located in.

• A LAC visioning led by the Health Strategic Partnership Board is scheduled for February.

The Committee recommends the report for approval

8.0 Performance CCG Scorecard 2017/2018

EP updated the committee on the score card.

There are currently 13 low risk, six medium risk and seven high risks.

The seven targets considered high risk are:

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• Cervical Cancer Screening • Diabetes Structured Education • Renal • CHC Assessments in 28 days • A&E performance at Whipps Cross • Pressure ulcers at Whipps Cross • Delayed Transfers of Care

Based on the latest data the CCG does not expect to meet the above targets for 2017/18. However the committee was requested to note that majority have shown improvements.

The most challenging targets have been diabetes, renal and A&E.

For diabetes the CCG continues to focus on patient engagement and referrals to both the face to face and the online training. TM noted that it was important that the number of referrals were reduced. IDT updated that this was due to be discussed at the patient reference group for January.

EP flagged that personal health budgets were a risk however KH confirmed that the target would be met by the end of March however CHC assessments will not be met but will see an improvement.

Action: The scorecard for 2018/19 will be reviewed by the March Committee

Action: The committee requested that a review of what personal health budgets were used for come to the committee. KH agreed to do this for March.

JC asked if indicators will be reviewed EP confirmed that they would.

JC asked if the Public Health scorecard could come to the February Committee and this was greed. EP stated that he was happy to discuss in advance and share our scorecard with JC.

Action: Public Health scorecard to come to committee in February.

The committee agreed that the public health scorecard should come for review every quarter.

DK requested that a Primary Care review come to the committee from the Primary Care Committee. EP agreed to update at February Committee.

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Action: EP to bring an update on primary care to the February committee.

Planned Care Report – Forward Planner

SG requested that the committee state what feedback is required regarding planned care.

Agreed that the July committee would discuss independent hospitals and the contractual issues, performance and availability of service as well as what is commissioned and the delivery model.

An MSK update on where mobilisation is since the last update for April.

TM requested that waiting times were included in the update report. DK confirmed MSK is on agenda for clinical forum.

KA suggested that the committee should look at the paediatric hot clinic model review for other services.

9 Governing Body Escalation No items were requested for escalation.

10. AOB

TM updated the committee that the current CAMHS issues will be added to risk register The committee noted that NELFT are only accepting urgent referrals for 6 months due to current waiting times and an update will come to the committee at a later meeting.

Details of next meeting:

Date: Wednesday 14 February Time: 9.45am – 12.15pm Venue: Boardroom Kirkdale House

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Highlights [Planning & Innovation Committee] [January 2018]

Item 7.3a Committee Minutes

Planning and Innovation Committee – January 2018

From Jane Mehta, Managing Director - WFCCG Key highlights Out of Hours Home Visiting EP presented the report and updated the committee on commissioning plans regarding the home visiting element of the current GP Out of Hours. The paper outlines the current service and data from the national GP patient survey which shows negative figures for the overall experience of the service. The proposed change would also support the development of the proposed Accountable Care System for Urgent Care by bringing home visiting services within the scope of this work. The new model has expanded the Rapid Response service to include a senior prescribing nurse as well as a sitting service. The aim of the new model is to make Rapid Response a 24/7 service. In addition to this NELFT have agreed nurses can now confirm death and training is in place with roll out planned for 1st April. The committee approved the report. Commissioning Strategic Plan 2018 Refresh SYM presented the Draft CSP SYM requested that all Clinical Directors with portfolios should review the relevant sections and feedback to SYM by Monday 15th January. A draft will go to Governing Body in January provided there are only a few amendments the CSP will be approved, if there are a large number of amendments it will be approved in February’s Governing Body. Direct GP Access for Non Obstetric Ultrasound and Echocardiogram Service Specification Ambulatory, Blood Pressure and ECG Services Spec Items 6 and 7 were taken together. The committee was requested to approve both service specs verbally and agreed that there would be some slight tweaks but no change to delivered services only a need to re-procure. TM stated that it was important to get the service specifications right and ensure that Barts Health follow the same model. The committee agreed that subject to some minor changes the service specifications could be signed off virtually or at the latest at the February meeting. Accountable Care System for End of Life Care in Waltham Forest JM presented a summary paper for discussion around the difficulties relating to changes with the End of Life care in Waltham Forest. The aim is to create an ACS which has 24 hour system of care for Waltham Forest and a dedicated resource into facilitation in care homes. JM asked the committee to note that there is currently no Governing Body representative on

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the End of Life working group. There is also no clinical lead and the CCG are currently looking for a replacement. JM confirmed that NELFT/Whipps Cross will work together as providers and staff will report to both organisations. Rapid Response are also part of the conversations. Agreed that CDs are not happy with the services provided by NELFT and there needs to be another discussion regarding this at the next Committee in February. JM also confirmed that St Josephs are part of the discussions and the CCG are currently unpicking some of the gaps in CCG contracting highlighting the differences between the three Barts Health sites and how they are run. Updates will continue to come to the committee Amalgamation of the P&I Committee and Finance & QIPP Committee JM and AW proposed that Planning and Innovation Committee should be merged with Finance and QIPP committee. The committee were in support of this suggestion. JM agreed to work up the review for the January Governing Body including a review of the Terms of Reference The committee agreed the proposal and requested that the committee was renamed. The forward plan will be merged with the Finance and QIPP forward plan going forward. The committee agreed the proposal.

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PLANNING AND INNOVATION COMMITTEE

Minutes of Meeting held on 10 January 2018

Boardrooms B&C

Chair: Alan Wells (AW) Attendees: Ken Aswani (KA) Ravi Gupta (RG) Abdul Sheikh (AS) Dinesh Kapoor (DK)

Mayank Shah (MS) Syed Ali (SA) Tonia Myers (TM) Jane Mehta (JM)

In Attendance: Paul Smollen (PS) Kelvin Hankins (KH)

Sharon Yepes-Mora (SYM)

Apologies: Anwar Khan (AK)

Item Action

1 Apologies Apologies were noted as above.

2 Declarations of Interest

None

3 Minutes of the last meeting / Matters Arising The minutes of the last meeting were agreed as accurate with a minor

amendment to the section under planning. The quarter 2 update will be presented at Governing Body not the Planning and Innovation Committee.

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4 Out of Hours Home Visiting EP EP presented the report and updated the committee on commissioning

plans regarding the home visiting element of the current GP Out of Hours. The role of GP Out of Hours is changing in response to national reconfiguration of NHS 111 services. GP triage is being integrated within NHS 111 and what was previously termed “GP Out of Hours” will no longer be provided. CCGs need to consider how the functions previously provided by GP Out of Hours are mainstreamed to provide access to urgent primary care. The paper outlines the current service and data from the national GP patient survey which shows negative figures for the overall experience of the service. The proposed change would also support the development of the proposed Accountable Care System for Urgent Care by bringing home visiting services within the scope of this work. The new model has expanded the Rapid Response service to include a senior prescribing nurse as well as a sitting service. The aim of the new model is to make Rapid Response a 24/7 service. In addition to this NELFT have agreed nurses can now confirm death and training is in place with roll out planned for 1st April. This will ensure a reliable service for care homes out of hours as some care homes have experienced issues with six hours waiting times for out of hours GPs. KA stated that the intention is to provide better quality of service. EP confirmed that this does not need a procurement as NELFT are providing the service which fits into the ACS plan. The plan is also within budget with a small efficiency saving. EP also confirmed that NELFT will not do home visits. MS felt uncomfortable with phrasing and IC felt that the risks were poorly described. AW requested that EP rewrite this section. EP to relook at phrasing and speak to MS offline Approved.

