Joint Committee of Barking and Dagenham, Havering and ... · Budget update 2.552018/19 17/18 and...

Joint Committee of Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

24 May 2018 2.15pm

Boardrooms, Becketts House, Ilford, IG1 2QX

Item Time Lead director

Attached, verbal or to

follow

1.0

1.1 1.2

1.3

Welcome, introductions and apologies

Declaration of conflicts of interest Minutes of the meeting held on 29 March

2018 Matters/actions arising

2.15 Chair

Attached Attached

Attached

2.0

2.1 2.2 2.3

Chair and chief officer reports

Chairs’ report Accountable officer’s report Patient engagement report

2.20 2.25 2.30

Chairs JM SW/RC/KA

Attached Attached Attached

3.0

3.1

Governing body assurance

Joint committee risk assurance framework 2.35 MP Attached

4.0

4.1 4.2 4.3 4.4 4.5

Corporate strategy and planning

Corporate objectives 2018/19 Budget update 2018/19 17/18 and 18/19 Financial Recovery Update Sustainable development management plan East London Health and Care Partnership

Update

2.45 2.55 3.05 3.15 3.20

CJ TT ME MP JM

Attached Attached Attached Attached Attached

5.0

5.1 5.2 5.3

Quality and performance

Integrated performance report Finance risk overview Report Quality report

3.30 3.40 3.50

SR TT AFC


6.0

6.1 6.2 6.3

Development/governance

Finance & delivery committee chair’s report Audit & governance committee chair’s report Minutes of committees and relevant fora:

Quality & safety committee

Patient engagement forum

Primary care commissioningcommittee

Primary care transformation

programme board

4.00 4.05 4.10

TT KP


7.0 AOB 4.15

8.0 Questions from the public 4.20

9.0 Date of next meeting – 26 July 2018 4.30

1

Barking and Dagenham CCG Conflicts of interest register - Governing Body members and other decision makers

Conflics of interest will remain on the register for a minimum of 6 months following expiry

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King Edwards Medical Group

X Direct GP partner and other GPs are family members

Jun-10 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

King Edwards Medical Group

X Indirect Other GPs are family members


Health 1000 X Direct Director. PMCF lead Dec-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Proactive Care, Healthy London Partnerships, NHS England

X Direct Clinical Lead Mar-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

North East London Foundation trust

X Direct GPwSI - Cardiology service, Barking & Dagenham Community Cardiology Service

Aug-11 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Together First X Direct Shareholder May-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Harley Fitzrovia Health Ltd

X Direct Director and Shareholder Jan-18 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Action taken to mitigate risk

Is the interest direct or indirect?

Name

Current position (s) held- i.e. Governing

Body, Member practice, Employee or other

Declared Interest- (Name of the

organisation and nature of business)

Type of Interest

Nature of Interest

Date of Interest

Date - 11 May 2018

Dr Jagan John Governing Body Member - CCG Chair

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Date of Interest

Monifieth Limited X Direct Director and Shareholder Mar-18 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Historic - Barking, Dagenham and Havering LMC

X Direct Member Oct-13 Mar-18 Historic

Thames View Health Centre

X Direct GP principal Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Primary Clinical Partnership Ltd

X Direct Director/Shareholder Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Apex Healthcare Ltd (who own Knightswood Residential Care Home)

X Direct Director/Shareholder Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Queen Mary Medical School-London

X Direct Honorary Lecturer Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Together First X Direct Shareholder May-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

BHR CCGs Area Prescribing Committee

X Direct Chair Mar-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Dr Gurkirit Kalkat Governing Body Member - Clinical Director

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Ramneek Hara Governing Body Member - Clinical Director

Urswick Medical Centre

X Direct GP Principal Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Together First Ltd X Direct Shareholder May-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

London Deanery X Direct GP registrar and GP appraiser mainly in Havering

Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Barts Hospital & Queen Mary's university

X Direct Under-graduate tutor Oct-16 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Medimmune (Astrazeneca)

X Indirect Spouse is medical director Apr-11 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Historic - Pharmaceutical companies

X Direct Speaker and chair at educational lectures and meetings

2016 Historic.

Anju Gupta Governing Body Member - Clinical Director

Abbey Medical Centre X Direct GP Principal. Apr-16 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

BHR CCGs X Direct Diabetes lead Sep-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

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Together First Ltd X Direct Shareholder Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

NELFT X Direct GPwSI -Diabetes Mar-10 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

NHSE X Direct GP Appriaser Sep-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

London Deanery X Direct GP Trainer Nov-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Wilson Mason PLC(Architects)

X Indirect Spouse is a consultant 2015 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

White House surgery, Barking

X

X

X

Direct

Indirect

Indirect

GP principal

Sister is a GP partner and GPwSI-dermatology

Brother is also a GP partner

Sep-06 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Castleton Road Health Centre, Redbridge

X Direct GP principal April 2018 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Kanika Rai Governing Body Member - Clinical Director

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B&D CCG X

X

Indirect

Indirect

Brother-in-law is a B&D Clinical director.

Husband is a B&D GP

April 2018 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Together First Ltd X Direct Shareholder. Brother is also a director

May-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

MacMillan X Direct GP for Barking and Dagenham


NEL Cancer X Direct Cancer Lead Dec-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

London Deanery X Direct FY2 Superviser and GP trainer

2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Queen Mary University & Imperial College

X Direct Under-graduate tutor 2007 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Tulasi Medical Practice X Direct Salaried GP and medical director

Jul-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

St Albans Surgery X Direct Salaried GP - one session May-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Dr Amit Sharma Governing Body Member-Clinical Director

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B&D CCG X Direct Macmillan GP Apr-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

X Indirect Sister-in-law is a B&D Clinical Director

Nov-11 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

X Indirect Wife is a B&D GP Aug-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Barking, Dagenham & Havering LMC

X Direct Member Sep-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Care Quality Commission

X Direct GP specialist adviser Nov-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Veda Solutions X Direct Director Aug-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

NEL Commissioning Support Unit

X Indirect Partner is employed substantively


NHSE X Indirect Partner on secondment to London Regional Director for primary care

Jan-18 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Jane Milligan Employee - Governing Body Executive Member - Accountable Officer, NEL CCGs

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Action for stammering X Indirect partner is a Trustee Oct-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Family Mosaic Housing Association

X Direct Non-executive director May-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Stonewall X Direct Ambassador Oct-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Peabody Housing Association

X Direct Non-executive director Jan-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Chartered Physiotherapists

X Direct Member (non-practising) Sep-87 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Historic - University Schools Trust, East London

X Direct Trustee Dec-17 Historic.

Ceri Jacob Employee - Governing Body Member - Managing Director

Ruislip Primary School X Direct Chair of Governors Feb-18 Current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Tom Travers Employee - Governing Body Excecutive Member - Chief Finance Officer

Royal Free Foundation Trust

X Indirect Wife employed in the Finance Department


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Steve Rubery Employee - Governing Body Executive Member - Director of Delivery & Performance

BHR CCGs X IndirectCo-habiting partner is Planned Care Programme Lead

Feb-18 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Jacqui Himbury Employee - Governing Body Executive Member - Nurse director

None

NHS Havering CCG X Direct Lay member, Governance and Audit Chair

2013 2019 No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

NHS Redbridge CCG X Direct Lay member, Governance and Audit Chair


University of Essex X Direct Independent Audit Committee member


Southend-on-Sea Borough Council

X Direct Independent Audit Committee member


Brentwood Citizen's Advice Bureau

X Direct General Advisor 2009 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Essex Ministry of Justice Advisor Committee

X Direct Lay member, Governance and Audit Chair


Kash Pandya Governing Body Member - Lay member, Governance

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PriceWaterhouseCooper

X Indirect Son is employeed as a management accountant


Accenture X Indirect Son is employeed as Legal Counsel


Historic - Her Majesty's Inspector of Constabulary

X Direct Associate Inspector 2011 Jan-18 Historic.

Newham Deanery CIO X Direct Trustee 01/06/2016 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Redbridge Healthwatch X Direct Member 01/04/2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

London Borough of Redbridge

X Indirect Husband is a Councillor 01/05/2014 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Historic - Forum for Health & Wellbeing

X Direct Director (paid employee) 01/12/1994 01/04/2018 Historic.

BHR CCGs X Indirect Lay member PPI (Havering CCG) PPI is brother in law

01/10/2017 Current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Arthur Rank Hospice Charity - Cambridge

X Direct Trustee 01/05/2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Governing Body member - Lay member, PPI

Sahdia Warraich

Dr Arnold Furtig Independent GP member of BHR CCGs Primary Care Commissioning Committee

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X Indirect Son is a partner (south Korea)


Mayor of London (Sadiq khan)

X Indirect Son is a speech writer 2016 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

University Hospital, Birmingham

X Indirect Son is an employee in middle management


Charles Beaumont Independent Lay Member of BHR CCGs Audit & Governance Committee

None

Halbutt Street Surgery X Direct GP 2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

PELC X Direct Council Member Dec-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Together First Ltd X Direct Board Member & shareholder


Primary Care Clinical partnership Ltd

X Direct Shareholder 2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Dr Adedayo Adedeji GP member and member of BHR CCGs Primary Care Commissioning Committee

11

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Jane Gateley Employee - Director, Strategy & Integration

PHP (Hurley Group) X Indirect Spouse is Prgramme Director

On-going on-going No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Greater London Authority (GLA)

X Indirect Husband is area regeneration manager for North East London

2017 on-going No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Lower Clapton GP practice

X Direct Registered as a patient where City & Hackney CCG Chair is based.


Vertergi Limited X Direct Holder of 100% of the company shares


MCB Software X Direct Holder of 100% of the company shares


Sarah See Employee - Primary Care Transformation Director

NELFT X Indirect Partner is an employee working within Redbridge CAMHS

Mar-14 on-going No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Care UK (surrey wide) X Direct Nurse Practitioner, Clinical Lead - bank work


Greenbrook Healthcare (Londond wide)

X Direct Nurse Practitioner, Clinical Lead - bank work


Robert Meaker Employee - Innovation & Information Technology Senior Responsible Officer

Lucy Botting Employee - Deputy Director, Primary Care Transformation

Marie Price Employee - Corporate Services Director

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Mole Valley District Council

X Direct Local district councillor 2014 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Sharon Morrow Employee - Unplanned Care SRO

None

Alan Steward Employee- System OD and Transition SRO (currently on secondment)

Steward and Steward Ltd

X Direct Director. Partner is also a director.


Louise Mitchell Employee - Planned Care SRO

None

Mark Eaton Consultant - Director of Recovery

Amnis Ltd X Direct Shareholder. Apr-18 current Amnis Ltd will not provide any services within NEL.

Regina ShakespeareHistoric

Consultant - Interim Director, Delivey & Performance

Regina Shakespeare Consulting Limted

X Direct Managing Director Feb-17 01/12/2017 Historic

Conor Burke -Historic

Employee - Acting Managing Director

CPB Healthcare Consulting Ltd

X Direct Director & owner Jan-18 Mar-18 Historic.

Markyate Surgery X Direct GP Apr-17 Mar-18 Historic.Together First Ltd X Direct Shareholder May-15 Mar-18 Historic.London Wellbeing care Ltd

X Direct Director Apr-17 Mar-18 Historic.

Kensington & Chelsea CCG

X Direct GP Partner Apr-14 Mar-18 Historic.

Tulasi Medical Centre X Direct GP partner. Spouse is practice manager

19/09/2006 Mar-18 Historic.

Tulasi Properties Ltd X Direct Director/Shareholder 01/08/2016 Mar-18 Historic.

Health & Happiness Clinic Ltd

X Direct Director/Shareholder 01/08/2012 Mar-18 Historic.

Dr Ravali Goriparthi-Historic

Governing Body Member - Clinical Director

Dr Waseem Mohi -Historic

Governing Body Member - CCG Chair

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Together First Ltd X Direct Shareholder 01/06/2017 Mar-18 Historic.

Barking, Dagenham and Havering LMC

X Direct Member 07/09/2009 Mar-18 Historic.

Royal College of GPs X Direct Member Apr-17 Mar-18 Historic.

14

Havering CCG Conflicts of interest register - Governing Body members and other decision makers


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Maylands Healthcare X Direct GP Partner Apr-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Maylands Healthcare Ltd

X Direct Director and shareholder in on-site pharamcy


Parkview Dental Practice

X Indirect Sister is NHS dentist within Havering


Essex Medicare LLP X Direct Part owner which owns Westland Clinic, Hornchurch. Space rented out to Inhealth (Diagnostic),Nuffield Health (Brentwood), Communitas Clinics (Dermatology & Gynaecology)


Havering Health Ltd X Direct Shareholder. GP partner (Dr Kendall) is a director



X Direct Co-opted member 2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Westlands Clinic (Langton Dental)

Indirect Spouse is a dentist who has an outsourced contract with BHRUT for oral surgery.

May-18 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Hornchurch Healthcare X Direct GP principal 2007 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Dr Atul Aggarwal Governing Body Member - CCG Chair

Dr Alex Tran Governing Body Member - Clinical Director



Name





Type of Interest

Nature of Interest

Date of Interest

Date - 11 May 2018

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Havering Health Ltd X Direct Shareholder 2016 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Hornchchurch Healthcare Ltd

X Direct Director Jul-05 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Rush Green Medical Centre

X Direct Senior GP partner 2000 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Practice Based Clinical Service Ltd (ENT service)

X Direct Director/Shareholder abd GPwSI


Havering CCG X Direct GP Tutor & education lead 2000 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Havering Health Ltd X Direct Shareholder 2014 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Inspire Health Ltd (not trading)

X Direct Director/Shareholder 2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Central Park surgery, Harold Hill

X Direct GP partner 2009 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Havering Health Ltd X Direct Shareholder Aug-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.


X Direct Joint vice chair Jun-17 May-19 No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.


Dr Ann Baldwin Governing Body Member-Clinical Director

Dr Maurice Sanomi

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Royal College of GPs and British Society of Rheumotology

X Direct Member 2012 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Havering CCG X Direct GP Appraiser 2012 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.






Action for stammering X Indirect Partner is a Trustee Oct-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.









X Direct Trusteee Dec-17 Historic.

Jane Milligan Employee - Governing Body member - Accountable Officer, NEL CCGs

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Ceri Jacob Employee - Governing Body member - Accountable Officer, NEL CCGs

Ruislip Primary School X Direct Chair of Governors Feb-18 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Tom Travers Governing Body member - Chief Finance Officer





BHR CCGs X Indirect Co-habiting partner is Planned Care Programme Lead


Jacqui Himbury Governing Body member - Nurse director

None











X Direct General Advisor 2009 Current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.






2013 Current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Kash Pandya Governing Body member - Lay member, Governance

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Richard Coleman Associates

X Direct Director/Co-owner. Spouse is also Director/Co-owner

01/04/2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

BHR CCGs X Indirect Brother-in-law is Independent GP on the Primary Care Commissioning Committee

01/10/2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

1-2-1 Social Enterprise X Direct Associate 01/10/2014 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.


X Indirect Nephew is a partner 01/08/2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.










Richard Coleman Governing Body member - Lay member, PPI


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Rosewood Medical Centre

X Direct GP Partner 2011 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Havering Health Ltd X Direct Shareholder/Director and company secretary


PELC X Direct Council member 2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.


X Direct member 2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

BHRUT X Indirect Wife is a nurse 2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.



On-going On-going No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.



2017 On-going No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.




Dr David Derby GP member and member of BHR CCGs Primary Care Commissioning Committee


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Sep-14 Current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.


Jun-16 Current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.



Mar-14 On-going No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.










None


None

Alan Steward Employee - System OD and Transition SRO (currently on secondment)










Conor Burke-Historic



X Direct Director & owner Jan-18 Mar-18 Historic.

Wood Lane Medical Centre

X Direct Senior partner. Wife, daughter and son-in-law also GP partners

1989 Mar-18 HistoricDr Ashok Deshpande - Historic


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Havering Health Ltd X Direct Shareholder. GP partner is the Chair

Aug-14 Mar-18 Historic


X Direct Associate member current Mar-18 Historic

Communitas (dermatology service)

X Direct Company conducts weekly clinic from Wood Lane Medical Centre and GP partner (daughter) provides dermatology sessions with Communitas

2016 Mar-18 Historic

Nuffield Health X Direct Wife works in gynaecology 2017 Mar-18 HistoricNational ME Charity, Harold Wood

X Direct Chair Apr-17 Apr-18 Historic

St Francis Hospice, Romford

X Direct Trustee May-17 Apr-18 Historic


X Direct Associate Member Jun-17 Apr-18 Historic

Barking, Dagenham and Havering LMC Ltd

X Direct Chairman/Director Jul-17 Apr-18 Historic

Dr Gurdev SainiHistoric


22

Redbridge CCG Conflicts of interest register - Governing Body members and other decision makers


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Fullwell Cross Medical Centre

X Direct GP partner Apr-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Metropolitan Police X Direct Forensic examiner Nov-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

The Cleaning Company

X Indirect Sister-in-law is the owner 2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

NHSE X Direct GP appraiser Feb-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Healthbridge Direct X Direct Shareholder Sep-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Fouress enterprises Ltd

X Direct Director 2015 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Prescon X Direct Ad-hoc screening work Jan-18 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

The Shrubberies Medical Centre

X Direct GP partner Oct-05 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.


Dr Anil Mehta Governing Body member - CCG Chair

Dr Sarah Heyes Governing Body member - Clinical Director

Date - 11 May 2018



Name





Type of Interest

Nature of Interest

Date of Interest

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Newbury Group Practice

X Direct GP partner Jun-05 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Communitas Clinics X Direct GPwSI - Dermatology 2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

DMC Healthcare X Direct GPwSI - Dermatology & minor surgery


ESS Wanstead X Direct GPwSI - Dermatology 2011 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Ealing Hospital Trust X Direct GPwSI - Dermatology 2010 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

NELFT X Direct GPwSI - Diabetes 2007 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Soods Ltd X Direct Director and husband is a partner.


NHSE X Direct GP appraiser Jun-05 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Health Education England

X Direct GP trainer 2004 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Imperial College X Direct GP trainer 2011 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Dr Jyoti Sood Governing Body Member - Clinical Director

24

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Redbridge LMC X Direct Member Sep-16 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Care Quality Commission

X Direct Special adviser Jul-16 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Healthbridge Direct X Direct Shareholder Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Metrolaw Solicitors X Indirect Husband's firm 2002 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Royal College of GPs X Direct GPWSi assessor 28/02/2018 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Castleton Road Health Centre

X Direct GP Partner Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Healthbridge Direct X Direct Shareholder and locum doctor at urgent care centre


PELC X Direct Locum doctor Apr-16 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Partners in Healthcare Ltd

X Direct Director Apr-16 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

BHR GP Solutions X Direct Locum GP Jul-16 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Dr Shujah Hameed Governing Body member - Clinical Director

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Seven Kings surgery X Direct GP partner Oct-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Raza Syed Medical Ltd X Direct Director Jun-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Healthbridge Direct X Direct Shareholder and employed as a locum at the hub


PELC X Direct Locum GP current current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

London Deanery X Direct GP Trainer 2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Historic - Chadwell Heath surgery

X Direct Salaried GP Sep-17 Oct-17 Historic.

Southdene Surgery X Direct GP partner/principal 2008 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Healthbridge Direct X Direct Shareholder. Daughter also works in reception/admin


NELFT X Direct GPwSI - cardiology 2008 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Avicenna Ltd X Direct Director. Husband also a director


Dr Syed Raza Governing Body member - Clinical Director

Dr Shabana Ali Governing Body member - Clinical Director

26

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BMA X Direct member 2004 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

PCGP X Direct member 2006 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

NHSE X Direct GP appraiser (B&D and Havering)


Forest Edge practice, Hainault

X Direct GP partner Oct-93 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Dagenham & Redbridge Football Club

X Direct Medical doctor 1999 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Redbridge Local Medical Committee

X Direct Member current 2019 No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Healthbridge Direct X Direct Shareholder 2015 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Mathukia Surgery X Direct GP principal. Brother is also GP principal



Valia Consultancy X Direct Director & Shareholder 2014 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Dr Muhammad Tahir Govering Body member - Clinical Director

Dr Mehul Mathukia Governing Body member - Clinical Director

27

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NOCLOR & NIHR X Direct GP research champion 2015 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

PELC X Direct GP Locum 2010 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Southdene Surgery X Direct GP partner current current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.


MyChem Ltd X Indirect Husband is owner/director of pharmacy

current current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Phoenix Medics Ltd X Indirect Brother is a director current current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Essex Local prescribing Committee

X Indirect Husband does ad-hoc work current current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.






Action for stammering X Indirect Partner is a Trustee Oct-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Anita Bhatia Governing Body member - Clinical Director

Jane Milligan Employee - Governing Body Executive Member - Accountable Officer, NEL CCGs

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X Direct Trustee Dec-17 Historic.

Tom Travers Governing Body Executive Member - Chief Finance Officer





BHR CCGs X Indirect Co-habiting partner is Planned Care Programme Lead


Jacqui Himbury Governing Body Executive Member - Nurse director

None

Ceri Jacob Governing Body Member - Managing Director

Ruislip Primary School X Direct Chair of Governors Feb-18 Ccurrent No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.



Kash Pandya Governing Body member - Lay member, Governance

29

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X Direct General Advisor 2009 Current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.











Dr Joseph GP practice, Collier Row

X Indirect Famiy doctor 01/04/2017 31/03/2018 No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

St Francis Hospice X Indirect Spouse is a regular donor 01/04/2017 31/03/2018 No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Khalil Ali Governing Body member - Lay member, PPI

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Cancer Research UK X Indirect Spouse is a regular donor 01/04/2017 31/03/2018 No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

North Middlesex University Hospital Trust

X Direct Consultant Anaesthetist May-96 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Nadia Medical Secrives Ltd

X Direct Director (provides anaesthetic services)

Mar-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.














None

Dr Shabnam Ali GP member and member of BHR CCGS Primary Care Commissioning Committee

Cranbrook & Loxford Locality

X Direct Network Lead Mar-11 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

Ah-fee Chan Governing Body member - Secondary Care Consultant


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On-going On-going No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.



2017 On-going No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.





Sep-14 Current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.


Jun-16 Current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.



Mar-14 On-going No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.









None




32

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Alan Steward Employee - System OD and Transition SRO (currently on secondment)





None







Conor Burke - Historic



X Direct Director & owner Jan-18 Mar-18 Historic

33

Minutes of the Joint Committee of Barking and Dagenham, Havering and Redbridge

Clinical Commissioning Groups 29 March 2018

1.30pm Becketts House

Present Barking & Dagenham CCG

Dr Waseem Mohi (WM) Clinical Director/Chair Dr Gurkirit Kalkat (GK) Clinical Director Dr Kanika Rai (KR) Clinical Director Dr Jagan John (JJ) Clinical Director Sahdia Warraich (SW) Lay member – patient and public involvement Havering CCG Dr Ann Baldwin (AB) Clinical director Dr Ashok Deshpande (AD) Clinical director Dr Maurice Sanomi (MSan) Clinical director Richard Coleman (RC) Lay member – PPI Redbridge CCG

Dr Anil Mehta (AM) Clinical Director/Chair Dr Sarah Heyes (SH) Clinical Director Dr Muhammad Tahir (MT) Clinical Director Dr Mehul Mathukia (MM) Clinical Director Dr Syed Raza (SR) Clinical Director Dr Anita Bhatia (ABh Clinical Director Khalil Ali (KA) Lay Member-PPI BHR CCGs

Jane Milligan (JM) Accountable Officer Tom Travers (TT) Chief finance officer Jacqui Himbury (JHim) Director of nursing Kash Pandya (KP) Lay member – governance Louise Mitchell (LM) SRO – Planned care Steve Rubery (SR) Director of delivery and performance

In attendance

Anne-Marie Keliris Company secretary – BHR CCGs Marie Price (MP) Director of corporate services – BHR CCGs Lee Eborall (LE) NELCSU Matthew Cole (MC) LBBD Gladys Xavier (GX) LBR Apologies

Cathy Turland (CT) Healthwatch Redbridge Alan Steward (AS) System OD and Transition SRO

34

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Dr Atul Aggarwal (AA) Clinical director/Chair Dr Gurdev Saini (GS) Clinical director Dr Alex Tran (AT) Clinical director Dr Shabana Ali (SA) Clinical Director Dr Anju Gupta (AG) Clinical Director Dr Ravali Goriparthi (RG) Clinical Director Dr Ramneek Hara (RH) Clinical Director Sharon Morrow (SM) SRO – Unplanned care Dr Jyoti Sood (JS) Clinical Director Dr Shabana Ali (SA) Clinical Director Dr Shujah Hameed (SHam) Clinical Director Dr Ah Fee Chan (AFC) Secondary Care Consultant

Item Action

1.0 Welcome and apologies

Dr Anil Mehta, the Chair of the meeting welcomed members to the meeting and apologies for absence were noted. It was noted that Barking & Dagenham were not quorate but members were expected to arrive shortly.

1.2 Declarations of conflicts of interest

The Chair of the meeting reminded members of their obligation to declare any interest they may have on any issues arising at the meeting which might conflict with the business of the BHR clinical commissioning groups. Declarations declared by members of the governing body are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the governing body or the CCG website at the following link: http://www.barkingdagenhamccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm http://www.haveringccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm http://www.redbridgeccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm There were no additional declarations.

1.3 Minutes of the last meeting

The minutes of the joint committee held on 25 January 2018 were agreed as a correct record.

1.4 Matters/Actions arising

The joint committee noted the actions taken since the last meeting.

2.0 Chair & Accountable Officer’s Reports

35

http://www.barkingdagenhamccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm

http://www.barkingdagenhamccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm

http://www.haveringccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm

http://www.haveringccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm

http://www.redbridgeccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm

http://www.redbridgeccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm

3

2.1 Chair’s report

The Chair presented his report covering the following areas:

Managing director

Barking & Dagenham CCG Chair

Financial situation

Primary care stocktake

North East London commissioning developments

Election outcome – clinical directors

Health and wellbeing boards

The joint committee noted the report. 2.2 Accountable Officer’s report

JM presented her report covering the following areas:

Managing director update

North East London Commissioning Alliance update

BHR Provider Alliance and Joint Commissioning Board update

RC questioned how closer working between NHSE and NHSI will support

the local system. JM responded that closer working will support the local

system as it will across London with the development of devolution.

The joint committee noted the report.

2.3 Patient experience report

RC presented a report which provided a summary of the various feedback that has come through to the CCG from patients and stakeholders highlighting the following areas:

The local Patient Engagement Forum meetings (PEFs)

Joint PEF meeting

VCS meeting in Havering

The Networks Leadership Summit

Spending money wisely public facing communications

Community urgent care review – engagement with Healthwatch

KA highlighted the importance of ensuring representation of the

population on the citizen panel. MP agreed and reported that funding had

been received to develop the citizen panel.


3.0 Governing body assurance

3.1 Joint committee assurance framework (JCAF)

MP presented a report which outlined the key risks to the clinical commissioning groups in achieving its corporate objectives as identified in the joint committee risk assurance framework. There are five risks on the JCAF which includes one risk newly escalated. Risk ratings are based on the February 2018 risk register.

36

4

The five risks on the JCAF are :-

1. Risks to the delivery of the Clinical Commissioning Groups’

(CCGs) budget

2. Barking, Havering and Redbridge University Hospitals Trust

(BHRUT) emergency care performance

3. Barts Health (BH) performance against key targets, A&E and RTT

4. BH quality concerns

5. BHRUT’s mortality rate is higher than expected and indicates the

number of patients dying for certain clinical conditions is higher

than the expected number of patient deaths.

The Chair questioned why GP alerts were not on the JCAF and other

members also requested that this risk was reviewed to assess whether it

should be included. SR agreed to review the GP alert risk and add if

appropriate.

KA commented that it would be useful to see mitigations against objective

3. He added that it would also be helpful to review how collaborative

working with and across north east London can help to mitigate or resolve

some of the BHR risks.

KP suggested that trend analysis of how risks have moved is a good

approach to risk management and would be useful to include. He also

thanked teams involved in the area where risks has reduced.

The joint committee noted the report and requested that milestones are

added to each risk to show improvements and also highlight new

mitigations.

2.09pm Dr Raza arrived.

3.2 Barts Health contract briefing

LE presented a report which set out the headline issues and updates in relation to the actions being taken by the lead Commissioner of the Barts Health Acute Contract and to provide assurance that all appropriate contractual actions are duly being undertaken on behalf of all associates. The report covered the following key areas:

Cancer 62-Day Performance

A&E Performance

Clinical Quality (by exception)

17/18 Contract Issues/Year End

BHR Financial Performance

2018/19 Contract Variation The Chair questioned whether there is a clear timeline for reporting mechanism on RTT. LE confirmed that the Trust will be reporting on national requirement by May 2018. The Chair commented that A&E data is over simplified.

SR MP/PD

37

5

JJ questioned whether there is full understanding of the RTT risk and suggested it would be useful to understand the value of implemented schemes in urgent and emergency care. JM reported that the winter leads meet twice a week and highlighted the need to request an update on themes. She agreed that comparing A&E performance was a crude marker, as although Whipps Cross, Royal London and Newham hospitals are performing against target, this was not stable. KA questioned whether the indication activity plan factors in any changes to day case and outpatient activity resulting from the recent deep dive of this. LE responded that work continues with the Trust and will continue to monitor indicative activity reports. He added that QIPP schemes are also monitored and tracked. SR reported that RTT impact on patients had been subject to a full clinical harm review of all patients on the waiting list and no patients at harm were identified during this review. Dr Tahir arrived at 2.20pm The joint committee noted the report, endorsed the actions taken by the lead commissioner in relation to the 2017/18 risks and noted the progress on 2018/19 contract variation.

LE

4.0 Corporate strategy and planning

4.1 East London Health and Care Partnership update

JM presented a report which updated on the progress made by the East

London Health and Social Care Partnership (ELHCP) to deliver the NEL

Sustainability and Transformation Plan (STP), highlighting the following:

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.

The Chair suggested that the clinical senate requires momentum to ensure benefits for BHR CCGs and suggested that the venue for this crucial meeting rotates and meets in BHR. It was also suggested that

synergy between the clinical cabinet and senate was strengthened. Members suggested that communications are streamlined across NEL to

ensure that members receive regular updates on changes. SW commented that she feels disengaged from these meetings and suggested that minutes are shared. JM responded that the JCC had not met formally and expected that the minutes of these meetings will be

38

6

shared with the joint committee. She also reported that a communications review had recently been undertaken which will streamline future communications and also agreed to review interaction between the

cabinet and senate. KP questioned what support is available to the accountable care system. JM responded that the framework to support integrated systems is developing and some of the drive to lead at a north east London level had

lessened and highlighted the need to re-energise at a local level. KA commented that it will be critical to the success of improvement to outpatients that it takes into account the cultural changes expected of patients and clinicians, hopefully working together on this. For example, the partnership should look at ways to capture patient feedback on their experiences of outpatients at the key main providers in primary care and acute settings. MT commented that equalisation across the patch to address underfunding in outer north east London needs to be included as part of

JCC role and should be high on the agenda. AB questioned what the value of the transformation funds available and who will be imputing into this work. JM reported that London details are

yet to be finalised and will share information once available. The joint committee noted the report. Dr Raza left at 2.45pm 4.2 Draft budget update TT presented the draft Operating Plan which was submitted to NHSE on 8 March 2018. This version of the plan is based on Month 9 forecast outturn. The March 2017 Operating Plan assumed an in-year deficit of £10.2m for 2017/18 and an in-year break even position in 2018/19. As agreed with NHSE the 2017/18 outturn moved from an in-year deficit of £10.2m to £20.4m (Month 9 forecast outturn). The movement of the in-year position resulted in a deterioration of the 2018/19 opening budget which means that the second year of the plan needs to be re-stated to reflect the current forecast. The reported underlying position (2018/19 opening budget) at Month 9 was a deficit of £9.9m. This includes the full year effect of 2017/18 QIPP schemes – circa £12m.

JJ welcomed the report and highlighted the need to be more innovative to achieve the outstanding QIPP requirement, as he felt concerned that this won’t be achieved if clinicians across the sector are not engaged.

He added that integration of pathways still requires development and suggested holding clinical meeting with regulators to be pro-active. He also asked whether there was scope to ask NHSE to collaboratively access investment. TT reported that additional investment is already played into allocations and will need to be clear whether any additional investment is available. SR reported that at a recent contract review meeting there was acknowledgement that senior managers want clinical input to make change together.

JM

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SW reported that the minor ailment service is treating patients with products that were stopped due to the spending money wisely consultation. LM agreed to review this.

SM arrived at 3pm.

MC commented that an alliance of providers may solve problems with placed based care. JM reported that this needs to be discussed with NELFT and also focus on clinical ownership.

WM expressed concern at the level of QIPP increasing each year and suggested that mitigation on this is required. SR reported that CCGs have been successful in generating QIPP but increases in activity from the Trust needs to be addressed by joint work streams.

The joint committee approved the draft budget update.

4.3 Operating Plan and 2018/19 QIPP update

SR presented a report which provided a high level summary of the first

draft Operating Plans which we were required to submit to NHS England

on the 8 of March 2018.

The 18/19 QIPP requirement has increased to £45m, to date CCGs have

identified £34m leaving £11m unidentified.

It was noted that a director of recovery had been appointed for a six

month period. JJ requested clarification on the Commissioner Sustainability Fund (CSF) scheme process and questioned whether the decision can be challenged. TT reported on assurance meetings which included support around QIPP

and STP level discussion on challenges. KP referred to national fund for commissioner and providers and requested clarity on why London is being treated differently and suggested seeking clarity on this. He also referred to scenarios around expert determination and questioned whether CCGs have capacity to deliver schemes. SR reported that part of the process of FRPDM and FRPB includes reviewing capacity. KA commented that BCF was intended to achieve better use of health and social care resources and questioned whether CCGs can have an evaluation as to economic health care benefits including savings in the system. He also suggested that the integrated care system needs to have an operational strategy plan to help deliver savings in this economy and whether social prescribing, self-care and prevention of ill health

should be explored.

The joint committee agreed to delegate authority to the FRPB to sign off

the April submission of the operating plan

Dr Baldwin left at 3.30pm

LM

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5.0 Quality and performance

5.1 Integrated contract report

SR presented a report which provided an integrated view of performance, including finance and activity, in its contracted services, to identify the key risks presented by that performance and provide assurance that those risks are being appropriately managed. This report is based on month 10 activity and month 11 finance information.

This report concerns the CCGs’ main providers - Barking, Havering and

Redbridge University Hospitals NHS Trust (BHRUT), Barts Health NHS

Trust (Barts Health), North East London Foundation Trust (NELFT),

Partnership of East London Cooperatives (PELC) and the London

Ambulance Service (LAS).

The main points of note are:

BHRUT: Following the Trust’s rejection of the Quarter 1 voluntary

independent mediation, BHR CCGs and the Trust have entered formal

Expert Determination arranged by NHSE and NHSI. BHR CCGs

submitted position statements on each item under dispute to NHSE on 26

February. The Trust subsequently submitted their position statements to

NHSI on 7 March. Following the submissions, exact timelines on next

steps are awaited from NHSE and NHSI, although the outcome is

anticipated by end of April 2018. The outcome of Expert Determination

will be binding, and as agreed with the Trust, will be used as a basis to

reach a year-end agreement and will in part inform the 2018-19 Indicative

Activity Plan (IAP). Regulators have mandated the move off a pure cost

per case contract in 2018-19. The BHRUT 2017/18 financial forecast

across the three CCGs is £10.7m above plan. This over spend is driven

by over performance in the following areas: elective, maternity, day cases

and outpatients. One of the key drivers of the projected overspend is the

increased average unit cost of non-elective activity compared to last year

- this item has been submitted to Expert Determination.

The mandated National Variation, which is to be implemented from 1

February 2018 has been signed by Commissioners and is currently with

the Trust for signature. The National Variation introduces a number of

new obligations including that, from 1 October 2018, providers need not

accept referrals by GPs other than those made through e-RS, and a

requirement to implement revised overseas visitor charging regulations.

A period of purdah, agreed in respect of formal contract actions, has now

ended and work is in progress to close down a number of open

contractual notices with the Trust.

On performance, against constitutional performance measures, the Trust

met 7 of the 8 cancer standards in the month of January 2018. RTT

performance in January was 91% against the 92% standard. The monthly

52 week wait reported position indicates five patients having waited over

52 weeks in January, down from 7 in December. The 4 hour A&E

performance in November was 74.1%, below the recovery trajectory of

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9

92%.

Barts Health: The Barts Health 2017/18 financial forecast across the

three CCGs is £9.1m above plan. This is based on a year-end agreement

agreed with the Trust to a value of £102.4m, which gives an overall

benefit to the CCGs year-end financial position of £640k. The agreement

includes the 0.5% CQUIN that CCGs were holding in reserve but does not

include the additional transport mobilisation costs of £0.3m. The revised

forecast of £102.4m is expected to be lower than an outturn based on

cost and volume over the full 12 months.

On performance against constitutional standards, the Trust met seven of

the eight cancer standards with the exception of the 62 screening

standard owing to a late identified breach with UCLH. Against the 4 hour

A&E standard, the Trust achieved 86.5% in January against the STF

trajectory of 92.3%. The Trust has agreed to return to RTT reporting in

May 2018 (April performance). There are a reported 164 52 week

pathways in the January month end position. While the Trust continues to

work towards clearance trajectory of long waiters by March 2018, there

will continue to be a number of patients waiting over 52 weeks at this time

across plastics, dental, urology and colorectal specialties. The Trust is

expected to confirm the number of remaining long waiting pathways for

March 2018 and recovery plans at site level in order to manage treatment

of these specialties at the Technical meeting on 19 March 2018.

NELFT: The mediated negotiation, which took place in November, has

concluded with a contract variation signed by all parties which includes an

amended contract value (a reduction to the contract value of £1.6m)

which reflects both QIPP delivery and Commissioner investments and set

out requirements for more detailed reporting of costs by the Trust in this

financial year.

Quarter 3 IAPT Recovery performance (latest reported position) shows

achievement of recovery target for Havering, with a reported performance

of 50.8% against a target of 50%. Barking and Dagenham and Redbridge

missed the target of 50% with performance of 43.2% and 47.4%

respectively. IAPT Access targets are still not being met consistently.

Against the 3.75% access target, Barking and Dagenham, Havering and

Redbridge CCG performance is at 3.2%, 3.0% and 3.1% respectively.

KP questioned whether failure to meet constitutional targets should be reflected in the JCAF. SR confirmed these would be included and will flow into JCAF when reaching the appropriate level. KA commented that many members have been on governing bodies for five years and are still reviewing and discussing the same issues. He suggested that a review of what impact governing bodies have achieved over the last five years. SR agreed to review how this could be achieved.

SR

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JJ referred to IAPT and suggested that the CCGs needs a way of mitigating and improving performance. He also referred to workforce issues and suggested that debate is needed around differences in models at Trusts. MS commented that waiting times are affecting referrals. SM reported there is a recovery action plan around recovery of the access standard. She added that there is disappointment that the progess made had not been sustained and reported that a new mental health commissioner will take up post shortly. MM referred to overbilling and questioned whether there will be any repercussions for the Trust if expert determination finds the Trust at fault. SR reported that coding audits tend to show financial drivers as a main reason for this and will be reviewed depending on the outcome. GK requested an update on ICM position and impact of additional resource for HCAs in CTT. The joint committee noted the report. 5.2 Finance risk overview report

TT presented the month 11 finance risk overview report which reported that the CCGs agreed a revised forecast deficit with NHSE in Month 11 of £27.8m (slippage of £12.8m against plan). There have been two movements to the forecast position since the previously reported forecast deficit of £25.2m. The first movement of £4m relates to the inclusion of the national short stock drugs pressure. In Month 11 the CCGs received risk share funding of £1.4m from City and Hackney CCGs to support the mitigation of risk to outturn. However, NHSE require the CCGs to show this as an improvement in forecast. As a result, the in-year forecast deficit is £23m with a year to date deficit of £19.2m. Due to ongoing contractual discussions with BHRUT the level of gross risk and mitigated risk that the CCGs face remains high. The forecast position reported for the BHRUT contract is based on the technical view of the independent mediation entered into for Quarter 1. This has resulted in a likely forecast overspend of £10.7m. A further independent review of the CCGs’ assumptions has been concluded. This view gives a range of financial scenarios which support the position taken by the CCGs. The BHRUT position poses a risk to the CCGs’ forecast. Any movement from the reported position will result in a risk to the CCGs’ control total as all reserves and contingencies are released in the reported position. STP reporting shows a contract triangulation gap with BHRUT of circa £25m. The CCGs and Trust have initiated the next stage of the contract process which is expert determination. This process is not expected to conclude until after year-end. The CCGs have sought audit advice about how the risk should be reflected in the annual accounts. For Barts Health the contractual processes have been concluded and the lead commissioner has reached an agreement on the year end values. The final reported value for BHR CCGs is an overspend of £9.1m.