5 Commissioning Strategic Plan 2018 Refresh SYM SYM presented the Draft CSP

DK requested that 6.4 relating to the WEL system in the body of report reads which reads £1.97 in error is corrected. SYM requested that all Clinical Directors with portfolios should review the relevant sections and feedback to SYM by Monday 15th January. A draft will go to Governing Body in January provided there are only a few amendments the CSP will be approved, if there are a large number of amendments it will be approved in February’s Governing Body.

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6 Direct GP Access for Non Obstetric Ultrasound and Echocardiogram Service Specification

7 Ambulatory, Blood Pressure and ECG Services Spec KH Items 6 and 7 were taken together.

KH updated on items 6 and 7. Dr Sheikh has already had sight of the service specifications and was happy. The committee was requested to approve both service specs verbally and agreed that there would be some slight tweaks but no change to delivered services only a need to re-procure. TM stated that it was important to get the service specifications right and ensure that Barts Health follow the same model. The committee agreed that subject to some minor changes the service specifications could be signed off virtually or at the latest at the February meeting.

8 Accountable Care System for End of Life Care in Waltham Forest JM JM presented a summary paper for discussion around the difficulties

relating to changes with the End of Life care in Waltham Forest. The aim is to create an ACS which has 24 hour system of care for Waltham Forest and a dedicated resource into facilitation in care homes. JM asked the committee to note that there is currently no Governing Body representative on the End of Life working group. There is also no clinical lead and the CCG are currently looking for a replacement. MS asked how the CCG have managed the Margaret Centre/NELFT. JM explained that this has been managed by discussions with them and ensuring that they are on board to work with the community and having primary care to support Whipps Cross. It has also been important to support the change of focus and for the Margaret Centre to understand the changes are positive. There has also been support from consultants to change the focus of The Margaret Centre and reassuring them that there is no desire to decommission. JM confirmed that NELFT/Whipps Cross will work together as providers and staff will report to both organisations. Rapid Response are also part of the conversations. SA asked if there will be a change to NELFT as a provider JM/AW clarified that this was not a re-procurement. Agreed that CDs are not happy with the services provided by NELFT and there needs be another discussion regarding this at the next Committee in February. TM stated that it was important to ensure that staff are adequately trained. JM confirmed that there are lots of discussions around rolling out training and recruitment.

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JM also confirmed that St Josephs are part of the discussions and the CCG are currently unpicking some of the gaps in CCG contracting highlighting the differences between the three Barts Health sites and how they are run. Updates will continue to come to the committee.

9 Amalgamation of the P&I Committee and Finance & QIPP Committee JM/AW JM and AW proposed that Planning and Innovation Committee should be

merged with Finance and QIPP committee. The committee were in support of this suggestion. DK supported the suggestion and noted that there would need to be a strict monitor of all conflicts of interest. DK was in support of a review of all committees in order to make the best use of Clinical Directors time. AW noted that it had not been possible to combine committees over WEL as there was a need to have committees relating to primary care, performance, audit etc at a local level. AW stated that there was a need to keep a strong clinical input even though the committee would no longer exist as a standalone. PS suggested that any clinical reviews could be done before meeting takes place. AW also stated that adding finance to Planning and Innovation would be beneficial with two thirds of the meeting dedicated to planning and innovation and one third to finance and QIPP. MS was also in support of the idea of streamlining committees. PS made the point that clinical input was not just GPs and there was a need for a wide range of clinical input from nurses to special directors at Barts Health. AW noted that this was from a commissioning perspective only and that would be only GPs on our governing body. Barts Health would be conflicted as a provider. SYM noted that it was important not to lose strategic planning with the merge of the two committees. JM agreed to work up the review for the January Governing Body including a review of the Terms of Reference The committee agreed the proposal and requested that the committee was renamed. The forward plan will be merged with the Finance and QIPP forward plan going forward. The committee agreed the proposal.

Date of next meeting: Wednesday 14 February 2018

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Highlights [Finance and QIPP Committee] [January 2018]

Item 7.3

Committee Minutes

Finance and QIPP Committee – January 2018

From Jane Mehta, Managing Director - WFCCG

Key highlights The Committee received the month 9 (December) finance report.

The Committee reviewed the QIPP performance report reflecting M8 SLAM data.

The Committee received an update regarding the development of the local end of life care pathway and the move towards risk sharing within an ACS framework.

The Committee received a detailed report covering Q2 performance on GP prescribing budgets.

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Meeting Finance and QIPP Committee

Date and time 17 January 2018

Boardrooms B&C, Kirkdale House

Chair Alan Wells

Attendees: Apologies:

Alan Wells (AW), Enrico Panizzo (EP) Ian Clay (IC), Jane Mehta (JM), Vineeta Manchanda (VM) Abdul Sheikh (AS), Kelvin Hankins (KH), Sharon Yepes-Mora (SYM), Steve Collins (SC), Ben Jupp (BJ) Les Borrett (LB)

Agenda Items and Summary 1-2 Notes of last meeting The minutes of the last meeting were agreed with minor amendments as set out below.

• To consider having an annual review of current QIPP schemes and their achievements and to be considered by an amalgamated Finance & QIPP Committee and Planning and Innovation Committee if such an amalgamation is approved by the Governing Body.

• JM /AW to raise the possibility at the Governing Body of an individual Clinical Director being responsible for the QIPP programme.

3. Conflict of interest None 4. Matters arising None

5.QIPP Report Month 8 EP presented the report to The Committee and explained that the figures and the risk areas remain the same as the previous, last month. The full year forecast savings are £13.57m (94.1% of plan) and M8 YTD savings are £6.9m. EP noted that the integrated care figures from month five onwards were not accurate due to changes in the counting and coding of ambulatory care at Whipps Cross. This has resulted in an apparent increase in emergency admissions that is the result of a change in counting and not the impact of a change in patient pathway. The QIPP forecast assumes that savings have continued to be made and there has been no underlying change in performance in relation to Integrated Care projects. The change in coding of ambulatory care was undertaken to provide a greater richness in the clinical record for ambulatory care but had an unintended impact on CCG performance reporting. This has been discussed and clarified with NHS England. IC noted that contract discussions for 17/18 with Barts were progressing and that this would include resolution of risks related to QIPP. The bottom line prediction for this year should not worsen.

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6. Finance Report Month 9 IC presented the M9 finance report focusing on any material changes since last month.

The CCG are still reporting that it will deliver its control total surplus of £0.4M and meeting the running cost cap. As of month 9 we are still maintaining the £1.7M of non-recurrent head room uncommitted in line with business rules.

Revised BH projection is £3.7M over plan which is a deterioration of £0.6M.

A risk has emerged associated with a practice handing back their list to the CCG which will be assessed and included within our M10 reporting.

The CCG has now applied all other reserves in support of the M9 projected position.

The Committee discussed the financial risk this lack of available reserves poses in terms of meeting our control total and recognised that this is a very different financial position to previous financial years.

IC clarified that negotiations were ongoing with Barts regarding reaching a year end settlement and that this remained the largest outstanding risk within our reporting. He went on to clarify that NHSE are reviewing the significant impact of unforeseen drug tariff increases on CCG prescribing budgets and the potential that control totals may be relaxed in recognition of this pressure. For WF, the impact would be between £1.2M and £2.0M depending on the methodology applied by NHSE. Further updates should be available for M10.

7. Quarter Finance Report on Optimisation

KS highlighted the £475k saving, OPAT service was commissioned to help deliver savings to contribute to the QIPP target of £1 million, but also to deliver care to home and better manage the prescribing of antibiotics.

Page 2 - Table 1 month 6 elements underspent.

Risk out of area prescribing, wrong prescribing code.

Questions: The Clinical Prescribing Lead has contacted the Ecclesbourne Practice to discuss prescribing and facilitate a visit with the prescribing advisor. There is no contractual requirement for practices to come within their specified budget. However, in order to be eligible for full payment for the work delivered as part of the Medicines Optimisation Scheme, practices would need to meet their individual prescribing budgets. A total sum of £175k has been ring fenced to reward the practices for the work they undertake as part of the scheme, which will be divided amongst practices according to the ASTRO Pus.

Kay to bring any indicators back and the dashboard. Deep dive in prescribing.

8. End of Life Care

BJ from Social Finance presented the business case to The Committee and informed the members that the Business Case from July had been slightly revised. It had been considered by the Planning and Innovation Committee a number of times and will also be considered by the Governing Body for approval.

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It was discussed that during Phase One, the proposal would be to start with a limited ACS with a direct role managing the enhanced community service but with a view to also stimulating collaboration and improvement more widely and preparing to take on wider capitated budget responsibilities. An invest-to-transform arrangement would be formed around it, with the following features:

1. A Service Agreement between the CCG and NELFT (employer of new service) on the service delivery and payment through a block payment. This is expected to be a variation to the standard, existing NHS contract held with NELFT.

2. An Investment Agreement between the EoLCI and CCG to cover half of CCG costs in the first two years in return for 40% of savings in the first two years and surpluses in the following 2-3 years up to a monetary cap of the amount invested.

3. A wider Memorandum of Understanding, as part of the emerging wider Waltham Forest ACS, to review overall impacts over time and share unexpected gains/losses between local parties. This might include:

a. Principles of collaborative working

• Shared decision making using data • Identifying efficiencies that could be made with current ways of working

b. Financial arrangements to share risk and gains

• 20% of savings shared with Barts Health (nb. 40% shared with EoLCI as per (2) and remaining 40% retained by CCG)

• Downside risk-share between the CCG, NELFT, and Barts Health – should savings not exceed the amount initially invested by the CCG, this shortfall would be shared three-ways between NELFT, the CCG, and Barts Health.

• When the initial investment from the CCG/EoLCI is repaid, broaden the gainshare arrangement (e.g. split three-ways between CCG, NELFT, and Barts Health).

This approach would help reduce downside risk faced by CCG should impact on acute activity not be as high as hoped for. However, the risk that acute activity amongst patient groups outside the scope of this agreement (i.e. not within last six months of life) goes up is still a risk which the CCG must manage.

The approach to Phase Two (including which budgets would be brought within the capitation and governance) is being discussed and will be presented to Finance & QIPP for update in a later meeting.

JM asked the committee to note that there is currently no Governing Body representative on the End of Life working group and no there is also no clinical lead and the CCG are currently looking for a replacement.

JM confirmed that NELFT/Whipps Cross will work together as providers and staff will report to them both.

Updates will continue to come to The Committee

The committee agreed the split and approved

10. Any other business

None

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Highlights (IT Committee) [January 2018]

Item 7.4

Committee Minutes

IT Committee Minutes – January 2017

From Dr Mayank Shah, Chair of the Committee - WFCCG

Key highlights ERS roll-out CE updated the committee as follows:

1. It is the goal of the WFCCG to have 100% of appointments available on the ERS system, by the end of this financial year we are up to 95%.

2. 51% of patients are booking their appointments on line, which is the highest in five years.

3. CCG are working with the CSU on a communications, engagement and training programme to be implemented from April-June.

Online Consultations NHS England have made available funds for each CCG across England under the General Practice Forward View to enable the utilisation of online consultation solutions across general practice. The approach is currently being led by the North East London (NEL) STP which is creating an opportunity to embed consistency across the STP footprint. T-Quest

• T-Quest data – NP-M to circulate data via email once received. • Issue about WX requiring signatures but not at BH. DK to take to TST diagnostic

board and Phil to escalate through his route. eLPR There have been no major updates from December. Still awaiting NELFT to feedback data into the shared care function and there had been some delays with Barts. By the end of March GPs would be able to see the data in the sharecare records from:

• Barts • NELFT • ELFT

WF are also trying to get the social care data involved in this too. 18 practices required to sign up to Discovery information sharing.

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Highlights (IT Committee) [January 2018]

Patient Online:

• Patient Online: We continue to work towards set targets for Patient Online & e-

Referrals Support team continuing GP Practice visits. • Average usage across the borough is 20%. • There still had been ongoing issues with Emis 7.1 which has caused inaccuracies

with the Patient Online searches therefore data provided by CEG should be used with ‘caution’ until this issue is resolved. Emis has advised that there will be some fixes Version in 7.2.

• Priority for the MyGP app to roll out, training session for all practices on 19th January 2018. MS stated that he had received positive feedback from the patients regarding the app.

GP WIFI:

• Deployment in progress (35 sites have gone live – up from 9 last month). • Firewall issue to be overcome in some practices. • PSTN line installation in progress. • Installed Power extensions sockets in nominated practices.

CCG to ensure that an IT update is provided to Directors for Locality meetings.

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IT Committee

Date: Wednesday 17th January 2018

Time: 15:00 – 17:00

Venue: Boardroom B/C, Kirkdale House, Leytonstone

Chair: Dr Mayank Shah (MS)

Attendees: Les Borrett (LB) Dr Dinesh Kapoor (DK) Phil Koczan (PK) Carl Edmonds (CE) Adrian Dodd (AD) Shahnaz Begum (SB) Jessica Johnny (JJ) Edward Keating (EK) Aysha Patel (AP)

Apologies: Harry Nyantakyi (HN)

Bill Jenks (BJ)

Nicola Pearce-McGinn (NP-M)

Agenda items

1. Welcome and apologies MS

The chair welcomed attendees and apologies noted.

2. Updated declaration of interest forms MS

No changes advised.

3. Notes from last IT committee & Matters Arising MS

Notes approved by committee.