SR

43

11

Other Associate contracts and Independent Providers have reported forecasts based on the latest activity and referral trends. The previous trend of a month on month increase in costs has slowed in Months 10 and 11 and costs appear to have stabilised. This will be further analysed through contractual processes. Assessment of risk arising from the Month 11 position suggests an unmitigated risk for BHR CCGs of circa £13.1m. The majority of relates to the BHRUT contract. The outcomes of the contractual processes outlined may impact this probability analysis. If the risks materialise, this will result in the CCGs’ in-year deficit increasing to £36m. The other main areas of spend are showing variances as a result of QIPP slippage, investment slippage and pressures on Continuing Healthcare (CHC) packages of care. The forecast position across the entire QIPP portfolio includes QIPP delivery of £32.2m, a slippage of £12.8m against plan. Of this, £6.9m slippage relates to the QIPP in acute contracts and £4m relates to acute QIPP schemes that are not currently in contracts. (For more information on QIPP delivery please refer to the IPR) MS commented that a reduction in independent sector referrals had not been achieved and questioned whether there was any support needed to achieve this. TT reported that analysis on this will be reported to the next financial and delivery committee and FRPB. JJ commented that GPs are referring to independent sector due to waiting times with Trusts. LE reported that he was developing a piece of work with GP colleagues to support this. The joint committee agreed the financial position noting the risks within it. 5.3 Quality report

JH presented a report which provided assurance that the CCG continues to measure and monitor the quality of the services we commission from all providers including:

BHRUT never events,

NELFT CQC

Barts Health External Clinical Harm Assurance

CCG quality issues including diabetic charcot foot serious incident,

discharge email serious incident

Learning from deaths national guidance

Safeguarding adults and children’s boards

The Chair expressed concern at the number of never events across BHR.

JH reported that following a review there was a trend around issues of

sustainability and human factors were part of this. She added that the

CCG were working with the Trust to benchmark criteria of serious

incidents to ensure they do not become never events.

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12

JJ expressed concern that BHR are an outlier in England for pressure

sores. JH agreed to include assurance within the next report.

JM suggested that the committee invites Trust colleagues to discuss

issues of concern to a future meeting.


JH JH

6.0 Development/governance

6.1 NEL commissioning arrangements

JM presented a report on the NEL commissioning arrangement

highlighted the following:

the membership and leadership of the shadow Joint Commissioning

Committee (JCC)

Set out the proposed arrangements for establishing the Joint

Commissioning Committee including the Scheme of Reservation and

Delegation

Advised on the constitutional changes required by NEL CCGs to

establish the JCC and ensure it operates effectively, noting that the

process to agree these with BHR CCGs’ GP members is underway.

The joint committee noted the membership and leadership of the Joint Commissioning Committee and approved the Scheme of Reservation and

Delegation for the Joint Commissioning Committee. (Following the meeting Dr Aggarwal confirmed his support of the recommendations above as Havering CCG were not quorate due to a

clinical director leaving the meeting).

6.2 Terms of reference updates

MP presented the joint committee terms of reference and a minor update

to the quality and safety committee terms of reference for approval. The joint committee approved its terms of reference and the updated

quality and safety committee terms of reference. (Following the meeting Dr Aggarwal confirmed his support of the recommendations above as Havering CCG were not quorate due to a clinical director leaving the meeting).

6.3 Work of the FRPB and Financial Recovery Programme

TT presented a summary report which provided key highlights of the FRPB and financial recovery programme.

The joint committee noted the report. 6.4 Finance & delivery committee chair’s report The Chair presented a report which provided key highlights of the finance and delivery committee held on 15 March 2018. It was noted there was a typographical error under third bullet point and this should read amber rating due to financial challenge.

45

13

The joint committee noted the report. 6.5 Audit & governance committee report

The Chair presented a report which provided key highlights of the audit and governance committee held on 13 February 2018. The joint committee noted the report. 6.6 Minutes of sub committees: The joint committee noted the minutes of the:

Primary care transformation programme board held on 15 November 2017

Patient engagement forum held on 15 January 2018

Quality & safety Committee minutes held on 27 February 2018

Primary Care Commissioning Committee held on 13 December 2017.

7.0 Any other business

GP Alerts

SR updated on the position on the backlog of GP alerts and the system in place to continuously monitor going forward. It was agreed that

A threshold would be put in place so members are aware when

GP alerts reach an agreed level.

Numbers of GP alerts per provider would be included in future

reporting.

There would be a discussion outside the meeting to agree where

future reporting should take place

JH/SR

8.0 Questions from the public

Mr Andy Walker questioned whether the committee would consider live broadcasting of meetings. MP reported that the committee have considered the request and will not be live broadcasting but will upload audio recordings to the CCGs websites after future meetings. Mr Andy Walker commented that Redbridge Health Scrutiny Committee has requested that two extra wards to be opened at KGH. SR responded that CCGs need to understand the use of the current bed base and are working with system partners to review future requirements. Mr Antell, Havering MIND questioned whether the committee would like to receive proposals from Havering MIND on utilising resources effectively. JM welcomed the support of the local voluntary sector with suggestions and ideas. Mr Antell also questioned why mental health investment in Havering was low compared to other boroughs. It was agreed to provide a response to this question after the meeting.

AMK

9.0 Date of the next meeting

24 May 2018

46

BHR CCGs Joint Committee action log

Action ref: Meeting date

Action required Lead Required by Status

3.1 JCAF

29 March 2018

The Chair questioned why GP alerts were not on the JCAF and

other members also requested that this risk was reviewed to

assess whether it should be included. SR agreed to review the

GP alert risk and add if appropriate.

The committee requested that milestones are added to each

risk to show improvements and also highlight new mitigations.

SR MP/PD

May 2018 May 2018

CLOSED Completed. Completed.

3.2 Barts Health contract briefing

29 March 2018

JM reported that the winter leads meet twice a week and

highlighted the need to request an update on themes.

LE May 2018 Verbal update

4.1 East London Health and Care Partnership update

29 March 2018

JM reported that a communications review had recently been

undertaken which will streamline future communications and

also agreed to review interaction between the cabinet and

senate.

JM

May 2018

A communications workshop is taking place on 16 May.

47



4.2 Draft budget update

29 March 2018

SW reported that the minor ailment service is treating patients

with products that were stopped due to the spending money

wisely consultation. LM agreed to review this.

LM May 2018 CLOSED Discussed with Communications team and a reminder of the CCGs decisions following SMW Phase 1 and 2 has been issued to all respective providers.


29 March 2018

KA suggested that a review of what impact governing bodies

have achieved over the last five years is undertaken. SR

agreed to review how this could be achieved.

GK requested an update on ICM position and impact of

additional resource for HCAs on CTT.

SR SR

May 2018 May 2018

Review will take place at IJEC. Verbal update

5.3 Quality report

29 March 2018

JJ expressed concern that BHR are an outlier in England for

pressure sores. JH agreed to include assurance on this within

the next report.

JM suggested that the committee invites Trust colleagues to

discuss issues of concern to a future meeting.

JH JM/JH

May 2018 May 2018

Complete – Section 3.4 Quality Report. To be arranged with the Trust.

7.0 Any other business – GP alerts

29 March 2018

It was agreed that

A threshold would be put in place so members are

aware when GP alerts reach an agreed level.

Numbers of GP alerts per provider would be included in

future reporting.

SR/JH May 2018 CLOSED Section 3.3.7 Quality Report CLOSED 3.3.5 Quality Report

48



There would be a discussion outside the meeting

to agree where future reporting should take place

CLOSED – QSC 15 May 2018

8.0 Questions from the public

29 March 2018

Mr Antell also questioned why mental health investment in

Havering was low compared to other boroughs. It was agreed

to provide a response to this question after the meeting.

AMK May 2018 CLOSED Response sent to Mr Antell.

BHR CCGs Joint Committee- CLOSED ACTIONS




25 January 2018

AA referred to spending money wisely 2, reporting that further

communications to patients were required and suggested that

posters in practices should be larger with more information

included. MP welcomed the feedback and if any other

members had any other comments/ feedback this would also

be welcomed.

MP March 2018 CLOSED The communications team are working on materials following feedback.

3.2 Barts

Health contract

briefing

25 January 2018

JM also commented that comparative data would be useful for members to receive and suggested finding a way of reflecting flows into Whipps Cross. LE reported that Whipps Cross have recently provided a useful update which will be shared. AA referred to 52 week wait clinical harm review which only identified one case of clinical harm and questioned how many patients were reviewed. JH reported that she attends the clinical harm panel on a regular basis. It was noted that it

LE

March 2018 CLOSED Barts Health report on agenda.

49



follows the same process as BHRUT but progress has not been as quick as anticipated. JH reported that no specific risks had been identified and will include further detail in future quality reports. KA referred to the additional £2.5m winter monies and suggested that it would be helpful to understand the impact on A&E performance at Whipps Cross, especially for Wanstead and Woodford patients. AFC referred to the mortality index and requested that details included are correct. LE agreed to clarify. JH reported that Barts Health have lower than expected number of deaths and will need to investigate this with colleagues across London. The Chair welcomed the updates and suggested that issues for clarity are included in a report to the next meeting.

JH LE LE LE

Quality report on agenda. Verbal update. Verbal update. Barts Health report on agenda.

5.1 Integrated

contract report

25 January 2018

RC referred to paediatric therapy waiting times and suggested it would be useful to see an improvement plan. KA referred to associate provider activity and costs which were significantly over target and whether there was any underlying reason why critical care activity is over target for all providers. LE responded that there is a volatile trend in this area and will provide more analysis in future reporting. KA also referred to comparative data for LAS which is poor for Redbridge and suggested that further benchmarking would be useful.

LE LE LE

March 2018 CLOSED Verbal uipdate. Report on agenda. Report on agenda.

50



5.2 Finance & activity report

25 January 2018

KA suggested that locality networks could look at patient flow and it would be useful to bring this data to this meeting.

LE March 2018 CLOSED Verbal update.


25 January 2018

KA referred to questions raised in regard to the follow up of patients that had moved from Meadow Court. SM agreed to provide a briefing to Redbridge CCG members after the meeting.

SM March 2018 CLOSED Completed.

4.1 NEL Commissioning arrangements

30 November 2017

TT requested clarity on funding for the Director of Strategic Commissioning role to ensure this is cost neutral. AS agreed to provide further information on this, adding it was an interim arrangement and that costs would be split on a weighted population basis.

AS January 2018 Issue being picked up between CFOs. Verbal update at meeting.

5.4 Safeguarding child annual report

30 November 2017

WM suggested it would be useful to see outcomes comparison to previous years. KR suggested that it would also be helpful to see reports from other boroughs as information sharing would be useful for all GPs. The Chair commented on the remarkable increase in the number of unaccompanied asylum seeking children and the need to ensure that there are services for these children. JH agreed, adding that this data needs to be reviewed as we have not had this level of data in the past.

JH JH

January 2018 CLOSED Verbal update CLOSED In progress. The designated nurses are finalising a report for February QSC.

5.3 Quality report

12 July 2017 Crisis Team – JH reported that a number of serious incidents had highlighted access to the crisis team as a theme and this had been raised at the NELFT CQRM. A report will be presented to the quality and safety committee and governing

JH September 2017

CLOSED Updated November 2017 - To be discussed at December

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body meeting updating on action taken to address access including a plan, timeline and learning.

quality & safety committee. Update within quality report on agenda.

3.1 GBAF 30 November 2017

SW commented that it was important that the lead commissioner meets with BHR CCGs to give assurance on Barts Health position. It was agreed to write to the lead commissioner to invite them to the next meeting. The Chair questioned whether there is confidence in Barts Health completing the demand and capacity modelling by March 2018 that achieves compliance with the RTT standard by September 2019. CB responded that he did not have confidence in this and would be part of the request to lead commissioners to give assurance to the CCGs, along with finance, activity and performance information.

LM January 2018 CLOSED Item on agenda.

14 December 2017

Development session to be arranged for Join Committee members to focus and explore conflicts of interest.

MP CLOSED Being arranged for a Thursday in February.

5.3 Quality report

30 November 2017

CB was pleased to note the recent improvements at NELFT Brookside unit and the Chairs agreed to write to the Trust to congratulate the team.

Chairs/JH January 2018 CLOSED Completed.

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Barking & Dagenham CCG - CLOSED ACTIONS




26 September 2017

Discussion ensued on the future of the patient engagement forum and the plans to reflect the new commissioning structure. MP agreed to provide the governance structure to the Chair.

MP November 2017

CLOSED Information on new arrangements shared.

3.1 GBAF

26 September 2017

GK referred to supporting practices that do not have access to district nursing services to immunise house bound patients with flu vaccine. SM/GK agreed to discuss this outside the meeting. KP commented that it was refreshing to see the reduction in risks at the governing body level and reported that the finance and delivery committee continue to review 30 risks below this level. He also suggested that the target for the financial risk of 30 March was unrealistic, TT agreed to review this.

SM/ GK TT

November 2017

CLOSED NHSE are commissioning NELFT to provide a housebound service for people who are the district nursing caseload; the CCGs are commissioning a service from GPs for housebound patients who are not on the district nursing caseload. Revised GBAF on agenda.

53



5.4 Quality report

23 May 2017 Dr Rai raised further concerns with the GP alert process and suggested exploring different ways the process could be run. She also questioned whether CDs are aware of alerts and suggested that a pathway and protocol is required for GP alerts just as there are for specialities. KP reported that internal audit would be in touch with CDs who had raised concerns.

JH September 2017

CLOSED Within quality report on agenda.

5.4 Quality report

23 May 2017 Dr John raised concern at BHRUT’s CQC mortality rates for UTIs and requested an urgent GB report including what the issues are and how they are being dealt with and suggested that BHRUT internal audit was required. SM reported that BHRUT will be reviewing the data by 1 June.

JH September 2017

CLOSED Within quality report on agenda.


18 July 2017 KR commented that she was unaware that IAPT will set up clinics within surgeries and suggested that this information should be circulated to practices to ensure they are aware. SM agreed to report this at the next PTI.

SM September 2017

CLOSED Verbal update at meeting.

6.3 Quality report

18 July 2017 Barts Health - CB advised that input to the contracting monitoring process via the lead commissioner has been escalated. CB suggested that the Governing Body consider inviting the lead commissioner to address the Governing Body.

CB September 2017

CLOSED To review this suggestion at the next meeting and determine whether this action is required. Agreed to invite lead commissioner to attend future meeting.

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4.3 Quality report

26 September 2017

The Chair thanked the quality team for clearing the GP alerts backlog. He requested that the number of GP alerts with RAG ratings are included within the next quality report. JH reported that this would also be shared at the next PTI meeting and it was agreed to add this to the intranet for GPs who are not in attendance.

JH November 2017

CLOSED RAG ratings not included, however detailed report on GP alerts in quality report on agenda.

Havering CCG CLOSED ACTIONS



5.2 Contracting report

17 May 2017

It was agreed to discuss further at a future clinical directors meeting and share personal experiences of the service and CB agreed to challenge the urgent care board to consider approaches to improve utilisation of the urgent care centre.

AS TBC CLOSED This will programmed into a future Havering CDs meeting. Our system UEC improvement plan – agreed through the A&E Delivery Board - includes measures to improve UCC use. It is monitored at each meeting and has seen

55



improvement in Quarter 1.

5.2 Contracting report

17 May 2017

The Chair referred to the IAPT KPI and reported that the waiting times for the crisis team were too long and there was no indication of this in the report. JH reported that this will be part of the next quality report due to the high number of GP alerts

JH September 2017 CLOSED Update within quality report.

5.3 Quality report

17 May 2017

The Chair suggested in preparation for winter a report on the review of pneumonia deaths should be escalated to the governing body for review.


1.4 Matters arising

12 July 2017

NELFT survey – The chair reported that he had not seen this survey and questioned whether there is an opportunity to input into questions. He advised that there should also be a GP survey – AS agreed to investigate.

AS

September 2017 CLOSED The Chair has received a copy of the GP survey on MH services. The questions were developed with Dr Kumar as MH GP lead.

2.2 Chief officer report

12 July 2017

GS expressed concern that there had been no attendance from a NELFT mental health lead at the dementia partnership board. CB suggested writing to the Trust expressing disappointment.

CB September 2017 CLOSED Verbal update.

6.3 Quality report

12 July 2017

Discussion ensued on BHRUT mortality outlier status and JH reported on the action BHRUT are taking including setting up a multi-agency system wide group to review 30 mortality reviews. She added that this will be reflected on the GBAF at the next meeting.


56



CB commented that it is the CCGs duty to improve quality. He added that system wide issues need to be adequately responded to and reflected on the GBAF with the CCG’s responsibilities and assuring the governing body. It was agreed that a report would be presented to the next meeting addressing BHRUT and the CCG’s role of system requirement and what we are doing to address wider system issues.

2.3 Patient engagement report

27 September 2017

MP agreed to share the summary of the adult inpatient survey

with members.

MP November 2017 CLOSED Complete.


27 September 2017

The Chair reported that there were issues with NELFT stating they would not undertake flu vaccinations for the housebound. The Chair agreed to discuss this further with TT after the meeting.

Chair/TT November 2017 CLOSED NHSE are commissioning NELFT to provide a housebound service for people who are the district nursing caseload; the CCGs are commissioning a service from GPs for housebound patients who are not on the district nursing caseload

57

Redbridge CCG – CLOSED ACTIONS



3.1 GBAF

26 May 2017

The Chair questioned whether a sixth risk was whether the WEL proposals for multiple ACS posed any risk and a seventh was primary care risk due to lack of GPs and district nurses and the ageing current professionals. MP advised it was a technical issue registering risk but she would discuss these proposals with the relevant directors and report back to the risk lead.

MP July 2017 CLOSED

4.2 Health & Wellbeing Strategy

26 May 2017

The governing body noted the draft and consultation period. The governing body also noted the required CCG input and responsibilities and agreed to receive the agreed strategy following consultation in July.

VH September 2017 CLOSED On Agenda

5.3 Contract report

26 May 2017

JH requested CDs provide any details of access issues re CAMHS as this linked to her responsibilities around Safeguarding Children and Sue Elliott would pick these up. ShH had letters transferring care from CAMHS to NELFT that he could forward on. JH would bring a report to the next meeting on any issues and explore if LBR dis-investment had an impact on provision and consider the risks.

SE/JH September 2017 CLOSED Update within quality report.

5.4 Quality report

26 May 2017

BHRUT was a CQC mortality outlier for UTI in May and fuller

understanding was awaited on the cause. The CCG had been monitoring the upwards trend in SHMI data as this was the highest reported level in London. The Quality & Safety Committee was setting up a clinician to clinician meeting to understand this further, whilst noting a serious robust approach to mortality at the Trust was evident.

JH

September 2017 CLOSED Update within quality report

3.1 GBAF

20 July 2017

KA referred to A&E performance and questioned whether any thoughts have been considered on new LAS targets and what impact these could have. VH reported that these are focused on

CB/AS September 2017 CLOSED The new standards are

58



flexibility of response time to reaching patients rather than a direct impact on A&E performance. CB agreed he did not believe there was a direct impact but would ask for this to be reviewed.

not directly linked to Trust’s A&E performance. In theory, if call handlers are being given more time to assess calls then it could be expected that more alternative care pathways are utilised which should help Trust’s manage their A&E performance. An objective of the alternative care pathways is to reduce the number of ambulance conveyances to hospital so that LAS and the Trust can focus on emergency and life-

59



threatening calls/ needs.


20 July 2017

CB suggested that an update on ICM should be presented to the next meeting.

CB September 2017 CLOSED Verbal update.

6.3 Quality report

20 July 2017

ShH referred to the Barts Health duty of candour target which was consistently not being met and questioned whether the Trust had a plan for improvement. JH reported that Whipps Cross do have an action plan which has been reviewed and strengthened which has resulted in recent improvements and is on an upward trajectory. ShH also asked whether both Trusts are meeting their NHSI requirement to report serious incidents on STEIS and a follow up email. JH reported that BHRUT have a system in place and are compliant and Barts Health have a system but staff are not always using it. JH agreed to provide a status update after the meeting. JH would provide further detail following the meeting.

JH September 2017 CLOSED Email update sent to members

6.3 Quality report

20 July 2017

CB referred to the 60% of identified open alerts that are from Barts Health and asked whether the CCG can be confident that the clinical harm process will identify everyone affected. JH agreed to follow this up and report back.

JH September 2017 CLOSED Within quality report.

2.2 Chief Officers report

20 July 2017

CT reported that she had been receiving a number of concerns from patients about access to Barts Health services and was also concerned that patients are not receiving quality discharge information. CT agreed to write to CB with further detail.

CT (HealthWatch)

September 2017 CLOSED CT to gather further information and share.

60

To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Dr Jagan John, Chair, Barking and Dagenham CCG

Dr Atul Aggarwal, Chair, Havering CCG

Dr Anil Mehta, Chair, Redbridge CCG

Date: 24 May 2018

Subject: Chairs’ report

Executive summary

The report provides an overview of our key activities and those of the CCGs since the last Committee

meeting in September.

Recommendations

The Joint Committee is asked to note the report and agree the action regarding the Accident &

Emergency Delivery Board plan in section 7.0

1.0 Purpose of the report

1.1 To provide an update on activities since the last meeting and on key CCG news.

2.0 BHR senior roles

2.1 Managing Director (MD) – We are working closely with our new Managing Director, Ceri Jacob

who we welcomed to BHR last month. We have weekly meetings with Ceri and together have

instigated weekly sessions with the wider management team and governing body members.

2.2 B&D Chair – at the last Joint Committee meeting we thanked the outgoing Chair for Barking and

Dagenham and congratulated Dr Jagan John who was elected as the new CCG Chair. We are

working well as a BHR team of CCG Chairs, with weekly meetings to discuss BHR and NEL

developments.

3.0 CCG objectives

3.1 We have reviewed our objectives for last year and report on progress within our annual reports.

Last year our leading priority was to address the financial challenge and implement the

requirements of the well-led review required under our legal directions. That still remains key, but

we want to focus on wider transformation rather than transactional changes, so that we can

achieve our overriding objective to deliver improved and safe, compassionate care for local

people. The paper on the agenda later provides more information.

61

4.0 North East London Commissioning Alliance

4.1 As a team we are linking in well with our NEL colleagues in driving the new commissioning

alliance arrangements forward. Through our regular chairs’ meeting, the clinical senate and

newly formed joint commissioning committee. We shared our good practice with clinical

colleagues at the last senate meeting, and have invited colleagues to come to BHR and find out

more about our achievements. Sharing best practice and learning from each other is a real

benefit of the commissioning alliance.

4.2 The Joint Commissioning Committee met in public for the first time earlier this month. The

meeting went well, with discussions on governance changes, the East London Health and Care

Partnership (ELHCP) joint strategic needs assessment and business plan; overall NEL

performance; strategic estates and of particular interest to us as clinicians, the NEL outpatient

transformation programme . We were pleased to see a good attendance from members of the

public.

5.0 Constitution and clinical director election outcome - clinical directors

5.1 Since the last meeting we have each held local GP member committee meetings to discuss a

range of issues, including BHR and NEL developments and our collective and respective financial

positions. We also each considered and agreed a number of changes to the CCGs’ constitutions

to reflect the BHR and NEL ways of working and joint committee arrangements. The

Constitutions have been updated to reflect these changes and have been submitted to NHS

England for approval.

5.2 We are also pleased to confirm that Dr Alex Tran has been confirmed in his role as clinical

director for Havering for a further term following his successful selection and election process.

We also welcome Dr Amit Sharma to Barking and Dagenham CCG as a new clinical director.

We are beginning recruitment campaigns in Barking and Dagenham and Havering to fill the

vacant positions.

6.0 CCG development and information sessions

6.1 With Ceri our managing director we have been holding more regular sessions as mentioned in

section 2.1. At our most recent development sessions we have considered and agreed a series

of actions in relation to wider member engagement, partnership working and an overall

programme of Thursday sessions, some of which we will invite provider and local authority

colleagues to join, depending on the topic area. We reflected on our 360 survey results, which

provide a mixed picture in terms of stakeholder feedback.

7.0 A&E performance

7.1 A&E performance remains challenged at BHRUT. The Accident and Emergency Delivery Board

improvement plan and associated trajectory has been considered and agreed by our urgent and

emergency care (UEC) lead and colleagues within the unplanned care programme. We are

putting in place the necessary resources to deliver our responsibilities under the plan. We

suggest that a wider discussion with joint committee colleagues takes place at a future Informal

Joint Executive Committee (IJEC) meeting, to provide assurance on progress and delivery. It is

also proposed that the plan be reviewed and formally ratified by the three Chairs and clinical

director leads for UEC, along with our Managing Director, Chief Finance Officer and Director of

Delivery and Performance.

8.0 Health and Wellbeing Boards

8.1 There have not been any meetings since our last report, with the next meetings due in June (B&D

and Redbridge) and July (Havering).

62

9.0 Resources/investment

9.1 There are no additional resource implications/revenue or capital costs arising from this report.

10.0 Equalities

10.1 There are no direct equality implications arising from this report.

11.0 Risk

11.1 The CCG is managing a number of serious risks which are outlined in further detail in the

assurance section of this agenda.

12.0 Managing conflicts of interest

12.1 There are no conflicts of interest arising from this report.

15 May 2018

63


From: Jane Milligan, Accountable Officer

Date: 24 May 2018

Subject: Accountable Officer’s Report

Executive summary

This report provides an overview of key activities undertaken by the Accountable Officer since the last

meeting, with a specific focus on the developments within the North East London (NEL) Commissioning

Alliance.

Recommendations

The Committee is asked to:

Note the progress report

1.0 Barking and Dagenham CCG Chair update

1.1 I am pleased to congratulate and welcome Dr Jagan John to his first joint committee meeting in the

role of Chair of Barking and Dagenham CCG.

2.0 Managing Director Update

2.1 I am also pleased to welcome the CCGs’ new managing director, Ceri Jacob, who joined us from

NHS England on 2 April 2018. Ceri has focussed much of her first month on meeting with local

stakeholders and I know is keen to build and strengthen relationships within the patch. Ceri will be

working with partners over coming months to set out a clear roadmap for the delivery of integrated

care in BHR. There is more detail on this in the next section.

3.0 BHR Provider Alliance and Joint Commissioning Board update

3.1 I updated in March that the BHR Provider Alliance and Joint Commissioning Board (JCB) had

agreed to test the principles of integrated care in BHR through the development of a proposal by

the BHR group of leads involved in the UCLP/Dartmouth Place Based Care Network (PBCN)

programme.

3.2 This work continues to progress through the facilitated workshops, and the BHR group have started

to form the basis for their proposal; a place based model of care around frailty, which will be locally

designed with health and care staff on the ground, based on the needs of local people. The group

developing the proposal are continuing to test it with the BHR Provider Alliance. The group has,

recently started to share the proposal more widely, at GP network leads meetings, and, in the case

of Havering, with all GPs within each network; so that they have the opportunity to feed in to its

development.

3.3 By June, the Integrated Care Partnership (ICP) are expecting a more concrete plan from the BHR

Group (which at that stage should have been through a process of review with the Joint

64

Commissioning Board and BHR Provider Alliance) that demonstrates the principles of integrated

care delivery in 2018/19, and the resource requirement to do this. If this proves successful, it has

the potential to be rolled out across the whole of BHR.

4.0 North East London Commissioning Alliance Update

4.1 I am pleased to confirm that Managing Directors have now been appointed in all CCGs covered by

the Commissioning Alliance.

4.2 The NEL Joint Commissioning Committee (JCC) met in public for the first time on 9 May. This first

meeting considered the committee’s terms of reference, the East London Health and Care

Partnership plan, the transformation programme around improving outpatient services and the

committee’s forward plan. It was well attended by members of the public who submitted questions

in advance. The JCC will meet each month and meetings will be held in public every other month.

4.3 Annual reports are being finalised and these will be submitted to NHS England by 29 May.

4.4 This month I attended an end of year meeting with NHS England to discuss the CCG Improvement

and Assessment Framework (IAF) scores across north east London. This was the first time we

have covered all seven CCGs at once and it was a helpful approach, outlining areas of focus

particularly around workforce, cancer and primary care.

4.5 The Operating Plan was published in February 2018 and given that two-year contracts are in place,

2018/19 will be a refresh of existing plans to enable organisations to continue to work together to

develop system-wide plans that reconcile and explain how providers and commissioners will work

together to improve services and manage within their collective budgets.

4.6 I recently attended a roundtable event with the Secretary of State for Health along with other

leaders from across acute, mental health and community trusts as well as a number of STP

chairs. It was a useful discussion around NHS strategy focusing on workforce and finance.

Future meetings are planned and I will keep the Committee updated on these.

4.7 Following the recent local elections, I will be working with Chairs and Managing Directors in each

CCG/system to set up meetings with newly elected leaders and existing council leads to ensure we

maintain strong relationships with the local authority, particularly focusing on health inequality.

5.0 East London Health and Care Partnership (ELHCP)

5.1 The estates strategy for NEL continues to develop. This sets out the current estate held by all NHS

providers and commissioners across NEL and the challenges in making sure these are fit for

purpose for our ambitious plans to improve services and health outcomes. This is part of the wider

London devolution work. The full strategy will come to a future Committee meeting.

5.2 Along with the Chair I met local Healthwatch representatives this month, as part of our ongoing

approach to co-production. We updated the group on the work of the partnership and discussed our

plans for a citizen’s panel.

5.3 Perinatal funding success – we have been successful in our application to the community services

development fund (CSDF) and have been awarded funding to deliver specialist community

perinatal mental health services across north east London. This will allow us to expand service

provision and ensure improved access to treatment and better outcomes for women and families.

6.0 Equalities

6.1 There are no equalities implications arising from this report.

65

7.0 Risk

7.1 There are no risks arising from this report.

8.0 Managing of conflicts of interest

8.1 There are no conflicts of interest issues relevant to this report.


9.1 There are no additional resource implications/revenue or capitals costs arising from this report and

no impact on sustainability.

14 May 2018

66


From: Sahdia Warraich, Richard Coleman and Khalil Ali Lay Members (PPE)

Date: 24 May 2018

Subject: Patient Engagement report

Executive summary

This joint report summarises patient and public engagement activities over the past month, as well as

feedback and insight gathered since the last meetings.

Areas covered:

Patient engagement forum (PEF) update

CCG produced urgent care films

Community Urgent Care (CUC) consultation

Havering Compact

Engagement on the future of Whipps Cross Hospital

Recommendations

The governing body is asked to:

Note and comment on the contents of the report


1.1 To provide a summary of the CCGs’ engagement with patients, the public and other stakeholders

since the last meeting.

2.0 Joint PEF Update

2.1 March saw a return to our individual CCG PEF meetings as we continue to alternate between joint

and local meetings reflecting the strategic direction of the wider system. Members of the

communications team provided members with a general NHS update covering recent

developments across north east London (NEL) and answered questions.

2.2 Our primary care team presented on ‘GP online’, a proposed service for e-consultations to those

who want them, and sought the views of members as to how likely they would be to use this

access route and any issues/queries they had with the proposal. We also discussed plans to

widen engagement in the future via an online citizens’ panel across NEL, which members

acknowledged largely as a positive move.

2.3 Local issues were also discussed by members and a number of actions picked up by the CCG

team as appropriate. These included a number of provider queries that have been forwarded

appropriately. Elections for the PEF Chairs in Havering and Redbridge will take place in July.

67

2

2.4 A range of updates, news releases and invitations for PEF members to take part in various ‘patient

voice’ initiatives across NEL and London have been shared with members. Our most recent Joint

PEF meeting will take place on 22 May in Ilford, where members will have their first opportunity to

meet with our new Managing Director, Ceri Jacob.

3.0 Community Urgent Care (CUC)

3.1 The CCGs launch a 12 week public consultation during the last week in May around proposals for

changes to accessing Community Urgent Care. Local Healthwatch have helped develop the

consultation document, feeding back on drafts to help make the document as easy to understand

as possible for the public. The team will be engaging with various community groups in coming

months to gather as many responses as possible. Our PPE lay member for Redbridge has been

involved in developing the proposals as part of the Project Board.

4.0 Havering Compact

4.1 The CCG attended the Havering Compact Forum and Steering Groups last month, as agreed

following the demise of the separate joint local authority/CCG Havering community and voluntary

sector meetings. The changes were made to reduce duplication given the success of the wider

Compact Forum as a means to engage the wider VCS in Havering. Our overarching NHS

presentation was very well received by a large Compact Forum and the Chair wrote to thank us.

We will continue to attend these meetings and distribute information and materials to its member

groups.

5.0 CCG films on urgent care

5.1 Three short films, produced by the CCGs, are giving local people advice on where to go for urgent

care as part of our ongoing drive to reduce pressure on our busy A&Es. The films promote the

alternatives available in the community including our GP hubs, pharmacists and NHS 111 – and

star local health professionals including Dr John, the new Chair of Barking and Dagenham CCG.

These have been shared widely across the system with our partners.

6.0 Whipps Cross Hospital

6.1 Our neighbouring CCG Waltham Forest are leading some engagement work in relation to the

redevelopment of the Whipps Cross Hospital, which is of interest to residents and stakeholders

from Wanstead and Woodford in particular. There is further information on the Waltham Forest

CCG website about their March event and more detail on the Barts Health website, including the

latest newsletters, here: https://www.bartshealth.nhs.uk/whipps-cross

7.0 Joint Commissioning Committee

7.1 The Havering and Redbridge CCG Lay Members attended the first formal NEL Joint

Commissioning Committee meeting earlier this month. The Barking and Dagenham CCG Lay

Member continues to provide patient voice input to the CCGs’ quality and safety committee.

8.0 Resources

8.1 There are no resource issues relevant to this report.

9.0 Equalities

9.1 Engagement in the borough should contribute to reducing inequalities in access to healthcare and

support the CCG in meeting its equality objectives. This work is progressed through the CCG’s

patient engagement forum structure and in collaboration with patients, the voluntary sector and

other key stakeholders.

10.0 Risks

10.1 There are no identified risks in relation to this report.

68

https://www.bartshealth.nhs.uk/whipps-cross

3


11.1 There are no conflicts of interest relevant to this report.

Author: Andy Strickland, Head of Communications, BHR CCGs

Date: 4 May 2018

69


From: Marie Price, Director of Corporate Services

Date: 24 May 2018

Subject: Joint Committee Risk Assurance Framework

Executive summary

The joint committee assurance framework (JCAF) has been reviewed to reflect the current significant

risks to the three organisations. There are seven risks on the JCAF. Risks ratings are based on the

April 2018 risk register.

The seven risks on the JCAF are :-

1. Risks to the delivery of the Clinical Commissioning Groups’ (CCGs) budget/control total

2. Barking, Havering and Redbridge University Hospitals Trust (BHRUT) emergency care

performance

3. Barts Health’s (BH) performance against RTT

4. BH performance against A&E

5. BH quality concerns

6. BHRUT’s mortality rate is higher than expected and indicates the number of patients dying for

certain clinical conditions is higher than the expected number of patient deaths

7. New - BHRUT’s performance against RTT

Updates to mitigating actions are included in italics following feedback at the last joint committee

meeting for a clearer indicator of new mitigations. In addition the most recent dates for each of the

assurance items listed is included in the assurance framework appendix in line with this committee’s

request.

Recommendations


Note and comment on the current risks escalated to the JCAF and that assurance, levels, controls

and mitigating actions being taken are appropriate

Raise and discuss other potential risks that may require escalation to the next JCAF or, where the

risk has reduced, de-escalation.

1.0 Purpose of the Report

1.1 The purpose of the JCAF is to outline the key strategic risks to the CCGs in achieving its

corporate objectives and the controls in place to provide assurance that the risks are being

managed.

2.0 Background/Introduction

2.1 The CCGs’ joint committee has a responsibility to maintain sound risk management processes

and ensure that internal control systems are appropriate and effective, and where necessary to

70

2

take appropriate remedial action. The CCGs’ collaborative risk register consists of risks that are

specific to the individual functions across the CCGs and risks that the CCGs have in common.

3.0 Current risks on the JCAF

3.1 There are seven significant risks on the collaborative risk register that have been escalated to the

JCAF. Updates to mitigating actions are included in italics following feedback at the last joint

committee meeting for a clearer indicator of new mitigations. In addition the most recent dates for

each of the assurance items listed is included in the appendix in line with this committee’s

request. Appendix 1 shows the full detail of these risks. These fall under three of our five

corporate objectives as follows:

Corporate objective 1 - Secure financial recovery.

Risk 1.1: Significant risks to the delivery of the CCGs’ financial plan - legal directions on financial delivery of our QIPP requirements in year and management of any over-activity: a) Legal Financial directions, b) If we do not deliver against the CCGs’ QIPP plans the CCGs will be in breach of financial control totals and c) risk of over performance in acute, continuing care or prescribing activity. Mitigation:

Implementation of our action plan from the Well Led Review overseen by BHR CCGs and associated System Delivery Framework and Plan

Fortnightly Financial Recovery Programme Board (FRPB) chaired by the Chief Financial Officer

Financial Recovery Planning, Delivery and Monitoring group (FRPDM) established with the responsibility for oversight of the QIPP development process and monitoring delivery against plan, reporting to the FRPB

Financial risk mitigation via our integrated financial strategy across north east London sustainability and transformation plan (STP) and NEL Commissioning Alliance (NELCA), supported by the NEL risk share agreement

18/19 planning requirements informed by expert determination (ED) in relation to 17/18 BHRUT contract

ED process being managed on a daily basis jointly with CSU and sign off by CFO/MD in place

Approach to accounting for acute risk agreed with external auditors

Review of high cost packages of care and the approval process by the SRO for unplanned care

Recovery Director appointed for six months to close the QIPP gap/risk

Proposals for a different form of a contract for 18/19 with a new risk share arrangement included

External review of activity commissioned to inform 18/19 contract baseline. The outcome of the review will be available to be priced by the outcome of ED in early June 2018.

Collaborative objective 3: - Ensuring that we deliver on the objectives within our CCGs’ and

system wide transformation programmes

Risk 3.1: BHRUT's on-going failure to deliver A&E performance standards will impact on the

delivery of services to patients. Mitigation:

A&E delivery Board overseeing the implementation of single system UEC delivery plan

BHRUT is being held to account via contract meetings including Service Performance Reviews (SPR) and Contract Quality Review meetings (CQRMs)

71

3

Monthly escalation meetings with the Trust, BHR CCGs, NHS England (NHSE) and NHS Improvement (NHSI)

Twice daily system calls to support BHRUT in improving performance and flow

Joint interim system improvement director appointed across BHRUT and the CCGs - post extended for four months

System support from NHSE, NHSI and through the Emergency Care Improvement Programme (an intensive support team providing hands-on expert support).

System plan refresh plus additional focus on pathway areas that will provide the greatest improvement

CCGs to contract directly with the primary care provider for the delivery of the Queen ’s Hospital Urgent Treatment Centre (UTC) with a revised specification and KPIs (July 2018)

Delivery of UTC performance to be managed through UTC delivery group from July 2018

Workforce constraints - Inclusion of detailed remedial actions in the written plan and contingencies. Strengthened rota resilience at the urgent care centre at Queens' site

Risk 3.2: Barts Health has a significant RTT backlog and the PTL is currently being validated.

The attribution of increased numbers of 52 weeks wait patients is not available in validated form and BHRCCGs are not sighted on their patients. There is therefore a risk that those patients could be subject to clinical harm and the CCGs are not assured.

Mitigation:

Monthly assurance sought via lead commissioner in regard to the exact number of patients

waiting over 52 weeks who are residents of BHR

Barts Health report 17 (reduced from 43) pathways waiting 52 weeks or longer for BHR CCGs in the unvalidated month-end shadow unify report to NHSE for February 2018

BHR CCGs requested information via the lead commissioner.re number of over 52 week waiters that are waiting for reasons of compliance, complexity or choice (3 Cs)

Monthly external clinical harm review process via the co-ordinating commissioner is in place chaired by NHSE’s London Medical Director with a representative from BHR CCGs - assuring the associate commissioners the Trust are reviewing patients for any potential clinical harm caused through delays in referral to treatment.

Risk 3.3: Barts Health A&E - failure to deliver quality improvements in urgent and emergency

care at BH (specifically at Whipps Cross hospital).

Mitigation:

BH contract managed by Newham CCG with support via NELCSU

Performance meetings including the Trust, co-ordinating commissioners and NHS Improvement (NHSI) with regular updates at contract review group (CRG) meeting.

Risk 3.4: BHRUT RTT - BHRUT have failed to deliver the required National RTT 18 weeks

standard of 92% against their own recovery plan since September 2017. There is a risk that the

number of patients waiting over 18 weeks will continue to rise and that the Trust will not recover

the required standard.

Mitigation:

Performance meetings – through overall joint programme board, contract review meetings and technical sub-group,

Revised and agreed trajectory for recovery

Report and deeper consideration through CCGs’ Quality and Safety Committee

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4

Collaborative objective 5 - High quality, compassionate and safe care.

Risk 5.6: There is a risk that patients may receive poor quality of care and or suffer harm as a

result of BH's failure to achieve quality indicators (never events, levels of healthcare acquired Infections (HCAIs) and management processes for serious incidents (SIs) and complaints). Mitigation:

Contract Performance Notice issued via the co-ordinating commissioner for overdue Serious Incident reports and response to the complaints process. The Trust have not delivered the improvement plan and these matters have been escalated to the Collaborative Commissioning Committee.

The Trust are out to procurement for an external Quality Improvement partner and this is expected to be completed in May 2018.