4. Action Log

Please refer to action log for all actions

Actions Deadline Owner


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5. Patient Online Update JJ

JJ updated The Committee from her report: There still had been ongoing issues with Emis 7.1 which has caused inaccuracies with the Patient Online searches therefore data provided by CEG should be used with ‘caution’ until this issue is resolved. Emis has advised that there will be some fixes Version in 7.2. She added that she would continue the SMS campaign with high priority on practices (below 10%) Priority for the MyGP app to roll out, training session is being held for all practices on the 19th January 2018. MS stated that he had received positive feedback from the patients regarding the app. CE asked where there had been some practices that had been on zero – had there been some technical issues. SB stated that this had meant that practices had not taken up on the free promotion.



6. WEL Updates BJ

BJ updated The Committee as follows on any key issues:

BJ stated that there had been no major updates from December. Still awaiting NELFT to feedback their data into the shared care function, there had been some delays with Barts.

He stated that by the end of March GPs would be able to see the data in the sharecare records from:

• Barts • NELFT • ELFT

WF are also trying to get the social care data involved in this too.



7. ERS update Training CE

SB updated The Committee on the following: NEL CSU IT provided some ERS training. The training had been very useful – as they had been working towards the paper switch off. She added that there had been no GPs in attendance – felt that it would have been beneficial for clinical staff to have received training. Stated that they wanted to improve the uptake of the training. CE felt that it had been important to educate GPs with the Following:

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• Allowing GPs to book on ERS • Allowing GPs to request advice and guidance • RAS – this allows request direct to the consultant

GP would also need to recognise there is a paper switch off later in the year. PK asked what the difference had been between the (1) Advice and guidance (2) RAS system. CE confirmed that (option 1) Had been able to receive lots of advice and guidance but the GP would need to make the booking. (Option 2) the consultant can only send one message back or make an appointment. Stated that the board had been deciding which had been the best offer. PK stated that there needed to be a clear message with regards to the paperless being switched off later this year. MS asked this could be brought to the locality meeting to inform the GPs. CE stated that there had been an education event at the county hotel.

Actions: Please refer to the action log for all actions

9. IT & Digital Highlight progress report HN

HN gave a verbal update from his highlighted report:

• NHS GP WiFi Implementation - 1. Wi-Fi deployment in progress 2. 39 sites completed 3. PSTN line installation in progress 4. Installed Power extensions sockets in nominated practices

Discussions were had around the staff Wi-Fi. HN stated that the CCG had to abide by what is ever on the list. He added that there had been certain websites that would be blocked. PK raised his concerns around some apps that he felt should not be blocked. HN stated that he would provide the national guidance.

• T-Quest data – NP-M to circulate data via email once received. HN stated that WX palliative care had had their log ins but still have been awaiting for their IT to be installed. NELFT are waiting to go live. He stated that Handsworth are due to be trained in February. MS asked for a monthly update on IT for the monthly Locality meetings. CE asked Harry to ensure that his update is ready for the end of the month.

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Actions: Please refer to the action log for all actions

Deadline Owner

12 AOB

None.

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Highlights [Primary Care Commissioning Committee & Primary Care Advisory Committee] [January 2018]

Item 7.5

Committee Minutes

Primary Care Commissioning Committee / Primary Care Advisory Committee – January 2018

From Alan Wells, Chair of the Committee - WFCCG

Key highlights The January PCCC meeting was held jointly with PCAC meeting. Highlights of the meeting are summarised below:

1. Walthamstow Pilot for working at scale Walthamstow Locality which is made up of fifteen practices, is in the process of developing a pilot proposal for a centralised telephone clinical triage service that will cover all practices within the Locality. The clinical sponsor for the CCG is Dr Abdul Sheikh, the locality Clinical Director.

2. Funding allocation for Waltham Forest SYM highlighted key points from her paper and informed the Committee that GPs at Walthamstow Locality meetings have raised the issue of LISs not being equitable to that of neighbouring CCGs - particularly Newham and requested an explanation from the CCG as to why there is a disparity in funding. The GPs perceived that they are not being paid for work they are already doing, which receives additional funding in Newham.

3. Electronic Referral Service

The e-Referral service was outlined and the Committee were informed that the date for paper switch off for referrals is 1st October 2018. GPs referring patients to acute care will be required to send electronic referrals, and the acute would not be paid if a paper referral is made after this date.

4. Dashboard – Primary Care Quarterly Report The Committee were updated on key highlights of the primary care dashboard. Patient online access has improved and over 60k patients can now access this. The CCG will be employing a facilitator to help practices improve uptake further. Feedback from practices is that there is a lack of support from NHSE. Red and amber ratings were discussed at length and suggestions on improvement were made.

5. Discharge to Pharmacy Project The Committee were updated on the discharge to pharmacy project that WF are leading on behalf of the STP. The aim of the project is to reduce admissions related to medication errors, adverse events or where the medication hasn’t been optimised. A working group has been set up, looking at IT and clinical aspects choosing the most appropriate patients to be part of the project.

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Highlights [Primary Care Commissioning Committee & Primary Care Advisory Committee] [January 2018]

6. Primary Care Delivery Plan/ Strategy Implementation Plan/ Achievements in

year An update of the key achievements of the PCAC and PCCC meetings for 2017 was provided, and highlights of the outcomes that had been delivered by each of the committees.

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JOINT PRIMARY CARE ADVISORY COMMITTEE PRIMARY CARE COMMISSIONING COMMITTEE

Part 1 Minutes of Meeting held on 3 January 2018

Board Room B/C, Kirkdale House

VOTING MEMBERS

Initials Role

Alan Wells AW Chair, PCCC, Lay Member, WFCCG Azeem Nizamuddin AN Independent GP, WFCCG Jane Mehta JM Director of Strategic Commissioning Caroline White CW Deputy Chair, Lay Member, WFCCG MEMBERS

Aysha Patel AP Senior Commissioning Manager, WFCCG Lorna Hutchinson LH Assistant Head Primary Care, NHSE Ian Clay IC Deputy Director of Finance, WFCCG Jonathan Cox JC Consultant, PH Alison Goodlad AG NEL Primary Care Commissioning Team, NHS England Abdul Sheikh AS Chair, PCAC, Clinical Director, WFCCG Dinesh Kapoor DK Clinical Director, WFCCG Sharon Yepes-Mora SYM Associate Director, Strategic Planning Vineeta Manchanda VM Lay Member/Conflicts of Interest Guardian Tonia Myers TM Clinical Director, WFCCG Jacqueline Pluck JP Primary Care Project Support, WFCCG Scott Smith SS Primary Care Commissioning Manager, WFCCG IN ATTENDANCE Matthew Henry MH Senior Business Intelligence Specialist Harry Nyantakyi HN IT and Digital Manager, WFCCG Carl Edmonds CE Deputy Director of Commissioning, WFCCG Shahnaz Begum SB Commissioning Manager, WFCCG APOLOGIES

Anne Walker AWa Deputy Nurse Director, Quality and Clinical Governance, WFCCG Les Borrett LB Director of Strategic Finance, WFCCG Rebecca Waters RW Communications & Engagement Manager, WFCCG

ACTIONS LOG

Who : Actions from last meeting When Complete

SYM A CCG Improvement & Assessment Framework report will be presented to the Committee post publication of the next quarter’s performance

October/ November

Outstanding.