All mitigations for assurance against risks 3.2, 3.3 and 5.6 are via the co-ordinating commissioner, Newham CCG

Risk 5.7: BHRUT’s mortality rate is higher than expected evidenced by summary hospital level

mortality indicator (SHMI) and hospital standardised mortality ratio (HSMR) data. This indicates the number of patients dying in BHRUT for certain clinical conditions is higher than the expected number of patient deaths.

Mitigation:

CCGs issued Contract Performance Notice In August 2017 in respect of non- assurance of BHRUT's mortality action plan. This contract performance notice has now been closed as the Trust has delivered on all the reporting milestones.

Mortality Faculty established by the Trust and commissioners are seeing some improvement in mortality data.

The Trust Mortality Clinical Director has met with the CCGs’ Clinical Lead and have agreed next steps to develop a system wide approach to support improvements in patient mortality.

3.0 Resources / investment

3.1 There are no additional resource implications/revenue or capital costs arising from this report.

The cost of operating effective risk management arrangements is met from within existing

resources.

4.0 Equalities

4.1 There are no equalities considerations arising from this report.

5.0 Risk

5.1 This report also links to the following GB papers being presented at this meeting and provide

greater detail on key risks mentioned above and the organisations mitigations.

JCAF risk ref. 1.1 relates to the Integrated Performance report (IPR), Finance report and

the Financial recovery report

JCAF risks ref. 3.1,3.2,3.3 and 3.4 relates to the IPR

JCAF risk ref. 5.6 and 5.7 relates to the Quality report

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5


6.1 There are no conflicts of interest considerations arising from this report.

Attachments:

Appendix 1 – Joint Committee assurance framework and summary

Author: Pam Dobson, deputy director, corporate services, BHR CCGs

Date: 16 May 2018

74

Page 1 of 11

Appendix 1 – NHS Barking and Dagenham, Havering and Redbridge CCGs

Collaborative objective 1: secure financial recovery.

Risk Description:

Significant risks to the delivery of the CCGs' financial plan - legal directions on financial delivery of our QIPP requirements in year and management of

any acute over activity relating to underlying performance: a) Legal Financial directions, b) If we do not deliver against the CCGs' QIPP plans the CCGs

will be in breach of its financial control total and c) risk of over performance in acute, continuing care or prescribing activity.

Lead director:

Tom Travers

Risk ref: 1.1

Initial

Risk

Rating

8/2015

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps Proposed

actions

Target

Rating

29/03/19 Control Assurance

Lik

elih

oo

d (

4)

x Im

pact (

5)

= S

evere

20

1 Weekly Financial Recovery

Planning, Delivery and

Monitoring group (FRPDM)

oversight of the QIPP

development process and

monitoring delivery against plan

2 Fortnightly Financial Recovery

Programme Board (FRPB)

Senior Executive meetings

(revised TOR)

3 Formal escalation route to

Finance and Delivery Committee

4 Clinical engagement and

leadership strengthened via

FRPB and F&D committee

5 Monthly NHSE London

Assurance meeting

6 Formal contractual escalation

and agreements for local

mediated solutions

7 STP risk share agreement in

place for 18/19

1 Minutes of FRPDM meetings, risk log and mitigations for all schemes (I) (24/4/18)

2 Minutes of the FRPB Senior

Executive meetings (I)

(19/4/18)

3 Minutes of the bi monthly

Finance and Delivery (F&D) committee (I) (15/3/18)

4 Minutes of bi monthly Joint

Committee (I) (29/3/18) 5 Minutes of the NHSE London

assurance meeting (E) (12/4/2018)

6 Outcome letters anticipated in

June 2018 (E)

7 As point 3.

Lik

elih

oo

d (

4)

x Im

pact (

5)

= S

evere

20

The integrated

performance

report, finance

risk overview

report and

17/18 and

18/19 financial

recovery

update report

provides

greater detail

on the

management

of this risk.

1. Not enough

schemes

identified to

close the

savings gap.

2. Further activity

growth beyond

current

projections.

1. Continued working

with providers and

STP partners to

identify additional

schemes on going

2. Agreement around

a commissioning

risk share

supporting the

activity

management plan

3. Recovery Director

appointed.

1. Approval and

implementation

of actions

arising from

appointment of

the Recovery

Director

2. CCGs and

BHRUT looking

to agree a

different form of

contract

arrangement

for 18/19

including risk

sharing on

costs and

activity.

Lik

elih

oo

d (

2)

x Im

pact (

5)

= H

igh 1

0

75

Page 2 of 11

Corporate objective 3: Ensuring that we deliver on the objectives within our CCGs and system wide transformation programmes.

Risk Description: BHRUT's on-going failure to deliver A&E performance standards will impact on the delivery of services to

patients.

Lead director: Steve Rubery

Risk ref: 3.1

Initial

Risk

Rating

6/2013

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps

Proposed actions

Target

Rating


Lik

elih

oo

d (

4)

x Im

pact (

4)

= S

evere

16

1. Accident and Emergency

Delivery Board (AEDB)

(formerly the SRG).

2. Detailed A&E delivery

Board governed system

plan in place monitored by

the AEDB.

3. Contractual meetings –

SPR / CQRM – and

contractual levers.

4. Winter only (extended) -

daily surge calls (7 days)

with the Trust and

reassurance with NHSE.

5. BHRUT and BHR CCGs

fortnightly assurance calls

with NHSE and NHSI.

6. BHRUT and BHR CCGs

monthly escalation

meetings with NHSE and

NHSI.

1. Minutes of the fortnightly

AEDB. (E) (4/4/2018)

2. See point 1

3. Minutes of monthly

contractual meetings – SPR / CQRM. (I) (9/4/18)

4. Daily action log from

daily surge calls. (E).

5. Notes of the meetings (E). (29/3/18)

6. Notes of the meetings (E). (29/3/18)

Lik

elih

oo

d (

4)

x Im

pact (

4)

= S

evere

16

The integrated

performance

report provides

greater detail

on the

management

of this risk.

1. AEDB has not

signed off the

A&E trajectory

for 18/19

1. Agreed and

signed off

trajectory by the

AEDB by 30 June

2018

Delayed trajectory raised at

the AEDB and assurances

sought that the trajectory will

be finalised by the deadline.

Lik

elih

oo

d (

4)

x Im

pact (

3)

= H

igh

12

76

Page 3 of 11

Risk Description: Barts Health (BH) performance. Barts Health A&E - failure to deliver quality improvements in urgent and emergency care at BH (specifically at Whipps Cross hospital)

Lead director: Steve Rubery Risk ref: 3.2 (was 5.4c)

Initial

Risk

Rating

7/2014

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps

Proposed actions

Target

Rating


Lik

elih

oo

d (

4)

x Im

pact (

5)

= S

evere

20

1. Monthly Collaborative

Commissioning Committee

(CCC) meetings led by the co-

ordinating commissioner,

Newham CCG (Chief Officer)

(CCGs only)

2. Monthly A&E Delivery Board

meeting, led by BH Chief

Executive, attended by Newham

CCG on behalf of

commissioners.

3. Bi-monthly Technical Sub Group

(TSG) and monthly Contract

Review Group (CRG) meetings,

led by Newham CCG, attended

by BH.

4. Monthly BH Internal (BHR CCGs)

Escalation Review meeting

receiving updates on

performance (RTT, A&E, and

diagnostics) and quality.

1. Minutes of the CCC

meeting. (E) (24/4/2018)

2. Minutes of the A&E

Delivery Board. (E)

(2/5/2018)

3. Minutes of the TSG

and CRG. (E) (29/3/2018)

4. Monthly BH Internal

Escalation Review meeting report. (I) (11/4/2018)

Lik

elih

oo

d (

4)

x Im

pact (

4)

= S

evere

16

The

integrated

performance

report

provides

greater detail

on the

management

of this risk.

Lik

elih

oo

d (

3)

x Im

pact (

4)

= H

igh 1

2

77

Page 4 of 11

Risk Description: Barts Health has a significant RTT backlog and the PTL is currently being validated. The attribution of increased numbers of 52 weeks wait patients is not available in validated form and BHRCCGs are not sighted on their patients. There is therefore a risk that those patients could be subject to clinical harm and the CCGs are not assured.

Lead director: Steve Rubery Risk ref: 3.3 (was 5.4a)

Initial

Risk

Rating

7/2014

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps

Proposed actions

Target

Rating


Lik

elih

oo

d (

4)

x Im

pact (

5)

= S

evere

20

1. Monthly Collaborative


(CCC) meetings led by the co-

ordinating commissioner,

Newham CCG (Chief Officer)

(CCGs only)

2. Bi-monthly Technical Sub Group

(TSG) and monthly Contract

Review Group (CRG) meetings,


by BH.

3. Monthly RTT assurance meeting,


by BH, monitoring RTT

performance and recovery






1. Minutes of the CCC

meeting. (E) (24/4/2018)

2. Minutes of the TSG

and CRG. (E) (29/3/2018)

3. Minutes of the RTT

assurance meeting. (E) (19/4/2018)

4. Monthly BH Internal

Escalation Review meeting report. (I) (11/4/2018)

Lik

elih

oo

d (

4)

x Im

pact (

4)

= S

evere

16

The

integrated

performance

report

provides

greater detail

on the

management

of this risk.

1. Absence of

agreement on a

date to achieve

compliance with

the 92%

standard for

RTT.

1. Working

through the lead

commissioner

agree a date for

the Trust to

achieve the

RTT standard

via the monthly

RTT assurance

meeting.

The co-ordinating

commissioner to advise

BHR CCGs of the agreed

date.

Lik

elih

oo

d (

3)

x Im

pact (

4)

= H

igh 1

2

78

Page 5 of 11

Risk Description: BHRUT have failed to deliver the required National RTT 18 weeks standard of 92% against their own recovery plan since September 2017. There is a risk that the number of patients waiting over 18 weeks will continue to rise and that the Trust will not recover the required standard.

Lead director: Steve Rubery Risk ref: 3.4 (new)

Initial

Risk

Rating

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps

Proposed actions

Target

Rating


Lik

elih

oo

d (

4)

x Im

pact (

4)

= S

evere

16

1. Bi –monthly Technical Sub

Group

2. Third revised recovery

trajectory approved and

signed off

3. Briefing report on the current

RTT position to the Quality

and Safety (Q&S) Committee

4. Assurance from BHR CCGs’

Nurse Director on the Trust’s

compliance with their clinical

harm process

1. Minutes of the TSG (E)

2. Minutes of the RTT

Technical group and CRG

(E)

3. Minutes of the Q&S Committee (I)

4. As point 3

Lik

elih

oo

d (

4)

x Im

pact (

4)

= S

evere

16

The

integrated

performance

report

provides

greater detail

on the

management

of this risk.

The Trust does

not have an

agreed signed off

trajectory

confirming when

the standard will

be met

Trust trajectory to

be agreed and

signed off as per

their governance

process.

Timeline in which

to receive the

Trust’s recovery

trajectory agreed

with the Trust

The outstanding trajectory

and timeline for receipt to

be discussed at the RTT

Technical Sub Group

Lik

elih

oo

d (

3)

x Im

pact (

4)

= H

igh 1

2

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Page 6 of 11

Collaborative objective 5: High quality and compassionate and safe care

Risk Description: There is a risk that patients may receive poor quality of care and or suffer harm as a result of BH's failure to achieve

quality indicators (never events, levels of HCAIs and management processes for SIs and complaints).

Lead director: Steve Rubery

NB: The Nurse Director retains overall responsibility for Quality and Safety

Risk ref: 5.6

Initial Risk

Rating

2/2015

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps Proposed actions

Target

Rating


Lik

elih

oo

d (

4)

x Im

pact (

4)

= H

igh

16

1. Contract performance notice

issued and remains open.

Remedial action plans and

recovery trajectory

2. BH Contract Review Group

(CRG), attended by the co-

ordinating commissioner on

behalf of BHR CCGs






4. Barts Health (Whipps Cross)

Collaborative Commissioning

Committee (CCC) monthly

5. Performance enforcement notices

issued by the Care Quality

Commission (CQC) following an

inspection in July 2016.

6. Quality reports to every Quality

and Safety (Q&S) Committee

detailing issues, actions taken and

impact.

7. Monthly SI panels including NEL

CCGs

1. t. Minutes of the CQRM. (E) (15/3/2018)

2. Minutes of monthly

CRG (E) (27/2/2018) 3. Minutes of the

escalation review

meeting (E)

(March 2018)

4. Minutes CCC (E)

(24/4/2018)

5. BH reporting

improvements against

CQC improvement

plan minutes of the

Trust Board meeting

(E)

6. Minutes of the Q&S

Committee (I)

(3/04/2018)

7. Minutes of the SI

panel meetings. (E)

(18/4/2018 – NELFT)

Lik

elih

oo

d (

4)

x Im

pact (

4)

= S

evere

16

The Quality

report provides

greater detail

on the

management

of this risk.

1. Absence of

agreed and

signed off

Remedial action

plans for SI

Signed off and

compliant action

plans

1. Remedial action plans

have been received

and reviewed by the

co-ordinating

commissioner and the

CCGs and have been

found to be non-

compliant. .

Lik

elih

oo

d (

3)

x Im

pact (

4)

= H

igh

12

80

Page 7 of 11

Risk Description: BHRUT’s mortality rate is higher than expected (evidenced by SHMI and HSMR data) and this indicated the number of

patients dying in BHRUT for certain clinical conditions is higher than the expected number of deaths

Lead director: Steve

Rubery

NB: The Nurse Director retains overall responsibility for Quality and Safety

Risk ref: 5.7

Initial

Risk

Rating

7/2017

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps

Proposed actions

Target

Rating


Lik

elih

oo

d (

4)

x Im

pact (

5)

= H

igh

20

1. Bi monthly Quality and Safety

(Q&S) Committee

2. Monthly Clinical Quality Review

Meeting (CQRM)

3. Escalation to the monthly

contract review group (CRG)

4. Joint Committee Meeting of BHR

CCGs bi monthly

5. BHRUT’s Mortality faculty

developed from September 2017

and undertaking a number of

thematic mortality reviews

6. BHRUT’s Mortality reviews

presented to the Mortality

Assurance Group (MAG)

7. Full compliance with the National

Guidance on learning from

deaths issued in March 2017 by

the National Quality Board

1. Minutes of the Quality

and Safety Committee

(I) (3/4/2018)

2. Minutes of the CQRMs

(I) (9/4/2018 BHRUT)

(18/4/2018 – NELFT)

3. Minutes of the CRG

meeting (I) (27/4/2018)

4. Minutes of the JC

meeting (I) (29/3/2018)

5. Reviews presented to

CQRM (I) (9/4/2018)

6. External minutes of the

Clinical Harm Review

meeting (E) (4/01/2018)

7. Full assurance of

compliance received via

– paper presented to

Q&SC.(I) (3/4/2018)

Lik

elih

oo

d (

4)

x Im

pact (

4)

= S

evere

1

6

The Quality

report provides

greater detail

on the

management

of this risk.

1. Not assured of

the robustness

of plans

2. 6 months lag in

published data.

Proxy data

developed with

BHRUT

1. SHMI data was

published in

December

2017 which

showed a slight

improvement

2. A

comprehensive

report

regarding the

plan and

performance

was to be

presented at

the Q&S

committee in

February 2018

but has been

delayed by the

Trust.

To receive the plan

at the CQRM in

April 2018.

Plan reviewed by

commissioning 8

May 2018. Report

to be presented at

Q&SC on 15 May.

Lik

elih

oo

d (

2)

x Im

pact (

3)

= H

igh

6

81

Page 8 of 11

Barking and Dagenham, Havering and Redbridge CCGs Governing Body Assurance Framework - overall summary (2016 – 2018)

Lead /

GBAF ref. Risk description (summarised)

Previous risk ratings Current

rating End of year

forecast Target

risk

level April

2016

June

2016

July

2016

Sept

2016

Nov

2016

Jan

2017

April

2017

June

2017

Aug

2017

Oct

2017

Dec

2017

Feb

2018

April

2018 This

time

Last

time

T Travers

1.1

(was 6.1)

Risk of failure to deliver the CCGs’ budget

plans. 16 16 20 20 20 20 20 20 20 20 20 20 20 16 20 10

S Rubery

3.1

Failure to deliver quality improvement in

urgent and emergency care at BHRUT. 16 16 16 16 16 16 16 16 16 16 16 16 16 12 16 12

S Rubery

3.2

(was 5.4c)

Failure of Barts Health (BH) to meet a

number of operational standards, A&E, 20 20 20 20 20 20 20 20 20 16 16 16 16 9 12 12

S Rubery

3.3

(was 5.4a)

Failure of Barts Health (BH) to meet a

number of operational standards, RTT & 20 20 20 20 20 20 20 20 20 16 16 16 16 12 12 12

S Rubery

5.6

There is a risk that patients may receive

poor quality of care and or suffer harm as a

result of BH's failure to achieve quality

indicators.

20 20 20 20 20 20 20 20 16 16 16 16 16 8 12 12

S Rubery

5.7

BHRUT’s mortality rate is higher than

expected. The number of patients dying in

BHRUT for certain clinical conditions is

higher than the expected number of deaths

20 20 20 20 16 6 16 6

S Rubery

3.4 (new)

BHRUT have failed to deliver the required

National RTT 18 weeks standard of 92%

against their own recovery plan since

September 2017

16 6 12

Risk Summary Number

Total risks last report 5

New risk(s) escalated 1

Risk 5.4a&c split into two risks 1

Risks de-escalated this report 0

Total JCAF risk this report 7

82

Page 9 of 11

NHS BHR CCGs Joint Committee Assurance Framework - overall summary (2013 – 2016)

Lead /

GBAF ref. Risk Description

Initial

rating

(June

2013)

Previous risk ratings

Sept

2013

Jan

2014

Mar

2014

June

2014 Sept 2014

Nov

2014

Dec

2014

Feb

2015

May

2015

Aug

2015

Oct

2015

Dec

2015

Feb

2016

T Travers

1.1

(was 6.1)

Risk of failure to deliver the CCGs’

budget plans. 20 20 20 16

S Rubery

3.1

Failure to deliver quality

improvement in urgent and

emergency care at BHRUT

16 16 20 20 20 20 25 25 25 16 16 16 16 16

S Rubery

5.4, a, b

& c

Failure of Barts Health (BH) to

meet a number of operational

standards, RTT and A/E, data

quality and others.

20 20 16 20 20 16 20 20 20

S Rubery

5.6

Quality standards not being met at

BH - for C.Diff, and MRSA and

FFT

16 20 20 20 20 20

83

Page 10 of 11

84

Page 11 of 11

How to interpret the CCGs Joint Committee Assurance Framework (JCAF):

Risk ref

This is a risk

identifier

attributed to the

risk by the CCG

risk lead

Lead director

This is the executive lead

with responsibility for:

- managing the risks to the

corporate objectives and

- liaising with the risk lead to

ensure the BJCF is up to

date

Reporting to the CCG

governing body or other

committee on progress

Risk ratings:

The risk rating is derived from conversation between the lead director (or

nominated deputy) and the risk lead. The risk score is calculated using the risk

grading matrix. There are three types of risk rating used in the CCG JCAF.

- initial risk rating: this grades the risk as if there were no remedial measures

in place. This is called the ‘inherent risk’.

- current risk rating: this grades the risk taking into account the remedial

measures. The remedial measures should aim to 1, reduce the likelihood of the

risk materialising, 2, reduce the impact of the risk if it does happen and 3,

reduce both.

- target risk rating: this is the level of risk that the CCG is prepared to accept

and the level of risk that must be aimed for.

Risk description

For each risk note down:

Who can be harmed and how

can they be harmed if the risk

materialises.

Areas to consider are: harm/

injury, objectives, claims or

litigation, service disruption,

staffing and competence,

morale, financial, external

assessment and adverse

media interest

Controls

What is being

done to reduce

the likelihood and

severity of the

risk.

One specific risk

may be mitigated

by a number of

controls

Assurance

Assurances are inevitably ‘bits of

paper’ that act as evidence the

controls are in place. Examples

include:

Job descriptions /organisation charts

Regular reports

Contracts / service level agreements

Policies and procedures

Minutes / agendas / terms of

reference

Gaps in controls

What more can be done to

control the risk and what

controls could be improved

Gaps in assurance

What associated

documentation will

demonstrate that the controls

are in place?

Proposed actionsWhere gaps have been identified, list the actions required to put them into place. Ensure they have a named lead and target date

85


From: Ceri Jacob, Managing Director Date: 24 May 2018 Subject: Corporate Objectives 2018/19

Executive summary

Barking and Dagenham, Havering and Redbridge CCGs have shared a set of corporate objectives

over the past three years, reflecting our increasingly collaborative approach.

We have had a challenging few years, and our objectives have reflected our particular priorities,

namely tackling the referral to treatment delays at BHRUT and in addressing the deterioration in

our financial position last year.

We recognise though that we cannot solve our system challenges by working alone. We

understood the importance of this and made an early and successful bid with our system partners

for devolution status.

The right foundations for us to build our integrated care system are in place and the imperative is

clear given the financial and quality challenges from both a provider and commissioner perspective.

With the support of our regulators, we plan to accelerate system working this year – and we think

this will be the key to delivering what all our three governing body members agree is our key

objective – delivering quality, safe and compassionate care for local people – underpinned by

patient engagement.

Our objectives build on those agreed last year and are as follows:

High quality safe and compassionate care for all commissioned services – delivering

better outcomes for local people

Transforming care and meeting constitutional standards through building on our current

programmes for planned and unplanned care with a cross-cutting focus on key population

and priority groups, such as older people and those with long term conditions.

Development of our integrated care system, through a collaborative population based

solution to our system challenges of quality and resources.

Secure financial recovery, meeting our control total agreed with NHSE, and agreeing a

realistic plan to achieve financial balance

Continued implementation of our agreed Primary Care Transformation Strategy,

recognising primary care as the foundation of our integrated care system

Recommendations

The Joint Committee is asked to:

Consider, discuss and agree the corporate objectives

86


1.1 To seek approval for the corporate objectives, which are common across the BHR CCGs.

2.0 Introduction

2.1 Each year the CCGs agree corporate objectives that set out what we hope to achieve over

the coming 12 months.

2.2 For the past three years we have agreed collaborative objectives for the BHR CCGs given

our joint working arrangements. The objectives have generally covered common themes –

financial sustainability, quality care, meeting constitutional standards, transforming care in

mental health, urgent and planned care, primary care development, organisational

development and integrated/accountable system working.

2.3 We’ve refocused our priorities based on our specific challenges, which over the past few

years have been urgent and emergency care, referral to treatment and financial recovery.

We have received legal directions from NHS England for the last two.

2.4 We’ve made real progress in tackling our challenges, and have focussed much of our

energies on financial recovery during 2017/18. We report on our achievements against our

objectives in the annual reports discussed in the separate May governing body meetings. In

addition we plan to hold a focussed debrief with all governing body members in June to

ensure that we reflect on our successes over the past few years.

2.5 We know though that for our system to be truly sustainable and delivering quality care for

local people within the resources available that something fundamental needs to change.

That’s why our plans for developing an integrated care system must be a key priority this

year. It’s only by working with our partners that we will address the underlying challenges

within our patch. We’ve made great progress but this must be accelerated in 2018/19.

3.0 Objectives for 2018/19

3.1 It is proposed that the objectives for 2018/19 build on last year’s and are summarised in the

section below. It should be noted that the information in this report is high level and more

detailed delivery plans to support each objective are being developed by director and clinical

leads.

High quality safe and compassionate care for all commissioned services – delivering

better outcomes for local people

This will be achieved through:

Collaboration and close monitoring of our providers, linking with regulators and partners such as the CQC

Keep the reduction of community acquired pressure ulcers Optimising care for children and young people and ensuring that care is integrated

across settings to improve the overall outcomes, especially access to child and adolescent mental health services.

Improving end of life care and increasing the number of people who die in their preferred place of death by 10%

Optimising medication usage through working to reduce wastage and improve decision making, increasing the number of patients who have an annual medication review

Improving the experience of patients who are discharged from an acute setting ensuring that all discharges are safe

87

Transforming care and meeting constitutional standards through building on our

current programmes for planned and unplanned care with a cross-cutting focus on key

population and priority groups, such as older people and those with long term conditions.


Continued focus on delivery of the constitutional standard for A&E, working

with partners across the BHR system and the A&E Delivery Board

Working with BHRUT to ensure that patients are seen in the most appropriate

care setting thereby making the best use of secondary care capacity to enable

the achievement of Referral to Treatment and Cancer constitutional standards

Appointing an older people’s (OP) commissioner to lead and pull together

transformation programmes for patients in this cohort, with the aim of

improving their care and keeping them healthier for longer.

Working with BHRUT to deliver joint quality, innovation, productivity and

prevention (QIPP) and quality cost improvement (QCIP) schemes that improve

the quality of care at the same time as reducing the costs of service provision

Improving parity of esteem across physical health and mental health services

Development of our integrated care system, through a collaborative population based

solution to our system challenges of quality and resources.


Continued collaboration with partners via the Integrated Care Programme

Board, to refine the roadmap that enables and supports tangible changes to

the way services are delivered in line with the system vision, resulting in

improved outcomes for local people

An incremental and pragmatic approach with a number of key initiatives going

live in18/19

A robust strategic commissioning focus through the BHR Joint Commissioning

Board

The introduction of new delivery models by the BHR Provider Alliance

Secure financial recovery, meeting our control total agreed with NHSE, and agreeing a

realistic plan to achieve financial balance

This will be achieved through

Agreeing and implementing a recovery plan for 2018/19

Appointment and retention of a recovery director to coordinate the programme

of work

Sound financial governance, in line with the outcome of the well-led review

linked to the CCGs’ legal directions

A joined up approach to finance and mutual aid where possible through NEL

commissioning alliance risk share arrangements

Agreeing a three stage plan including a realistic position for 18/19 with NHSE

that moves the CCGs and wider BHR system on to a more sustainable footing,

with joined up resources such as PMO arrangements and with the full support

and a coordinated approach from regulators

Continued participation in the STP programmes of work and exploration of new

ways of operating, such as reformed payment mechanisms

Continued implementation of our agreed Primary Care Transformation Strategy,

recognising primary care as the foundation of our integrated care system

88

This will be achieved through four key workstreams which underpin the delivery of the CCGs’

Primary Care Transformation Strategy and the GP Forward View, namely:

Provider development: ongoing development and maturity of GP Federations

and resilience of individual GP practices, leading to a sustainable primary care

model to underpin the integrated care partnership

Quality improvement (QI): continuation of our primary care QI programme,

further embedding a culture of QI at a practice and network levels to reduce

variation between practice performance, enabling practice efficiencies and

improved health outcomes and increasing patient satisfaction

Primary care workforce: implementing recruitment and retention schemes for the

primary care family and developing new roles and leadership capacity to work in

primary care and across an integrated care partnership

All workstreams will be underpinned by aligned approaches to making best use

of health and care estate to provide services from fit for purposes premises, and

maximising opportunities under the NHS digital programme#

As delegated commissioners, the CCGs’ will proactively work with NHS England

to improve practice performance and individual competencies to support

improved CQC ratings and practice achievement against health outcomes and

patient feedback.

3.2 The relevant committees and this BHR Joint Committee will receive regular update reports so

that members can be assured on delivery.


4.1 There are no specific resource requirements arising from this report.

5.0 Equalities

5.1 There are no specific equalities implications arising from this report.

6.0 Risks

6.1 The CCGs cannot deliver this level of change alone. We rely on collaboration with our local

partners and stakeholders, so our continued focus on developing relationships and a system

rather than organisation first approach, supported by both sets of regulators, should help to

mitigate this risk.

7.0 Conflicts of interest

7.1 There are no conflict of interest considerations arising from this report.

Author: Marie Price, Director of Corporate Services, BHR CCGs

Date: 14 May 2018

89


From: Tom Travers, Chief Finance Officer

Date: 24 May 2018

Subject: Budget Update 2018/19

Executive summary

The draft Operating Plan was submitted to NHSE on 8 March 2018. An updated version based on Month 12 outturn was submitted to NHSE on 30 April 2018. As agreed with NHSE the 2017/18 outturn moved from an in-year deficit of £10.2m to £16.4m (Month 12 outturn). The improvement to the Month 12 position was as a result of the release of the 0.5% risk reserve into the bottom line, the reduction in short stock drugs and the Category M rebate. The reported underlying position (2018/19 opening budget) at Month 12 was a deficit of £10.6m. This includes the full year effect of 2017/18 QIPP schemes – circa £11m. The main elements of the revised plan are the same as the draft plan submitted in March. Details of the planning assumptions, application of growth and revised budget can be found in the attached presentation. The control total in 2018/19 requires BHR CCGs to deliver an in-year break even position. This is a challenging target given the size of the 2017/18 deficit, underlying position and risks to final 2017/18 outturn position. The application of planning assumptions, business rules, cost pressure and investment assumptions have led to a savings requirement of circa £45m. This is split £11m full year impacts and £33.8m new 2018/19 schemes. The plan includes investment into Mental Health Services to meet the Mental Health Investment Standard. Other cost pressures and investments largely relate to the continuation of existing non-recurrent 2017/18 spend, including investment in Primary Care and property costs. The plan does not attempt to erode the brought forward historic deficit.

The level of risk within the draft 2018/19 plan is high. BHR CCGs are subject to an expert determination process with BHRUT. The expert determination gap with BHRUT is circa £29m and the current 2018/19 planning gap is more than £50m. In that context alignment between provider and commissioner cannot be fully achieved until after the outcome of the expert determination. Until the 2017/18 exit position with BHRUT is resolved there is a high level of financial risk within the 2018/19 plan. Movement from the Month 12 reported outturn for BHRUT will result in a deterioration of the 2018/19 plan.

90

The risk assessment of the finance plan includes 50% of the contract gaps (excluding the element relating to QIPP). Therefore, a total risk of £45.3m has been included which is made up of, £18.9m Contract gap, £22.1m QIPP risk, £0.6m CHC, £1.5m prescribing, and £2.2m acute growth. The CCGs and BHRUT have agreed a block payment for Quarter 1 of 2018/19 pending finalisation of an activity review and Expert Determination. Following this final payment for Quarter 1 will be agreed. The intention is to agree a non PbR, non-block contract with BHRUT for 2018/19, with an agreed risk share mechanism that seeks to manage risks for both parties. Once the contract is agreed the CCGs will submit a revised operating plan.

Recommendations


To note the update to the Operating Plan and to approve the revised draft budgets detailed in the attached presentation.


1.1 The purpose of this report is to brief the Joint Committee on the position relating to the revised

Operating Plan.


2.1 The revised Operating Plan was submitted to NHSE on 30 April 2018 and as agreed with NHSE

the 2017/18 outturn moved to reflect a deterioration of the 2018/19 opening budget.

3.0 Report Content

3.1 As agreed with NHSE the 2017/18 outturn moved from an in-year deficit of £10.2m to £16.4m

(Month 12 outturn). The movement of the in-year position resulted in a deterioration of the

2018/19 opening budget which means that the second year of the plan needs to be re-stated to

reflect the current forecast.


4.1 Further details of the planning assumptions, application of growth and draft budget can be found

in the attached presentation.

5.0 Equalities

5.1 N/A

6.0 Risk

6.1 The Joint Committee is asked to note the high level of risk as outlined in the draft

Operating Plan and the expert determination process with BHRUT.


7.1 N/A.

Attachments: Presentation - 2018/19 Planning Update

Author: Tom Travers, Chief Finance Officer

Date: May 2018

91

Joint Committee of BHR CCGs

2018/19 Planning Update

Meeting Date: 24 May 2018

92

Background

• A draft plan was submitted to NHSE and approved by the Joint Committee in March 2018.

• An updated plan, based on Month 12 outturn was submitted to NHSE on 30 April 2018.

• As agreed with NHSE, the 2017/18 in-year position has moved from an in-year deficit of

£10.2m to £16.4m (Month 12 outturn). The Month 12 position improved from previous

months as a result of the release of the 0.5% risk reserve into the bottom line, the

reduction in short stock drugs and the Category M drugs rebate.

• The reported underlying position (2018/19 opening budget) at Month 12 was a £10.6m

deficit. This includes the full year effect of 2017/18 QIPP schemes.

• The main elements of the plan are the same as the March submission

• The latest submission includes a challenging QIPP target of £44.86m, this includes

brought forward and new schemes.

• The Expert Determination process with NHSE is continuing. Until this process is complete

a significant level of risk is inherent within the plan.

• The CCGs and BHRUT have agreed a block payment for Quarter 1 of 2018/19 pending

finalisation of an activity review and Expert Determination. Following this final payment for

Quarter 1 will be agreed. The intention is to agree a non PbR, non block contract with

BHRUT for 2018/19, with an agreed risk share mechanism that seeks to manage risks for

both parties. Once the contract is agreed the CCGs will submit a revised operating plan.

293

Financial Framework and Business Rules

• Resources available to CCGs have increased in 2018/19. The original notified growth was £37.2m. The

additional growth allocation for 2018/19 is £8.1m bringing the total growth to £45.3m (4% uplift). Growth

is intended to fund:

• An increase in levels of emergency activity

• Additional elective activity to tackle waiting lists

• Mental Health Investment Standard

• Cancer transformation

• Primary Care

• The additional investment has been made available by:

• Lifting the requirement to underspend 0.5% of allocation

• Additional CCG allocations

• CCGs are expected to plan against financial control totals communicated at the outset of the planning

process. For BHR CCGs the requirement is to deliver an in-year break even position.

Business Rules

• Creation of 0.5% contingency. This equates to £5.3m

• No requirement to spend 0.5% non recurrently

394

Planning Assumptions and Priorities

NHSE guidance has a number of priorities and deliverables built into it. The Operating Plan is expected to

address the funding of the priorities.

• Move towards system working through STPs and the voluntary rollout of Integrated Care Systems.

• Mental Health – all CCGs to meet the Mental Health Investment Standard (MHIS).

• Cancer – delivery of the national cancer strategy.

• Primary Care – deliver next steps of the GP 5 year forward view.

• Urgent and Emergency Care (UEC) – redesign and strengthen the UEC system. This includes planning for

sufficient capacity to meet activity growth through a combination of additional beds and / or a reduction in

delayed transfers of care and length of stay.

• Referral to Treatment Times – the additional allocation allows for an increase in the volumes of elective

activity and improvements to waiting times.

• Transforming Care for People with Learning Disabilities.

• Maternity Services.

495

Planning Assumptions and Priorities

Planning Assumptions

• Planning assumptions are in line with the previous Operating Plan and include funding the two year National

Tariff Payment System, the impact of HRG 4+ including CNST, demographic and non demographic growth,

pay inflation and the impact of national guidance regarding emergency care and referral to treatment times.

• The increased allocations allow for increased growth in acute activity. Analysis of local growth rates shows

local rates are inline with national assumptions. Therefore, acute activity growth in the plan is in line with

national assumptions and are shown below.

5

% Uplift

Activity Assumptions

Emergency Care

Non Elective and Ambulance 2.3

A&E Attendances 1.1

Referral to Treatment Times

Outpatient Attendances 4.9

Elective Admissions 3.6


Tariff Uplift 0.1

Demographic Growth (applied to non acute areas) 1.17 - 1.22

Non Demographic Growth - Continuing Care 4.2

Non Demographic Growth - Prescribing 3.1

Non Demographic Growth - Primary Care Services 4.0

Impact of HRG 4+ 0.9

Pay and Pensions Inflation 1.6

96

Cost Pressures and Investments

There are a number of cost pressures and investments required to meet the standards that CCGs are expected

to plan for. The majority of these pressures and investments relate to the continuation of existing non recurrent

2017/18 spend.

• Acute cost pressure – includes RTT capacity in line with existing expenditure.

• Mental Health – cost pressure relating to Transferring Care Partnership and investment into NELFT and other

contracts in line with the Mental Health Investment Standard.

• Other Programme cost pressures and investments – these represent the continuation of existing commitments

including market rent, STP costs, investment into primary care and the Better Care Fund

• Co-commissioning - investment to match the received allocation.

6

B&D

£'000s

Havering

£'000s

Redbridge

'£000s

Total

18/19

COST PRESSURES

Acute

RTT 1351 1761 1727 4,839

Other Acute 961 893 (578) 1,276

Mental Health - TCP Costs 112 317 495 924

Market Rent 1,099 765 505 2,368

Healthy London Partnership 308 402 395 1,105

STP Charges 250 250 250 750

Programme Cost Pressures

NHS Property Services 77 (195) 671 552

Other Programme 489 (42) 756 1,203

Total Cost Pressures 4,647 4,150 4,221 13,018

INVESTMENTS

CHS and CHC (659) 1,147 361 849

NELFT MH Contract 381 779 440 1,600

Mental Health Investment Standard 750 49 2,993 3,792

Other Programme - Better Care Fund 25 30 31 86

GP Forward View 794 986 1,117 2,897

Co-Commissioning 119 139 795 1,053

Total Investments 1,411 3,130 5,736 10,277

97

BridgeApplication of growth, business and planning rules, cost pressures and investments results in a savings

requirement of £44.86m.

7

BHR CCGs Total

£m % of allocation

2017/18 Underlying (Deficit)/Surplus (10.61) (0.94%)

Growth 45.34 4.00%

Business Rules

1% Reserve (Programme and Co-Comm) 0.0 0.00%

0.5% Contingency (Programme and Co-Comm) (5.3) (0.47%)

Revised Total 29.42 2.60%


Tariff (3.3) (0.29%)

Demographics (12.6) (1.11%)

Non Demographics (17.6) (1.56%)

Pay inflation (0.4) (0.03%)

CQUIN to 100% (2.0) (0.18%)

Impact of HRG 4 (5.1) (0.45%)

Revised Total (11.45) (1.01%)

Cost Pressures

Acute Cost Pressures (6.1) (0.54%)

Mental Health Cost Pressures (0.9) (0.08%)

Market Rent (2.4) (0.21%)

HLP Charges (1.1) (0.10%)

STP Charges (0.8) (0.07%)

Other Programme Cost Pressures (1.8) (0.15%)


Investments

Community & CHC investments (0.8) (0.07%)

Mental Health Investment Standard (5.4) (0.48%)

Other Programme Investment (0.1) (0.01%)

GP Forward View (2.9) (0.26%)

Co-Commissioning investment (0.1) (0.01%)


18/19 Surplus / Deficit (33.82) (2.99%)

Additional 2018/19 QIPP Requirement 33.82 2.99%

2017/18 Full Year Impact QIPP 11.04 0.97%

Total 2018/19 QIPP Requirement 44.86 3.96%

98

QIPP

• Total QIPP is £44.86m (3.96%)

• The split between 2017/18 full year impact and new 2018/19 QIPP requirement is shown in the table below.

• Development of QIPP opportunities is an ongoing process. Further work has been completed since the

Operating Plan submission, led by the Director of Recovery. This is presented in a separate paper to the

Governing Body.

899

2018/19 Budget before In-Year QIPP

9

BHR CCGs Total2017/18 Month 12 Actual

Non Rec Adj / FYE

2018/19 Net Opening Budget Business Rules


Cost Pressures Investments

Do Nothing Plan 2018/19

£m £m £m £m £m £m £m £m

BHRUT 351.6 (8.1) 343.5 15.5 0.0 1.8 360.9

Barts 102.8 (0.5) 102.3 5.5 0.0 (2.5) 105.3

Homerton 9.4 (0.3) 9.0 0.4 0.0 (0.1) 9.2

Associates 51.5 (0.5) 51.0 1.6 0.0 0.7 53.3

LAS 28.9 (0.6) 28.4 0.9 0.7 0.0 29.9

Other acute 57.6 (2.0) 55.5 1.3 0.0 0.8 57.6

Acute Reserve 11.9 (0.1) 11.8 1.2 4.8 0.0 17.8

Unidentified Acute QIPP 0.0 0.0 0.0 0.0 0.0 0.0 0.0

IR & Tariff Adjustment 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Total Acute 613.7 (12.1) 601.6 0.0 26.4 5.5 0.6 634.1

Prescribing 102.8 (3.2) 99.6 4.4 0.2 0.0 104.2

Other Primary Care 18.9 (5.4) 13.5 0.6 (0.1) 2.9 16.9

Total Primary Care 121.6 (8.6) 113.0 0.0 5.0 0.1 2.9 121.0

NELFT MH Including IAPT 78.2 0.3 78.5 0.1 0.0 1.0 79.6

MH Reserves Investment 0.0 0.0 0.0 0.0 0.0 3.6 3.6

CAMHS 1.5 (0.5) 1.0 0.0 0.0 (0.4) 0.6

Other MH 13.9 (3.6) 10.3 0.1 0.9 1.3 12.6

MH QIPP 0.0 0.0 0.0 0.0 0.0 0.0 0.0

MH Investment Standard 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Total Mental Health 93.6 (3.8) 89.8 0.0 0.2 0.9 5.4 96.4

NELFT CHS 76.5 0.0 76.5 0.1 (1.2) 0.4 75.7

Community QIPP 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Other Community 9.8 (0.1) 9.7 1.1 1.2 0.1 12.1

Community Investment 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Total Community 86.2 (0.1) 86.2 0.0 1.2 0.0 0.5 87.8

CHC 58.0 0.7 58.8 0.0 3.1 (0.1) 0.4 62.1

1% Risk Reserve 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

0.5% Contingency 0.0 0.0 0.0 5.1 0.0 0.0 0.0 5.1

Programme Projects (6.3) 11.9 5.6 0.0 1.6 0.0 7.2

Non Recurrent Programmes 6.1 (3.3) 2.8 0.0 3.8 0.0 6.6

Other Programme Spend 24.1 0.0 24.1 0.3 0.6 0.1 25.0

Unidentified QIPP 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Total Other 23.9 8.6 32.5 5.1 0.3 6.0 0.1 44.0

Delegated Primary Care 95.4 (0.0) 95.4 4.4 0.0 0.1 99.8

Delegated Primary Care 1% 3.7 (0.6) 3.0 0.0 0.1 0.0 0.0 3.1

Delegated Contingency 0.5% 1.3 (0.4) 0.9 0.2 0.0 0.0 0.0 1.1

Total Delegated Primary Care 100.4 (1.0) 99.3 0.2 4.5 0.0 0.1 104.1

Running Costs 16.8 (0.0) 16.8 0.1 0.0 0.0 17.0

Total BHR CCGS Expenditure 1,114.3 (16.3) 1,097.9 5.3 40.9 12.4 10.0 1,166.5

100

Risks and Financial Plan Scenarios

Until the 2017/18 exit position with BHRUT is resolved there is a high level of financial risk within the 2018/19

plan. Movement from the Month 12 reported outturn for BHRUT will result in a deterioration of the 2018/19

plan. There has been three financial plan scenarios modelled.

Scenario 1

• Based on Month 12 reported forecast with an underlying opening budget of a £10.6m deficit.

• The application of 2018/19 business rules, growth assumptions, planning guidance, investments and cost

pressures highlight a total QIPP requirement of £44.9m (3.96%) to meet the in year breakeven control total

Scenario 2

• Scenario 2 includes the risk of increased contractual over performance, including the BHRUT ED process.

The total QIPP ask in this scenario would increase to £62.3m (5.5%)

Scenario 3

• Scenario 3 extends Scenario 2 to reflect impact of further potential risks in 2018/19.

• Scenario 3 includes further risk with regard to the 2018/19 contract gap with BHRUT The total QIPP ask in

this scenario would increase to £81m (7.15%)

10101

Risks and Financial Plan Scenarios

11

Scenario 1

CCG17/18 underlying

Allocation growth

Business Rules



18/19 In Year QIPP

17/18 FYE QIPP Total QIPP 18-19 Plan

Barking and Dagenham CCG (5.3) 12.9 (1.6) (10.6) (4.6) (1.4) 10.7 2.1 12.8 0.0

Havering CCG (4.5) 15.7 (2.1) (14.3) (4.2) (3.1) 12.4 3.3 15.7 0.0

Redbridge CCG (0.8) 16.7 (2.0) (14.7) (4.2) (5.7) 10.8 5.6 16.4 0.0

BHR Total (10.6) 45.3 (5.7) (39.6) (13.0) (10.3) 33.8 11.0 44.9 0.0

Scenario 2

CCG17/18 underlying

Allocation growth

Business Rules



18/19 In Year QIPP



Havering CCG (13.4) 15.7 (2.1) (14.3) (4.2) (3.1) 21.3 3.3 24.6 0.0

Redbridge CCG (5.6) 16.7 (2.0) (14.7) (4.2) (5.7) 15.5 5.6 21.1 0.0

BHR Total (28.1) 45.3 (5.7) (39.6) (13.0) (10.3) 51.3 11.0 62.3 0.0

Scenario 3

CCG17/18 underlying

Allocation growth

Business Rules



18/19 In Year QIPP



Havering CCG (18.6) 15.7 (2.1) (17.8) (4.2) (3.1) 30.0 3.3 33.3 0.0

Redbridge CCG (7.5) 16.7 (2.0) (18.1) (4.2) (5.7) 20.8 5.6 26.5 0.0

BHR Total (37.4) 45.3 (5.7) (48.9) (13.0) (10.3) 70.0 11.0 81.0 0.0

102

Summary

• Budget modelling highlights a savings requirement of £44.86m to reach in-year break even.

• This includes activity increases and mental heath investment in line with national requirement.

• BHRUT expert determination poses a significant risk and may increase the savings requirement.

• The plan does not attempt to erode the brought forward historic deficit.

12103

Attachments

• Appendix 1 - CCG specific bridge

• Appendix 2 - CCG specific budget

13104

Appendix 1

2018/19 Bridge - May 2018 Governing Body Report

£m % of allocation £m2017/18 Underlying (Deficit)/Surplus (5.30) (1.66%) (4.48)

Growth 12.87 4.04% 15.74

Business Rules1% Reserve (Programme and Co-Comm) 0.0 0.00% 0.00.5% Contingency (Programme and Co-Comm) (1.6) (0.50%) (1.9)Revised Total 5.98 1.88% 9.38

Planning AssumptionsTariff (0.8) (0.26%) (1.0)Demographics (3.3) (1.04%) (4.4)Non Demographics (4.5) (1.41%) (6.8)Pay inflation (0.1) (0.03%) (0.1)CQUIN to 100% (0.5) (0.16%) (0.5)Impact of HRG 4 (1.3) (0.42%) (1.9)Revised Total (4.60) (1.44%) (5.26)

Cost PressuresAcute Cost Pressures (2.3) (0.73%) (2.7)Mental Health Cost Pressures (0.1) (0.04%) (0.3)Market Rent (1.1) (0.34%) (0.8)HLP Charges (0.3) (0.10%) (0.4)STP Charges (0.3) (0.08%) (0.3)Other Programme Cost Pressures (0.6) (0.18%) 0.2Revised Total (9.25) (2.90%) (9.41)

InvestmentsCommunity & CHC investments 0.7 0.21% (1.1)Mental Health Investment Standard (1.1) (0.36%) (0.8)Other Programme Investment (0.0) (0.01%) (0.0)GP Forward View (0.8) (0.25%) (1.0)Co-Commissioning investment (0.1) (0.04%) 0.0Revised Total (10.66) (3.35%) (12.40)

18/19 Surplus / Deficit (10.66) (3.35%) (12.40)

Additional 2018/19 QIPP Requirement 10.66 3.35% 12.402017/18 Full Year Impact QIPP 2.13 0.67% 3.28Total 2018/19 QIPP Requirement 12.79 4.01% 15.68

Barking and Dagenham CCG Have

105

% of allocation £m % of allocation £m % of allocation(1.09%) (0.83) (0.21%) (10.61) (0.94%)

3.84% 16.72 4.14% 45.34 4.00%

0.00% 0.0 0.00% 0.0 0.00%(0.46%) (1.8) (0.45%) (5.3) (0.47%)

2.29% 14.07 3.48% 29.42 2.60%

(0.24%) (1.5) (0.36%) (3.3) (0.29%)(1.08%) (4.8) (1.19%) (12.6) (1.11%)(1.66%) (6.3) (1.56%) (17.6) (1.56%)(0.02%) (0.2) (0.05%) (0.4) (0.03%)(0.11%) (1.0) (0.26%) (2.0) (0.18%)(0.47%) (1.8) (0.45%) (5.1) (0.45%)(1.28%) (1.59) (0.39%) (11.45) (1.01%)

(0.65%) (1.1) (0.28%) (6.1) (0.54%)(0.08%) (0.5) (0.12%) (0.9) (0.08%)(0.19%) (0.5) (0.12%) (2.4) (0.21%)(0.10%) (0.4) (0.10%) (1.1) (0.10%)(0.06%) (0.3) (0.06%) (0.8) (0.07%)

0.06% (1.4) (0.35%) (1.8) (0.15%)(2.30%) (5.81) (1.44%) (24.47) (2.16%)

(0.28%) (0.4) (0.09%) (0.8) (0.07%)(0.20%) (3.4) (0.85%) (5.4) (0.48%)(0.01%) (0.0) (0.01%) (0.1) (0.01%)(0.24%) (1.1) (0.28%) (2.9) (0.26%)

0.00% 0.0 0.00% (0.1) (0.01%)(3.02%) (10.75) (2.66%) (33.82) (2.99%)

(3.02%) (10.75) (2.66%) (33.82) (2.99%)

3.02% 10.75 2.66% 33.82 2.99%0.80% 5.63 1.39% 11.04 0.97%3.82% 16.38 4.06% 44.86 3.96%

ering CCG Redbridge CCG BHR CCGs Total

106

Appendix 2

2018/19 Budgets - May 2018 Governing Body Report

Barking and Dagenham2017/18 Month 12 Actual

Non Rec Adj / FYE

2018/19 Net Opening Budget

Business Rules

£m £m £m £mBHRUT 97.4 (2.3) 95.1Barts 23.7 (0.1) 23.6Homerton 2.5 (0.1) 2.4Associates 11.6 (0.1) 11.5LAS 8.5 (0.2) 8.3Other acute 12.5 (0.2) 12.3Acute Reserve 4.1 0.0 4.1Unidentified Acute QIPP 0.0 0.0 0.0IR & Tariff Adjustment 0.0 0.0 0.0Total Acute 160.3 (3.0) 157.3 0.0Prescribing 26.9 (0.8) 26.1Other Primary Care 5.3 (1.6) 3.7Total Primary Care 32.2 (2.4) 29.9 0.0NELFT MH Including IAPT 26.9 0.1 27.0MH Reserves Investment 0.0 0.0 0.0CAMHS 0.4 (0.2) 0.2Other MH 4.1 (0.5) 3.6MH QIPP 0.0 0.0 0.0MH Investment Standard 0.0 0.0 0.0Total Mental Health 31.4 (0.6) 30.8 0.0NELFT CHS 29.5 0.0 29.5Community QIPP 0.0 0.0 0.0Other Community 2.9 0.1 3.0Community Investment 0.0 0.0 0.0Total Community 32.4 0.1 32.5 0.0CHC 16.2 (0.0) 16.2 0.01% Risk Reserve 0.0 0.0 0.0 0.00.5% Contingency 0.0 0.0 0.0 1.4Programme Projects (2.3) 4.2 1.8Non Recurrent Programmes 1.8 (0.9) 0.9Other Programme Spend 7.3 0.0 7.3Unidentified QIPP 0.0 0.0 0.0Total Other 6.8 3.3 10.0 1.4Delegated Primary Care 29.3 0.4 29.7Delegated Primary Care 1% 0.3 (0.3) 0.0 0.0Delegated Contingency 0.5% 0.0 0.0 0.0 0.2Total Delegated Primary Care 29.6 0.1 29.7 0.2Running Costs 4.6 (0.0) 4.6Total B&D CCG Expenditure 313.5 (2.5) 311.0 1.6

107

Havering2017/18 Month 12 Actual

Non Rec Adj / FYE


Business Rules

£m £m £m £mBHRUT 161.3 (3.4) 158.0Barts 11.3 (0.1) 11.2Homerton 1.7 (0.1) 1.6Associates 18.5 (0.2) 18.3LAS 10.2 (0.2) 10.0Other acute 22.7 (0.9) 21.9Acute Reserve 4.6 (0.5) 4.0Unidentified Acute QIPP 0.0 0.0 0.0IR & Tariff Adjustment 0.0 0.0 0.0Total Acute 230.3 (5.3) 225.1 0.0Prescribing 38.2 (1.2) 37.0Other Primary Care 6.9 (1.7) 5.1Total Primary Care 45.1 (2.9) 42.2 0.0NELFT MH Including IAPT 26.9 0.1 27.0MH Reserves Investment 0.0 0.0 0.0CAMHS 0.2 (0.0) 0.2Other MH 3.8 0.2 3.9MH QIPP 0.0 0.0 0.0MH Investment Standard 0.0 0.0 0.0Total Mental Health 30.9 0.3 31.2 0.0NELFT CHS 26.7 0.0 26.7Community QIPP 0.0 0.0 0.0Other Community 3.6 (0.0) 3.6Community Investment 0.0 0.0 0.0Total Community 30.3 (0.0) 30.3 0.0CHC 20.2 (0.1) 20.1 0.01% Risk Reserve 0.0 0.0 0.0 0.00.5% Contingency 0.0 0.0 0.0 1.9Programme Projects (1.6) 3.4 1.8Non Recurrent Programmes 1.4 (0.4) 1.0Other Programme Spend 7.9 0.2 8.1Unidentified QIPP 0.0 0.0 0.0Total Other 7.6 3.3 10.9 1.9Delegated Primary Care 32.8 (0.4) 32.4Delegated Primary Care 1% 0.3 (0.3) 0.0 0.0Delegated Contingency 0.5% 0.9 0.0 0.9 0.0Total Delegated Primary Care 34.1 (0.7) 33.4 0.0Running Costs 5.8 (0.0) 5.8Total Havering CCG Expenditure 404.3 (5.5) 398.8 1.9

Redbridge2017/18 Month 12 Actual

Non Rec Adj / FYE


Business Rules

£m £m £m £m

108

BHRUT 93.0 (2.5) 90.5Barts 67.7 (0.3) 67.4Homerton 5.2 (0.2) 5.0Associates 21.4 (0.2) 21.2LAS 10.3 (0.2) 10.1Other acute 22.3 (1.0) 21.3Acute Reserve 3.2 0.5 3.7Unidentified Acute QIPP 0.0 0.0 0.0IR & Tariff Adjustment 0.0 0.0 0.0Total Acute 223.1 (3.9) 219.2 0.0Prescribing 37.6 (1.2) 36.4Other Primary Care 6.7 (2.1) 4.6Total Primary Care 44.3 (3.3) 41.0 0.0NELFT MH Including IAPT 24.4 0.1 24.5MH Reserves Investment 0.0 0.0 0.0CAMHS 0.9 (0.3) 0.6Other MH 6.0 (3.2) 2.7MH QIPP 0.0 0.0 0.0MH Investment Standard 0.0 0.0 0.0Total Mental Health 31.3 (3.5) 27.8 0.0NELFT CHS 20.2 (0.0) 20.2Community QIPP 0.0 0.0 0.0Other Community 3.2 (0.1) 3.1Community Investment 0.0 0.0 0.0Total Community 23.5 (0.1) 23.3 0.0CHC 21.7 0.8 22.5 0.01% Risk Reserve 0.0 0.0 0.0 0.00.5% Contingency 0.0 0.0 0.0 1.8Programme Projects (2.3) 4.3 2.0Non Recurrent Programmes 2.9 (2.0) 0.8Other Programme Spend 8.9 (0.2) 8.7Unidentified QIPP 0.0 0.0 0.0Total Other 9.5 2.1 11.5 1.8Delegated Primary Care 33.2 (0.0) 33.2Delegated Primary Care 1% 3.0 0.0 3.0 0.0Delegated Contingency 0.5% 0.4 (0.4) 0.0 0.0Total Delegated Primary Care 36.6 (0.4) 36.2 0.0Running Costs 6.5 0.0 6.5Total Redbridge CCG Expenditure 396.4 (8.3) 388.1 1.8

BHR CCGs Total2017/18 Month 12 Actual

Non Rec Adj / FYE


Business Rules

£m £m £m £mBHRUT 351.6 (8.1) 343.5Barts 102.8 (0.5) 102.3Homerton 9.4 (0.3) 9.0Associates 51.5 (0.5) 51.0LAS 28.9 (0.6) 28.4

109

Other acute 57.6 (2.0) 55.5Acute Reserve 11.9 (0.1) 11.8Unidentified Acute QIPP 0.0 0.0 0.0IR & Tariff Adjustment 0.0 0.0 0.0Total Acute 613.7 (12.1) 601.6 0.0Prescribing 102.8 (3.2) 99.6Other Primary Care 18.9 (5.4) 13.5Total Primary Care 121.6 (8.6) 113.0 0.0NELFT MH Including IAPT 78.2 0.3 78.5MH Reserves Investment 0.0 0.0 0.0CAMHS 1.5 (0.5) 1.0Other MH 13.9 (3.6) 10.3MH QIPP 0.0 0.0 0.0MH Investment Standard 0.0 0.0 0.0Total Mental Health 93.6 (3.8) 89.8 0.0NELFT CHS 76.5 0.0 76.5Community QIPP 0.0 0.0 0.0Other Community 9.8 (0.1) 9.7Community Investment 0.0 0.0 0.0Total Community 86.2 (0.1) 86.2 0.0CHC 58.0 0.7 58.8 0.01% Risk Reserve 0.0 0.0 0.0 0.00.5% Contingency 0.0 0.0 0.0 5.1Programme Projects (6.3) 11.9 5.6Non Recurrent Programmes 6.1 (3.3) 2.8Other Programme Spend 24.1 0.0 24.1Unidentified QIPP 0.0 0.0 0.0Total Other 23.9 8.6 32.5 5.1Delegated Primary Care 95.4 (0.0) 95.4Delegated Primary Care 1% 3.7 (0.6) 3.0 0.0Delegated Contingency 0.5% 1.3 (0.4) 0.9 0.2Total Delegated Primary Care 100.4 (1.0) 99.3 0.2Running Costs 16.8 (0.0) 16.8Total BHR CCGS Expenditure 1,114.3 (16.3) 1,097.9 5.3

110


Cost Pressures

Investments


QIPP - Recurrent and Non Recurrent

2018/19 Plan with QIPP £m

£m £m £m £m £m £m4.3 0.0 1.1 100.5 (4.0) 96.51.2 0.0 (0.8) 24.0 (0.5) 23.60.1 0.0 0.1 2.6 0.0 2.60.4 0.0 0.2 12.1 0.0 12.10.3 0.2 0.0 8.7 0.0 8.70.3 0.0 0.2 12.8 0.0 12.80.2 1.4 0.0 5.7 0.0 5.70.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 0.0 0.0 0.06.8 1.5 0.8 166.4 (4.4) 162.01.1 0.1 0.0 27.3 (1.1) 26.20.1 (0.4) 0.8 4.2 0.3 4.51.3 (0.4) 0.8 31.6 (0.8) 30.70.0 0.0 0.0 27.0 0.0 27.00.0 0.0 0.8 0.8 0.0 0.80.0 0.0 (0.1) 0.1 0.0 0.10.0 0.1 0.4 4.2 (0.1) 4.20.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 0.0 0.0 0.00.1 0.1 1.1 32.2 (0.1) 32.10.0 (1.2) (0.1) 28.3 0.0 28.30.0 0.0 0.0 0.0 (0.3) (0.3)0.4 1.2 (0.7) 3.9 (0.0) 3.80.0 0.0 0.0 0.0 0.0 0.00.4 0.0 (0.8) 32.2 (0.4) 31.80.9 0.0 0.1 17.2 (0.6) 16.50.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 1.4 0.0 1.40.0 1.1 0.0 2.9 (1.0) 1.90.0 1.4 0.0 2.3 (0.1) 2.20.1 0.1 0.0 7.5 0.0 7.50.0 0.0 0.0 0.0 (3.3) (3.3)0.1 2.6 0.0 14.2 (4.3) 9.81.0 0.0 0.1 30.8 0.0 30.80.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 0.2 0.0 0.21.0 0.0 0.1 31.0 0.0 31.00.1 0.0 0.0 4.6 0.0 4.6

10.6 3.9 2.2 329.3 (10.7) 318.6

111


Cost Pressures

Investments




£m £m £m £m £m £m7.2 0.0 0.3 165.4 (6.4) 159.00.6 0.0 (0.2) 11.7 (0.2) 11.50.1 0.0 (0.1) 1.6 0.0 1.60.6 0.0 0.2 19.1 (0.0) 19.00.3 0.2 0.0 10.5 0.0 10.50.5 0.0 0.4 22.8 (0.1) 22.70.5 1.8 0.0 6.3 0.0 6.30.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 0.0 0.0 0.09.7 2.0 0.7 237.4 (6.7) 230.71.6 0.1 0.0 38.8 (1.3) 37.50.3 0.3 1.0 6.7 0.4 7.11.9 0.4 1.0 45.4 (0.9) 44.60.0 0.0 0.4 27.5 0.0 27.50.0 0.0 (0.2) (0.2) 0.2 0.10.0 0.0 0.1 0.2 0.0 0.20.1 0.3 0.5 4.9 (0.2) 4.70.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 0.0 0.0 0.00.1 0.3 0.8 32.4 0.1 32.40.0 0.0 0.1 26.9 0.0 26.90.0 0.0 0.0 0.0 (1.0) (1.0)0.4 0.0 0.8 4.8 0.4 5.20.0 0.0 0.0 0.0 0.0 0.00.4 0.0 1.0 31.7 (0.6) 31.11.1 (0.1) 0.2 21.2 (0.7) 20.50.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 1.9 0.0 1.90.0 (0.3) 0.0 1.5 (0.3) 1.20.0 1.3 0.0 2.4 (0.1) 2.20.1 (0.2) 0.0 8.0 0.0 8.00.0 0.0 0.0 0.0 (3.1) (3.1)0.1 0.8 0.0 13.8 (3.6) 10.21.3 0.0 0.0 33.8 0.0 33.80.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 0.9 0.0 0.91.3 0.0 0.0 34.7 0.0 34.70.0 0.0 0.0 5.8 0.0 5.8

14.6 3.5 3.7 422.5 (12.4) 410.1


Cost Pressures

Investments




£m £m £m £m £m £m

112

4.0 0.0 0.5 95.0 (3.8) 91.23.7 0.0 (1.6) 69.6 (1.5) 68.10.2 0.0 (0.2) 5.0 0.0 5.10.7 0.0 0.3 22.2 (0.1) 22.10.3 0.2 0.0 10.6 0.0 10.60.6 0.0 0.1 22.0 0.0 22.00.5 1.7 0.0 5.8 0.0 5.80.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 0.0 0.0 0.09.9 2.0 (0.8) 230.3 (5.3) 225.01.6 0.1 0.0 38.1 (1.3) 36.80.2 (0.0) 1.1 5.9 0.4 6.31.8 0.1 1.1 44.0 (0.9) 43.10.0 0.0 0.6 25.1 0.0 25.10.0 0.0 3.0 3.0 0.0 3.00.0 0.0 (0.4) 0.2 (0.1) 0.10.0 0.5 0.3 3.5 (0.1) 3.50.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 0.0 0.0 0.00.1 0.5 3.4 31.8 (0.2) 31.60.0 0.0 0.3 20.5 0.0 20.50.0 0.0 0.0 0.0 (0.3) (0.3)0.3 0.0 (0.0) 3.4 (0.3) 3.00.0 0.0 0.0 0.0 0.0 0.00.3 0.0 0.3 23.9 (0.6) 23.31.2 (0.1) 0.1 23.7 (0.5) 23.20.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 1.8 0.0 1.80.0 0.8 0.0 2.7 (0.6) 2.10.0 1.1 0.0 1.9 (0.1) 1.80.1 0.7 0.0 9.5 (2.5) 7.10.0 0.0 0.0 0.0 0.0 0.00.1 2.6 0.0 16.1 (3.3) 12.82.1 0.0 0.0 35.3 0.0 35.30.1 0.0 0.0 3.1 0.0 3.10.0 0.0 0.0 0.0 0.0 0.02.2 0.0 0.0 38.4 0.0 38.40.1 0.0 0.0 6.6 0.0 6.6

15.7 5.0 4.1 414.7 (10.8) 404.0


Cost Pressures

Investments




£m £m £m £m £m £m15.5 0.0 1.8 360.9 (14.2) 346.75.5 0.0 (2.5) 105.3 (2.2) 103.20.4 0.0 (0.1) 9.2 0.1 9.31.6 0.0 0.7 53.3 (0.1) 53.20.9 0.7 0.0 29.9 0.0 29.9

113

1.3 0.0 0.8 57.6 (0.0) 57.61.2 4.8 0.0 17.8 0.0 17.80.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 0.0 0.0 0.0

26.4 5.5 0.6 634.1 (16.4) 617.74.4 0.2 0.0 104.2 (3.7) 100.50.6 (0.1) 2.9 16.9 1.1 18.05.0 0.1 2.9 121.0 (2.6) 118.40.1 0.0 1.0 79.6 0.0 79.60.0 0.0 3.6 3.6 0.2 3.80.0 0.0 (0.4) 0.6 (0.1) 0.40.1 0.9 1.3 12.6 (0.3) 12.30.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 0.0 0.0 0.00.2 0.9 5.4 96.4 (0.2) 96.20.1 (1.2) 0.4 75.7 0.0 75.70.0 0.0 0.0 0.0 (1.6) (1.6)1.1 1.2 0.1 12.1 (0.0) 12.00.0 0.0 0.0 0.0 0.0 0.01.2 0.0 0.5 87.8 (1.6) 86.23.1 (0.1) 0.4 62.1 (1.9) 60.30.0 0.0 0.0 0.0 0.0 0.00.0 0.0 0.0 5.1 0.0 5.10.0 1.6 0.0 7.2 (1.9) 5.30.0 3.8 0.0 6.6 (0.4) 6.30.3 0.6 0.1 25.0 (2.5) 22.50.0 0.0 0.0 0.0 (6.4) (6.4)0.3 6.0 0.1 44.0 (11.2) 32.94.4 0.0 0.1 99.8 0.0 99.80.1 0.0 0.0 3.1 0.0 3.10.0 0.0 0.0 1.1 0.0 1.14.5 0.0 0.1 104.1 0.0 104.10.1 0.0 0.0 17.0 0.0 17.0

40.9 12.4 10.0 1,166.5 (33.8) 1,132.7

114


From: Mark Eaton, Director of Recovery

Date: 24 May 2018

Subject: 17/18 and 18/19 Financial Recovery Update

Executive summary

During 17/18 the BHR CCGs delivered a total of £32.2m of the £45.1m target achieving a 72% delivery

rate and contributing to the in-year deficit.

The plan for 18/19 is for the CCGs to deliver a further £45m to achieve an in-year balance but currently

there is only £31m identified. Closing this gap further creates the need for a substantial new number of

schemes and de-risking of existing schemes through rapid delivery. To support rapid delivery of QIPP,

transformational change and to ensure the system as a whole is not destabilised it will be important that

the CCGs work collaboratively with its providers to deliver the necessary system changes.

Recommendations

The Joint Committee is asked to note the report and agree the plan for 18/19.


To update the Committee on the delivery of the 17/18 Financial Recovery Programme and to

provide an update on the status of the 18/19 Financial Recovery Programme.


The 17/18 Financial Recovery Plan for the BHR CCGs required the CCGs to deliver £45.1m of

efficiencies (QIPP) against which a total of £32.2m (72%) was delivered leaving a £12.9m gap

that contributed to the in-year deficit position of £10.6m. The in-year deficit for 17/18 assumes

that no additional risk is added to the CCGs through the current Expert Determination Process

that is underway and that should conclude in June 2018.

Based on the expected final position for 17/18 not changing the 18/19 Financial Recovery Plan

requires the BHR CCGs to deliver a further £45m of efficiencies. As at April 18 ~£23m of this

remained unidentified. To address this significant gap a further ~£10m of broadly transformational

opportunities (phased to consider mobilisation timescales) closing the unidentified gap to £13.8m

and focusing the CCG on delivery £31m of QIPP in 18/19. Without considering other unmitigated

financial risks or slippages that may arise the delivery of £31m of QIPP will present the CCG with

a further cost pressure of £13.8m. However, due to the phasing of the new schemes there is a

significant Full Year Effect in 19/20.

Closing the residual gap will prove difficult for a number of reasons as detailed below:

115

1. There are already a large number of schemes that will require both management and clinical

resourcing and adding more schemes will increase this further.

2. Any transformational schemes that are added in at this stage of the year will naturally be back end

loaded. Therefore to deliver £13.8m of in-year transformational QIPP would require us to identify at

least twice that amount given that schemes are unlikely to mobilise until Q3 at the earliest and more

likely Q4.

3. The only other option would be to increase the transactional efficiencies such as claims and

challenges and to a much lesser degree cost reductions associated with further decommissioning of

services and reducing running costs and other expenditure. Given the growing system deficit (£25m

deficit in 14/15 growing to £65m in 17/18) this approach would do little to arrest the rate of decline.

Therefore it is proposed that the Committee approve the current 18/19 plan at £31m (against the target

of £45m), with the understanding that a number of schemes will be dependent on a range of factors such

as consultation outcomes, and note that the CCGs will continue to work on the pipeline of schemes the

current list of which are outlined within this document and to de-risk existing schemes through rapid

delivery.

3.0 Report Content

17/18 QIPP Outturn Position

A summary of the £32.2m of QIPP delivered in 17/18 is shown in the table below:

This table shows that the greatest variances were against Planned Care and Barts Health QIPP,

both of which need to be addressed as part of the CCGs’ Financial Recovery Plan for 18/19.

116

18/19 QIPP Plan Summary

The current list of schemes for 18/19 are detailed in the two charts below. The first covers the

acute focused QIPP (ie those we would wish to see in the contracts for BHRUT and Barts) and

the second the non-acute QIPP.

QIPP Scheme Transformation Area

Scheme

Type

(New/

Rollover)

Planned Start

Date

Actual Start

Date

Gross value

£000's

Investment

£000's

Net value

£000's

Community based gynaecology service Out of Hospital Rollover N/A N/A 20.07 11.53 8.54

Dermatology pathway reconfiguration Out of Hospital Rollover N/A N/A 304.89 144.23 160.66

Diagnostic Gastroscopy for Dyspepsia Out of Hospital New 01/04/2018 01/04/2018 21.63 - 21.63

ENT Reprocurment Out of Hospital New 01/06/2018 01/06/2018 715.94 564.04 151.91

Gastroenterology Virtual Pathway Out of Hospital Rollover N/A N/A 521.36 295.81 225.54

Improving Referrals Together Out of Hospital Rollover N/A N/A 573.71 299.33 274.38

Lymphedema contract negotiation Long Term Conditions Rollover N/A N/A 96.00 - 96.00

MRI Choosing Wisely Out of Hospital Rollover N/A N/A 159.27 - 159.27

Ophthalmology Reprocurement Out of Hospital New 01/12/2018 01/12/2018 340.04 262.94 77.10

Optical Coherence Tomography in the community Out of Hospital New 01/10/2018 01/10/2018 89.06 75.26 13.80

Prior Approval Scheme Out of Hospital Rollover N/A N/A 1,414.35 9.17 1,405.18

Review of CCG contributions to children in residential care Children & Young People Rollover N/A N/A 22.00 - 22.00

Spending Money Wisely Phase 1 Out of Hospital Rollover N/A N/A 308.08 - 308.08

Spending Money Wisely Phase 2 Out of Hospital Rollover N/A N/A 2,453.66 - 2,453.66

BHRUT PTS Service Review System Enablers New 01/01/2019 01/01/2019 50.00 - 50.00

Barts PTS Service Review System Enablers New 01/07/2018 01/07/2018 388.54 - 388.54

Independent Sector Contract Review & Audits Out of Hospital New 01/06/2018 01/06/2018 200.00 - 200.00

Spending Money Wisely 3: VIP Impact Out of Hospital New 01/09/2018 01/09/2018 250.00 - 250.00

Spending Money Wisely 3: Hips & Knees Out of Hospital New 01/09/2018 01/09/2018 198.24 - 198.24

Clinical Audit: MSK Outpatient Procedures Out of Hospital New 01/09/2018 01/09/2018 87.03 - 87.03

Clinical Audit: Dermatology Minor Skin Procedures Out of Hospital New 01/06/2018 01/06/2018 41.28 - 41.28

Clinical Audit: ENT Out of Hospital New 01/06/2018 01/06/2018 69.81 - 69.81

Clinical Audit: Gastro Out of Hospital New 01/09/2018 01/09/2018 75.62 - 75.62

Clinical Audit: General Surgery Out of Hospital New 01/09/2018 01/09/2018 142.42 - 142.42

Clinical Audit: Prior Approval Compliance Out of Hospital New 01/06/2018 01/06/2018 500.00 - 500.00

Diabetes: Redbridge Community Service Long Term Conditions New 01/01/2019 01/01/2019 81.60 30.00 51.60

Cardiology: Havering Community ECG Service Long Term Conditions New 01/06/2018 01/06/2018 190.81 - 190.81

Cardiology: Havering CCG Community Service Long Term Conditions New 01/09/2018 01/09/2018 137.31 45.00 92.31

Complex Wound Care Programme Out of Hospital New 01/09/2018 01/09/2018 87.50 25.00 62.50

Urology: Community Service Out of Hospital New 01/01/2019 01/01/2019 82.14 25.00 57.14

Gynaecology: Community Service Out of Hospital New 01/01/2019 01/01/2019 149.83 25.00 124.83

Stretch on Gastro Virtual Pathway (Medefer) Out of Hospital New 01/06/2018 01/06/2018 50.00 - 50.00

MSK: Pain Community Service Out of Hospital New 01/09/2018 01/09/2018 171.49 50.00 121.49

MSK: SPA Out of Hospital New 01/07/2018 01/07/2018 465.92 75.00 390.92

Planned Care Total (SRO Louise Mitchell) 10,459.59 1,937.32 8,522.27

Advanced Diabetic care enhanced service Long Term Conditions Rollover N/A N/A 12.00 - 12.00

BHR Diabetes LIS - Primary Care Long Term Conditions New 01/04/2018 01/04/2018 737.19 - 737.19

Kings Park APMS Contract reduction Out of Hospital Rollover N/A N/A 221.69 - 221.69

Primary Care Total (SRO Sarah See) 970.88 0.00 970.88

Additional Community Savings Schemes Long Term Conditions New 01/04/2018 01/04/2018 796.64 - 796.64

Community Treatment Team increased capacity Older People & End of LifeRollover N/A N/A 952.06 151.92 800.14

Enhanced Nursing Home Care Older People & End of LifeNew 01/10/2018 01/10/2018 963.99 755.37 208.62

Grays Court Beds - Stroke Double Running Costs Older People & End of LifeNew 01/03/2019 01/03/2019 316.70 - 316.70

Health 1000 contract renegotiation Older People & End of LifeRollover N/A N/A 108.00 2.00 106.00

Significant 7 training for Care Homes Older People & End of LifeNew 01/05/2018 01/05/2018 446.26 152.69 293.57

Diagnostics in the UCC at King George Hospital Out of Hospital New 01/08/2018 01/08/2018 1,081.44 702.57 378.87

CKD/AKI Service Long Term Conditions New 01/09/2018 01/09/2018 99.46 - 99.46

Respiratory: BHR Community Sleep Apnoea Service Long Term Conditions New 01/09/2018 01/09/2018 65.23 10.00 55.23

Respiratory: Havering CCG Community Service Long Term Conditions New 01/09/2018 01/09/2018 224.74 75.00 149.74

Respiratory: B&D CCG Service Review Long Term Conditions New 01/06/2018 01/06/2018 29.47 - 29.47

North East London LoS/XBD Reduction Programme Out of Hospital New 01/01/2019 01/01/2019 12.50 - 12.50

Ambulatory Emergency Care Activity Increase Urgent & Emergency Care New 01/07/2018 01/07/2018 562.50 - 562.50

Urgent Care Review/Stretch on Hub Activity Urgent & Emergency Care New 01/09/2018 01/09/2018 150.00 40.00 110.00

Expanded UCC Patient Cohort Urgent & Emergency Care New 01/09/2018 01/09/2018 100.00 25.00 75.00

A&E Frequent Attenders Programme Urgent & Emergency Care New 01/09/2018 01/09/2018 241.50 100.00 141.50

Redirection & Health Navigation Urgent & Emergency Care New 01/09/2018 01/09/2018 50.00 - 50.00

Alternative Care Pathways for LAS Urgent & Emergency Care New 01/01/2019 01/01/2019 209.06 50.00 159.06

Integrated End of Life Support Older People & End of LifeNew 01/01/2019 01/01/2019 74.36 24.75 49.61

Falls Older People & End of LifeNew 01/09/2018 01/09/2018 597.31 125.00 472.31

Discharge Bundle - COPD Out of Hospital New 01/07/2018 01/07/2018 75.00 - 75.00

Unplanned Care Total (SRO Sharon Morrow) 7,156.21 2,214.30 4,941.91

ACUTE QIPP TOTAL 18,586.69 4,151.62 14,435.07

117

The following table summarises the 18/19 non-acute QIPP:

QIPP Scheme Transformation Area

Scheme

Type

(New/

Rollover)

Planned Start

Date

Actual Start

Date

Gross value

£000's

Investment

£000's

Net value

£000's

Integrated Community Equipment Service System Enablers Rollover N/A N/A 254.19 69.11 185.08

CHC Choice Programme Other New 01/07/2018 01/07/2018 2,000.00 - 2,000.00

CHC Efficiency Programme Other New 01/07/2018 01/07/2018 300.00 - 300.00

Continuing Care Total (SRO Sharon Morrow) 2,554.19 69.11 2,485.08

Change to Biosimilars price System Enablers Rollover N/A N/A 572.68 - 572.68

Primary Care Prescribing Efficiencies 2017/18 (FYE) System Enablers Rollover N/A N/A 1,595.55 - 1,595.55

Primary Care Prescribing Efficiencies 2018/19 System Enablers New 01/04/2018 01/04/2018 1,493.31 - 1,493.31

Primary Care Prescribing Incentive Scheme investment System Enablers New 01/03/2019 01/03/2019 - 36.86 (36.86)

Primary Care Prescribing Rebates System Enablers New 01/04/2018 01/04/2018 745.31 - 745.31

Primary Care Prescribing SMW 2 System Enablers New 01/04/2018 01/04/2018 488.99 - 488.99

National OTC Consultation Implementation System Enablers New 01/07/2018 01/07/2018 489.75 - 489.75

Review of Repeat Prescribing System Enablers New 01/09/2018 01/09/2018 100.00 - 100.00

NHSE Funded Care Home Support Older People & End of LifeNew 01/09/2018 01/09/2018 100.00 - 100.00

Discharge to Pharmacy Pathway System Enablers New 01/09/2018 01/09/2018 50.00 12.50 37.50

Medicines Management Total (SRO Jacqui Himbury) 5,635.59 49.36 5,586.23

Average Patient flows reduction Mental Health New 01/04/2018 01/04/2018 393.31 - 393.31

CAMHS Efficiency Saving Mental Health New 01/04/2018 01/04/2018 140.00 - 140.00

Closure of Meadow Court Site Mental Health Rollover N/A N/A 2,509.36 424.82 2,084.54

Dementia Service Redesign Mental Health New 01/12/2018 01/12/2018 225.20 202.02 23.18

Dementia Service Redesign (Tapestry reduction) Mental Health Rollover N/A N/A 18.51 - 18.51

Management of mental health individualised placements Mental Health New 01/04/2018 01/04/2018 219.05 42.81 176.24

Strategic Investment Driving System Benefits Mental Health New 01/09/2018 01/09/2018 250.00 - 250.00

Mental Health Total (SRO Sharon Morrow) 3,755.44 669.65 3,085.79

Becketts House back office consolidation System Enablers New 01/04/2018 01/04/2018 160.00 - 160.00

Corporate Efficiencies System Enablers New 01/07/2018 01/07/2018 374.63 - 374.63

Running Costs (Including Estates) Total (SRO Tom Travers) 534.62 0.00 534.62

Community Wheelchair re-procurement System Enablers New 01/04/2018 01/04/2018 963.13 806.94 156.19

Contract Efficiences System Enablers New 01/03/2019 01/03/2019 1,049.00 - 1,049.00

Contract Efficiences System Enablers New 01/03/2019 01/03/2019 552.50 - 552.50

CSU Contract Efficiences System Enablers New 01/04/2018 01/04/2018 388.66 - 388.66

Review contract - BAME Community Development Worker Service System Enablers Rollover N/A N/A 22.50 - 22.50

Review contract - Chiropody service System Enablers New 01/08/2018 01/08/2018 40.80 - 40.80

Review contract - Citizens Advice Burearu contribution System Enablers Rollover N/A N/A 37.16 - 37.16

Review contract - Community HIV Support System Enablers Rollover N/A N/A 17.49 - 17.49

Review contract - Community Paediatric Eye Service System Enablers New 01/04/2018 01/04/2018 189.39 - 189.39

Review contract - Loxford Sub-reception System Enablers Rollover N/A N/A 98.01 - 98.01

Review contract - Osteopathy Service System Enablers Rollover N/A N/A 333.00 - 333.00

Review contract - Run Up contribution System Enablers New 01/04/2018 01/04/2018 2.10 - 2.10

Review contract - Sycamore Trust contribution System Enablers New 01/04/2018 01/04/2018 8.10 - 8.10

Review contract - Voiceability contribution System Enablers Rollover N/A N/A 47.25 - 47.25

In Year Finance & Contract Efficiencies System Enablers New 01/06/2018 01/06/2018 2,000.00 - 2,000.00

Finance & Contract Efficiencies Total (SRO Steve Rubery) 5,749.10 806.94 4,942.16

Unidentified N/a New 01/07/2018 01/07/2018 13,796.05 - 13,796.05

Unidentified Total 13,796.05 0.00 13,796.05

NON-ACUTE QIPP TOTAL 32,024.98 1,595.05 30,429.93

GRAND TOTAL 50,611.67 5,746.67 44,865.00

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18/19 Pipeline

The following chart shows the additional schemes not currently within the plan that are being

worked up into schemes to both assist in closing the gap and also to mitigate any slippage in the

schemes above. This shows that we currently have approximately £5m of additional opportunities

in the pipeline but the full year effect for 18/19 is only £2.7m given mobilisation lead-times.