JP/AP Homeless Health Programme and NHS England Registration policy– to add to the PCCC agenda for February or March meeting

Feb/March

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AW/JM Funding allocation for WF: The Committee to recommend to Anwar Khan to write to Jane Milligan with queries about transformation money being sustainable or a single investment.

Feb

AS Walthamstow collaborative working pilot to be presented to Patient Reference group

Feb/ March

Item Summary / Actions

Action

1 Welcome and Apologies AW/AS The Joint Chairs, AW and AS, welcomed members of the Committee to the

meeting. Apologies were noted as above.

2 Declaration of Interest ALL None.

3 Approve Minutes of the previous PCAC & PCCC Part 1 / Actions update AW/AS PCAC

The minutes of the last PCAC meeting were agreed. It was however noted that

• The minutes should reflect the discussions in a more comprehensive way without them becoming transcribed verbatim.

• Item 5 – Homeless Health Programme – to add to the PCCC agenda for February or March meeting, as some members were unclear about the link with the NHS England registrations policy for general practice and a practices contractual obligations in relation to providing access to vulnerable groups. There was also reference made to how these vulnerable groups are managed and how potential abuse of the system in relation to multiple registrations and prescribing controlled drugs can be avoided.

PCCC The minutes of the last PCCC Part 1 were agreed. Action update: A CCG Improvement & Assessment Framework report will be presented to the Committee post publication of the next quarter’s performance- SYM The Q1 for 2017/18 has been published and is being reviewed. A paper will be presented to the Committee in February.

JP

SYM

4. Walthamstow Pilot for working at scale AS/All Walthamstow Locality which is made up of fifteen practices, is in the process of

developing a pilot proposal for a centralised telephone clinical triage service that will cover all practices within the Locality. The clinical sponsor for the CCG is Dr Abdul Sheikh, the locality Clinical Director. Waltham Forest is keen to explore its joint team-based working within and between practices in the delivery and administration of care in order to reduce duplication and free up GP time to focus on caring for more complex patients.

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The proposal responds to the national strategic drivers for change for general practice. The GP Forward View demonstrates a national commitment to supporting general practice by 2020/21, improving patient care and access and investing in new ways of providing primary care. The model also addresses the high impact changes for general practice including partnership working, productive work flows and new consultation types. It supports national imperative to reduce pressures and release efficiencies by reducing the bureaucracy for practices and provides rapid access for patients for primary care appointments. The collaborative model will provide a single point of contact for patients; appointments will be made via a central booking system, sourced from a pooled resource from practices according to list size. The service will offer patients a same day consultation, either face to face or via a telephone consultation with a health professional. The service will be backed up by primary care centres with the ambition that there will be no A&E attendances due to a lack of primary care capacity. FedNet will be the vehicle to deliver the service and the business case documentation is currently being developed. If evaluation of the pilot is successful the intention is to roll out the model across Waltham Forest and ultimately have one single point of contact for all local health services. The CCG is actively engaging support for the development of this innovative proposal for how Walthamstow practices could work more collaboratively. Primary Care needs to transform the way it has traditionally provided services. • Single point of contact for patients for all GP service • Central triage system • Central booking for GP practices • Sharing resources • Offer same day consultation – face to face or telephone – to a health

professional • No patient should attend A&E as a walk-in only because he could not get

an urgent appointment with a GP. • Improving access • Reducing practice workload • Efficient and effective use of skill mix • Reducing pressure on A&E • Innovative use of technology • Promote self-care • Patients with primary care problems are seen in primary care • Telephone consultation model have proved popular and successful Back up primary care centre (PCC) (HUB) • Minor injuries centre • GP/physician assistant • Respiratory nurse • Diabetic nurse • Pharmacist • Nurse practitioner • Nurse • Dietician • Diagnostics in community

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Locality primary care centre is the way to address GP workload and working levels in general practice. Next • All GP practices in Waltham Forest • Single point of contact for all the local health services • Single contract on behalf of all practices (through Fed Net) and

community services • (PCC 8-8 7 days a week) JM asked for this project be taken to the Patient Reference Group in February. The CCG are not commissioning this pilot, but may wish to commission a set of services in the future from at scale providers. It was made clear that there is a limited amount of funding for primary care, and that if these services are commissioned, then it will affect how funding is currently distributed to individual GP practices. There will be an educational event on 22 February where the topic being covered is ‘at scale working’ and this model will be looked at as well as other models. Nav Channa will also be attending to present about the Primary Care Home work.

AS

5 Funding allocation for Waltham Forest SYM SYM highlighted key points from her paper and informed the Committee that GPs

at Walthamstow Locality meetings have raised the issue of LISs not being equitable to that of neighbouring CCGs - particularly Newham and requested an explanation from the CCG as to why there is a disparity in funding. The GPs perceived that they are not being paid for work they are already doing, which receives additional funding in Newham. SYM explained that in real terms WFCCG receives 2% less than the target funding whereas Newham receive c£8m above the equitable funding allocation. This equates to £20m difference between the two CCGs for commissioning health care for an equivalent health need. Taking into account that there has been an increased allocation, the CCG continues to face significant pressures on its budgets including for example: • Growth in population generally, and a younger population in particular, linked

to rising maternity activity • Increasing life expectancy and prevalence of long term conditions • Growth in prescribing and continuing care costs • Financial pressures at Barts Health • Reductions in funding for local authorities, including social care services. JM explained that to equalise PMS and GMS practices the CCG could use its own resources. However to equalise with other CCGs additional funding is necessary. The current restructure of NEL Commissioning allows transformation funding to be moved between CCGs. TM asked whether the transformation money is sustainable or a single investment, and whether the Governing Body has written formally to Jane Milligan asking how this will be addressed. AW agreed that the Committee would recommend to Anwar Khan to write to Jane Milligan with these queries. IC clarified that currently transformation funding is allocated non-recurrently. However it is in the gift of the STP to ensure that available investment in any financial year is targeted towards need and on an equitable basis. JM informed the Committee that the assurances given at the Board when the NEL

AW

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arrangements were discussed were that recurrent resources funding would be transferred between CCGs. Clarity about current and recurrent funding should be sought in the letter.

6 Electronic Referral Service CE/SB CE outlined the main points from his paper on the e-Referral service and

reminded the Committee that the date for paper switch off for referrals is 1st October 2018. GPs referring patients to acute care will be required to send electronic referrals, and the acute would not be paid if a paper referral is made after this date.

The CQUIN 2017/18 will encourage hospitals to ensure that the e-Referral system is up and running for all services. The Advice and Guidance CQUIN allows GPs to ask for advice before making a referral. There are three platforms in which a referral can be made; e-RS advice and guidance, e-RS referral assessment service (RAS), and e-RS Urgent or Routing referral.

WFCCG has been engaging with practices since 2016 to increase e-RS utilisation. Providers have been encouraged to ensure all services are on the system and this has been included in all contracts. At a WEL level the technology has been tested in terms of GP, patient and consultant experience. Pilots are underway for 10 services and these will be evaluated in March.

At a WEL level plans are to initiate a communications, engagement and training programme. A bid for £100k from NHSE has been successful and this is help to roll out e-RS over the next 6 months.

It was confirmed that as this system replaces the Choose and Book system, it will still allow patients to choose their date and timeslot for an appointment. The use of paper will be reduced.