This plan will continue to evolve over the coming months. It should be noted that the new

potential schemes will be subject to consultation if appropriate as they are developed.

4.0 Resources/Investment

At this stage we are still working to identify the full management and clinical resource required to

deliver the plan and are aiming to keep within our current headcount. A further report will be

prepared for a future Joint Committee meeting.

5.0 Equalities

There are no additional equalities implications arising from this report. All individual schemes will

have an Equalities Impact Assessment completed as part of the approval process.

6.0 Risk

The major risks relating to this report are concerned with the failure to deliver an in-year recovery

position. This already appears within the Corporate Risk Register for the CCGs.


There are no conflicts of interest (COI) in regard to this paper. CoI will be considered within the

workup and mobilisation of each of the main QIPP Schemes detailed above.

Author: Mark Eaton, Director of Recovery

Date: 10.05.18

LOCK

QIPP Scheme

(Description/Classification)

Scheme Type

(New/

Rollover)

Gross value

£

Investment

£

Net value

£

Gross value

£

Investment

£

Net value

£

Urgent and Emergency Care

Further Stretch on AEC New 642 0 642 321 0 321

Community Ambulatory Follow Up New 400 200 200 100 50 50

Critical Care Coding Audit New 200 0 200 100 0 100

UEC Total 1,242 200 1,042 521 50 471

Planned Care

Converting Daycases to OPPROCs New 75 0 75 37 0 37

Targeted Reduction in New:FUP Ratios New 200 0 200 50 0 50

Increasing OPFA Discharges New 2,000 0 2,000 1,000 0 1,000

Review of Charges for Cancelled Activities New 200 0 200 50 0 50

PC Total 2,475 0 2,475 1,137 0 1,137

Sub Total Acute Contract QIPP 3,717 200 3,517 1,658 50 1,608

Primary Care/Prescribing

Advice & Guidance New 1,500 0 1,500 1,125 0 1,125

New 0 0 0

Total Primary Care/Prescribing 1,500 0 1,500 1,125 0 1,125

1,500 0 1,500 1,125 0 1,125

5,217 200 5,017 2,783 50 2,733

Subtotal Non-Acute QIPP

TOTAL QIPP PROGRAMME

FYE Effect Values 18/19 Values (Part Year)

119


From: Marie Price, Director of Corporate Services

Date: 24 May 2018

Subject: Sustainable Development Management Plan

Executive summary

The NHS Carbon Reduction Strategy for England: Saving Carbon, Improving Health, published in

January 2009, reinforces that all parts of the NHS must take action to reduce carbon emissions arising

from their operations. All NHS organisations have an obligation to contribute to the target of a 34% cut

in the overall national carbon footprint by 2020, which is outlined in the Climate Change Act 2008.

The CCG recognises the impact the organisation has on the environment and the strong links between

sustainability and the health of the population. We acknowledge there is a need to work smarter and

achieve more with increasingly limited resources. As part of our response to this challenge a

Sustainable Development Management Plan was developed for 2016-2018 which set out how we

planned to operate in a more sustainable way and how we could work to decrease our carbon footprint.

The progress on our 2016-2018 actions is outlined below.

We have also developed a new plan for 2018-2020 which has been reviewed by Executive

Management Team members and is included for approval.

Recommendations

The Joint Committee is asked to:

Review and note the progress made against the previous plan.

Agree the Sustainable Development Management Plan 2018-2020.


1.1 To provide assurance that the CCGs are taking their obligations to sustainable development

seriously and that we are compliant in our statutory duties. To ask the Joint Committee to note

the work undertaken over the last two years and the requirements for the next two years by

approving the Sustainable Development Management Plan.


2.1 The Climate Change Act was passed in 2008 and introduced legally binding framework to tackle

climate change. The Act created a new approach to managing and responding to climate change

by setting ambitious targets and enhancing the UK’s ability to adapt to the impact of climate

change. As the largest public sector emitter of carbon emission, the NHS has a duty to respond

to meet these new targets.

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2.2 In response to this Act, in January 2009, the NHS Carbon Reduction Strategy for England:

Saving Carbon, Improving Health was published. It gives the NHS vision and guidance on how

and why to become an exemplar low carbon public sector organisation. It details the type of

action required to deliver carbon reductions in line with Government targets on climate change.

The main obligation is the requirement of all NHS organisations to contribute to a 34% cut in the

overall national carbon footprint by 2020.

3.0 Sustainable Development

3.1 Sustainability is about meeting the needs of today without compromising the needs of tomorrow.

It is about using resources wisely to make sure that resources will still be available in the years to

come. Sustainability is not just about using financial resources carefully. It is also about making

sure that we make the most of existing social and community resources (e.g. community

buildings, local groups) and ensuring that we minimise any adverse impact on the local

environment. .

3.2 The CCGs will seek to implement the principles of sustainable development across all areas of our

operations. The Sustainable Development Management Plan sets out how we can deliver

sustainability improvements with the help of our staff, GP members, key partner and stakeholders.

3.3 Our CCGs work collaboratively with a shared management team and so sustainability has been

at the forefront of everything we have done since our establishment in April 2013. For this

reason it made sense to produce one Sustainable Development Management plan across the

three CCGs.

4.0 Progress of 2016-2018 Sustainable Development Management Plan

4.1 The CCGs have progressed the majority of the actions agreed in the 2016-2018 sustainable

development plan.

4.2 We have reduced our office space significantly and reconfigured existing office layouts to make

better use of the space. This will reduce long term costs in rent and utilities as well as our carbon

footprint.

4.3 We have implemented a car parking policy and encouraged use of public transport to reduce the

numbers of staff that travel to work by car.

4.4 We have also promoted national campaigns such as NHS Sustainability Day and this year

agreed an organisation pledge to reduce our printing and implemented a new printing system to

help with this.

4.5 We arranged a staff volunteering session where staff helped out at a local food bank facility.

4.6 The CCG continues to work closely with local partners to align commissioning across health and

social care to provide integrated local, sustainable services.

4.7 We have incorporated a sustainable development section in our primary care strategies and will

ensure promotion of sustainability awareness and initiatives at practice level.

4.8 Any actions in progress have been carried forward into the 2018-2020 plan.

5.0 Resources/Investment

5.1 There are no planned additional resources or investment required. If there are future initiatives

implemented due to the actions in the plan that require investment these are likely to offset by

any savings made by other initiatives outlined in the plan.

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6.0 Equalities

6.1 There are no equalities considerations arising from this report.

7.0 Risk

7.1 There will be changes to the way the CCGs operate in future given the developments of

integrated commissioning and the wider north east London alliance. This may result in some

different ways of working for functions and teams, including office locations. This will impact on

particular carbon targets per building. However this will be mitigated by a more efficient use of

office space, with improved ratios and a move to agile working, requiring fewer desks.

Attachments:

BHR CCGs’ Sustainable Development Management Plan – 2018-2020

Author: Lisa Wood, Senior Business Manager

Date: 2 May 2018

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Page 1 of 9

SUSTAINABLE DEVELOPMENT MANAGEMENT PLAN

2018/19 – 2019/20

Next Review date: March 2020

Version number & date

Summary of changes Ratified By/Date

0.1 Approval of draft plan

1.0 Approval of final plan BHR CCGs Joint Committee– May 2018

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Page 2 of 9

Introduction This Sustainable Development Management plan has been developed in response to the NHS Carbon Reduction Strategy, which reinforces all parts of the NHS to take action to reduce carbon emissions arising from their operations. All NHS organisations have an obligation to contribute to the target of a 34% cut in the overall national carbon footprint by 2020, which is outlined in the Climate Change Act 2008. Barking and Dagenham CCG, Havering CCG and Redbridge CCG (BHR CCGs) recognise the impact the CCGs have on the environment and the strong links between sustainability and the health of the population. We acknowledge there is a need to work smarter and achieve more with increasingly limited resources. As a group of CCGs with a shared management team, the organisation structure was created with sustainability in mind and has been at the forefront of everything we have done since our establishment in April 2013. It is also the same reason that we have one Sustainable Development Management plan across the three CCGs. Each CCG covers a geographical borough area and our three CCGs combined population is over 696,000 and rising. Each CCG is a membership organisation made up of GP member practices which combined across the three CCGs totals 134 practices. We acknowledge that although we are a small employer across the boroughs we need to embed sustainability throughout the organisation and are best placed to help our GP practices make their own contribution as together we can make a difference. We are committed to demonstrate leadership in sustainability and this plan represents a route map for us to delivery sustainability improvements with the help of our staff, GP members and key partners and stakeholders. The BHR CCGs are committed to planning and buying healthcare on a sustainable basis now and in the future and this plan sets out how we intend to deliver that commitment. The CCGs are also part of the North East London Commissioning Alliance, closely working with four other CCGs, as well being a partner in the East London Health and Care Partnership, working together with providers and local authorities to improve health outcomes for our residents. This plan sets out how we as a group of CCGs will operate in a sustainable way and sets some targets for measuring success over the next 2 years, acknowledging there are likely to be some changes in that time which may mean the size of the organisation increases and with it the challenge to continue to decrease our carbon footprint. This plan is a public document and we welcome comments on what we are doing and suggestions as to how we can continue to approve. What is Sustainable Development?

Sustainability is about meeting the needs of today without compromising the needs of tomorrow1. It is about using resources wisely to make sure that resources will still be available in the years to come. Sustainability is not just about using financial resources carefully. It is also about making sure that we make the most of existing social and community resources (e.g. community buildings, local groups) and ensuring that we minimise any adverse impact on the local environment. The BHR CCGs are committed to embracing sustainable commissioning for the following reasons; - to save public funds - to save resources

1 Bruntland Commission

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Page 3 of 9

- to reduce our impact on the environment - to benefit staff, patients and the local population - there is a legal duty to reduce carbon emissions under the Climate Change Act 2008

Sustainable Commissioning

Commissioning for sustainable development in the healthcare system means; - Planning services which are efficient and effective - Buying services which provide highest quality at best value and which have the least impact on the environment - Avoiding duplication, inefficiency and waste - Focus on preventative, proactive care - Patients and public engagement and involvement in planning and design of services - Building resilience and protecting and developing community assets and strengths - Making best use of all the resources we have - Minimising carbon emissions

As a group of CCGs, together we can support sustainable development in the local health economy by; - continuing to work collaboratively with each other to share resources - reducing carbon emissions by;

a) planning and buying services which are sustainable b) making sure we do not waste resources, energy or supplies c) implementing a green travel plan

- ensuring that our governing body members, staff and GP practices are aware of the importance of sustainability and the CCGs’ obligations to contribute to this

- adopting working practices and policies that contribute to sustainable development, including commissioning processes that support environmental and social sustainability

- making sure we have plans in place to adapt to the changing environment, social and financial climate (adaptation) - making sure we have plans in place to deal with adverse events such as power failure and flooding (resilience) - promoting and supporting action on sustainable development across our GP member practices - developing sustainable models of care - regularly reviewing and assessing progress of our plan and reporting to our Governing Bodies. - sharing good practice with other organisations - being open to suggestions and alternative ways of working which can increase productivity and reduce waste

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Page 4 of 9

Key areas of focus for sustainable development

Based on the Good Corporate Citizen Assessment Model, the following areas comprise the priority focus for action and the CCGs will seek to implement the principles of sustainable development across these areas.

Travel

The NHS is responsible for 5% of all journeys made in this country. Its travel policies can influence the behaviour of millions of people every day – not only the 1.4 million people who work for the NHS but the vast numbers of patients, visitors and suppliers who flow in and out of the system.

Procurement

The NHS Sustainable Procurement Strategy sets out how the health and social care sector will use sustainable procurement to achieve improved health and wellbeing for people, the environment and the economy. We will seek to implement these principles in our procurement and contracting processes.

Facilities management This is covered by various elements such as energy, waste, supplies and resources. This is a key area where immediate changes can be made for maximum benefit and outcomes.

Workforce

The NHS is the biggest employer in the UK and the employment standards and policies it follows can have a positive impact on sustainability in the communities they serve.

Community Engagement

NHS organisations play a central role in the community and can make a significant contribution to health beyond clinical functions. They can help local people make informed decisions, enabling them to live healthy, sustainable lifestyles and involve them in the planning and delivery of local healthcare. By working with local partners they can help to produce positive outcomes more efficiently.

Buildings Decisions about the planning, design and construction of new buildings and the refurbishment of existing ones allow opportunities to contribute to a more sustainable NHS.

Promoting sustainability to membership practices

The CCGs have a responsibility to promote sustainable development to member practices and support and encourage them to instil principles and initiatives to increase the practice, and in turn, patient awareness of the importance of sustainability.

Models of care

The CCGs vision is to commission high quality integrated services that are sustainable and have a positive impact on our local populations.

Corporate & Governance

The CCGs are committed to complying with all relevant UK environmental legislations and will embed sustainability in its operations and monitor performance accordingly.

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Page 5 of 9

SUSTAINABLE DEVELOPMENT ACTION PLAN 2016-2018

Action Expected outcomes CCG Lead Deadline/ Progress

Priority Area: Travel

Encourage use of public transport between the three CCGs’ offices, where appropriate and time allows

Reduction in carbon emissions from car travel All Directors / SROs

Ongoing

Commission healthcare services that are accessible to all of our populations and ensuring this is taken into account during the procurement process

If services are accessible by public transport there will likely be a reduction in patients travelling by car, resulting in reduced in carbon emissions.

All Directors / SROs

Ongoing

Ensure stationery orders are placed in bulk, ideally on a monthly basis to limit the numbers of journeys the supplier has to make

Reduction in carbon emissions from the reduced amount of deliveries made by the supplier

Corporate Services

Ongoing

Introduction of a bike scheme, making bicycles affordable for all staff. Improved health and wellbeing of staff and potential of increase of staff cycling to work, reducing carbon emissions from car travel

Corporate Services

By 31/3/2019

Carry out an annual staff travel survey and develop and implement a Green travel plan

Increased staff awareness of their travel options and a reduction in carbon emissions

Corporate Services

By 31/3/2019

Priority Area: Procurement

The implementation of the BHR CCGs’ Procurement Strategy and associated processes

Commissioning of health services which are environmentally, socially and economically sustainable

Director of Delivery & Performance (DDP)

Ongoing

Continue to assess business/commissioning cases for new schemes against sustainability criteria

Ensures sustainability remains a key priority for the CCGs and a way to ensure this is always considered

DDP Ongoing

Use of NHS Standard Contracts which require providers to demonstrate progress of sustainable development plans ensuring an annual review and assurance of provider sustainability plans and progress via contract management process

Using providers that are aware of their own obligations around sustainable development will result in them contributing to a reduction in carbon emissions and sustainable services being provided

DDP Ongoing

Continue to fully participate in national initiatives to align commissioning across health and social care such as the Better Care Fund

Pooling of resources and funds to jointly commission integrated local services results in high quality sustainable services


Ongoing

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Page 6 of 9


Seek opportunities to commission in partnership and to integrate services e.g. ICS and network development

Pooling of resources and funds to jointly commission integrated local services results in high quality sustainable services


Ongoing

Undertake market development work to provide local organisations with information in order to increase their awareness of opportunities to tender

Increased number of local organisations bidding for services which will contribute to the local economy by way of employment opportunities

All Directors /SROs

Ongoing

Procure services in line with the Social Value Act 2013 and make any necessary changes to the BHR CCGs Procurement Strategy to align with this

Ensures sustainability remains a key priority for the CCGs and ensure this is always considered as part of the procurement process

Chief Financial Officer

Ongoing

Priority Area: Facilities Management

Participate in national sustainability campaigns (Sustainability Day, Climate Change Week, Green Office Week, Energy Saving Week)

Increased staff awareness and reduction in energy usage, resources and waste

Corporate Services

Ongoing

Promote energy conservation throughout the organisations

Reduction in energy usage All Directors /SROs

Ongoing

Annual review of energy usage at all BHR CCGs’ offices, with the support of landlords

To establish a baseline to monitor progress of reduction of usage

Chief Financial Officer / AD for Estates

By 31/3/2020

Produce an Energy Efficiency Policy with a specific target to reduce energy usage

Increased staff awareness and reduction in energy usage Chief Financial Officer / AD for Estates

By 3/3/2020

Priority Area: Workforce

Delivery of training to staff via online platforms whenever possible

No travel required and reduced cost Corporate Services

Ongoing

Where possible training sessions shared with other BHR CCGs staff and with NEL CSU staff where appropriate

This ensures all spaces on course are fully utilised which will reduce the number of additional sessions required

Corporate Services

Ongoing

Include sustainability awareness in staff job descriptions Ensures sustainability remains a key priority for the CCGs across all areas of the organisation

Corporate Services

Ongoing

Ensure sustainability development is covered in all new staff induction

Ongoing promotion of sustainability amongst staff Corporate Services

Ongoing

Encourage staff to provide suggestions and ideas on how sustainability can be improved in all areas across the organisations

Increased involvement from staff around sustainability All Directors /SROs

Ongoing

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Invite NHS Sustainable Development Unit to present at an all staff briefing

Raise awareness and importance of sustainability amongst staff

Corporate Services

By 31/3/2019

Development and implementation of health and wellbeing initiatives for staff and apply for accreditation to the London Healthy Workplace Charter

Improved health and wellbeing of staff will have a positive impact on productivity and staff retention

Corporate Services

By 31/3/2019

Priority Area: Community Engagement

Proactively involve patients and the public in planning and decision making via Patient Engagement Forums

Engagement and input from patients and service users will mean the right services are commissioned in the right place

Comms team Ongoing

Work with key stakeholders such as local Healthwatch organisations, local authorities and Health and Wellbeing Boards to ensure local priorities and decisions support improved health and sustainability

Increased sustainability of services Comms team Ongoing

Increase patient and public engagement to a wider range of people being invited to join the Patient Engagement Forums

Ensures sustainability remains a key priority for the CCGs across all areas of the organisation

Comms team Ongoing

Continue to seek innovative ideas from the public and other partners and stakeholders as to how sustainability can be improved

Improvements to sustainability management plan Comms team Ongoing

Priority Area: Buildings

When commissioning services, include assessment of the location and building – energy, transport, sustainability (in liaison with NHS Property Services)

Reduction in carbon emissions and raised awareness of sustainability


Ongoing

Should any of the CCGs need to move offices (or need to increase space within the same building) an assessment on the location and building - energy, transport, sustainability - needs to be carried out. Review for 2019/20 office requirements – encouraging agile working and improved staff;desk ratios

Reduction in carbon emissions and raised awareness of sustainability

Chief Financial Officer/AD Estates

Ongoing April 2019

Development of an IT strategy to allow for agile working practices to be adopted to ensure maximum office space utilised

Reduction of carbon emissions if the need for additional space is limited

SRO for Innovation & IT

31/12/2018

Priority Area: Promoting sustainability development to member practices

Promote Primary Care sustainable development via Primary Care Increase in practice sustainability initiatives being Director of Primary Care

Ongoing

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Page 8 of 9


strategies implemented Transformation

Encourage and support practices to promote active travel with practice staff and patients

Reduction in carbon emissions and increase in staff and patients’ health and wellbeing

Director of Primary Care Transformation

Ongoing

Circulate sustainable development management plan to GP member practices once approved

Raise awareness of sustainable development within GP practices, contributing to the reduction of carbon emissions

Comms team By 31/7/2018

As part of CCGs’ awards programme include an award to the practice that is considered to have made the most significant contribution to sustainable healthcare

Increase in practice sustainability initiatives being implemented

Corporate Services

By 31/3/2019

When the CCG Constitution is next updated add a section about sustainable development and the role of GP members in contributing to this

Increase in practice sustainability initiatives being implemented

Corporate Services

By 31/3/2020

Priority Area: Models of Care

Work closely with other CCGs across the North East London Commissioning Alliance and partners of the East London Health and Care Partnership to commission services across the wider NEL footprint

High quality local care and improved outcomes for patients, increased efficiencies

All staff Ongoing

To continue to work to reduce secondary care admissions with more services being delivered close to home in primary or community settings

High quality local care and improved outcomes for patients All Directors / SROs

Ongoing

To continue to focus on prevention and early intervention measures to ensure that our populations stay as healthy as possible for as long as possible and are cared for within the community if required

Increased health of the local population All Directors / SROs

Ongoing

To work with local authorities and other key partners to plan and commission integrated services

High quality sustainable services


Ongoing

Priority Area: Corporate and Governance

Complete mandatory annual return to NHS England on all areas of sustainable development and reference progress in annual reports

Awareness of progress made over the last year Corporate Services

Ongoing

Work with partners across local authorities and Health and Wellbeing Boards to develop Adaptation Plans, which describe the potential risk and impact assessments associated with climate and other changes

A robust plan to ensure we are well placed to deal with changes

Chief Operating Officers

Ongoing

Ensure the CCGs embed sustainability into all policies and procedures and that accountability is clear

Increased staff awareness and move towards sustainability becoming business as usual

Corporate Services

Ongoing

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Page 9 of 9


Carry out Good Corporate Citizen Assessment so a baseline can be recorded and progress monitored on a yearly basis

Improved reporting for comparison purposes Corporate Services

By 31/3/2019

Reference sustainable development within the CCGs’ Corporate Objectives

Sustainability will remain a priority for the CCGs Accountable Officer

Ongoing

Draft a Sustainable Development Management Plan for 2018-2020 and report on progress to Governing Bodies in April 2019.

Progress of sustainable development will be monitored to ensure initiatives are being implemented

Corporate Services

By 31/4/2018

131


From: Jane Milligan, Accountable Officer

Date: 24 May 2018

Subject: East London Health and Care Partnership Update

Executive summary

The report updates the Committee on the progress made by the East London Health and Social Care

Partnership (ELHCP) to deliver 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.

Recommendations


Note the progress report

Introduction

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).

2. An update on the ELHCP will be provided at each meeting of the CCGs’ Joint Committee.

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

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2

integrated care partnerships (formerly accountable care systems) and the establishment of the NEL

Commissioning Alliance and the appointment of a Single Accountable Officer.

4. The ELHCP is reviewing its governance and operating model 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 an NEL Assembly that meets every 3 months with a wide 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

strengthening the links between the ELHCP Executive and the three System Delivery Boards

established to deliver the local integrated care partnerships that will be the main vehicles for

delivering improvements in services and health outcomes. Future ELHCP updates will ensure

CCG GBs/JCs (BHR) are updated on the progress being made.

5. Senior Delivery Officers (SDOs) have been identified for all of the ELHCP and Commissioning Alliance

programme workstreams and a series of stocktake meetings are being held with each to discuss

progress, synergies with other workstreams, risks/ issues and governance. These will be completed

during May 2018. A Programme workshop event is scheduled for 26 th April 2018 to enable

workstreams to share their plans for 2018. A summary will be circulated to all CCG GB/JC members.

Delivery of the NEL Sustainability and Transformation Plan (STP)

6. 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.

7. 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.

Maternity: Demand and capacity workstream has been established. The programme “Starting a

Career as a Midwife in East London” from The Maternity recruitment and retention Programme

goes live in May; this is aimed at encouraging new talent into north east London.

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3

Transforming Care: Plans to focus on Bed closures and National Service model; redesigning two

local assessment and treatments units (ATUs) by way of increasing local services to support the

cohort and ensure when people do need inpatient treatment, it’s close to home and effective.

Digital: All trust, all GPs and Councils are connected to east London Patient Record (eLPR).

Discovery actively being used in some care settings.

Infrastructure: The STP Estates Board has been established. Plans are underway by the STP

board to develop a ELHCP wide Estates Strategy fit for purpose, cost-effective, integrated,

accessible estate which enables the delivery of high quality health and social care services for

local residents.

Provider Productivity: A business case requesting funds to commission external organisation

(PwC) to undertake assessment of NEL wide single procurement service has now been

developed.

Medicines Optimisation: Defining an overall clinical strategy in relation to demand & capacity to

provide a baseline from which changes can be formulated. Established an engagement between

CCGs and Community Pharmacy in regards to maximising the utilisation of resources to provide

efficient services to patients.

Clinical Senate

8. The Clinical Senate is focussing on outpatients in 2018/19 and have developed a delivery plan that

coordinates outpatient transformation across NEL.

at the March meeting the senate received the NEL estates plan and gave clinical input

the forward business plan will focus on the potential model for community hubs. In June the

senate will be holding a joint workshop with UCLP to explore potential innovations in care and

strengthening links with UCLP around health innovation exchange.

Digital: Local Health and Care Record Exemplars

9. NHS England (NHSE) has launched 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.

10. 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 discussions with NHSE and colleagues across London, north east

London (ELHCP Informatics Group) is leading on the development of this pan London proposal in

collaboration with the full London system. The pan London bid is in the process of being written with

contribution from all London STPs. The final bid submission date is 25th April 2018.

11. 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 was supported at the NEL Informatics Steering Group

on 6 March 2018.

Communication and Engagement

12. 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

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

4

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/.

13. The communications team is continuing to support the maternity workstream with a staff recruitment

and retention campaign, which will launch at the end of May 2018. The campaign will have two target

audiences: people looking for a career and those already working here that we want to retain. We

have developed creative treatment for the campaign, enlisting the help of maternity staff to generate

ideas, key messages and to also front it. A preview of some of the video material is available to view:

https://youtu.be/CUQ6qtIN1ts

14. We held a very successful second meeting with Community and Voluntary Sector (CVS) colleagues at

the end of March. This was a follow-up to a meeting held earlier in the year, where we collectively

identified STP workstream areas that the CVS could support. This was taken a step further and they

have been linked in with the work stream leads for Mental Health, Cancer and Digital.

15. More than 70 health and care professionals from across east London attended the ELHCP ‘Let’s Get

Digital’ conference in February. The aim of the event was to give delegates an opportunity to find out

how the digital agenda is progressing and future opportunities to align our digital offer across the

whole of east London.

The event focused on four key themes:

1. Shared patient records

2. Patient engagement

3. Population health analytics

4. Assistive technology such as Telehealth

Keynote speakers included the head of Barclays Bank’s Digital Eagles programme who spoke about

how they have encouraged more people, especially older people, to use the internet and online

services.

A video from the event is available to view: https://youtu.be/uNa2sYE8OYw

Author(s): Nichola Gardner, Andy Lappin, Joy Ogbonna; ELHCP

Attachments: Appendix 1, STP programme updates

135

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

https://youtu.be/CUQ6qtIN1ts

https://youtu.be/uNa2sYE8OYw

Document STP Programme Update

Version 1.0

Author(s) Nichola Gardner, Andy Lappin, Joy Ogbonna

Presenter(s) Jane Milligan

Meeting BHR CCGs Joint Committee

Date 25 April 2018

Purpose To update on the progress of the ELHCP programme as a standing agenda item. This includes a proposed forward plan for the programme focus.

Background This report provides an update on the progress made by the programme, upcoming key meetings, workstream updates and a summary of the programme risks.

Recommendations For noting

Appendix 1

136

STPProgramme Update

April 2018

137

25 April: Highlight Report for ELHCP Programme Overall Programme Status Green

Activities completed in previous period Activities planned for next period

• Pathology network model workshop • Develop resource plan and STP estates team to take the capital plan• NELFT and LB Hackney to start contributing data to electronic patient record (eLPR)• Joint TCP Board meeting to consider views and plan next steps on LD access to good local

inpatient care• Promoting new version of PC QI database and electronic platform across NEL with PC

Providers• Direct Booking into GP Hubs live across BHR• Programme Stocktake event for April 2018• Bid for Perinatal Mental Health Services (2nd Wave) successful

• NHSI pathology lead workshop arranged for the end of May 2018• Continue STP-wide 111 direct booking pilot to commence extended hours hub sites • Maternity staff recruitment and retention campaign to launch end of May 2018• Promoting new version of PC QI database and electronic platform across NEL with PC

Providers• Continue to develop programme forward planner to demonstrate clear sign off process to

STP level for key deliverables for May Executive• Debrief from stocktake event

Upcoming key meetings Upcoming key deadlines

Meeting Date Deadline Date

Operating Delivery Group meeting Weekly ELHCP Programme Stocktake event 23 April

Clinical Senate meeting 9 April

ELHCP Executive meeting 10 May

Provider Chief Executive meeting 10 May

Healthwatch meeting 10 April

National Milestone Date RAG

Winter Plans June 18 G

18/19 QIPP/CIPs April 18 A

18/19 Contracting round April 18 A

Operating plan

submissionsApril 18 G

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Programme Activities completed in previous period Activities planned for next period

Transformation • Proposal on EOL workstream to Exec for decision on developing as a workstream

• Ongoing support to developing CYP with the view to taking proposal to executive in April

• Preparatory work for Q3/ year end programme stocktake report

• stocktake workshop• Development of programme forward planner to demonstrate clear sign off process to STP

level for key deliverables

• Ongoing support to developing STP governance structure

• Proposal on CYP workstream to Exec for decision on developing as a workstream with the view to

taking proposal to executive in May• Preparatory work for Q3/Q4 year end programme stocktake report

• stocktake workshop in April• finalise programme forward planner to demonstrate clear sign off process to STP level for key

deliverables for final sign on May Executive meeting• Ongoing support to developing STP governance structure

Provider

Productivity• Procurement: PwC recommended options to be decided upon by provider CEOs.

• Pathology: NHSI pathology lead meeting all NEL provider CEOs to discuss Pathology network

and workshop agenda.

• IT Productivity: Decision taken to refocus direction of IT productivity toward improving

efficiencies leading to clinical improvements for patients and practitioners.

• Bank & Agency: NEL B&A Sub group to convene monthly – focus on preparation for 09/04/18

pan-London Bank rate cap.

• Procurement: PwC recommended options to be decided upon by provider CEOs. Continuing.• Pathology: NHSI pathology lead workshop arranged for the end of May 2018• IT Productivity: Defining KPIs and timelines for new initiatives.• Bank & Agency: SWL STP expressed anxiety in regard go-live for bank rate cap in April 2018.

Current delay to June 2018. Soft launch across NEL to go ahead from April.

Infrastructure • STP Estates Board April • STP Infrastructure Operational working Group meeting• Formal governance and a mechanism for decision making in line with the LEB operating

model.• Consolidated summary of the clinical model at ACS/STP level linking to the STP wider themes

that we can use in the estates plan.• Finalise the STP strategic estates plan and investment plan linked to disposals and any capital

receipts to be recycled.• Resource plan and appoint STP estates team to take the work forward• Progressing with identify potential colocation savings by share of corporate functions

between CCGs/Providers and LA.

• Formal governance and a mechanism for decision making in line with the LEB operating model.

• Consolidated summary of the clinical model at ACS/STP level linking to the STP wider themes that we can use in the estates plan.

• Finalise the STP strategic estates plan and investment plan linked to disposals and any capital receipts to be recycled.

• Resource plan and appoint STP estates team to take the work forward• Progressing with identify potential colocation savings by share of corporate functions

between CCGs/Providers and LA.

25 April : Highlight Report for ELHCP Delivery Programmes

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MedicinesOptimisation

Low Value Drugs (drop list): Individual CCGs reviewing and approving NHSE

recommendation of 18 medicines to be stopped. Target commencement in April 18.

Biosimilars: Information Sharing Agreement for NEL partnership approved (Feb 18) –

Collation of CCG contract amendments to be collated and shared.

Pharmacy Workforce: ‘Discharge to Pharmacy’ task and finish group being set up and

inaugural meeting to be convened.

Pathway redesign / Medicines waste / Antibiotics / IT / Waste / Decommissioning /

Procurement / Dressings: Scoping, benchmarking and reviewing these initiatives through

Q4 17/18.

Low Value Drugs (drop list): Monitoring of medicines which are not longer to be routinely prescribed (Await information regards next national NHSE consultation).Biosimilars: NEL CSU to present to regional pharmacy and finance leads findings in mid April. Recommendations to be disseminated.Pharmacy Workforce: ‘Discharge to Pharmacy’ task and finish group highlight focus in regards to ensuring that community pharmacists are aware and able to view patient information via information system.Pathway redesign / Medicines waste / Antibiotics / IT / Waste / Decommissioning / Procurement / Dressings: Scoping, benchmarking and reviewing these initiatives through Q4 18/19.

Digital Enablement • STP-wide 111 direct booking pilot to commence with first extended hours hub sites in Tower Hamlets and Newham

• NELFT and LB Hackney to contribute data to eLPR in February• Place based Population Health Analytics assessment to be published• Barts Health HIE to be upgraded to allow any to any sharing (rather than bi-directional)

but still requires GPs to accept latest sharing policy

• Continue STP-wide 111 direct booking pilot to commence extended hours hub sites • NELFT and LB Hackney to contribute data to eLPR in February• Place based Population Health Analytics assessment to be published• Barts Health HIE to be upgraded to allow any to any sharing (rather than bi-directional)

but still requires GPs to accept latest sharing policy

TransformingServices

Access to good local inpatient care: • Joint TCP Board meeting to consider views and plan next steps • Joint TCP Board meeting to agree strategy to influence forensic inpatient development• Learning to be shared across transforming Care Partnerships• Boards to agree approach to PBS across NEL• Pilot schemes to commence

Implementing the National Service Model• Service spec to be developed in partnership with CLDTs and local families/carers• Confirm commissioning intentions with NHSE• Procurement of project work• To be delivered with 10 families

Access to good local inpatient care: • Joint TCP Board meeting to consider views and plan next steps • Joint TCP Board meeting to agree strategy to influence forensic inpatient development• Learning to be shared across transforming Care Partnerships• Boards to agree approach to PBS across NEL• Pilot schemes to commence

Implementing the National Service Model• Service spec to be developed in partnership with CLDTs and local families/carers• Confirm commissioning intentions with NHSE• Procurement of project work• To be delivered with 10 families

Maternity • Ongoing work with STP Finance and ELLMS team to develop a credible financial case for change in line with NEL Maternity transformation plan.

• HEE bid submitted to provide clinical, admin and project support to deliver Better Births for Maternity Transformation Workforce model in NEL

• Development of ELLMS Maternal Medicine Network across NEL: Lead consultant obstetrician has begun engagement with consultant obstetricians across the STP to develop a plan in line with the Sectary of State’s new policy; Safer Maternity Care; Nov 2017 to introduce a network of maternity medicine specialists across STPs to

• continuing to progress Maternity staff recruitment and retention campaign with launch end of May 2018

• Estates: The ELLMS is currently developing NEL provider care for pregnant women with significant health conditions

• Continue to map the current digital roadmap for maternity services across NEL

25 April : Highlight Report for ELHCP Delivery Programmes

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Primary Care Communications Campaign for Primary Care Quality developing campaign with support fromELH&CP communications team, in partnership with quality improvement board members. To belaunched in Q1 18/19

BI Systems Reviewing systems for analysing activity/efficiency (e.g. Edenbridge and other similarsystems) and making recommendations for a NEL approach.

Quality Scorecard Agreeing approach to monitoring outcomes, in discussion with the ClinicalEffectiveness Group and commissioners.

Access Hubs Working towards delivering key aspects of 18/19 access specification and delivering30 minutes per 1000 population key standard across NEL. Ensuring alignment of hubs to new IUCmodel and ensuring practice pilots are underway to link to IUC.

At-Scale Providers Working with provider forum to develop a strategic framework forfederations/networks to address key STP issues.

Primary Care Networks Review implementation of primary care home model across pilot sites. Workforce Maintain focus on improving primary care workforce returns through communicating

with practices prior to March 18 submission. GP Retention Undertake GP career pathway mapping exercise, literature review and focus group

consultation to inform GP retention plans – recommendations for addressing GP retention to bemade at the end of Q1 18/19.

Online Consultations Order to be placed with supplier for online consultations across 5 CCGs atthe end of March 18 after procurement exercise – all of NEL will then be covered for onlineconsultations in primary care for 18/19.

GPN Review General Practice Nursing recruitment and retention plans in line with GP forwardview trajectories.

Communications Campaign for Primary Care Quality developing campaign with support from ELH&CP communicationsteam, in partnership with quality improvement board members. To be launched in Q1 18/19

BI Systems Reviewing systems for analysing activity/efficiency (e.g. Edenbridge and other similar systems) and makingrecommendations for a NEL approach.

Quality Scorecard Agreeing approach to monitoring outcomes, in discussion with the Clinical Effectiveness Group andcommissioners.

Access Hubs Working towards delivering key aspects of 18/19 access specification and delivering 30 minutes per 1000population key standard across NEL. Ensuring alignment of hubs to new IUC model and ensuring practice pilots areunderway to link to IUC.

At-Scale Providers Working with provider forum to develop a strategic framework for federations/networks to addresskey STP issues.

Primary Care Networks Review implementation of primary care home model across pilot sites. Workforce Maintain focus on improving primary care workforce returns through communicating with practices prior to

March 18 submission. GP Retention Undertake GP career pathway mapping exercise, literature review and focus group consultation to

inform GP retention plans – recommendations for addressing GP retention to be made at the end of Q1 18/19. GPN Review General Practice Nursing recruitment and retention plans in line with GP forward view trajectories.

25 April : Highlight Report for NEL ELHCP Delivery Programmes

Mental Health • Submission of 2nd NEL Workforce plan for HEE • Bid for Perinatal Mental Health Services (2nd Wave) successful to enable 30, 000

women each year to access appropriate specialist treatment and support by 2021

• Bid for Health Based Places of Safety capital monies • Delivery groups continuing work on priorities identified, including:

I. Development of bid for Individual Placement and Support schemes for East London

II. Ongoing mwork to develop a future model for IAPT services across East London

III. Continue work on Crisis Care pathways including Health Based Places of Safety and ‘warm transfers’ from 111

IV. Continue work on NEL wide approach to ‘Improving physical healthcare for people living with SMI in primary care’

V. Continue work on new models of care and MH outcomes and payments

• Delivery groups continuing work on priorities identified, including:I. Development of bid for Individual Placement and Support schemes for East LondonII. Ongoing mwork to develop a future model for IAPT services across East LondonIII. Continue work on Crisis Care pathways including Health Based Places of Safety and ‘warm

transfers’ from 111 IV. Continue work on NEL wide approach to ‘Improving physical healthcare for people living

with SMI in primary care’ V. Continue work on new models of care and MH outcomes and payments

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Comms and Engagement

• Continue to add more content to the ‘Live and Work in East London’ publication.• Supporting general workforce recruitment and retention across the Partnership –

eg building internet ‘portal’ for jobs and careers; establishing link with housing providers for key worker accommodation; and building relationships with colleges and universities, particularly in creating understanding about the new roles emerging in health and care

• Continuing to support the Maternity workstream with a staff recruitment and retention campaign, to be launched in May 2018

• Providing communications and engagement support to the primary care quality improvement programme

• Continuing to build and develop relationships with local authorities and encouraging their involvement in work streams

• Continuing to build and develop relationships with other key stakeholders – e.g. RCN, LMCs, business groups and education sector

• continuing to support the maternity workstream with a staff recruitment and retention campaign with launch end of May 2018.

• We have developed creative treatment for the campaign, enlisting the help of maternity staff to generate ideas, key messages and to also front it

• held a second meeting with Community and Voluntary Sector (CVS) colleagues at the end of March.• More than 70 health and care professionals from across east London attended the ELHCP ‘Let’s

Get Digital’ conference in February• Continuing to build and develop relationships with other key stakeholders – e.g. RCN, LMCs,

business groups and education sector


Urgent and Emergency Care (UEC)

• IUC Programme Plan completed• NHS Online - to go live across BHR/ WF mid-January. Testing to begin across Tower

hamlets, Newham and City and Hackney end of January• Direct Booking into GP Hubs live across BHR. Testing to begin and issues to be fixed

for Tower Hamlets, Waltham Forest, Newham and City & Hackney. • Update primary care leads across NEL regarding GP early adopters to discuss issues

and risks. To set and join regular primary care meetings. • HLP to prepare options paper for direct booking into UTC that do not currently use

Adastra. Discussions between HLP and CCGs to commence and site visits to be arranged.

• Engagement with Mental Health Crisis leads to regarding MH Warm Transfer from 111 and CAS to City and Hackney, Newham and Tower Hamlets

• Initial mobilisation meetings with LAS • Complete programme overview document• Review UEC ACP Pathways

• IUC mobilisation – Governance, sub groups and memberships established • Pharmacy Formulary to be developed by end of April 18 • SPN / Care pathway workshops scheduled in April to continue developing revised care pathways • NHS Online – Live across BHR / Waltham Forest. Tower Hamlets, Newham and C&H to go August 18 • Direct booking into GP Hubs – Live across BHR / Waltham forest and Tower Hamlets. Testing

underway in Newham / C&H. Live across NEL April 18 • Direct Booking into GP practices – Pilot to go live May 18. Welcome packs to pilot practices circulated• IUC Digital Lead to prepare options paper for Direct booking into all UTC’s• Mental Health – BHR and WF warm transfer SOP finalised. Tower Hamlets and City & Hackney plan to

meet by June 2018. Newham ongoing discussions re plans

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Finance • Continue Discussions around implementation of new payment reforms• Refresh Control Total monitoring tool for month 11• Revising 17-18/18-19 for review with NHSE• Continue integration of ELHCP financial model into power BI with a focus on

developing a monitoring and reporting system with improvements on current PwC system

• To Continue Work with STP Workstreams to understand the financial Impact of schemes from 18-19

• Continue deep dive into activity flows between the system in order to distinguish between genuine activity increases and shifts in activity from one locality to another.

• Collate CCG and provider plans with a bid to understanding the bridge between 17-18 forecast outturn and 18/19 plans. Taking into account allocation increases, expenditure growth, QIPPs, CIPs, contract triangulation variances. Etc

Analytics• Dashboard created to support the Clinical senate Outpatient programme & analyse

GP referrals patterns;• Completed the Elective Demand Modelling dashboard to support INEL;• Designed a pharmacy dashboard – supporting the medicine utilisation work stream; • Designed a maternity dashboard – supporting the maternity programme work

stream; • On-going designed a Mental Health dashboard – supporting the MH programme

work stream; • On-going designed a Diabetes dashboard – to highlight system-wide variation in

quality;• Development of the ELHCP Analytics Portal which links data across the STP (and

multiple care settings)

• Continue Discussions around implementation of new payment reforms• Refresh Control Total monitoring tool for month 12• Finalising 17-18 outturns and agreeing 18/19 Plans with NHSE• Continue integration of ELHCP financial model into power BI with a focus on developing a

monitoring and reporting system with improvements on current PwC system• To Continue Work with STP Workstreams to understand the financial Impact of schemes from 18-

19• Continue deep dive into activity flows between the system in order to distinguish between

genuine activity increases and shifts in activity from one locality to another.• Collate CCG and provider plans with a bid to understanding the bridge between 17-18 forecast

outturn and 18/19 plans. Taking into account allocation increases, expenditure growth, QIPPs, CIPs, contract triangulation variances. Etc

• Support Mental health Work stream in understanding the gaps in the level of achievement of mental health investment standard with a view to identifying areas that need improvement;

• Support Commissioners and providers in aligning their contracts for 2018/19• Support Commissioners and providers in aligning their QIPP and CIPs for 2018/19

Analytics• Complete the development of the ELHCP Analytics Portal;• User acceptance testing of the portal to ensure security, user interface and functionalities work as

expected; • Stocktake of existing analytics dashboards/needs across the STP & creating of the relevant

measures (within the portal) to support them;• Migration of existing dashboards (across the STP) onto the ELHCP Analytics Portal;• Creation of End of Life dashboard to support the programme work stream;• Further development of Estates dashboard to include Demand & Capacity modelling for ONEL &

INEL;• Re-development of the TST modelling tool to include the various programme work streams across

the STP.


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Risk description and impact Mitigating action

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 of these are high risk.ODG to review high risk CIP and QIPP to identify work stream level mitigation plans.

There is a risk that funding is unavailable or limited for initiatives and thus at 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

There is a risk that there is insufficient programme resource to deliver the ELHCP programmes Funding proposal developed and all organisations have been requested to share costs of

programme funding

Progressing recruitment of central PMO roles

Investigate possibility of secondments from NHSE, NHSI, HLP and also local organisations

Review the programme structure (meeting cycles, programme team responsibilities) to ensure

most efficient use of resource.

There is a risk of pace of estate, digital and workforce enabler responses being insufficient and impede the

necessary step change required the for Transformational change identified

Further work planned to cross pollinate priorities and deliverables into jointly owned project plans

between transformation and enabler work streams.

There is a programme level risk of lack of achievability of some national targets including national, mandatory

targets, given current performance levels and some data lags

Map the key Transformation programme outcomes for review and cross-workstream resolution at

workstream collaboration event

There is a risk that existing contracts in place may impact the net savings through collaboration in some areas.Include cost of exit fees or phased approach to consolidation when developing options for

moving to a shared platform / shared business service.

There is a risk that the transformation programmes defined in the ELHCP do not deliver the scale of savings

required to close the finance gap, and are not sufficiently developed to meet demand levels projected through

modelling work

PwC have been commissioned to undertake detailed finance and activity review of ELHCP

delivery plans

Plan, resource and delivery of the EL proposed improvements to be identified by Executive

Group

Summary of high level programme risks

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From: Steve Rubery, Director of Delivery and Performance

Date: 24 May 2018

Subject: Integrated Performance Report 2017/18 (Month 11 Activity, Month 12 Finance)

Executive Summary

This report is provided to present the Joint Committee of Barking and Dagenham, Havering and

Redbridge (BHR) CCGs with an integrated view of performance, including finance and activity, in its

contracted services, to identify the key risks presented by that performance and provide assurance that

those risks are being appropriately managed. This report is based on month 11 activity and month 12

finance information.

This report concerns the CCGs’ main providers - Barking, Havering and Redbridge University Hospitals

NHS Trust (BHRUT), Barts Health NHS Trust (Barts Health), North East London Foundation Trust

(NELFT), Partnership of East London Cooperatives (PELC) and the London Ambulance Service (LAS).

The main points of note are:

BHRUT: The BHRUT 2017/18 financial forecast across the three CCGs is £11.8m above plan. This

overspend is driven by over performance in the following areas: non-elective, elective, maternity, day

cases and outpatients.

Following the Trust’s rejection of the mediation outcome entered into for quarter 1, The parties have

now entered into a national Expert Determination process to resolve both the outstanding items in the

quarter 1 reconciliation process, and to inform the closedown position for quarters 2 - 4. The Expert

Determination process commenced on 16 April and is expected to conclude by the end of May.

Following the cessation of an agreed period of purdah with respect to contract management activities,

two contract performance notices (CPNs) issued to the Trust for critical care and mortality have been

closed. The former being closed due to commissioner concerns on critical care over performance,

following the Trust’s expansion of capacity not being realised. With regard to the latter, closure of the

CPN is due to commissioner assurance that the Trust has implemented a robust Mortality Reduction

Improvement Plan, which will continue to be monitored via CQRM.

A third CPN related to referral to treatment (RTT) is expected to be closed subject to the Trust providing

specialty level demand and capacity plans.

On performance against constitutional performance measures the Trust met all 8 cancer standards in

the month of February (and in 7 of the last 8 months). RTT performance in December was 90.6% which

is below the agreed trajectory of 91%. At the end of February the waiting list size was 34,709 (from

33,130 in January) and the 52 week wait position has increased from 5 reported in January to 6 in

February. The 4 hour A&E performance in September was 73.9%, which is below the STF trajectory of

95%.

145

Barts Health: The Barts Health 2017/18 financial forecast across the three CCGs is £9.1m above plan

and is driven by non-elective, critical care and outpatients. Uncoded activity in month has a financial

value of £0.1m. This is a decrease against from the previous month and represents an estimate spend

of 2.7% of the relevant total spend, compared to 3.6% last month. Barts have improved coding across

the contract and coded activity has been above 97% for the last three months, significantly reducing

financial risk to the CCGs. A year end deal has been agreed with Barts Health to a value of £102.4m for

BHR CCGs. This was similar to the forecast based on M9 SLAM data, before QIPP deductions, of

£102.7m.

On performance against constitutional performance measures, the Trust achieved all cancer standards

including the 62 day standard, reporting 85.47% against the 85% standard. The Trust underperformed

against the 4 hour A&E standard and achieved 84.6% in February against the STF trajectory of 92.8%.

For RTT the Trust will, as agreed by the Trust Board on 4 April and supported by the WEL-procured

external assurance, return to national RTT reporting in May 2018 (April 2018 data). The volume of 52

week waiters is expected to improve prior to the return to reporting, however the Trust forecasts that

there will be more pathways waiting >52 weeks than previously expected, with 63 pathways expected

high risk and 49 pathways considered low risk. A breakdown of all pathways waiting over 52 weeks by

CCG and specialty, including the reason for delay, assessment of harm and next steps has been

requested via the Contract Review Group and the RTT Recovery Board.

NELFT: The contract with NELFT is predominantly a block contract with financial adjustments made on

a quarterly basis according to the outcome of Key Performance Indicators (KPIs) and CQUIN

performance. The latest quarterly positon (Q3) highlights that all the KPIs that carry a financial penalty

were achieved and there was a partial achievement on CQUINs. The partial achievement of CQUINs is

in respect of “Preventing ill health by risky behaviours; alcohol and tobacco” with a financial withholding

of £38k across BHR CCGs.

Havering’s IAPT recovery performance reported across several quarters has been very strong;

however, Q3 published data shows Havering only just achieved the 50% target for the second

consecutive quarter with a performance of 50%. The published data show that Barking and Dagenham

and Redbridge again failed to meet the IAPT Recovery target at 42% and 48% respectively.

The IAPT access targets have consistently not been met. In Q3, published data show that the national

3.75% target was missed across BHR as follows: Barking and Dagenham 3.16%, Havering 3.04% and

Redbridge 3.11%.

Recommendations

The Joint Committee of BHR CCGs is recommended to:

review the report;

note the actions that are being take and;

seek any further assurances they require in respect of risks and their management.


1.1 The purpose of this report is to inform the Joint Committee on the contract activity and

performance for acute, community, mental health contracts including the LAS contract, and

agree any actions required.


2.1 This is a report from Director of Delivery and Performance to inform the Joint Committee of the

position of acute, community and mental health contracts including the LAS contract.

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3.0 Report Content

3.1 Joint Committee Integrated Performance Report (IPR) 2017/18 (Month 11 Activity, Month 12

Finance). The attached report is a summary of an extensive IPR which is considered at several

levels within the organisations.


4.1 Resources/investment in each service/provider are highlighted for each individual provider as

required, under the relevant sections of this report.

4.2 The outcome of contractual performance has profound financial impact on the CCGs’ ability to

achieve financial balance.

5.0 Equalities

5.1 There are no equalities implications arising from this report.

6.0 Risk

6.1 Risks and mitigations for each area of activity and finance service are highlighted for each

individual provider, under the relevant sections of this report; for each CCG individually; and at a

BHR level.


7.1 There are no conflicts of interest to note related to this report.

Author: Acute and Non-acute MDT, BHR POD, NEL CSU

Date: 13 April 2018

147

Integrated Performance Report

2017/18

Report Publication Date: March 2018

(Month 11 Activity / Month 12 Finance)

BHR CCGs

148

Integrated Performance Report 2017/18 - BHR CCGs M11

Contents

2

Section Page Number

1. Executive Summary 3

2. Executive Summary – actions being undertaken 4

3. CCG Finance, Activity and QIPP Overview 5

4. Acute Contracts Performance 12

BHRUT 13

Barts Health 15

5. NELFT 17

6. Key Associates and Independent Sector 19

7. PELC & LAS 20

8. BHRUT and BHR CCG Performance 21

9. East London Health and Care Partnership 25

149


Executive Summary

BHRUT

• Discussions between BHR CCGs and BHRUT have resulted in the closedown of two of the ten items put forward for expert determination (ED), prior to the commencement of the formal

ED process; Hyper acute stroke unit (HASU) bed days was closed in favour of CCGs, who in turn, based on the Trust’s confirmation to only charge in accordance with National Tariff,

have agreed to pay Stroke Best Practice Tariff where the Trust can evidence that this has been achieved. The parties will inform respective regulators of the withdrawal of the two items.

• The outcome of the ED process (now anticipated by the end of May 2018) will serve to resolve Q1 and Q2 items of residual dispute, the principles of which will be applied to support the

agreement of a year end settlement for 2017-18 and will in part inform the 2018-19 Indicative Activity Plan (IAP). Regulators have mandated the move off a pure cost per case contract

in 2018-19.

• The adjusted forecast outturn (FOT) position is £351.6m against a plan of £339.8m (£11.8m above plan).

• 4.0% of spells remain uncoded in the BHRUT M11 flex position which is a worsened position from the previous month of 0.3% .

• BHRUT was compliant against all eight cancer waiting times (CWT) standards in February 2018.

• BHRUT performance against Referral to Treatment (RTT) target of 91% achieved 90.6% in February, which has deteriorated since January 91%,( (London All providers 88.0%). The

Trust reported 6 patients over 52 weeks (5 in January).

• A&E performance at BHRUT remains challenged in March2018 with performance of 73.9% against the Sustainability and Transformation Fund (STF) trajectory of 95%.

Barts Health

• As reported last month a year end deal has been agreed with Barts Health. For BHR CCGs the value is £102.4m. This was similar to the forecast based on M9 SLAM data, before QIPP

deductions, of £102.7m . It compared more favourably to last month’s underlying position which was £103.8m. Based on M11 SLAM, there has been a further increase in the underlying

forecast of £0.3m, driven by non elective spend. This increases the underlying forecast outturn to £103.9m giving an estimated benefit from the year end deal, subject to M12

performance, of around £1.5m. It should be noted that the deal includes the additional 0.5% CQUIN of £0.3m that CCGs were holding in reserve but does not include the additional

transport mobilisation costs of £0.3m. The latter increases the reported position to £102.8m, £9.4m above plan.

• Despite the year end deal the CSU continues to apply contract levers including claims to assist the management of financial risk moving forward into 18/19.

• A contract value of £103.2m has been agreed for 2018/19. This includes £2.3m for growth and £3.2m of QIPP.

NELFT

• The contract variation between BHR CCGs and NELFT for year 2 of the 2017/19 contract, was agreed within the permitted timeframe and signed by both parties. This included a

number of revised schedules including finance which reflected adjustments to QIPP and investments.

LAS

• Performance at M11 flex YTD is £64k below plan, all of which is within Barking and Dagenham (£142k below plan). Havering and Redbridge CCGs are above plan (£65k and £13k over

respectively).

QIPP

• CCGs have delivered £32.3m QIPP against a planned £45.1m (72.0% achievement against plan). The under delivered of £12.8m YTD, based on M12 Finance (M11 flex-activity)

represents an improvement of £0.1m from the forecasted performance at M11. Delivery against live schemes is positive at M12, with delivery against pipeline opportunities and

unidentified QIPP accounting for the majority of FOT underperformance (£10.4m against the forecasted £12.8m underperformance).

3

150


Executive Summary – Actions being undertaken

4

BHRUT

• The commissioners’ main priority is submitting the required evidence for the 8 areas of dispute as per the ED process. In addition to this, work is underway to close down all other

outstanding matters for 2017/18.

• Work is also underway to align activity assumptions completely.

• A block value (cash and not revenue) has been agreed with BHRUT for Q1 of 2018/19. Following the outcome of the ED process, the contract value and form for Q2-Q4 shall agreed.

Barts Health

• Despite the year end deal the CSU continues to apply contract levers including claims to assist the management of financial risk moving forward into 18/19.

NELFT

• As part of the mediation agreement NELFT have produced and shared with commissioners the initial iteration of Service Line Costing (SLR) in line with the milestones agreed. A review

of this information is currently being undertaken which will be further iterated as needed jointly through 2018/19 to develop an understanding of provider costs linked to outcomes and

activity in support of BHR ICS development.

Quality, Innovation, Productivity and Planning (QIPP)

• As reported last month, there is ongoing work to assure the delivery of existing schemes and identification of system wide ‘big ticket’ opportunities. CCGs and BHRUT have

commenced initial work to align PMO processes to support an enhanced review of QIPP performance, with a view to enable more robust interventions, this is expected to be in place to

support the 18/19 QIPP planning process. BHRUT were due to undertake their first internal QIPP assurance process on the 11/4 to review CCG QIPP, but as yet no formal feedback

from the Trust has been received. CCGs have been and continue to work with BHRUT to expedite this process.

• QIPP planning for 2018/19 continues, with £32.4m of schemes identified so far (note this includes unassured schemes at an early stage of development). Programme SROs will meet

with the PMO to further articulate the schemes within the development pipeline. The 18/19 QIPP requirement has now increased to £44.9m.

• The CCGs have appointed a Director of Recovery, who will be responsible for the identification of new QIPP and de-risking existing plans.

• The CCGs are undertaking work to reduce the overall level of unidentified QIPP and risk against the programme in advance of the next operating plans submission (30th April),

progress will be reviewed on a weekly basis at the Financial Recovery Planning Delivery and Monitoring (FRPDM) group.

151

1. CCG – Finance, Activity & QIPP

Overview

152

Integrated Performance Report 2017/18 - BHR CCGs M11 6

CCG Overview – Financial Summary – ReportedData Source: NHSE Return

Key Messages

• The BHRUT 2017/18 forecast outturn is £11.8m

above plan. This continues to be driven by non-

elective, elective, maternity, day cases and

outpatient activity.

• QIPP performance at month 12 indicates an

achievement of £32.3m against a planned £45.1m

(a variance of £12.8m).

• The Barts forecast is £9.1m above plan. High cost

critical care patients, non elective activity and

outpatient procedures continue to drive this

position.

• There is continued overspend on the Homerton

contract, which relates almost exclusively to IVF

and maternity related activity. Reductions in the

cost per patient for IVF referrals post August is

planned to reduce in line with the implementation

of the spending money wisely service restrictions.

Although due to patients being at different points

within the process and cycles this has not yet

materialised.

• The expected reduction in referrals to the

Independent Sector, which should have followed

the cessation of referral redirects from BHRUT at

the end of Q4 2016/17 has not been realised.

Activity Query Notices (AQNs) have been issued to

Spire Roding, Holly Private Hospital and Care UK.

There has been a reduction in spend again this

month, the forecast has been adjusted accordingly.

• Moorfields continue to over perform in high cost

drugs with associated activity increases. This is

partially driven by increased activity as a result of

the NHSE Diabetic Screening programme which

has identified more patients requiring treatment.

• The CCGs have seen a small increase in Critical

Care activity across a number of Associate

providers, although the forecast for Critical Care

continues to remain below the consolidated annual

plan.

Note. Overspends are shown in red in brackets, whilst numbers in black represent an underspend. This convention is used

throughout this report. All financial values are reported in £’000s.

The only exception to this convention is slide 27 (ELHCP Overview) which presents the financial position on an STP-level and

therefore follows STP conventions (red text for an overspend, negative values in black text for an underspend).

Rag

Plan Actual Variance Plan Actual Variance Plan Outturn Variance Rating

STP Acute Trusts 38,837 40,749 (1,912) 441,722 463,788 (22,066) 441,722 463,788 (22,066)

Other Acute Trusts 4,143 4,632 (488) 49,651 51,500 (1,849) 49,651 51,500 (1,849)

Other Acute 7,775 16,491 (8,716) 85,383 98,382 (12,999) 85,383 98,382 (12,999)

Acute Commissioning Total 50,755 61,872 (11,116) 576,756 613,670 (36,914) 576,756 613,670 (36,914)

Mental Health 8,458 8,787 (330) 94,984 93,609 1,375 94,984 93,609 1,375

Community 7,053 7,490 (437) 84,990 86,231 (1,241) 84,990 86,231 (1,241)

Continuing Care 4,978 4,171 807 59,019 58,043 976 59,019 58,043 976

Primary Care 10,767 8,909 1,857 126,355 121,644 4,711 126,355 121,644 4,711

Other 27,385 14,538 12,847 165,914 141,058 24,856 165,914 141,058 24,856

Total 109,395 105,767 3,628 1,108,018 1,114,255 (6,237) 1,108,018 1,114,255 (6,237)

Rag

Plan Actual Variance Plan Actual Variance Plan Actual Variance Rating

BHRT 30,195 31,119 (924) 339,812 351,648 (11,836) 339,812 351,648 (11,836)

Barts Health NHS TRUST 7,966 8,948 (983) 93,695 102,784 (9,089) 93,695 102,784 (9,089)

Homerton 677 682 (5) 8,214 9,355 (1,140) 8,214 9,355 (1,140)

Guys & St Thomas 535 498 37 6,408 6,813 (405) 6,408 6,813 (405)

Mid Essex 417 345 72 4,988 4,830 159 4,988 4,830 159

Moorfields 760 715 46 9,100 9,434 (334) 9,100 9,434 (334)

UCLH 770 835 (65) 9,207 9,114 93 9,207 9,114 93

London Ambulance Service 2,423 2,274 149 29,074 28,925 149 29,074 28,925 149

Spire Healthcare 714 885 (170) 8,566 11,065 (2,499) 8,566 11,065 (2,499)

Other Acute 6,300 15,573 (9,273) 67,691 79,702 (12,011) 67,691 79,702 (12,011)

Total 50,755 61,872 (11,116) 576,756 613,670 (36,914) 576,756 613,670 (36,914)

In Month Year to Date Annual Forcast

In Month Year to Date Annual Forcast

153


Key Messages

The latest reporting period for the Monthly Activity Return (MAR) is M10.

Referrals:

BHR CCGs are slightly above plan by 0.1% for total referrals in M10, a reduction from 0.3% above plan in M9. By CCG, NHS Barking and Dagenham CCG is the only over performing CCG

at 2.1% above plan with NHS Havering and NHS Redbridge CCGs both underperforming by 0.9%. Mitigating actions, such as single point of access have been implemented and is planned

to bring NHS Barking and Dagenham CCG within the NHSE tolerance level of 2%. When compared to 2016/17 there is a shift between providers with BHRUT up 8.3% and other providers

down by 7.4%. This reduction is predominantly seen at Homerton. It should be noted that referrals were diverted away from BHRUT from July 2016/17 (as part of the RTT redirect

programme) and that following the cessation of this programme, referrals to BHRUT have now reverted back to near pre-divert levels. However, Care UK and Spire Roding who provided re-

direct capacity, have not yet returned to pre-redirect levels.

All provider activity:

The system wide activity, monitored by NHSE, shows activity below operating plan levels. However, contract monitoring datasets are currently reporting over performance in these same

activity areas. This discrepancy is due to the different data sources applied in collating the SLAM and Operating Plan reports.

Acute Contract Performance – All Providers

7

Data Source: Monthly Activity Return published to Unify,

NHSE OP Plan Tool

7.1 Changes in market share of GP referrals (All specialties) 7.2 BHR CCG performance (referrals based on G&A specialties)

against Operational Plan as of M10

7.3 BHR CCG GP Referrals (All Specialties) to BHRUT by Month 2015/16 to 2017/18 M10

Key

variance

RED greater than +/- 10%

AMBER between +/- 5% and +/- 10%

Green less than +/- 5%

154


Network Performance

8

Data Source: SUS+, Community data

Notes

Please note that as rates per 1,000 population have been used to enable activity to be compared equally across GP Practices on this slide, the format of the information below will naturally

differ from the rest of the IPR report.

The BHR CCGs GP Practice Dashboard compares 2017/18 YTD (M1-M9) activity rates per 1000 population to the same period in the previous year, by point of delivery, summarised by

Network (locality) and CCG using weighted list size. Below is a snapshot of the latest and last published (M9) Network level summary.

The report shows significant movements between years for outpatient procedures for all CCGs with Barking and Dagenham CCG at 19.5, Havering CCG at 29 and Redbridge CCG at 17.1

(per 1000 Population). A&E shows a variance between years in the range of 9.3 to 22.7 per 1000 population, but this is offset by reductions in the urgent care centre due to recording issues

at BHRUT.

%

Key for Variances

greater than +/- 10%

Area POD (Point of Delivery) 2016/17 2017/18 Var % Var 2016/17 2017/18 Var % Var 2016/17 2017/18 Var % Var 2016/17 2017/18 Var % Var

Accident and Emergency 239.3 268.2 28.9 12.1% 264.9 287.6 22.7 8.6% 247.5 260.2 12.7 5.2% 261.1 283.8 22.7 8.7%

Non-Elective 54.3 60.4 6.2 11.4% 65.5 64.5 -1.0 -1.5% 59.4 60.3 1.0 1.6% 62.4 64.4 2.0 3.3%

Non-Elective Non-Emergency 22.3 25.1 2.8 12.3% 20.8 22.8 2.0 9.7% 22.2 20.6 -1.6 -7.1% 21.8 23.1 1.3 5.8%

Walk-In-Centre 69.2 57.0 -12.2 -17.6% 67.2 57.7 -9.6 -14.3% 110.7 94.8 -15.9 -14.4% 84.9 72.3 -12.6 -14.8%

Urgent Care Centre 64.2 49.9 -14.3 -22.3% 81.4 64.7 -16.6 -20.5% 61.7 57.6 -4.0 -6.6% 70.8 58.7 -12.1 -17.0%

Elective 10.2 11.1 0.8 8.3% 12.1 11.4 -0.7 -6.1% 11.8 11.8 -0.1 -0.6% 11.5 11.5 0.0 0.2%

Day Case 59.5 59.7 0.2 0.4% 64.8 68.5 3.8 5.8% 65.6 63.5 -2.1 -3.2% 63.9 64.8 0.9 1.4%

Regular Day Attender 2.1 9.8 7.7 363.3% 2.3 10.1 7.8 341.0% 3.0 9.6 6.6 217.9% 2.5 9.9 7.4 290.4%

Outpatient 1st (GP Referred) 146.7 149.5 2.8 1.9% 154.6 158.2 3.7 2.4% 161.3 155.3 -6.0 -3.7% 155.1 155.9 0.7 0.5%

Outpatient 1st (Other Referred) 125.3 119.3 -6.0 -4.8% 139.1 133.4 -5.8 -4.2% 112.0 106.1 -5.9 -5.3% 128.0 121.9 -6.0 -4.7%

Outpatient 1st discharged from consultants care 72.8 74.8 2.0 2.7% 82.4 80.9 -1.5 -1.8% 78.8 80.4 1.6 2.1% 78.9 79.9 1.1 1.3%

Outpatient Follow-Up 547.2 563.2 16.0 2.9% 581.0 582.4 1.4 0.2% 640.1 614.8 -25.4 -4.0% 593.6 593.2 -0.3 -0.1%

Outpatient Procedure 78.8 98.0 19.3 24.5% 88.0 109.6 21.6 24.6% 94.3 110.2 15.9 16.8% 88.1 107.6 19.5 22.1%

Medefer (Gastroenterology) 0.0 0.8 0.8 0.0% 0.0 3.0 3.0 0.0% 0.0 0.8 0.8 0.0% 0.0 1.6 1.6 0.0%

DMC (Dermatology) - First 0.0 4.6 4.6 0.0% 0.0 4.2 4.2 0.0% 0.0 4.7 4.7 0.0% 0.0 4.5 4.5 0.0%

DMC (Dermatology) - FollowUp 0.0 1.1 1.1 0.0% 0.0 1.0 1.0 0.0% 0.0 1.1 1.1 0.0% 0.0 1.0 1.0 0.0%

DMC (MSK) 0.0 18.7 18.7 0.0% 0.0 22.6 22.6 0.0% 0.0 16.6 16.6 0.0% 0.0 19.4 19.4 0.0%

Area POD (Point of Delivery) 2016/17 2017/18 Var % Var 2016/17 2017/18 Var % Var 2016/17 2017/18 Var % Var 2016/17 2017/18 Var % Var

Accident and Emergency 229.4 253.5 24.1 10.5% 235.3 258.9 23.6 10.0% 214.3 234.8 20.4 9.5% 236.2 258.9 22.7 9.6%

Non-Elective 63.6 69.1 5.5 8.6% 65.8 70.6 4.7 7.2% 66.1 69.9 3.7 5.7% 66.9 71.2 4.3 6.4%

Non-Elective Non-Emergency 16.7 19.0 2.3 13.9% 17.9 19.2 1.3 7.2% 14.6 15.7 1.2 8.0% 16.7 18.2 1.4 8.6%

Walk-In-Centre 76.7 77.4 0.6 0.8% 155.7 160.1 4.4 2.8% 101.8 100.8 -1.0 -1.0% 114.6 115.3 0.7 0.6%

Urgent Care Centre 59.9 39.3 -20.6 -34.4% 54.5 38.2 -16.3 -29.9% 46.8 29.8 -17.0 -36.3% 56.1 37.3 -18.8 -33.5%

Elective 15.0 14.2 -0.8 -5.0% 14.4 13.7 -0.8 -5.5% 17.7 14.9 -2.8 -15.7% 15.8 14.3 -1.5 -9.8%

Day Case 84.7 85.8 1.1 1.3% 75.6 80.3 4.7 6.2% 92.9 93.4 0.5 0.6% 84.9 86.4 1.5 1.8%

Regular Day Attender 2.8 14.8 11.9 423.9% 2.8 12.2 9.5 342.4% 1.8 15.5 13.8 765.9% 2.5 14.1 11.6 458.5%

Outpatient 1st (GP Referred) 181.0 170.0 -11.0 -6.1% 152.2 149.0 -3.3 -2.1% 174.0 174.8 0.8 0.4% 170.2 164.4 -5.8 -3.4%

Outpatient 1st (Other Referred) 146.5 137.9 -8.6 -5.9% 143.5 134.9 -8.6 -6.0% 138.2 132.3 -5.9 -4.3% 146.7 136.6 -10.2 -6.9%

Outpatient 1st discharged from consultants care 100.4 100.3 -0.1 -0.1% 87.9 87.2 -0.7 -0.8% 100.2 106.6 6.4 6.4% 98.6 98.4 -0.2 -0.2%

Outpatient Follow-Up 680.6 667.9 -12.8 -1.9% 607.0 626.8 19.8 3.3% 659.4 652.5 -6.9 -1.0% 654.7 651.7 -3.1 -0.5%

Outpatient Procedure 109.5 139.5 30.0 27.4% 98.9 125.8 26.8 27.1% 116.9 147.9 31.0 26.5% 109.1 138.1 29.0 26.6%

Medefer (Gastroenterology) 0.0 1.2 1.2 0.0% 0.0 1.0 1.0 0.0% 0.0 1.3 1.3 0.0% 0.0 1.2 1.2 0.0%

DMC (Dermatology) - First 0.0 6.7 6.7 0.0% 0.0 4.3 4.3 0.0% 0.0 6.4 6.4 0.0% 0.0 5.7 5.7 0.0%

DMC (Dermatology) - FollowUp 0.0 1.2 1.2 0.0% 0.0 1.2 1.2 0.0% 0.0 1.7 1.7 0.0% 0.0 1.3 1.3 0.0%

DMC (MSK) 0.0 17.0 17.0 0.0% 0.0 12.0 12.0 0.0% 0.0 15.4 15.4 0.0% 0.0 14.7 14.7 0.0%

Area POD (Point of Delivery) 2016/17 2017/18 Var % Var 2016/17 2017/18 Var % Var 2016/17 2017/18 Var % Var 2016/17 2017/18 Var % Var 2016/17 2017/18 Var % Var

Accident and Emergency 265.2 277.7 12.5 4.7% 240.7 247.1 6.4 2.7% 283.0 297.7 14.7 5.2% 217.7 219.7 2.0 0.9% 262.5 271.8 9.3 3.5%

Non-Elective 58.0 60.3 2.3 3.9% 59.4 62.4 3.0 5.1% 59.8 61.7 1.9 3.2% 54.0 59.1 5.1 9.4% 59.0 62.2 3.2 5.3%

Non-Elective Non-Emergency 23.3 25.0 1.7 7.3% 16.5 16.8 0.3 1.5% 21.8 23.3 1.5 6.7% 16.8 17.2 0.4 2.6% 20.1 21.2 1.1 5.5%

Walk-In-Centre 70.5 78.5 8.1 11.5% 18.7 13.3 -5.4 -28.8% 35.1 31.4 -3.7 -10.6% 5.4 4.0 -1.4 -26.0% 36.6 37.4 0.8 2.2%

Urgent Care Centre 65.0 59.2 -5.8 -8.9% 49.4 45.3 -4.1 -8.3% 81.5 77.0 -4.5 -5.6% 7.8 7.0 -0.8 -10.3% 52.0 47.7 -4.3 -8.2%

Elective 11.0 10.2 -0.8 -7.5% 13.6 12.2 -1.3 -9.8% 12.1 11.0 -1.1 -9.1% 13.9 13.4 -0.5 -3.6% 12.6 11.6 -0.9 -7.6%

Day Case 67.8 68.8 1.1 1.6% 73.3 75.5 2.2 3.0% 72.0 69.4 -2.6 -3.6% 61.6 66.6 5.0 8.2% 68.5 70.0 1.5 2.2%

Regular Day Attender 5.5 11.0 5.5 101.4% 8.4 16.8 8.3 98.9% 2.4 8.9 6.5 267.9% 22.8 30.8 7.9 34.8% 9.8 16.7 6.9 70.2%

Outpatient 1st (GP Referred) 203.2 186.1 -17.1 -8.4% 173.2 169.0 -4.2 -2.4% 185.2 174.4 -10.9 -5.9% 155.3 147.3 -7.9 -5.1% 181.6 170.7 -10.9 -6.0%

Outpatient 1st (Other Referred) 135.8 127.4 -8.3 -6.1% 125.6 118.7 -6.8 -5.5% 142.2 134.5 -7.7 -5.4% 97.0 93.2 -3.9 -4.0% 126.9 119.9 -7.1 -5.6%

Outpatient 1st discharged from consultants care 87.4 82.2 -5.2 -6.0% 85.8 81.9 -3.9 -4.6% 79.8 77.9 -1.9 -2.4% 74.8 70.1 -4.8 -6.4% 82.7 78.5 -4.1 -5.0%

Outpatient Follow-Up 681.5 661.4 -20.1 -2.9% 629.2 619.6 -9.6 -1.5% 716.8 700.7 -16.1 -2.2% 487.8 502.0 14.2 2.9% 633.2 624.3 -9.0 -1.4%

Outpatient Procedure 111.6 125.5 14.0 12.5% 121.5 138.3 16.9 13.9% 107.0 124.6 17.6 16.5% 128.3 149.3 21.0 16.4% 117.4 134.5 17.1 14.6%

Medefer (Gastroenterology) 0.0 1.9 1.9 0.0% 0.0 1.3 1.3 0.0% 0.0 1.1 1.1 0.0% 0.0 0.5 0.5 0.0% 0.0 1.3 1.3 0.0%

DMC (Dermatology) - First 0.0 6.9 6.9 0.0% 0.0 9.9 9.9 0.0% 0.0 7.1 7.1 0.0% 0.0 9.3 9.3 0.0% 0.0 8.1 8.1 0.0%

DMC (Dermatology) - FollowUp 0.0 2.4 2.4 0.0% 0.0 4.4 4.4 0.0% 0.0 2.8 2.8 0.0% 0.0 3.4 3.4 0.0% 0.0 3.2 3.2 0.0%

DMC (MSK) 0.0 9.5 9.5 0.0% 0.0 3.1 3.1 0.0% 0.0 17.7 17.7 0.0% 0.0 3.7 3.7 0.0% 0.0 8.6 8.6 0.0%

NH

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Acute Services

Acute Services

Reporting Month

Reporting Month

Acute Services

Reporting Month December

West

YTD Activity Rate

Per 1,000 Pop

North

YTD Activity Rate

Per 1,000 Pop

East

YTD Activity Rate

Per 1,000 Pop

YTD Activity Rate

Per 1,000 Pop

NHS Barking and Dagenham CCGNetwork

DecemberCentral North

DecemberCranbrook & Loxford

YTD Activity Rate

Per 1,000 Pop

NHS Havering CCG

YTD Activity Rate

Per 1,000 Pop

YTD Activity Rate

Per 1,000 Pop

Network

South

YTD Activity Rate

Per 1,000 Pop

YTD Activity Rate

Per 1,000 Pop

NHS Redbridge CCG

YTD Activity Rate

Per 1,000 Pop

Network

Wanstead & Woodford

YTD Activity Rate

Per 1,000 Pop

Fairlop Seven Kings

YTD Activity Rate

Per 1,000 Pop

YTD Activity Rate

Per 1,000 Pop

155


Service Delivery Plan (QIPP) – Delivery

9

Data Source: BHR CCGs and NHSE Assurance Meeting Report

Notes

Summary: There has been an improvement of £0.1m between Month 11 and Month 12 forecast positions. The key risks in QIPP delivery remain within the Planned Care Programme (the

single largest target value). Concordance with CCG commissioned pathways including MSK is highly variable and remedial actions are being taken.

QIPP achievement is monitored on an individual scheme basis and reported at transformation level.

SUS data is used to monitor individual schemes which are activity driven in nature, with flex and

freeze data used to calculate YTD achievement. Where SUS data cannot be used to monitor a

scheme, an accruals basis is used.

156


System Delivery Plan (QIPP) – Delivery

10

Key Messages

Overall System Delivery Framework (SDF)

• Current QIPP performance at month 12 indicates an achievement of £32.3m against a planned £45.1m (a variance of £12.8m). Overall this is a slight improvement compared to the

reported position at M11.

Planned Care programme

• Eight schemes are live with four under exception. Escalated schemes are MSK, gastroenterology, dermatology and Service Cessation.

• Key risk relates to lower than planned referrals into the community services, for gastroenterology, MSK and dermatology, for month 12 MSK performance is a significant outlier.

Referrals are now mandated to flow into the respective triage services (clinical exceptions apply) however BHRUT have written to the CCGs indicating that they are not actively

implementing this approach (with the exception of dermatology).

Unplanned, Complex and Mental Health

• One Urgent Care scheme remains under exception (A&E front door), work continues to address under performance against this area.

• Performance against the A&E front door scheme has been discussed with the Trust as part of the ongoing PMO-PMO work, this will lead to a recovery plan. Responsibility for delivery

of this QIPP sits with BHRUT. Recent performance (based on provisional December data) shows significant improvement and sustained delivery for several months. CCGs will review

the scheme to understand the implications of improved performance for 18/19 QIPP.

• KGH UCC is marginally under plan, with fewer diversions of activity than planned.

• All other Complex and Mental Health schemes are delivering to plan year to date.

Medicines Management

• Provisional M12 data indicates an improvement compared to the planned year end position with performance reported at £928k.

East London Health Care Partnership (ELHCP)-wide PoLCE (Procedures of Limited Clinical Effectiveness) Initiative

• The Clinical Panel has now started to meet and assess and score the evidence packs.

• CCGs wait for next steps from the STP-led project group.

• Key risks are: variable appetites for review of access thresholds across ELHCP and support for a nationally funded QIPP Programme.

Managing Elective demand

• Progression of modelling an ‘at scale’ System wide Referral Management System continues, with a number of key clinical workshops taking place to develop clinical pathways and

processes. A further workshop, reviewing five more specialities, has been scheduled.

• The GP delivery dashboard continues to be issued to all practices. This will now include a trajectory at speciality level.

• A project initiation document for the GP incentive package to support primary care has been assured. Initial rounds of negotiation are under way between CCGs and provider leaders.

157


CCG Overview – Performance by Programme – All Providers

11

Planned Care

BHRUT reported RTT performance of 90.6% in February 2018 against the agreed

trajectory of 91%. March’s unvalidated performance is 86.0% (as of 1 April 2018) which

is below a trajectory of 91.6%. Underperformance remains driven by ENT, General

Surgery (although both specialties improved over the last two months), T&O

(performance has dipped for the third consecutive month) and Maxfax.

QIPP

Demand Management - QIPP related schemes to reduce referrals into secondary care

including gastroenterology, MSK and dermatology, have not delivered to the expected

levels. The FRPB has now agreed to mandate compliance with these pathways in all

instances (excluding 2WW and agreed clinical exceptions), this has been

communicated to all GPs. BHRUT have written to CCGs indicating that they no longer

support the single point of access model. This poses a significant risk to QIPP delivery.

PoLCE & Cessations/Restrictions: PoLCE performance in month 12 has improved

compared to month 11, however issues linked to claims and IVF remain.

Other: All other schemes within planned care are delivering to plan, with no issues of

note.

Unplanned Care

BHRUT did not meet the Sustainability and Transformation Fund (STF) trajectory for

March 2018 reporting 73.9% against the STF trajectory of 95%. In March 2018, the main

reasons for ED breaches reasons were: wait for first clinician - not triage (30%) and bed

management (26%). 4 hours non-admitted performance in March was reported as 81.6%

whilst, 4 hours admitted performance in March was reported as 33.7%. The Trust is

working will system partners to manage the flow of patients effectively. Workforce is a

significant risk factor for the system (recruitment and retention of staff) with greater

reliance on temporary staff.

QIPP

A&E front door: The scheme remains under exception, however the level of redirection

weekly target is now being delivered consistently. Work continues to sustain this level of

achievement. BHRUT carry 100% of the risk for financial delivery against this scheme.

KGH UCC: Scheme under plan in January, both in terms of expected activity reduction and

with regard to weekly UCC utilisation rate.

111: The scheme continues to deliver marginally better than plan. BHRUT and CCGs are

undertaking an audit to triangulate reported reductions via 111 and A&E attendances,

which should confirm the effectiveness of the scheme.

Mental Health

The ambitions of the national Mental Health Five Year Forward View form the basis of BHR CCGs’ mental health programme priorities for 2017/18 and focus on the following areas:

• Maintaining the low acute psychiatric bed base, and ensuring that patients needing acute care are not placed out of area.

• Improving services for people experiencing mental health crisis, including home treatment teams provision, enhanced mental health liaison services at acute hospitals, and 24/7

access to information and advice.

• Improving access to talking therapies (IAPT), moving towards closer integration with physical health care provision.

• Improving IAPT recovery rates and sustaining waiting time performance for people referred to IAPT talking therapies.

• Improving the physical health of people with severe mental illness.

• Improving psychological interventions for people with psychosis, bi-polar disorders and personality disorders.

• Implementing the Transforming Care Programme for people with learning disabilities to develop viable alternatives to inpatient care wherever possible.

• CAMHS transformation, including increasing the numbers of children and young people in receipt of mental health services, and improving access to eating disorder services.

There has been overall progress on the delivery of these priorities. However, remaining challenges are in the consistent delivery of the IAPT Access and Recovery targets and in the

delivery of the Redbridge CAMHS service. Both of these areas are being addressed through SPR (and through CQRM in the case of CAMHS).