DK raised the concern that the LMC believe that it is against BMA guidelines to reject a handwritten referral. This would need to be addressed in LMC and locality meetings.

VM suggested that the communication and engagement plan be presented to the Committee at a future meeting of the PCAC for GP input and this was agreed.

It was felt that the cut-off date is too ambitious and the IT system is not ready. In that case would email referrals be accepted, or any other back up. AG confirmed that this is being negotiated at national level and may become a contractual requirement.

7 Dashboard: Primary Care Quarterly Report MH/ SYM

The Committee were updated on key highlights of the primary care dashboard. Patient online access has improved and over 60k patients can now access this. The CCG will be employing a facilitator to help practices improve uptake further. Feedback from practices is that there is a lack of support from NHSE. MH asked the Committee for suggestions to improve uptake, however it was agreed to concentrate on areas that were not improving as well. Amber highlight - Health checks have reached 32.65% as on November 2017. This is below trajectory to deliver 65% by year end. Feedback from GPs is that

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there is not enough incentive for them to carry out health checks as the time taken for checks is longer than a usual appointment. JC informed the Committee that the contract for health checks is coming up for renewal in April, and there is a proposal to write to practices with the option to sub contract health checks to FedNet. The pros and cons of this were discussed. A procurement process is not required as this is a list based service. Red highlight – As of November 2017 38.2% of under 65s have received the seasonal flu vaccine. This is rated red as below proper year at 44.8% and below target of 55%. Practices have been asked to target under 65s to address this underperformance. It was noted that media reports of lack of efficacy of the vaccine has affected the number of people wanting to be vaccinated. SS informed the Committee that there has been an increase of 3% from last year. WF are 0.1% down on last year, and it is not known why the decrease has been specifically for the under 65s. It was recognised that GPs do work very hard to reach targets and that the lack of vaccine stock might affect the number of people vaccinated. It was suggested that pharmacies would be able to target under 65s easily and could provide this service to them. AO would contact the LPC so that they can circulate this message to pharmacies. Diabetes structured education referrals is also rag rated red. It was reported that the CCG commissioned an online structured education course that patients could be referred to, this is run by NELFT. As of June 2017 237 patients had been referred. The CCG’s target of 1456 patients referred will not be met my March 2018. There was concern that a high number of patients that are referred do not take up the course. Renal - The CCG commissioned a virtual CKD clinic where GPs can refer patients before referring them to nephrology as an outpatient. The aim is to reduce costs for the CCG, however the number of patients referred to Nephrology via the electronic referral is not meeting its trajectory, as practices are not participating in the online referral. It was suggested that a mapping exercise is carried out to determine which practices have made paper referrals, and how many virtual referrals have been made. It was felt that the workload for WF GPs is high and unpaid and therefore there is resistance to use this service. TH GPs receive an incentive payment for their GPs to use the trigger tool, but it was highlighted that they are not incentivised to make a referral to the virtual clinic. It is therefore unclear why GPs are not referring in this way. TM raised the concern of GPs that referral to the virtual clinic means the consultant has access to full patient notes which she feels is not acceptable as only relevant information should be shared, there was some discussion about the pros and cons regarding this and VM highlighted that she would expect all doctors to abide by their professional standards and did not see an issue with this. AW and TM highlighted that particular vulnerable groups would not want all their information shared with secondary care colleagues.

8 Discharge to Pharmacy Project AO AO informed the Committee of the discharge to pharmacy project that WF are

leading on behalf of the STP. The aim of the project is to reduce admissions related to medication errors, adverse events or where the medication hasn’t been optimised. A working group has been set up, looking at IT and clinical aspects choosing the most appropriate patients to be part of the project. Patients with CVD, diabetes and respiratory conditions would be identified if they meet the criteria on discharge. A copy of the discharge summary will go to their nominated pharmacist as well as their GP to review their medication to avoid the

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patient being readmitted. Procurement is underway for an interim IT system to support the project. Education sessions are being planned using CEPN funding for all NEL pharmacists.

9 Primary Care Delivery Plan/ Strategy Implementation Plan/ Achievements in year

AP/ SYM

AP provided an update of the key achievements of the PCAC and PCCC meetings for 2017 and highlighted the outcomes that had been delivered by each of the committees. It was suggested that in future the targets relating to the Primary Care strategy are SMART targets, however members also highlighted that they should focus on outcomes and deliverables. The Committee recognised the hard work and achievements of both of the Committees.

10 Questions from the Public There were no members of the public at the meeting.

AOB None.

Date of the next meeting: 7 March 2018

142

Highlights [CCG Patient Reference Group] [January 2018]

Item 7.6

Committee Minutes

CCG Patient Reference Group (PRG) minutes – January 2018

From Caroline White, Lay Member for Public Participation - WFCCG

Key highlights

1. GP contracts - Personal Medical Services (PMS)

Linda Finch (LF), Programme Manager at the CCG, attended to share an update on the Personal Medical Services (PMS) contract as outcomes may result in a significant change for patients.

LF presented/explained what this meant in terms of payment and that this was a chance to bring in equity into the system. LF talked through the indicators document:

After the presentation PRG members asked the following questions;

• Can I confirm what the numbers mean?

• Is the contract is linking with the PPG local standard?

• Does the contract have anything in it about the PPGs?

• Can we know which practices have signed up to which service level?

• Are there different weightings for different patient needs? Such as interpreting and health needs?

2. Online consultations programme for discussion Presentation

Tarlochan Boparai (TB), Primary Care Transformation Manager explained fund was launched to invest in online consultations.

The CCG wants it to be clear that we are not reducing face to face appointments. It is expected that up to 10% of patients will access online consultations.

The fund available is £526,000 for the seven NEL boroughs. Working together gives us more power when talking to the suppliers.

The members were interested in the following:

• Looking at GP practice websites, they were not all accessible.

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Highlights [CCG Patient Reference Group] [January 2018]

• When you say online consultation do you mean they could be triaged or is it with a medical professional? How long will people wait for the form to be reviewed?

• Are there any confidentiality issues? How is it secure?

• Will there be another way to involve patients?

• What about people who want to see their registered doctor? Will the response from the doctor be nameless?

3. Being a patient representative in 2018

Member explained their roles as patient representatives in the borough. Details available in the full notes.

144

CCG Patient Reference Group (PRG) minutes

Date and time Wednesday 10 January 2017, 6-8pm

Venue Boardroom B&C, 7 Kirkdale Road, Kirkdale House, Leytonstone E11 1HP

Chair Richard Griffin CCG Lay Member for Community Participation

No conflicts of interest declared.

Guest speakers:

• Linda Finch Programme Manager • Tarlochan Boparai Primary Care Transformation Manager

CCG/Healthwatch standing attendees:

• Rebecca Waters Communications and Engagement Manager

Patient Reference Group members:

• Khadija Gitay Walthamstow PPG representative • Jim Sarginson Chingford PPG representative • Fatima Kassimi Faith representative • Neil Adie Sensory impaired representative • Mary Logan Save our NHS representative • Sylvia Debreczeny • Caroline White CCG Lay Member for Community Participation

In attendance:

• Helen Davenport Director of Nursing, Quality and Governance • Louise Pepper Accessible communication support

Apologies;

• Ana da Cunha Lewin • Alex Kafetz • Julia Walsh Head of Communication and Community Participation • Pat Stephenson Walthamstow PPG representative • Sumita Ahmed Healthwatch Waltham Forest • Liz Phillips Leyton/Leytonstone PPG representative • Gary Sultanti Leyton/Leytonstone PPG representative • Adrian Dodd

1. GP contracts - Personal Medical Services (PMS) Handouts and presentation

Linda Finch (LF), Programme Manager at the CCG, attended to share an update on the Personal Medical Services (PMS) contract as outcomes may result in a significant change for patients.

This process was designed to review a particular contract that is agreed locally to our GPs. There are 22 practices with PMS contracts and 19 practices with GMS

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contracts in Waltham Forest. Only the Orient Practices has an APMS contract. This was a national review and has been completed in Waltham Forest.

LF presented/explained what this meant in terms of payment and that this was a chance to bring in equity into the system.

PMS contract is a locally agreed contract which was last negotiated with the then Waltham Forest Primary Care Trust (PCTs) in 2008.

GMS contracts are nationally agreed and mean practices didn’t have a choice in which services that are provided as it was a national contract. But the core services should be the same.

The CCG chose to focus on access and patient satisfaction as these were local patient priorities.

Negotiations concluded in August 2017 followed by a checking process by NHS England. Local GPs started to implement these across all practices from 1 January.

LF talked through the indicators document:

1) The number of practices closing for half a day a week will reduce.

2) The number of consultations will increase with options to access health care from GPs, nurses, at home, online and by telephone.

3 & 4) aims to improve the experience of patients getting a consultation. This includes a mystery shopper exercise to be undertaken by Healthwatch Waltham Forest.

Payments will not be adjusted until an evaluation of performance against the indicators in March 2018.

After the presentation PRG members asked the following questions;

Q1. Can I confirm what the numbers mean?

A1. It is 80 consultations per 1,000 patients and so reflects the differing patient list sizes.

Q2. JS asked if this is connected to the PPG local standard.

A2. No, it isn’t connected as the PPG local standard is not a contractual requirement.

Q3. Does the contract have anything in it about the PPGs?

A3. No.

Q4. Can PRG members know which practices have signed up to which service level?

A4. LF said yes as this is not confidential. LF will need to look into a way of sharing this information and will update the PRG after the initial evaluations.

JS explained that he has received lot of PPG reps comments about poor communication. For example, people not knowing what Healthwatch are. HD suggested that we could set out the work that has been done on PMS so far, definitions and what can be expected of their practice.

HD informed the group that the CCG works with Healthwatch to promote their work. We have our own challenge to promote what CCGs are too. We will continue to over communicate in order to reach people.

Q5. ML asked if there were different weightings for different patient needs. Such as interpreting and health needs? Just because a practice is on a lower indicator level it doesn’t mean they will be offering an inferior service.

A5. LF explained that deciding the payment weighting was a big part of the negotiations. We did a survey of the number of consultations each practice is providing. It is not a perfect indicator but this is the only way we can begin to set a standard and it will be reviewed and refined. Most practices will receive

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more money as a result of this. TB explained that we are working to reduce variations across practices and working on sharing practice on how some are meeting targets and encourage collaboration.

Explanation was given of what the APEX software does to analyse activity in the practice.

ACTION 1.1: LF to prepare updates for PPG and PRGs on what the PMS contracts mean and who has signed up to it. Deadline March 2018.

2. Online consultations programme for discussion Presentation Tarlochan Boparai (TB), Primary Care Transformation Manager explained the GP Five Year Forward View (FYFV) and the aspirations to improve primary care. A fund was launched to invest in online consultations. Examples given were ‘Push Doctor’ or ‘GP at hand’ and members may have seen adverts at tube stations and articles in the media. These solutions provide access to primary care in another way. The CCG is working with partners in North East London (NEL), and the other six CCGs, to find an online consultation package for the region.

The CCG wants it to be clear that we are not reducing face to face appointments. It is expected that up to 10% of patients will access online consultations.

There are numerous systems and we are looking at the variety of providers. The CCG held two GP engagement events to show practices what some of the options are in the market. We are working with neighbouring boroughs but we will also choose what is needed for WF. There are benefits for having the same platform across 7 CCGs and means over 300 practices will use the same system.

The fund available is £526,000 for the seven NEL boroughs. Working together gives us more power when talking to the suppliers.

TB explained what he needed from the PRG. The members asked the following questions;

Q1. NA looked at GP practice websites and they were not all accessible.

A1. TB agreed that this will need to be a requirement and if there is not a solution then a clear alternative must be provided.

Q2. When you say online consultation do you mean they could be triaged or is it with a medical professional? The critical thing is how comprehensive the form is. How long will people wait for the form to be reviewed?

A2. TB explained that patients will go through their symptoms on an e-form on the website first, this will go to the GP who will review. The GP may feel there is enough information to prescribe or book a relevant consultation. If the GP needs more information they may call you to ask more questions or book a face to face appointment. A GP will be expected to respond to online consultations the next working day. The symptom checker look out for certain symptoms, such as chest pain, and alert the patient that the online form is not appropriate and advise them to access help immediately Testing has already been carried out on this system and decided that it is clinically assured as safe. It is similar to the scenarios on NHS symptom checker and some advice will have videos.

JS agreed that this is worth developing now as it needs to be ready for the generation who is used to using online solutions.

TB wants to make sure that there is patient engagement throughout procurement.

Q3. Are there any confidentiality issues? How is it secure?

A3. It will be built into the practice website so only connects to the practice system which is encrypted and it doesn’t go out of the UK.

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TB hopes that this will help people catch early symptoms and reduce the need to access urgent care such as 111 or A&E. These systems have been successfully used in Tower Hamlets and City and Hackney.

Q4. Will there be another way to involve patients?

A4. Yes, all patient involvement opportunities go to PRG first and, in this case, could be opened up to PPGs members.

TB explained that as we cannot be assured the website translations are clinically accurate it has been decided that this function will not be made available. This is because we cannot be sure that the translation is clinically accurate.

Group discussed how online consultations may increase access.

Q5. JS - what about people who want to see their registered doctor? Will the response from the doctor be nameless?

A5. TB hopes the clinical response will be from a GP and gave an example of how the practice would assign who is looking after the online consultations. This will be up to the practice and some may sign a duty doctor or some may have a rota basis to answer the queries. We would also hope the message would be signed off to say who has provided the response. The patient has one way to contact the practice but there could be multiple ways the practice responds; request for further information, a call from the receptionist to book you an appointment or a message containing self-care advice or a prescription issued for collection or sent to a local pharmacy.

We want to sign a one year contract. Quality and uptake will be monitored. Dr Koczan is involved as a clinical expert in this programme. Video consultations are an area we are closely monitoring but at present will not be offering. All of these solutions are up to the practice to take on.

The group discussed the benefits of increase in access but that online options also reduce personal contact.