158

2. Contracts Performance

159


Acute Contract Performance – BHRUT

13

Finance

The final year end position is an overspend of £11.8m at M11 following a risk assessment of outstanding areas of dispute and includes an additional MRET (Marginal Rate Emergency

Tariff )adjustment of £3.4m and challenges at £11.9m. Overspends have been identified in the unadjusted position in antenatal, day cases, elective, non-elective and outpatients. The key

areas identified are:

Maternity - Whilst the increase in the cost of deliveries appears to be in line with other providers (and driven by the changes to national Guidance), analysis suggests a change in

antenatal pathway case mix, with shifts from standard and intermediate pathways to the more costly intensive pathways. This has been referred to Expert Determination.

RTT - Activity in Planned Care PODs (Patient Outcome Data) for outpatients, day case and elective is continuing to increase in line with previous months.

Critical Care - has started to increase over the last couple of months although it is still forecasting an underspend at the end of the year.

Drug Spend - is increasing due to IR specialised commissioning transfers in gastroenterology and rheumatology.

Non-elective - several specialties including stroke, respiratory, A&E, ambulatory care, general surgery and endocrinology amongst others, have all seen a significant forecast increases,

although specialty level variances are potentially distorted by a Trust instigated change to the specialty level coding of activity at the beginning of 2017/18. After removing the stroke

increase, HRG4+, growth and sepsis the real increase is £7.8m (8.5%) against activity increases of 2.2%. This has been referred for Expert Determination.

Activity

M11 shows a slight improvement in outpatients and elective planned care areas when compared to M10 and corresponds to a deterioration in the RTT backlog and the start of

the spending money wisely phase 2 QIPP programme which has seen significant reductions. Over performance continues to be seen in unplanned care primarily associated with

stroke and sepsis activity. Following the audits undertaken in both areas earlier 17/18 the non-elective and stroke cost increases have both been challenged and escalated for

expert determination.

QIPP

Joint work is underway with the Trust to agree the likely FOT and required mitigations. BHRUT and CCGs meet on a weekly basis to discuss and resolve operational QIPP issues,

sessions so far have been well received, by both parties.

Performance

A&E – BHRUT did not meet the Sustainability and Transformation Fund (STF) trajectory for March 2018 reporting 73.9% against the STF trajectory of 95%. In March 2018, the main

reasons for ED breaches reasons were: wait for first clinician - not triage (30%) and bed management (26%). 4 hours non-admitted performance in March was reported as 81.6% whilst, 4

hours admitted performance in March was reported as 33.7%. The Trust is working with system partners to manage the flow of patients effectively. Workforce is a significant risk factor for

the system (recruitment and retention of staff) with greater reliance on temporary staff.

RTT – The Trust achieved 90.6% in February which is below the agreed trajectory of 91% (London All providers 88.0%). This is a deterioration from the 91% achieved in January. The

Trust reported 6 patients over 52 weeks (5 in January). In February the position deteriorated across several specialties from the previous month driven primarily by Dermatology (-5% from

the previous month). Underperformance remains driven by ENT, General Surgery (although both specialties has improved over the last two months), Maxfax and T&O (performance has

dipped for the third consecutive month). At the end of February the waiting list size was 34,709 (from 33,130 in January). As of 1 April 2018 the waiting list has grown back to 34,880.

March’s unvalidated performance is 86.0% (as of 1 April 2018) which is below a trajectory of 91.6%. The Trust recovery plan is based on additional capacity through extra clinics and

outsourcing between February 2018 and April 2018. On 21 March 2018 Commissioners made several recommendations to strengthen the plan including the addition of: capacity and

demand plans, plan to reduce waits at +40 weeks, recovery trajectory for challenged specialties, milestones, timelines and RAG status. The next technical meeting between BHR CCGs

and the Trust is scheduled for 18 April 2018 where performance against trajectory, backlog increase, latest PTL position and recovery plan will be further discussed. The RTT CPN issued

on August 2017 was closed on 3 April 2018 following review of performance, since the CCG no longer has concerns about the Trust planning to achieve 92% at specialty rather than the

agreed Trust-wide 92%.

Cancer – BHRUT achieved all 8 Cancer standards in February 2018. The 62 day Urgent GP Referral Standard performance has been sustained since July 2017 and performance in

February 2018 was 85.7% against the 85% threshold.

Diagnostics – BHRUT achieved 99.3% against the 99% DM01 standard in February 2018. The non-compliant modalities in February 2018 are: MRI (98.2%), audiology assessments

(91.9%), peripheral neurophysiology (97.6%), urodynamics (92.3%) and cystoscopy (90.9%). 160


Acute Contract Performance – BHRUT

14

Data Source: SLAM

Key

variance




Key Messages

The annual activity forecast has changed from an under

performance of 0.1% to an over performance of 0.4%

driven by an over performance in pathology. Costs have

decreased against the annual plan by 0.3% from M10,

mainly driven by increases to the claims and QIPP forecast.

• For non electives, issues of price variance over and

above the rate of activity increases continue with a

reported variance in activity of 5% above plan against a

cost up by 24.2% against plan in the month. Non

elective pricing has been raised as an challenge and is

part of the expert determination.

• The increased HRGs within the national stroke tariff

structure and change in case mix, increase and

improvement in sepsis recording/coding and general

case mix increase across non electives continue to be

the primary causes of the overspend in non elective.

• While both planned care and outpatients continue to

over perform, it is at a lesser rate than previous,

contributing to a slightly improved forecast (an

improvement of 0.9% and 0.4% respectively) and is

seen in day cases, electives and outpatient first

attendances.

• The forecast for deliveries 8,984 remain above plan at

8,647 deliveries for the year (3.9% above plan), which is

outside the midwife to birth planned ratio of 1:24. This is

being addressed through the Maternity Clinical Quality

review Meeting (CQRM) and is recognised as a system

wide issue regarding recruiting sufficient staff numbers.

The East London Local Maternity System (ELLMS) had

recently developed a five year plan which among an

number of objectives would seek to address workforce

recruitment, training and retention

Plan Actual Plan Actual Plan Actual

Urgent Care (Total) 11,135 12,579 (1,444) -13.0% 133,228 142,216 (8,988) -6.7% 145,568 155,392 (9,824) -6.7%

Accident and Emergency 2,390 2,306 84 3.5% 28,846 30,037 (1,191) -4.1% 31,497 32,825 (1,328) -4.2%

Non-Elective 6,856 8,514 (1,658) -24.2% 81,848 93,396 (11,548) -14.1% 89,445 102,070 (12,625) -14.1%

Non Elective non emergency (exl. Maternity) 75 57 18 24.1% 901 1,030 (130) -14.4% 984 1,126 (142) -14.4%

Critical Care 1,314 1,506 (192) -14.6% 15,677 14,066 1,610 10.3% 17,132 15,345 1,786 10.4%

Other (Excess bed days, HASU, inpatient DI) 499 196 303 60.8% 5,957 3,686 2,271 38.1% 6,510 4,026 2,484 38.2%

Planned Inpatient Care (Total) 3,736 4,244 (507) -13.6% 43,697 51,233 (7,536) -17.2% 47,674 55,911 (8,236) -17.3%

Day Cases 1,971 2,334 (363) -18.4% 23,134 28,307 (5,173) -22.4% 25,237 30,892 (5,654) -22.4%

Elective care 1,207 1,421 (214) -17.7% 14,042 16,248 (2,206) -15.7% 15,314 17,731 (2,417) -15.8%

Other (Excess bed days, Rehab, Regular attendees) 559 489 70 12.5% 6,521 6,678 (157) -2.4% 7,123 7,288 (165) -2.3%

Outpatients (Total) 3,958 4,565 (607) -15.3% 45,952 54,068 (8,116) -17.7% 50,218 59,005 (8,787) -17.5%

Outpatients First Appointments 1,751 1,782 (30) -1.7% 20,258 22,321 (2,063) -10.2% 22,160 24,359 (2,199) -9.9%

Outpatients Follow Up 1,235 1,609 (374) -30.3% 14,386 18,386 (4,000) -27.8% 15,728 20,065 (4,337) -27.6%

Outpatient Procedures 826 1,042 (216) -26.1% 9,646 11,788 (2,142) -22.2% 10,515 12,864 (2,349) -22.3%

Other (DI whilst outpatient, Non face to face attendances) 145 132 13 9.2% 1,663 1,574 89 5.4% 1,815 1,718 98 5.4%

Maternity 3,618 3,581 38 1.0% 42,463 44,964 (2,501) -5.9% 46,473 49,067 (2,594) -5.6%

Antenatal 1,181 1,273 (92) -7.8% 13,493 15,034 (1,540) -11.4% 14,805 16,406 (1,601) -10.8%

NELNE (Deliveries) 1,835 1,764 71 3.9% 21,887 23,090 (1,203) -5.5% 23,918 25,189 (1,271) -5.3%

NELNE (Maternity Non Delivery Spells) 402 360 42 10.4% 4,798 4,454 345 7.2% 5,244 4,867 377 7.2%

Postnatal 189 177 12 6.6% 2,160 2,283 (123) -5.7% 2,370 2,491 (121) -5.1%

Other (Excess bed days, social reasons) 10 7 4 33.8% 125 104 21 16.8% 136 113 23 16.9%

Other (total) 3,651 3,759 (108) -3.0% 41,858 32,395 9,464 22.6% 45,708 35,342 10,366 22.7%

Direct access and Diagnostic imaging (as DA) 2,133 2,086 47 2.2% 24,421 23,921 500 2.0% 26,661 26,105 556 2.1%

Drugs & Devices 822 996 (173) -21.1% 9,468 11,110 (1,641) -17.3% 10,338 12,119 (1,782) -17.2%

Other (Block, Audiology, Cardiac, Patient Transport) 695 677 18 2.6% 7,969 (2,636) 10,604 133.1% 8,710 (2,882) 11,592 133.1%

Underlying Total 26,098 28,727 (2,629) -10.1% 307,198 324,875 (17,677) -5.8% 335,641 354,717 (19,076) -5.7%

CQUIN 531 531 0 5,839 7,534 (1,695) 6,370 8,078 (1,707)

Fines & Penalties 0 0 0 0 (67) 67 0 (73) 73

Claims/Challenges (308) 0 (308) (3,523) (10,936) 7,413 (3,846) (11,930) 8,084

Other-Fin 1,357 0 1,357 1,980 0 1,980 1,647 0 1,647

Grand Total 27,678 29,258 (1,580) -5.7% 311,495 321,407 (9,912) -3.2% 339,812 350,791 (10,978) -3.2%

Variance Variance Variance

BHRUT M11Current month £ (000s) - BHR CCG Year to date £ (000s) - BHR CCG Annual forecast £ (000s) - BHR CCG

Plan Actual Plan Actual Plan Actual

Urgent Care (Total) 22,915 22,399 516 2.3% 275,266 272,569 2,697 1.0% 300,688 297,819 2,868 1.0%

Accident and Emergency 16,548 16,782 (234) -1.4% 199,249 203,083 (3,834) -1.9% 217,608 221,932 (4,324) -2.0%

Non-Elective 3,674 3,858 (184) -5.0% 43,889 46,107 (2,218) -5.1% 47,970 50,366 (2,396) -5.0%

Non Elective non emergency 35 14 21 59.8% 416 313 103 24.8% 455 341 114 25.0%

Critical Care 976 1,170 (194) -19.9% 11,638 11,425 213 1.8% 12,718 12,464 254 2.0%

Other (Excess bed days, HASU, inpatient DI) 1,682 575 1,107 65.8% 20,074 11,641 8,433 42.0% 21,937 12,717 9,220 42.0%

Planned Inpatient Care (Total) 4,732 4,989 (257) -5.4% 55,463 62,404 (6,941) -12.5% 60,543 68,097 (7,554) -12.5%

Day Cases 2,586 3,111 (525) -20.3% 30,377 37,001 (6,624) -21.8% 33,148 40,377 (7,230) -21.8%

Elective care 458 464 (6) -1.4% 5,310 5,418 (108) -2.0% 5,793 5,910 (117) -2.0%

Other (Excess bed days, Rehab, Regular attendees) 1,688 1,414 274 16.3% 19,776 19,985 (209) -1.1% 21,602 21,809 (207) -1.0%

Outpatients (Total) 29,325 33,769 (4,444) -15.2% 339,631 403,500 (63,869) -18.8% 371,263 440,340 (69,078) -18.6%

Outpatients First Appointments 9,004 9,030 (26) -0.3% 104,095 112,869 (8,774) -8.4% 113,864 123,174 (9,310) -8.2%

Outpatients Follow Up 14,333 17,846 (3,513) -24.5% 167,059 210,048 (42,989) -25.7% 182,605 229,226 (46,621) -25.5%

Outpatient Procedures 5,188 6,051 (863) -16.6% 59,314 70,515 (11,201) -18.9% 64,790 76,953 (12,163) -18.8%

Other (DI whilst outpatient, Non face to face attendances) 800 842 (42) -5.2% 9,163 10,068 (905) -9.9% 10,003 10,987 (984) -9.8%

Maternity 2,289 2,484 (195) -8.5% 26,649 30,823 (4,174) -15.7% 29,187 33,639 (4,452) -15.3%

Antenatal 690 704 (14) -2.0% 7,881 8,232 (351) -4.5% 8,647 8,984 (337) -3.9%

NELNE (Deliveries) 568 533 35 6.2% 6,783 6,980 (197) -2.9% 7,412 7,614 (202) -2.7%

NELNE (Maternity Non Delivery Spells) 405 710 (305) -75.4% 4,830 8,539 (3,709) -76.8% 5,278 9,324 (4,045) -76.6%

Postnatal 599 520 79 13.1% 6,836 6,816 20 0.3% 7,501 7,438 62 0.8%

Other (Excess bed days, social reasons) 27 17 10 36.4% 319 256 63 19.8% 349 279 69 19.9%

Other (total) 438,736 463,058 (24,322) -5.5% 5,023,538 4,979,117 44,421 0.9% 5,484,213 5,433,723 50,490 0.9%

Direct access and Diagnostic imaging (as DA) 437,074 461,006 (23,932) -5.5% 5,004,498 4,945,759 58,739 1.2% 5,463,426 5,397,328 66,098 1.2%

Drugs & Devices 3 243 (240) 37 2,590 (2,553) 41 2,825 (2,785)

Other (Block, Audiology, Cardiac, Patient Transport) 1,658 1,809 (151) 19,003 30,768 (11,765) 20,746 33,570 (12,824)

Grand Total 497,998 526,699 (28,701) -5.8% 5,720,546 5,748,413 (27,867) -0.5% 6,245,893 6,273,619 (27,726) -0.4%

BHRUT M11Current month activity - BHR CCG Year to date activity - BHR CCG Annual forecast activity - BHR CCG

Variance Variance Variance

161


Acute Contract Performance – Barts Health

15

Data source: SLAM, adjusted position

Finance

• The forecast of £102.8m reflects the year end deal of £102.4m and the additional transport mobilisation costs of £0.34m

• Based on month 11 SLAM data, the estimated benefit from the year end deal is £1.5m

• An adverse movement of £0.3m in the underlying FYO is primarily the result of a £0.5m increase in Non Elective spend. This is the continuation of an upward trend in spend over recent months

linked to seasonal increases in activity. This and other cost pressures were partially offset by a reduction in critical care spend of £0.4m.

• The underlying YTD over performance based on M11 SLAM of £9.5m continues to be driven by unplanned care (inpatients of £2.8m and critical care of £1.2m) and planned care (outpatients

including outpatient procedures £2.5m, and elective inpatients £0.4m).

• Uncoded activity in the month has a financial value of £0.1m. This is an decrease against last months value of £0.17m. This represents an estimate spend of 2.7% of the relevant total spend

compared to 3.6% last month. Barts have improved coding across the contract and coded activity has been above 97% for the last three months, significantly reducing financial risk to the CCGs.

Activity

• Unplanned Care increased to 6.3% above plan (5.8% last month). This was driven by an increase in the over performance of non elective which moved from 11.2% to 13.6% over plan. This

movement is primarily the result of seasonal increases in respiratory related conditions and paediatric activity. A&E also moved from 2.8% to 3.4% over the YTD plan. This is after adjusting for

zero cost streamed away activity and reflects the higher activity levels of activity seen at Whipps Cross and is in line with increased activity across the sector.

• Planned inpatient care performance increased to 2% above plan (1.2% last month). Over performance continues to be driven by Elective inpatients (5.3%, 99 spells) but Day Cases are also now

creating a pressure (1.2% 93 spells). There were 12% more day cases in month than planned. This was a result of increased activity in HRGS relating to ophthalmology, pain management, male

urology and ENT.

• Outpatients over performance as a whole increased again from 9.9% last month to 10.7% (8.7% M9). First attendances are 7.4% above plan (6.7% last month), despite a reduction in reported

referrals and the potential impact of the cyber attack. There is an upward trend in follow ups which moved from 0.8% to 2.3% last month and to 3% over the YTD plan this month. Outpatient

procedures are relatively unchanged and continue to be the key driver of over performance in this area at 33.6% over plan. This is in part due to a transfer from attendances as a result of HRG4+

but is also due to growth in Trauma and Orthopaedics, Dermatology and Cardiology.

• Births continue to be under plan in the year to date at 8.8% as against 8.3% under plan last month.

• Antenatal pathways are 7.4% under plan compared to 7.9% under last month.

• Post natal pathways are relatively unchanged and still significantly over plan, 118%, and are subject to a claim related to an increase level of activity in month 4. To date the Trust have not

substantiated this spike in activity.

• Uncoded activity is 1.8%, relatively unchanged from last month. Planned care uncoded activity is up to 1.2% compared to 0.8% last month. Non elective is down from 2.9% to 2.5%.

QIPP

The contract incorporates a target of £5.79m of QIPP reductions. Of this, £4.0m is not currently identified against specific contract areas. CCGs are currently engaging with lead commissioners to

ensure 18/19 QIPP is fully realised in the 18/19 contract.

Performance

• Diagnostics: The Trust continues to achieve the standard, reporting 99.51% in January; compliance is also expected for February. Neurophysiology remains challenged due to staffing capacity;

a site level recovery plan is in place to support compliance at modality level and an admin clerk is to commence work in April. In-sourcing is also being explored to support clinical recovery

capacity.

• Cancer 62 Standard: Barts Health met all Cancer standards in January including the 62 day standard, reporting 85.47% against the 85% standard.

• RTT: The Trust reported 116 unvalidated 52 week pathways in the February month-end position. As agreed by the Trust Board on 04 April and supported by the WEL-procured external

assurance the Trust will return to national RTT reporting in May 2018 (April 2018 data). The volume of 52 week waiters is expected to improve prior to the return to reporting, however the Trust

forecast that there will be more pathways waiting >52 weeks than previously expected, with 63 pathways expected high risk and 49 pathways considered low risk. A breakdown of all pathways

waiting over 52 weeks by CCG and specialty, including the reason for delay, assessment of harm and next steps has been requested via CRG and the RTT Recovery Board (expected 19th April

following Trust internal validation). Whilst the Trust have not submitted any RTT data for CCG Operating Plan submissions to date, the 18 week RTT performance trajectory and reduction

trajectories for long waiting pathways is expected for the regional Operating Plan submission on 20th April.

• A&E: The Trust achieved 84.61% against the monthly STF trajectory of 92.84% in February. Provisional data for March indicates performance of 85.41% and a year-end position of 86.47%.162


Acute Contract Performance – Barts Health POD Level Summary




Key for Variances

Please note that this is an unjusted activity report as per NELIE

16

Plan Actual Plan Actual

Urgent Care (Total) 32,547 36,225 (3,678) 11.3% 35,567 39,861 (4,294) 12.1%

Accident and Emergency 5,103 5,275 (173) 3.4% 5,576 5,772 (197) 3.5%

Non-Elective 20,745 23,560 (2,815) 13.6% 22,671 25,945 (3,275) 14.4%

Non Elective non emergency (exl. Maternity) 2,401 2,310 91 -3.8% 2,624 2,525 100 -3.8%

Critical Care 2,996 4,152 (1,155) 38.6% 3,275 4,668 (1,393) 42.6%

Other (Excess bed days, HASU, inpatient DI) 1,302 928 373 -28.7% 1,422 951 472 -33.2%

Planned Inpatient Care (Total) 15,358 15,808 (450) 2.9% 16,735 17,245 (510) 3.0%

Day Cases 7,270 7,393 (123) 1.7% 7,918 8,068 (150) 1.9%

Elective care 5,555 5,955 (400) 7.2% 6,053 6,498 (445) 7.4%

Other (Excess bed days, Rehab, Regular attendees) 2,532 2,460 72 -2.9% 2,764 2,679 85 -3.1%

Outpatients (Total) 14,730 17,237 (2,507) 17.0% 16,070 18,820 (2,750) 17.1%

Outpatients First Appointments 4,845 5,402 (557) 11.5% 5,285 5,895 (611) 11.6%

Outpatients Follow Up 5,956 6,555 (599) 10.1% 6,497 7,153 (656) 10.1%

Outpatient Procedures 3,930 5,280 (1,350) 34.4% 4,288 5,772 (1,483) 34.6%

Maternity 15,192 14,896 -(296) -1.9% 16,602 16,253 -(349) -2.1%

Antenatal 5,609 5,411 197 -3.5% 6,129 5,905 224 -3.7%

Deliveries 9,169 8,673 496 -5.4% 10,019 9,461 558 -5.6%

Postnatal 415 812 (397) 95.7% 453 886 (433) 95.5%

Other (total) 12,324 12,299 -(26) -0.2% 13,468 13,130 -(338) -2.5%

Direct access and Diagnostic imaging (as DA) 3,591 2,901 690 -19.2% 3,924 3,165 759 -19.3%

Drugs & Devices 5,227 5,648 (421) 8.0% 5,712 5,839 (127) 2.2%

Other (Block, Audiology, Cardiac, Patient Transport) 3,507 3,751 (244) 7.0% 3,832 4,126 (294) 7.7%

Subtotal 90,152 96,465 (6,313) 7.0% 98,443 105,310 (6,867) 7.0%

Other including financIal adjustments (4,503) (1,280) (3,223) -71.6% (5,090) (3,210) (1,880) -36.9%

Grand Total 85,649 95,185 (9,536) 11.1% 93,353 102,784 (9,089) 9.7%

Plan Actual Plan Actual

Urgent Care 52,103 55,365 (3,262) 6.3% 56,933 60,483 (3,549) 6.2%

Accident and Emergency 36,172 38,483 (2,311) 6.4% 39,524 42,055 (2,531) 6.4%

Non-Elective 9,799 10,045 (246) 2.5% 10,708 10,968 (260) 2.4%

Non Elective non emergency (exl. Maternity) 3,753 3,444 309 -8.2% 4,101 3,759 342 -8.3%

Critical Care 2,379 3,393 (1,014) 42.6% 2,600 3,701 (1,101) 42.4%

Planned Inpatient Care 9,597 9,789 (192) 2.0% 10,455 10,679 (224) 2.1%

Day Cases 7,739 7,832 (93) 1.2% 8,430 8,545 (115) 1.4%

Elective care 1,858 1,957 (99) 5.3% 2,025 2,134 (109) 5.4%

Outpatients 111,837 123,825 (11,988) 10.7% 121,997 135,130 (13,133) 10.8%

Outpatients First Appointments 24,916 26,754 (1,838) 7.4% 27,176 29,197 (2,021) 7.4%

Outpatients Follow Up 62,281 64,146 (1,865) 3.0% 67,932 70,003 (2,071) 3.0%

Outpatient Procedures 24,639 32,925 (8,286) 33.6% 26,889 35,930 (9,042) 33.6%

Maternity 7,750 8,769 (1,019) 13.1% 8,469 9,568 (1,099) 13.0%

Antenatal 3,473 3,217 256 -7.4% 3,795 3,511 284 -7.5%

NELNE (Deliveries) 2,971 2,709 262 -8.8% 3,247 2,955 292 -9.0%

Postnatal 1,306 2,843 (1,537) 117.7% 1,427 3,103 (1,676) 117.4%

Barts HealthYear to Date Activity Annual Forecast Activity

Variance Variance

Variance VarianceBarts Health

Year to Date (£'000s) Annual Forecast (£'000s)

163


Mental Health Contract Performance – North East London Foundation Trust

17

Finance

The Mental Health Services contract with NELFT is predominantly a block contract (with mental health tariff live trading position as advised below), with financial adjustments

made on a quarterly basis according to the outcome of Key Performance Indicators (KPIs) and CQUIN performance. The latest quarterly positon (Q3) highlights that all the KPIs

that carry a financial penalty were achieved and that there was a partial achievement on CQUINs. The partial achievement of CQUINs is in respect of “Preventing ill health by

risky behaviours; alcohol and tobacco” with a financial withholding of £29k across BHR CCGs.

Activity

• Mental Health Tariff live trading is being applied to three care clusters. M10 data shows, after the application of the risk share, an overall financial benefit to the CCGs of

£3,786.

• Mental Health Tariff cluster based activity plans do not include IAPT services. Activity and performance of IAPT services are based on % access rates calculated by a

monthly attainment target for each CCG of 1.3% of expected population prevalence of people with common mental health disorders. For M11, provider data for the IAPT

Access 1.3% monthly target shows under-performance across Barking and Dagenham, Havering and Redbridge services with achievements of only 1.04%, 1.18% and

0.95% respectively. Achievement of the IAPT access target is mainly dependent on increasing referrals to the services.

NELFT key performance indicators (KPIs) and CQUIN performance is reported quarterly in line with contractual targets and the quarterly SPR closedown process.

• Q3 and M10 performance indicators were presented for closedown at SPR on 13 April 2018.

• Havering’s KPI IAPT Recovery performance reported across several quarters has been very strong; however, 17/18 Q3 published data shows Havering having only just

achieved the 50% target for the second consecutive quarter with a performance of 50.0%. The published data shows that Barking and Dagenham and Redbridge once again

failed to meet the KPI IAPT Recovery target at 42% and 48% respectively.

• The IAPT Access targets are still not being met consistently. In Q3, published data show that the national 3.75% target was missed across BHR as follows: Barking and

Dagenham 3.16%, Havering 3.04% and Redbridge 3.11%.

• One other KPI shows as failed at Q3 closedown:

• The CAMHS Eating Disorders target: 89% of routine referrals receiving a NICE concordant treatment within 4 weeks of first contact; was missed by Redbridge at

83.0%. It should be noted that the 89% local target was set in the contract in preparation for the 95% target being required nationally by 2020.

• NELFT operates with a very low number of inpatient beds at Goodmayes Hospital and the occupancy rates for adults of working age since April have been very high. After a

more moderate occupancy rate in M7 and M8, data shows M9 and M10 rates once again rising thereby increasing the risk of placements having to be made out of area

which would have to be funded by NELFT.

• Q3 CQUINS indicate a partial achievement and financial withholding (approx. £29k) in respect of ‘preventing ill health by risky behaviours’ (tobacco and alcohol screening.)

The other Q3 CQUIN requirements have been met.

• The M11 published rates for dementia diagnosis continue to be below target in Havering (59.2% against a 67% target). In Redbridge the M11 performance is the third

consecutive month below target since June 2017, at 64.4%. Barking and Dagenham maintains their consistent achievement of the target at 69.6%

• The M11 Early Intervention in Psychosis (EIP) target (at least 50% of patients receiving a NICE treatment within two weeks) shows continued achievement of this target in

each borough.

Performance

164


Activity

• Year to date activity across adult and children’s services highlights a 2% over performance based on M11 flex activity data. The plan and variances to date include a broad

range of over and under performance against annual activity plans.

• NELFT is undertaking work and analysis to revise the current straight line activity plans to reflect seasonal variation where applicable. This work stream has been phased

with children services reporting adjusted from M9, and the majority of adult services now reporting from M11.

Community Contract Performance – North East London Foundation Trust

18

Finance

The Community Health Services contract with NELFT is a block contract, with financial adjustments made on a quarterly basis according the outcome of Key Performance

Indicator (KPIs) and CQUIN performance. The latest quarterly positon (Q3) highlights that all KPIs were achieved and partial achievement on CQUINs. The partial achievement

of CQUINs is in respect of “Preventing ill health by risky behaviours; alcohol and tobacco” with a financial withholding of £9k across BHR CCGs.

Performance

NELFT key performance indicators (KPI) and CQUIN performance is reported quarterly in line with contractual targets and the quarterly SPR closedown process.

The M11 performance data has been received, with the position reviewed and agreed at the Service Performance Review (SPR) meeting on 13 April 2018. The performance is

summarised below:

• 18 week Referral to Treatment (RTT) across both children's and adult services meets the 92% national target.

• Inpatient occupancy rates across general rehabilitation remain high at 93% on average. Stroke ward occupancy has increased to 91.4% from 87.9% in the previous month

and is reflective of the levels of demand.

• Average lengths of stay (ALoS) in both of the general rehabilitation wards (Japonica and Foxglove) highlight an improvement in Japonica reported at 20 days in the period

against a benchmark of 21 days, down from 27.7 days in the previous month. Foxglove also remaining within benchmark at 18.6 days. The ALoS jointly across the rehab

wards is 19.3 days.

• Average length of stay on the inpatient stroke ward at Gray’s Court shows an improvement at 26.5 days, down from 34.7 days in the previous month and is now below the

benchmark standard of 28 days. The variability of this position is mostly due to the small bed base and patient acuity.

• Acute admission avoidance: Community Treatment Team/LAS – 93 patients kept at home in M11 which represented 73% of calls attended in the period, compared to 64%

last month. CTT Acute hub - continued over achievement against target (51%) with 91% of referrals recorded as preventing an acute admission.

• Intensive Rehabilitation Service (IRS) Inreach to BHRUT wards to identify patients for intensive support to reduce LoS identified 89 patients against a target of 100 in the

period. NELFT have indicated that they have seen an increase in referrals requiring support of two therapists due to the dependency levels of patients now being referred to

IRS, this is impacting on the overall capacity of IRS.

• The Child Protection Medicals completed within 48 hours- 100% completion across BHR, against a target of 95%. A significant increase in demand in Redbridge has been

identified.

• Paediatric Therapies continue to have varied performance and longer waiting times than the national benchmarks, particularly in Barking and Dagenham. There are a

number of reasons for this performance, which have been highlighted through external review and business cases, recommending investment for additional resource, re-

design and re-specification, with a strategic aim to move to BHR wide rather than borough based services and have a wider skill mix of staff. This is to maximise capacity

and manage current and future demand across the BHR health economy.165


Contract Performance – Key Associates and Independent Sector

19

Finance

FOT has changed this month due to the year end agreements with Associate Acute.

Basildon, Royal National Orthopaedic, Marsden and Royal Free have all increased due to accruals of unreported positions. This has resulted in an increase in these Trusts on

the forecast of £600k for the 3 CCGs. These have been offset in the other Acute Trusts by £386k to show overall movement of £214k.

Care UK, Spire and Holly Private Hospital - the redirect program ended in April 2017, however demand (GP referrals) has not decreased accordingly. Over the last 3 months

the forecast position has improved, in month we have seen a further improvement of £140k

Activity

• Associate - over performance continues to increase. The impact is seen across all PODs with outpatients (follow ups in particular) followed by day cases are among the

PODs with the highest levels of over performance.

• Homerton is still over performing in all areas with YTD total activity 12% over plan and the key areas driving this being outpatients first up by 12% and follow ups up by 10%

and day cases up by 23% (mainly diagnostic procedures).

• Guy’s and St Thomas’ is the second highest over performing trust with activity over plan by 9%. Critical care is the main contributor of this increase with activity up by 82.9%

against plan.

• Independent Sector - as in previous months, the over performance has continued at most of the Independent Sector providers. This is seen predominantly within day case

activity and has been subject to Activity Query Notices issued by BHR CCGs to Spire Roding, Care UK and The Holly Private Hospital.

• Key findings to date are that there have been observed market share shifts away from NHS providers, to Independent Sector providers for certain procedures, notably hip

and knee replacements and cataracts. Additionally there has been an observed increase in PoLCE compliant procedures (for example an increase in bunion procedures)

compared to 2016/17.

• Trauma & Orthopaedics is the highest over performing specialty at 25% above plan followed by gynaecology at 17% above plan.

• Care UK and Spire Roding are seeing the highest YTD over performance in the Independent Sector, 15% and 23% respectively.

Performance

• Guy’s and St Thomas’ have not met the RTT performance standard in any month this year. Although an under performance is seen across most specialties, this excludes

general medicine, geriatric medicine, thoracic medicine, neurology, rheumatology and ophthalmology. Guy’s February reported performance is 87.6%.

• UCLH have not met the RTT performance standard for February 2018 with reported performance being 91.2%. Under performance in driven by the following specialties,

ENT, general medicine, neurosurgery and thoracic medicine.

• Diagnostics - North East London Treatment Centre has achieved the diagnostics standard for BHR CCGs during 2 months this year (July 17 and October 17).

Underperformance is due to MRI, non-obstetric ultrasound and colonoscopy tests. In February performance is 96.8% against the 99% standard with 2 breaches in MRI, 4 in

non-obstetric ultrasound and 4 in colonoscopy.

166


Contract Performance – NHS 111 and London Ambulance Service

20

Data Source: LAS Performance Reports,

LAS Monthly Activity Report

Finance

NHS 111

BHR CCGs spend at M11 is £3.295m, which is above plan by £323k.

The over performance in M11 is in line with anticipated growth in activity compared to the same period in 2016/17. Commissioners (in anticipation of the increase) have made

sufficient budgetary provisions to cover the cost of the additional activity.

LAS

Over performance costs and under performance rebates are calculated using the incident rate of £211, and as YTD pan-London over performance is within 3%, CCG costs are

not capped as per the contract. NEL continues to be the best performing STP in regards to activity and finance, and invoices / credits relating to Q1 and Q2 have been

processed accordingly. The Q3 close down position is pending the outcome of discussions on taxi journeys as well as a review of the charging for mental health pre-bookable

journeys. C4H activity has been validated by the LAS Commissioning Team as calls that were initially expected to be managed via hear & treat (H&T), but have subsequently

been dealt with as a face-to-face response. The reporting and charging of taxi journeys however is being discussed as commissioners believe that this is already funded in the

baseline – the reporting issue is on the agenda for the Finance & Information Group meeting on Friday 13 April.

Activity

NHS 111

In M11 the YTD activity (269,993) is 15% over plan, however the rate of growth in call volumes have slowed down compared to the first 6 months of 2017/18. The slowdown in

the growth trajectory for in call volumes is consistent with commissioners’ expectations, based on the knowledge that the increase in demand noted up to M6, was partly

attributable to the reconfiguration of a mobile network in M7 of the previous financial year (2016/17).

For the week ending 1 April 2018, PELC achieved 53.9% calls directed to a clinician in the Clinical Assessment Service (CAS) within NHS 111 service. This exceeds the

Integrated Urgent Care (IUC) target of 50%. In the last 4 weeks PELC has been consistently achieving 50-54% of calls directed to GPs in CAS.

LAS

The LAS switched over to the Ambulance Response Programme (ARP) in M8 in line with timescales for National Ambulance Trusts, and pan-London incidents post-ARP have

shown a general reduction, dropping to 0.6% above plan in M8 and -0.2% below plan in M9. Comparatively, M1-7 activity was 2.6% above plan. The position at M10 and M11

has been challenged as expected, however activity remained below the variances seen against plan pre-ARP, at 1.7% and 1.2% above plan, respectively. NEL has experienced

a similar trend with incidents in M10 and M11 coming in a lot closer to plan (-0.2% and -0.1%, respectively).

Performance

NHS 111

In M11 PELC did not achieve the operational performance against the 95% target for calls answered within 60 seconds (76.5%) and the call abandonment rate at 6.7% was also

outside the 5% target. This has been discussed with PELC in Service Performance Review (SPR) meetings. There has been a surge in call demand in London and across the

country during past three months and most other providers have experienced similar surges and have also been struggling to meet the target. PELC is usually amongst the best

performing providers in London and across the country.

LAS

LAS saw a decline in performance in M11 but remained in the top 3 ambulance Trusts nationally for the category 1 mean. School half term and the adverse weather were cited

as factors affecting both demand and capacity. National issues around the grading of specific category 2 calls are also affecting performance, and this is being picked up under

the ARP Spring review. Specific NEL issues will be discussed at the NEL Demand Management Group meeting in April. 167


Contract Performance – BHR CCGs – RTT & Diagnostics

21

Data Source: Unify2

Performance and Plan shown is for the BHR CCGs (All providers)

*Plan refers to the operating plan

The RAG is based on the national standard

Theme KPI MeasureApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

YTD

2017/18

National

Standard

18 Weeks RTT Adjusted Admitted 80.88% 77.22% 75.80% 77.19% 79.05% 77.40% 75.69% 76.75% 76.12% 75.31% 74.05% 76.87% -

18 Weeks RTT Non-Admitted 88.03% 88.13% 90.29% 89.75% 88.98% 89.19% 89.38% 63.99% 91.11% 89.67% 90.02% 86.99% -

18 Weeks RTT Incomplete Pathways 90.53% 91.95% 92.36% 92.07% 91.14% 91.21% 91.00% 92.07% 90.54% 91.63% 91.34% 91.43% 92%

18 Weeks RTT Incomplete Pathways (*plan) 85.44% 87.34% 88.89% 90.03% 91.14% 92.10% 92.56% 92.67% 92.65% 92.68% 92.66% 92%

Non-admitted >52 week waits 52 81 92 78 108 106 95 13 4 10 7 646 -

Incomplete >52 week waits 11 21 31 29 32 30 29 10 32 11 9 245 -

>6 Weeks Diagnostic Waits 0.76% 1.86% 2.52% 1.60% 1.17% 0.90% 0.68% 0.62% 0.90% 0.71% 0.71% 0.0113324 1%

> 6 Weeks Diagnostic Waits (*Plan) 0.97% 0.96% 0.96% 0.96% 0.96% 0.97% 0.98% 0.97% 0.96% 0.95% 0.96%18 W

eeks R

efe

rral t

o tre

atm

ent

and D

iagnostic

168


Contract Performance – BHR CCGs - Cancer

22

Data Source: Unify2

Performance and Plan shown is for the BHR CCGs (All providers)

*Plan refers to the operating plan

The RAG is based on the national standard

Theme KPI MeasureApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct -17 Nov-17 Dec-17 Jan-18 Feb-18

YTD

2017/18

National

Standard

2 Week Wait (2 Week Cancer Wait) 95.70% 98.22% 97.63% 97.81% 97.16% 95.76% 96.53% 97.27% 96.83% 95.91% 97.14% 96.92% 93%

2 Week Wait (2 Week Cancer Wait) (Plan) 93.31% 93.42% 93.47% 93.31% 93.32% 93.32% 93.47% 93.45% 93.40% 93.43% 93.37%

2 week wait:

Breast symptoms95.48% 100.00% 100.00% 97.57% 96.05% 97.50% 97.33% 95.37% 97.03% 96.77% 98.32% 97.53% 93%

2 week wait:

Breast symptoms (*Plan)94.44% 94.74% 93.85% 93.65% 93.75% 94% 94% 94% 94% 94% 95%

31 day Cancer Wait:

1st definitive treatment96.79% 96.07% 92.78% 96.56% 97.90% 93.80% 96.48% 97.50% 96.63% 95.07% 97.85% 96.21% 96%

31 day Cancer Wait:

1st definitive treatment (*Plan)96.55% 97.73% 98.00% 97.87% 96.49% 97.62% 98.00% 97.92% 96.55% 96.49% 96.72%

31-day Cancer Wait:

Subsequent cancer treatment-surgery93.62% 97.87% 98.28% 96.30% 98.04% 100.00% 97.83% 93.93% 97.93% 96.49% 97.62% 97.37% 94%

31-day Cancer Wait:

Subsequent cancer treatment-surgery (*Plan)100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

31-day Cancer Wait:

Subsequent cancer treatment-Chemotherapy98.11% 98.53% 100.00% 96.97% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 99.55% 98%

31-day Cancer Wait:

Subsequent cancer treatment-Chemotherapy

(*Plan)

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

31-day Cancer Wait: subsequent cancer

treatment - radiotherapy100.00% 100.00% 100% 94.85% 100.00% 100.00% 98.15% 100.00% 99.00% 100.00% 100.00% 99.46% 94%

31-day Cancer Wait: subsequent cancer

treatment - radiotherapy (*Plan)100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

62 Day Cancer Wait:

GP Referral78.69% 74.17% 72.56% 84.11% 84.94% 81.58% 85.62% 86.13% 88.07% 82.24% 82.86% 81.93% 85%

62 Day Cancer Wait:

GP Referral (*Plan)87.50% 88.00% 87.88% 88.46% 86.11% 86.21% 87.88% 85.19% 86.21% 85.37% 85.71%

62 Day Cancer Wait:

Screening service100.00% 94.44% 100.00% 96.30% 100.00% 100.00% 100.00% 100.00% 90.00% 79.17% 100.00% 95.90% 90%

63 Day Cancer Wait:

Screening service (*Plan)100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

62 Day Cancer Wait:

Consultant Upgrade88.24% 85.71% 77.50% 90.08% 90.25% 87.76% 83.02% 90.30% 75.57% 77.78% 94.12% 85.06%

No

Thresholds

63 Day Cancer Wait:

Consultant Upgrade (*Plan)100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Can

cer

Wai

ts

169


Contract Performance

23

Data Source: Unify2

London Ambulance Quality Indicators

BHRUT

Notes

New Ambulance Quality Indicators measure average response times

for 4 categories:

Cat 1: Average response time < 7 minutes

Cat 2: Average response time < 18 minutes

Cat 3: Average response time < 2 hours

Cat 4: Average response time < 3 hours

Category 1: Calls from people with

life-threatening illnesses or injuries

London Ambulance Service

(LAS)00:07:04 00:07:24 00:07:10 00:07:26

Category 2: Emergency callsLondon Ambulance Service

(LAS)00:18:27 00:24:11 00:20:25 00:23:21

Category 3: Urgent CallsLondon Ambulance Service

(LAS)00:56:52 01:14:42 01:01:34 01:15:46

Category 4: Less Urgent CallsLondon Ambulance Service

(LAS)01:12:06 01:22:16 01:08:21 01:17:08

Feb-182017/18

YTD

Lo

nd

on

Am

bu

lan

ce

Qu

ali

ty

Nov-17 Dec-17 Jan-18Theme KPI/ Measure Provider

King George H 89.72% 87.61% 91.33% 91.96% 91.58% 84.69% 86.56% 84.16% 86.56% 74.48% 72.09% 74.16% 84.51%

Queens 81.29% 76.49% 82.74% 83.19% 80.36% 85.06% 80.33% 73.55% 80.33% 69.58% 68.72% 67.36% 77.41%

BHRUT 84.05% 80.24% 85.51% 86.14% 84.07% 84.92% 82.42% 76.99% 72.79% 71.37% 69.85% 69.73% 78.95%

King George H 92.32% 91.10% 93.72% 93.93% 93.81% 88.69% 90.26% 88.39% 83.01% 81.24% 79.67% 80.82% 87.95%

Queens 82.44% 78.69% 84.77% 84.94% 82.43% 86.52% 81.87% 74.92% 72.50% 71.22% 70.32% 68.94% 78.40%

BHRUT 86.23% 83.02% 87.63% 88.02% 86.17% 86.95% 84.85% 80.21% 76.69% 75.40% 74.13% 73.85% 81.86%

No. of waits from decision to admit

to admission (Trolley waits) over

12 hours

BHRUT 0 0 0 0 0 0 0 0 0 0 0 0 0

Urgent Operations Cancelled for

the 2nd or more timeBHRUT 0 0 0 0 0 0 0 0 0 0 0

Theme KPI/ Measure Provider Feb-18 Mar-182017/18

YTDMay-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17

Ac

cid

en

t &

Em

erg

en

cy

A&E Type I Performance

A&E All Types Performance

Nov-17 Dec-17 Jan-18Apr-17

170


Contract Performance – BHRUT

24

Data Source: Unify2

VTE is reported on a quarterly basis

Date of Incident:Site of

Incident:Clinical Area:

SI Status on StEIS

Mar-17 Queens Theatre Closed 04/10/2017

Apr-17 Queens Theatre Closed 04/10/2017

May-17 King George Theatre Closed 04/10/2017

Jul-17 Queens Bluebell B Open

Jan-18 Queens ED Open

Feb-18

Queens Radiology Open

King George ED Open

Queens Theatres Open

BHRUT Never Events from 01/01/2017 - 12/02/2018

Data Source: BHRUT NE Report 12th Feb 2018 - Safety Team, NELCSU

MRSA reported infections BHRUT 0 0 2 1 0 0 0 0 0 0 0 3

C. difficile reported infections BHRUT 2 0 1 2 1 0 1 2 0 3 1 13

Mixed Sex Accommodation

(Number of breaches)BHRUT 0 0 0 0 0 4 2 1 0 0 4 11

VTE (% admitted patients

assessed for VTE risk)BHRUT 96.00% 95.62% 95.13% 97.45% 96.65% 96.76% 97.03% 97.12% 96.05% 96%

Theme KPI/ Measure Provider

Qu

ality

Nov-17 Dec-17 Jan-18 Feb-182017/18

YTDMay-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17Apr-17

171

7. East London Health and

Care Partnership – Finance &

Activity Overview

172

Integrated Performance Report 2017/18 - BHR CCGs M11 26

East London Health and Care Partnership Overview – M12 Financial Summary

Key Messages

• A £57.1m forecast over spend

across the STP represents a £1m

increase in the financial over

performance to 4% over plan.