ACTION 2.1: TB to share examples of technology and practice websites with RW to circulate to PRG. Blithehale http://www.blithehalemedicalcentre.nhs.uk/

Docklands http://docklandsmedicalcentre.com/

ACTION 2.2: TB to return to the PRG six months after the contract starts to update. Possibly November 2018.

ACTION 2.3: For PRG members to be invited to join in on procurement process.

3. Being a patient representative in 2018 Lay people

Richard and Caroline now sharing role as Lay member for public participation. This is due to Richard’s workload outside of CCG. They will use the survey results to review how to make the group effective and include the patient voice in coming meetings.

Caroline has been attending Accountable Care System (ACS) events where patient engagement has been discussed and other lay members from neighbouring CCGs attended. Not yet clear where it will sit.

PPG locality representatives

Khadija Gitay = finds it interesting being in the PRG and working on PPG. She does other voluntary work around health and has to explain to a lot of people what the different groups are. We have also been helping patients in the reception area of the practice. Is also a Care and support hubs steering group member and finds that useful in understanding the process for decision making and change.

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http://www.blithehalemedicalcentre.nhs.uk/

http://docklandsmedicalcentre.com/

Page 5

Jim Sarginson = presented at two ward forums on what PPGs are. Found a total lack of understanding of what the health service is. A difference in what people hear from the health minister and what you people see at their GP. He has been trying to explain the role of CCG and lots of people didn’t know that a PPG existed. One man went back to the practice to see that there was in fact a PPG advertised. Communication is very poor. JS offered to return to ward forums and will need permission as he doesn’t live in the ward. Has been to three PPGs. Plans to build on relationships with the other practices.

JS request: could we have a stand to take to promote PPGs future events.

Sylvia Debreczeny = chair of her PPG and enjoys it. The PRG gives her a heads up for issues from CCG and FedNet. SD is an associate patient for National Association for Patient Participation (NAPP) and shares information from PRG with them. She is a lay representative for local branch of the Royal College of GP’s (RCGP) and pushes the patient view there. SD has been supporting Jim and keeps him informed of other practices’ news. Is a member of CEPN but hasn’t been involved much but has dates of meetings and is going to be more active in 2018.

Mary Logan = Is a Save our NHS representative. Attended health and scrutiny meeting, Barts board. Hosted a talk on STPs and promoting changes to the public. Health & social care act means changes don’t go through parliament. Save our NHS’s role to let people know what is going on. Waiting for more information from Barts about beds and possible changes to the site. Attended an event in Newham about closure of King Georges A&E as this may result in loss of acute beds and puts at risk of death rates and possible hospital closure. Recently got involved in the closing of the hydrotherapy pool at Whipps Cross – patients offered to use Mile End but the transport is not direct, or without stairs, and the difference in the pool makes it difficult to staff.

Neil Adie = has found it useful to join the PRG meeting to give his feedback on sensory impairment experience for past six months. He wants to make sure that every service delivered is accessible for people who are deaf or blind.

Other reps

RW read out Alex, Ana and Pat’s updates.

4. AOB • Members asked to save the date on afternoon of 21 February for the next CCG Patient and Public

Participation event that will be held at Chingford Assembly hall. The theme is public involvement in health. An invite to go out shortly. The main topics are the Whipps Cross site redevelopment and how to involve children and young people.

• An update report on Phlebotomy will be circulated. This is a you said, we did, report and includes the events and service changes as a result of recent public involvement.

• There will be an email sent to PRG asking for ideas on how to promote the renal service to GPs and patients to improve early diagnosis.

Next meeting: Wednesday 14 February, 6-8:00pm. Boardroom B&C, Kirkdale House.

Day Date Time

Wednesday 14 March 6-8pm

Wednesday 11 April 6-8pm

Wednesday 9 May 6-8pm

Wednesday 13 June 6-8pm

Wednesday 11 July 6-8pm

Wednesday 12 September 6-8pm

149

Action Logs [Leyton/Leytonstone, Chingford and Walthamstow Localities] [January 2018]

Item 7.7

Committee Minutes

Locality Meetings – Leyton/Leytonstone, Chingford and Walthamstow – January 18

From Shahnaz Begum, Miren Querejeta-Lopez, Linda Fontaine, Commissioning Managers - WFCCG

Key highlights Please find attached the action log from Leyton/Leytonstone, Chingford and Walthamstow locality meetings – 3rd January 2018

Chingford Locality Meeting Action Log (Miren) – Chair Dr Tonia Myers

Actions Log

ACTION LOG: Leyton/Leytonstone (Shahnaz) – Dr Ken Aswani

Agenda Item

3rd January 2018 – CD Meeting Due Date Owner Status

No Meeting took place

150

Action Logs [Leyton/Leytonstone, Chingford and Walthamstow Localities] [January 2018]

Agenda Item

10th January 2018 CD Meeting Due Date Owner Status

No Actions recorded from the above meeting

Walthamstow Locality Meeting Action Log (Linda) 9th January 2018 – Chair Dr Ravi Gupta

Actions Log

Agenda Item

Actions from 9th January 2018 CD Meeting

No Action Recorded from the above meeting

151

Item 8

PART 128/02/2018 21/03/2018 23/05/2018 27/06/2018 25/07/2018 26/09/2018 24/10/2018 28/11/2018

GENERAL BUSINESS GENERAL BUSINESS GENERAL BUSINESS GENERAL BUSINESS GENERAL BUSINESS GENERAL BUSINESS GENERAL BUSINESS GENERAL BUSINESSChair's Report Chair's update Chair's update Chair's update Chair's update Chair's update Chair's update Chair's update

Accountable Officer's Report








Questions from Members and Public








GOVERNANCE GOVERNANCE GOVERNANCE GOVERNANCE GOVERNANCE GOVERNANCE GOVERNANCE GOVERNANCEJoint Commissioning

Committee ReportJoint Commissioning







Committee ReportBAF BAF BAF BAF BAF

Review of GB Governance

Terms of Reference Planning and Finance

Committee

PERFORMANCE AND QUALITY








P&Q Report P&Q Report P&Q Report P&Q Report P&Q Report P&Q Report P&Q Report P&Q Report

FINANCE AND QIPP FINANCE AND QIPP FINANCE AND QIPP FINANCE AND QIPP FINANCE AND QIPP FINANCE AND QIPP FINANCE AND QIPP FINANCE AND QIPPFinance Report Finance Report Finance Report Finance Report Finance Report Finance Report Finance Report Finance Report

Budget 2018/19 Annual Accounts

HEALTH AND WELL-BEING STRATEGY








STRATEGY AND PLANNING








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Item 8

NEL Transformation (NEL Commissioning Alliance

and East London Health & Care Partnership)















Planning for the future GP Federated Network

Organisational Development Report

Organisational Development Report

INFO INFO INFO INFO INFO INFO INFO INFO

Locality meeting reports for Jan

Locality meeting reports for Feb

Locality meeting reports for April

Locality meeting reports for June Locality meeting reports

PART 2

Procurement Pipeline

Direct GP Access Ambulatory BP, ECG and

plain ECG service Procurement Award Procurement update

Youth Justice Scheme Award F1

Direct Access Non-Obstetric and

Echocardiogram service Procurement Award

Internal Audit and LCFS Procurement - Contract

Award Report

153

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