• The forecast for Barts Health is

based on the year end deal of

£627m. The FYO is now £21.7m or

3.7% over plan.

• The Barts Health year end deal

mitigates an increase in the

estimated underlying spend based

on M11 flex increasing the expected

benefit against a cost and volume

outturn of over £5m.

• It should be noted that the Barts

contract included £19m of QIPP

plans and a further £2.5m of planned

savings in the form of a budget

reduction.

• Underlying cost pressures at Barts

Health continue to be driven

primarily by unplanned care.

• The forecast outturn for BHRUT

increased by £1.7m to £13.2m or

3.8% (3.3% last month) over plan

• The most notable adverse variances

across associates were BMI £0.5m

(planned care mainly across WEL

CCGs) and RNOH £0.4m

• A number of adjustments to the

forecast were reported through the

non contract and other acute

reporting categories.

Plan Actual

Varianc

e Plan Actual Variance Plan Outturn Variance RAG

Prior Mth

FOT Var Movement

%

Movement RAG

£'000s

STP Acute Trusts 91,496 95,543 4,047 1,088,893 1,125,432 36,539 1,088,893 1,125,432 36,539 34,651 1,889 0.2%

Other Acute Trusts 11,938 13,930 1,992 143,930 151,144 7,214 143,930 151,144 7,214 6,080 1,133 0.8%

Ambulance Services 6,318 5,611 -707 73,221 72,679 -542 73,221 72,679 -542 ec -55 -487 -0.7%

Other Acute 12,615 22,041 9,427 108,750 130,003 21,253 108,750 130,003 21,253 14,633 6,620 5.4%

Acute Reserves 893 1,444 551 11,134 3,816 -7,319 11,134 3,816 -7,319 ec 843 -8,162 -68.1%

Acute Commissioning Total 123,260 138,570 15,310 1,425,929 1,483,073 57,145 1,425,929 1,483,073 57,145 56,152 993 0.1%

Total 123,260 138,570 15,310 1,425,929 1,483,073 57,145 1,425,929 1,483,073 57,145 56,152 993 0.1%

Plan Actual

Varianc

e Plan Actual Variance Plan Outturn Variance RAG

Prior Mth

FOT Var Movement

%

Movement RAG

£'000s

Barts Health 47,408 49,461 2,054 581,932 603,580 21,648 581,932 603,580 21,648 21,684 -36 -0.0%

BHRUT 30,738 32,326 1,587 346,409 359,594 13,185 346,409 359,594 13,185 11,519 1,666 0.5%

Homerton 13,350 13,756 406 160,552 162,258 1,706 160,552 162,258 1,706 1,448 259 0.2%

UCLH 3,344 3,803 460 40,137 40,786 649 40,137 40,786 649 361 288 0.7%

Moorfields 2,338 2,229 -110 28,035 28,833 798 28,035 28,833 798 999 -201 -0.7%

Guys & St Thomas 1,627 1,735 107 19,559 20,823 1,264 19,559 20,823 1,264 1,260 5 0.0%

BMI 560 1,342 781 7,236 9,098 1,862 7,236 9,098 1,862 1,388 474 5.5%

North Middlesex 809 795 -14 9,726 10,664 939 9,726 10,664 939 1,038 -99 -0.9%

Royal Free 840 967 127 10,075 10,253 178 10,075 10,253 178 57 121 1.2%

Whittington 502 771 269 6,031 6,725 693 6,031 6,725 693 464 229 3.5%

Mid Essex 476 340 -136 5,700 5,453 -247 5,700 5,453 -247 -105 -142 -2.5%

RNOH 416 800 384 5,069 5,189 120 5,069 5,189 120 -280 400 8.4%

Imperial 414 299 -115 4,968 4,702 -266 4,968 4,702 -266 G -164 -102 -2.1%

Basildon & Thurrock 329 445 116 3,980 4,522 542 3,980 4,522 542 455 87 2.0%

King's College 282 404 122 3,414 4,095 682 3,414 4,095 682 609 72 1.8%

London Ambulance Service 6,318 5,611 -707 73,221 72,679 -542 73,221 72,679 -542 -55 -487 -0.7%

Non NHS Contracts 2,908 3,600 691 35,498 45,819 10,322 35,498 45,819 10,322 10,499 -177 -0.4%

NCA 2,577 6,588 4,011 24,913 29,891 4,978 24,913 29,891 4,978 1,502 3,477 13.2%

Other Acute Contracts 7,129 11,853 4,725 48,340 54,293 5,952 48,340 54,293 5,952 2,633 3,320 6.5%

Acute Reserves 893 1,444 551 11,134 3,816 -7,319 11,134 3,816 -7,319 843 -8,162 -68.1%

Total 123,260 138,570 15,310 1,425,929 1,483,073 57,145 1,425,929 1,483,073 57,145 56,152 993 0.1%

STP CCG's STP CCG's

In Month Year-to-Date Annual Forecast

STP CCG's STP CCG's

In Month Year-to-Date Annual Forecast

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From: Tom Travers, Chief Finance Officer

Date: 24 May 2018

Subject: Finance Risk Overview Report (March 2018 – Month 12 (Month 11 data)

Executive Summary The CCGs have submitted a final year-end position to NHS England (NHSE) for 2017/18. The final reported deficit is £21.2m (slippage of £11m against plan). The in-year deficit is £16.4m. The improvements to the Month 11 reported deficit of £27.7m in Month 11 relate to the release of the 0.5% risk reserve into the bottom line (£4.9m), the reduction is short stock drugs costs (£0.75m) and the Category M drugs rebate (£0.95m). As with previous months the month 12 position with BHRUT has not been agreed. The CCGs’ forecast for BHRUT has been prepared on the basis of the outcome of the independent mediation and additionally includes an adjustment for year-end partially completed spells. This has resulted in a year-end overspend of £11.8m The CCGs have submitted papers to the national expert determination process to resolve the contractual position. At year-end this process was not completed. Outstanding acute risk has been discussed with NHSE and the Auditors. The CCGs have, therefore, posted a general acute provision in relation to the outstanding risk. The Barts Health position is as per the agreed year-end settlement. For BHR CCGs this is an overspend of £9.1m. All other Acute spend has taken into account the Agreement of Balances (AOB) agreement where applicable. The other main areas of spend showing variances are as a result of QIPP slippage, investment slippage, Continuing Healthcare (CHC) packages of care and prescribing. There has been year-end QIPP delivery of £32.3m, a slippage of £12.8m against plan. Of this, £6.1m slippage relates to the QIPP in acute contracts and £4.1m relates to acute QIPP schemes that are not currently in contracts. The underlying position of the CCGs moving into 2018/19 is a deficit of £10.6m. This was used in the Operating Plan submitted at the end of April 2018.

1 Purpose of Report

The purpose of this report is to brief the Joint Committee on the overall financial position as at the end of March 2018 (Month 12).

Recommendations

The Joint Committee is asked to: Agree the financial position noting the risks within it.

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2 Background/Introduction

As at the end of Month 12 the CCG reported a year end deficit of £21.2m against resource limit (this includes the 17/18 in year deficit and the historic deficit reported by Havering CCG). 3 Month 12 Financial Position

See table on next page for detail

175

REVENUE POSITION

176

MAIN EXPENDITURE VARIANCES

Acute Contracts

The CCGs are reporting a forecast overspend of £11.8m with BHRUT. Unadjusted data suggests a significant underlying overspend of £39m. The CCGs have made a number of adjustments to the Trust’s data which include claims and challenges (£12m), QIPP delivery assumptions (£7.7m), and other technical adjustments (£8.5m). An additional year-end adjustment was made for partially completed spells which amounted to £1m.

The forecast position reported for the BHRUT contract is based on the technical view of the independent mediation entered into for Quarter 1 which is not agreed with the Trust. The CCGs and Trust have initiated the next stage in the contractual process which is expert determination. This had not taken place at year end.

The CCGs are reporting a forecast overspend of £9m with Barts. This is an agreed year end position with the Trust.

Homerton University Hospital is reporting a forecast overspend of £1.1m, relating to maternity and IVF cycles.

Other Acute areas are forecasting an overspend position of £10m. There are adverse variances reported against a range of associate contracts, largely relating to critical care. However, the largest adverse variances reported at Month 12 are against the Independent Providers. The Independent Providers have not seen the material reduction in referrals expected following the cessation of referral redirects from BHRUT at the end of 16/17.

The CCGs sought audit opinion on how to reflect the acute risk in the annual accounts and a general provision for acute risk was posted into the accounts.

There is also QIPP slippage of £4m against other acute QIPP commitments.

The overall acute forecast position is, therefore, a £36.9m overspend, of which £10.2m is assessed to be due to QIPP under delivery.

Mental Health

Mental Health outturn shows an underspend of £1.4m. This value includes an underspend against the NELFT contract, agreed with the Provider as part of the contract mediation process. Of the total underspend £0.39m has been classified as a QIPP saving.

Community

Community shows a year-end overspend of £1.2m. The main pressures relate to QIPP slippage and pressures against the insulin pump budget.

The annual QIPP target with NELFT is £2.2m. QIPP has been delivered in both the Community and Mental Health element of the contract. QIPP slippage against the Community contract is reported as £0.9m. However, this is offset by the over achievement of £0.9m against the Mental Health contract.

Continuing Care

Year-end outturn shows an under spend of £1m.

The position is driven by a range of factors - QIPP over achievement offset by use of agency staff and activity over-performance at Barking and Dagenham CCG.

Primary Care & Prescribing

Across BHR, Primary care and Prescribing are year-end outturn shows a £4.7m underspend. The Month 12 outturn is based on a Prescribing Monitoring Document (PMD) forecast, using Month 11 Prescription Pricing Authority (PPA) information extrapolated forward for Month 12. The impact of drug concession prices has been factored into the

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CCGs’ financial position. The outturn position assumes £3.2m of price concession costs and a Category M benefit of £0.95m.

Primary Care Co-Commissioning

Primary care co-commissioning reported break-even position at Month 12.

Running Costs

The CCGs have a running cost allocation of £16.8m. This was fully committed at year end.

Other Programme Services / Reserves / QIPP Investments and Disinvestments

The main budgets held under “Other Programme Services” includes budgets for the Better Care Fund (BCF), 0.5% uncommitted risk reserve, Property Services and other programme services. Within other programme services there is a charge of £0.85m relating to the STP and Commissioning Alliance.

In total there has been £19.6m released into the financial position from programme reserves and QIPP Investments. This relates to the release of contingency (£5m), brought forward creditors, release of provisions and savings shown against other investments.

Further detailed information across all contracts is found in the Performance Report.

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UNDERLYING POSITION

2017/18 Forecast at

M12

Remove

Non

Recurrent

Budget

(b/f

surplus)

Other Non

Recurrent

Spend

Non

Recurrent

QIPP

Schemes

FRP Full

Year

Impact

FYE of

Investments

2017/18

underlying

position

£m £m £m £m £m £m £m

Total Allocation 1,097.8 (10.5) 0.0 0.0 0.0 0.0 1,087.3

Total Spend 1,114.3 (10.5) (2.2) 6.2 (11.0) 1.2 1,097.9

Surplus / (deficit) (16.4) - 2.2 (6.2) 11.0 (1.2) (10.6)

The underlying position at Month 12 is a deficit of £10.6m.

Methodology

The start point is the Month 12 in-year deficit. Non recurrent budget allocations and spend of £10.5m are removed plus other non-recurrent spend of £2.2m. Other non-recurrent spend includes 2017/18 non-recurrent investments.

Non recurrent QIPP and the full year impact of 17/18 schemes are factored into the position to give the 2017/18 underlying position. At Month 12 it is expected that this will be a deficit of £10.6m.

The underlying deficit reported in Month 12 was used in the Operating Plan submitted to NHSE at the end of April.

Risk to the Underlying Position

The ongoing process in relation to the BHRUT contract may impact the underlying position. An acute provision was included in Month 12 outturn. It is assumed that this is recurrent. There is a risk that the outcome of the acute contract process will be different to this value.

FINANCIAL ACCOUNTING METRICS Cash Position at 31 March 2018 The CCGs draw down cash from the Department of Health each month to pay invoices and staff salaries. The CCGs are required to end each month with an actual cash balance that is less than 1.25% of the main cash drawdown for that month. Throughout March 2018, the CCGs continued to operate within their expected cash envelopes, and were not overdrawn on their bank accounts at any point. The CCGs are working closely with NEL CSU to ensure accurate and robust cash forecasts are in place, and that there continues to be appropriate cash and treasury safeguards.

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A summary of the cash position for the three CCGs is shown below, and further detail is provided at Appendix 3.

Barking & Dagenham

CCG Havering CCG Redbridge CCG

Closing cash balance at end of month

£9k £12k £9k

Closing cash balance less than 1.25%?

Y Y Y

Amount drawn down £280,860k of a MCD

of £289,992 £368,350k of a MCD of

£376,446k £350,730k of a MCD of

£357,518k

Invoice payment performance measure – Better Payment Practice Code (BPPC)

The BPPC requires the CCGs to pay all valid invoices by the due date, or within 30 days of receipt of a valid invoice, whichever is later. The CCGs are working closely with NEL CSU to ensure all valid invoices are being cleared in line with this target. The Barking and Dagenham BPPC figures for the value of NHS invoices paid within target has reduced in March due to the part payment of an acute over performance invoice. Similarly the value of Non NHS invoices paid within target for Redbridge has also reduced significantly due to a delay in payment of the BCF invoice for months 1 – 10. As the Borough was unable to pay the £8m it owed the CCG in February a part payment of £6m was paid in that month with the balance paid in March following receipt of the £8m from the Borough. A summary of the year to date results is shown below, and further detail can be found at Appendix 4.

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OVERVIEW

No Indicator Month 2 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12

1. Financial position year to date Amber Amber / Red Red Red Red Red Red Red Red Red Red

2. Financial position forecast outturn Amber Amber / Red Red Red Red Red Red Red Red Red Red

3. Savings Year to date Green Amber Red Red Red Red Red Red Red Red

4. Savings forecast outturn Red Red Red Red Red Red Red Red Red Red

Month 3

Amber

Red

The financial position of the CCGs remains extremely challenging. The underlying position moving into 2018/19 shows a deficit of £10.6m. The CCGs and Trust are currently participating in an expert determination process which will influence the final 2017/18 outturn position with the Trust. Until this process is completed there is a risk for the CCGs that the acute value assumed in Month 12 will be different to the value reported.

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4 Financial Summary

The financial position of the CCG is extremely challenging and year-end outturn shows a deficit of £21.2m (in-year deficit of £16.4m). The underlying deficit moving forward into 2018/19 is £10.6m. At year end the expert determination process with BHRUT hadn’t concluded. Until this process is concluded there is a risk that the financial value agreed with BHRUT will be different to the reported position.

5 Resources/Investments n/a

6 Equalities n/a

7 Risk

Financial risk is reported in section 3 of the report.

8 Managing conflicts of interest n/a Attachments:

1. Appendix 1 – CCG Revenue Position 2. Appendix 2 – CCG Underlying Position 3. Appendix 3 – CCG Cash position 4. Appendix 4 – CCG Better Payment Practice Code

Author: Tom Travers, Chief Finance Officer Date: May 2018

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Annual

Budget

M12 Actual YTD

Variance

QIPP

Variance

£'000 £'000 £'000 £'000

BHRUT 155,160 161,342 (6,182) (1,528)

Barts Health NHS TRUST 9,150 11,312 (2,161) (869)

Homerton 1,460 1,693 (233) 10

Other Acute 47,391 51,434 (4,042) 291

Acute Reserves 6,041 5,082 959 0

Other Acute QIPP Plans (1,814) (527) (1,287) (1,287)

Acute Commissioning Total 217,388 230,335 (12,946) (3,382)

Mental Health 32,184 30,880 1,304 319

Community 29,693 30,349 (655) (382)

Continuing Care 20,590 20,154 437 24

Primary Care & Prescribing 47,590 45,094 2,495 440

Primary Care Co-Commissioning 34,090 34,090 (0) 0

Other Programme Services 11,500 9,268 (4,366) (202)

Programme Reserves and QIPP Investments 6,890 292 6,598 0

QIPP Disinvestments (2,979) (1,917) (1,063) (1,063)

Running Costs 5,755 5,753 2 0

Total BHR CCGs Expenditure 402,701 404,297 (1,596) (4,246)

2017/18 Allocation (397,767) (397,767) 0

2017/18 Control Surplus / (Deficit) (4,934) (6,530) (1,596)

2017/18 Allocation including historic deficit (393,007) (393,007) 0

Control Total Surplus / (Deficit) (9,694) (11,290) (1,596)

Appendix 1: CCG Specific Revenue Position

Barking and Dagenham CCG

Annual

Budget

M12 Actual YTD

Variance

QIPP

Variance

£'000 £'000 £'000 £'000

BHRUT 92,674 97,353 (4,679) (782)

Barts Health NHS TRUST 22,378 23,745 (1,367) (563)

Homerton 2,231 2,488 (257) (7)

Other Acute 31,778 32,558 (780) 70

Acute Reserves 2,631 4,260 (1,628) 0



Mental Health 31,592 31,428 164 314

Community 31,827 32,432 (604) (289)

Continuing Care 15,534 16,200 (666) 153

Primary Care & Prescribing 32,931 32,240 690 269

Primary Care Co-Commissioning 29,645 29,645 0 0

Other Programme Services 11,330 9,093 (4,029) 0

Programme Reserves and QIPP Investments 5,842 (424) 6,266 0

QIPP Disinvestments (2,851) (1,894) (957) (957)



2017/18 Allocation (307,828) (307,828) 0


Havering CCG

183

Annual

Budget

M12 Actual YTD

Variance

QIPP

Variance

£'000 £'000 £'000 £'000

BHRUT 91,979 92,954 (975) (996)

Barts Health NHS TRUST 62,166 67,728 (5,562) (1,977)

Homerton 4,523 5,174 (651) (84)

Other Acute 48,890 54,006 (5,115) 275

Acute Reserves 3,097 3,272 (175) 0



Mental Health 31,208 31,301 (93) (245)

Community 23,469 23,451 18 (333)

Continuing Care 22,895 21,690 1,205 753

Primary Care & Prescribing 45,835 44,310 1,525 253

Primary Care Co-Commissioning 36,627 36,627 (0) 0

Other Programme Services 16,231 11,796 (2,317) 0

Programme Reserves and QIPP Investments 6,560 (192) 6,753 0

QIPP Disinvestments (3,788) (2,139) (1,649) (1,649)



2017/18 Allocation (392,223) (392,223) 0


Appendix 1: CCG Specific Revenue Position

Redbridge CCG

184

Appendix 2: CCG Specific Underlying Position

Barking and Dagenham CCG

2017/18 Forecast at

M12

Remove

Non

Recurrent

Budget

(b/f

surplus)

Other Non

Recurrent

Spend

Non

Recurent

QIPP

schemes

FRP Full

Year

Impact

FYE of

Investments

2017/18

underlying

position

£m £m £m £m £m £m £m

Total Allocation 307.8 (2.1) 0.0 0.0 0.0 0.0 305.7

Total Spend 313.5 (2.1) (0.5) 1.9 (2.1) 0.3 311.0

Surplus / (deficit) (5.7) - 0.5 (1.9) 2.1 (0.3) (5.3)

Havering CCG

2017/18 Forecast at

M12

Remove

Non

Recurrent

Budget /

Spend

Other Non

Recurrent

Spend

Non

recurrent

QIPP

Schemes

FYE of

QIPP

FYE of

Investments

2017/18

underlying

position

£m £m £m £m £m £m £m


Total Spend 404.3 (3.4) (1.2) 2.1 (3.3) 0.4 398.8

Surplus / (deficit) (6.5) - 1.2 (2.1) 3.3 (0.4) (4.5)

Redbridge CCG

2017/18 Forecast at

M12

Remove

Non

Recurrent

Budget /

Spend

Other Non

Recurrent

Spend

Non

recurrent

QIPP

Schemes

FYE of

QIPP

FYE of

Investments

2017/18

underlying

position

£m £m £m £m £m £m £m


Total Spend 396.4 (5.0) (0.5) 2.3 (5.6) 0.5 388.1

Surplus / (deficit) (4.2) - 0.5 (2.3) 5.6 (0.5) (0.9)

185

APPENDIX 3

Cash Position

186

APPENDIX 4 Better Payment Practice Code Performance

187

To: Meeting of the Joint Committee of Barking and Dagenham, Havering and

Redbridge CCGs

From: Jacqui Himbury, Nurse Director

Date: 24 May 2018

Subject: Quality Report

Executive summary

This report provides an update to the joint committee on the clinical quality matters, risks and actions that the Clinical Commissioning Groups (CCGs) continue to manage, working with our providers to seek continuous quality improvements. This paper builds on the issues and risks that have been reported in previous papers and that have been reviewed by the Quality and Safety Committee (QSC). The report is divided into two sections: Section 1: Quality matters and issues that give an indication of how the BHR system is performing and the system wide risks that are being managed collectively in collaboration with partners. This report focuses on Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) mortality reduction improvement programme, the Child Death Overview Panel (CDOP) forthcoming statutory changes, and the GP Service Alerts (GPSA) management plan, including progress to date. Section 2: Focuses on the quality priorities and performance of our main providers and

the issues we are currently monitoring and managing through the Clinical Quality Review Meetings (CQRM). This covers the management of never events for BHRUT and for NELFT the progress they are making to deliver and sustain the quality improvements required by the Care Quality Commission.

Recommendations


Note the actions being taken to date to mitigate the identified quality performance risks

Suggest any further actions that the CCGs should consider to address the performance and quality risks for local people


1.1 This report is presented to the joint committee to ensure that members are fully briefed and assured on the actions being taken to manage the quality challenges and risks that the CCGs are addressing through our range of commissioning activities. Areas of good quality practice are also reported as it is important we

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2

recognise and celebrate achievements to have a full understanding of the quality of our commissioned services.

1.2 This covers both strategic and operational quality issues and details how they are managed so that the people we commission services for receive the best possible care, delivered in a way that is safe and effective while providing value for money.

2.0 Introduction

2.1 Seeking continuous quality improvements for patients continues to be a high priority for the CCGs, and many of our specific quality improvement and assurance activities are aimed at achieving this. This is especially so for the actions that deliver improved provider quality performance, which we assure and monitor through our established contract monitoring processes for our main providers.

2.2 This report is divided into two sections:

Section 1 – Quality matters and issues that give an indication of how the

BHR system is performing and the system wide risks that are being managed collectively in collaboration with partners. This section covers, the Child Death Overview Panel forthcoming changes, BHRUT mortality improvements, the GP service alert backlog management plan and submission of provider Quality Accounts.

Section 2 – Focuses on specific quality improvement priorities for our main

two providers (Barts Health NHS Trust is covered in a separate report) and the priority issues we are currently monitoring and managing through the CQRMs. This includes the continued management of never events for BHRUT’s and the de-escalation position and the CQC improvement plan for NELFT.

3.0 Section 1 – System Quality Performance

3.1. Mortality Reduction Programme BHRUT – The original issue that first raised risks

about patient safety was the mortality data reported by BHRUT (Hospital

Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator

(SHMI) increased to higher than expected levels in December 2016. Since that time

the improvement programme BHRUT put in place has been reviewed and monitored

by commissioners each month at the CQRM and at every Quality and Safety

Committee (QSC) meeting. The most recent review by the QSC was at the meeting

held on 15 May.

3.1.1 The current position is that the data, both HSMR and SHMI, continue to show

improving trends. Appendix 1 shows the 12 month rolling data to December 2017

(last published data). In view of this continuous improvement in performance and the

decrease in the level of risk for patient safety the QSC have agreed to change the

level of monitoring for the mortality improvement plan from enhanced to routine. This

means that unless the level of risk to patient safety increases commissioners will

continue to monitor performance monthly, although not track the implementation of

each individual action on the improvement plan. We are now assured that the Trust’s

plan will deliver the required improvements in patient safety.

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3

3.1.2 Since the last report the CCG Clinical Lead for end of life care and the Nurse Director

met with the Trust Clinical Director for mortality and we have agreed the next steps to

develop a system wide mortality reduction plan. We have agreed a collaborative

approach using the national guidance on learning from deaths and will also work with

NELFT as a strategic partner.

3.1.3 The Trust have made good progress in implementing their plan and have further

strengthened their Mortality Faculty good practice throughout the organisation’s

divisions and completed over eighty structured judgement reviews in the last quarter.

3.1.4 There has been a focus on patients presenting with biliary sepsis and the care bundle

for this condition has been fully completed and launched in April 2018. This was in

response a mortality outlier alert issued by the CQC to the Trust in December 2017.

The CQC use the term mortality ‘outlier’ to describe a specialty that lies outside the

expected range of performance.

3.2 Child Death Overview Panel (CDOP) – The Children and Social Work Act 2017

requires significant changes to the processes and structures associated with

safeguarding children and young people, and especially the child death review

processes. The statutory responsibility for the CDOP is with the Local Authority

although this responsibility is transferring to CCGs in the future when the revised

statutory guidance “Working Together to Safeguarding Children” is published later

this year. We currently have three CDOPs across BHR, one for each borough that

are sub-committees of the Local Safeguarding Children Boards.

3.2.1 A key focus on the revision of child death review (CDR) systems is the need to tackle

unwarranted variations in local processes, address key developments arising in local

authorities and the NHS and to ensure the effectiveness of local, regional and

national systems to drive the prevention of deaths where possible. From July 2016

the Healthy London Partnership (HLP) has been delivering a support programme for

London CDOPs and wider partners with the aim of ensuring they are well placed to

meet the challenges of the new system, work in a closer networked manner and

eliminate where possible unwarranted variations in process, procedures and outputs

to drive –where this is possible - the prevention of deaths of children and young

people. BHR CCG’s are fully engaged in this work and are working closely with local

authority colleagues in preparation for the forthcoming changes.

3.2.2 There is now an agreement from the BHR CDOP Chairs to move towards

implementing one CDOP across BHR. This proposal will be taken to each of the

Local Safeguarding Children’s Boards in July for agreement across the partnership.

If this proposal is agreed our next steps will be to develop a plan to implement the

changes working closely with all stakeholders. The CCGs Safeguarding Assurance

Committee will oversee this work reporting to the QSC.

3.3 GP Service Alerts – The General Practice Service Alerts (GPSA) system was

initially implemented by BHR CCGs in 2013 in response to the Francis Report

Recommendation 123 following the Mid-Staffordshire Trust inquiry

The recommendation states that:

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4

“GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the quality of service, in particular in relation to an assessment of outcomes. They need to have internal systems enabling them to be aware of patterns of concern, so that they do not merely treat each case on its individual merits. They have a responsibility to all their patients to keep themselves informed of the standard of service available at various providers in order to make patients’ choice reality. A GP’s duty to a patient does not end on referral to hospital,

but is a continuing relationship”.

3.3.1 Since the initial implementation of the system, the process has been formally reviewed three times to incorporate and respond to GP feedback and to ensure improvements are made and sustained.

3.3.2 Current Position – All open GP service alerts have been clinically reviewed and a

priority for follow-up and closure has been agreed based on clinical indicators. The

time period for alerts to be classified as the historical ‘backlog’ was from July 2017

until 12 March 2018. This totalled 219 open alerts.

3.3.3 As of week commencing 7 May 2018 101 of the backlog alerts have been reviewed in

detail and appropriate actions taken to work towards closure of the alerts. This has

enabled 43 to be closed and the GPs given an opportunity to confirm if the matter

remains outstanding. Therefore the total number of open backlog alerts is 176.

3.3.4 Several of the open alerts have been grouped into themes which are similar to

current alerts that we are receiving, such as issues with the 2 week wait pathway and

service delays. These matters remain open as the CCGs continue to work with

providers to investigate the root causes of these themes. The number of GPSA

received by provider was reviewed by the last QSC on 15 May 2018 and going

forward a monthly themed report will be provided to the Planned Care and

Unplanned Care SRO’s for review at the clinical meetings.

3.3.5 The QSC have been assured that the plan to close all open alerts is progressing as

anticipated with an end date of 15 June 2018.

3.3.6 Current GP service alerts are being managed at 95% closed within twenty eight days

in accordance with the agreed performance indicator. It has also been agreed that a

weekly performance report against this indicator will be submitted to the CCG Chairs

and a monthly performance report will go to the QSC members. If the number of

GPSAs that remain open beyond 28 days reaches a total of 80 alerts an escalation

process to the QSC will be implemented.

3.4 Pressure Ulcers – Over the past twelve months the BHR health system has focused

on understanding and interpreting pressure ulcer data, and although the number of

people admitted to BHRUT with pressure ulcers from grades 1 to 4 is high, we are

not an outlier compared to the England baseline figure. The next action that we are

taking is to review all of the data sources in detail, especially in relation to the number

of people being admitted to BHRUT from community settings with pressure ulcers.

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5

3.4.1 The Clinical Cabinet have asked that a focused piece of work be completed that

identifies the source of admission, the patient pathway for all grade 3 and 4 ulcers

and the potential quality impact that these ulcers have on a patient’s stay in hospital.

3.4.2 This work aligns with the CCGs corporate objective to reduce the number of serious

(grade 3 and 4) community acquired pressure ulcers. For Q1 2018/19 BHRUT

reported that 500 patients were admitted via the emergency department with

community acquired pressure ulcers, grades 1 to 4. A pressure ulcer improvement

task and finish group is being established, led by the Nurse Director and sponsored

by Dr John to lead this work.

3.4.3 An update report will be taken to the next Clinical Cabinet who will agree next steps.

3.5 Quality Accounts– Both NELFT and BHRUT have submitted their annual Quality

Accounts (the Accounts) to commissioners for review. We have reviewed the contents of the Accounts and discussed the outcome of the review at the QSC.

3.5.1 Submission of a Quality Account and publication on the NHS Choices website is a

statutory requirement for NHS provider organisations.

3.5.2 Our review confirms the Accounts represents a true and balanced picture of the services that NELFT and BHRUT provide and confirms their quality improvement priorities for 2018/19. These quality improvement priorities align to the CCGs’ priorities and transformation plans.

3.5.3 Commissioners are required to provide a commissioner statement for inclusion in

the Account. The QSC approved our statement and this was submitted to both organisations on 17 May 2018.

4.0 Section 2: Provider Operational Quality Improvements and Challenges

4.1 BHRUT Never Events De-escalation – At the last joint committee meeting further

assurance was requested on the actions being taken by commissioners to reduce the number of Never Events occurring in BHRUT. This update is to advise the committee of progress and actions taken since the last meeting.

4.1.2 In Q4 of 2017/18 the Trust reported a succession of four potential Never Events

which led to risks being raised about clinical practice, patient safety and cultural

learning within the organisation. These events related to three incidents of

nasogastric tube (NG) insertions and one to the fixing of a prosthesis during a

surgical procedure. These events were declared as Never Events by the Trust at the

time of recognition that something had gone wrong, pending a review with the CCGs.

This is best practice and in full compliance to the national ‘Serious Incident

Framework’ (2015).

4.1.3 Actions taken to date are:

The planned Never Event review took place on the 26 April 2018 which was attended by members of the Trust, the CCG Quality and Safeguarding team and the NEL CSU Quality Lead. The four Never Events were reviewed in detail against the national framework, and the Never Event guidance.

The actions the Trust have put in place were also reviewed against the early learning emerging from the investigations, including the human factors.

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The CCGs have agreed that the surgical procedure Never Event can be de-escalated to a Serious Incident as there was no harm caused to the patient and because the Trust provided assurance that all the correct pre-operative checks were completed, including the correct prosthesis being selected. The Trust also demonstrated how they had progressed the learning with staff to prevent a recurrence.

The CCGs have also agreed that the three NG tube incidents can be downgraded to serious incidents on the basis that the patients were not harmed. However, because there were three incidents the process for closing the investigations on the STEiS system will be the process that is followed for closing never events, which includes a commissioner review of the evidence of improvements, such as organisational learning events.

4.1.4 The following next steps (actions) were agreed:

The Trust will:

Provide the formal de-escalation requests following our agreed process. This is now complete.

Draft a comprehensive and inclusive action plan with dates for provision of evidence to support learning and change in practice for the NG incidents.

Send the action plan in draft form to the CCGs for final sign off by the CCG/CSU team by 31 May 2018.

Ensure that the dates of compliance and evidence provided are achievable and that they will all be met.

Provide all four root cause analysis investigation reports to the serious incident panel fully adhering the mandated timeframe.

The CCGs will:

Include the updated position in quality reports for May/June and ensure that the CCGs’ integrated performance report reflects the agreed actions and proposed de-escalations.

5.0 NELFT

5.1 CQC Improvement Plan – NELFT continue to make good progress on

implementing their Quality Improvement Plan to meet all the CQC “Must Do” and “Should Do” requirements. Their plan has been reviewed at the CQRM. To provide assurance to their Board and ensure organisational learning the Trust have developed and implemented patient point of contact to Board reporting process, with improvement actions confirmed as completed locally prior to the Board receiving assurance.

5.1.2 Commissioners have continued to work with the Trust to focus on the

management of clinical risk, the use of restraint and implementation of the ligature risk capital work programme. We have agreed with the Trust that all actions related to the improvement of clinical risks assessments will be regularly audited against compliance standards and the outcome of the audits will be shared at the CQRMs. The Trust have confirmed this approach as a quality improvement priority for 2018/19 in their Quality Account.

5.1.3 Any residual risks that remain following completion of the actions must be

compliant with regulatory requirements and the Trust have assured us that this is the expectation of their Board.

5.1.4 A review of the CQC Quality Improvement Plan is completed at each CQRM.

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6.1 There are no additional resource implications/revenue or capitals costs arising from this report.

7.0 Sustainability 7.1 If we achieve the quality improvements detailed in this report the positive impact

will be on sustained quality improvement and an improvement in patient experience.

8.0 Equalities

8.1 This report has considered the CCGs’ equality duty and where relevant has identified relevant actions which address any likely impact on equality and human rights.

9.0 Risk

9.1 Risks exist related to the delivery of the CCGs’ early warning systems, specifically

the processing of GP service alerts and completion of the key line of enquiry tracker. The key line of enquiry tracker is our quality analysis and risk profiling tool. Strong mitigating actions are in place while permanent solutions are identified. The timeframe for implementing the required changes has been reviewed and is now 15 June 2018.

9.2 Failure to ensure that there are improvements to the quality performance of

commissioned services may result in a failure to manage and mitigate risks with potential harm to patients and reputational damage to the CCGs. The CCGs quality surveillance and management system provides mitigation to this risk. The management of this risk is assured by the Quality and Safety Committee.

9.3 Some patients may not be receiving the quality of care at the level which the

CCGs commission, and therefore may have a poor experience of using the services we commission.

9.4 Following recent review of BHR CCGs’ governance arrangements, the terms of

reference of the area prescribing committee have been reviewed and amended to ensure that any decisions taken which exceed the area prescribing committee’s financial authority are reported to the financial recovery programme board (FRPB) for approval. Minutes of the area prescribing committee will be presented the quality and safety committee for review and assurance.

9.5 Mitigating actions for the above risks have been specified in the body of the report.


10.1 There are no conflicts of interest raised in this report.

Author: Jacqui Himbury, Nurse Director Date: 15 May 2018

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Appendix 1 - Mortality Data

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195

To: Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Kash Pandya, Chair of BHR CCGs Finance & Delivery Committee Date: 24 May 2018

Subject: Feedback report from the April 2018 meeting of BHR CCGs Finance & Delivery

Committee Summary

BHR CCGs Finance & Delivery Committee considered the following key matters at the April meeting which are drawn to the attention of the governing bodies: Finance risk overview report - committee members were given an update on the financial

risks that the CCGs are facing in 2017/18 and the progress made to secure greater financial stability in 2018/19 and 2019/20. The financial situation for 2017/18 remains a matter of extreme concern. The Committee members were updated on the Expert Determination (ED) process and its implications for 2018/19. Updates were also given on RTT at both BHRUT and Barts Health and Committee members gave their full support to all the actions being taken. Performance – the latest Integrated Performance Report (IPR) was reviewed and particular

attention was given to the significant challenges with regard to provider overspends, RTT A&E performance. Deep dives on Continuing Health Care, London Ambulance Services and mental health were requested for future meetings. e-referral Service (Choose & Book system) – the CSU assured the Committee that the on-going issues experienced by GPs in regard to appointment slot issues at BHRUT continue to be raised with the Trust and a timeline was requested for when the issues will be resolved. Procurement Oversight Group – committee members were briefed on the risks associated

with the tranche 3 procurement pipeline. The Chair’s concerns about single tender waivers were acknowledged and he reiterated that they should only be issued in exceptional circumstances. Recommendation:

The Joint Committee of BHR CCGs is asked to note this feedback report and the April committee minutes which provide more detail on all the matters considered.

11 May 2018

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Draft Minutes of the Joint Finance & Delivery Committee of BHR CCGs Thursday 26 April 2018 - Becketts House

Members: Kash Pandya (KP) Lay Member, Governance, BHR CCGs Dr Jagan John (JJ) Chair, B&D CCG Dr Atul Aggarwal (AA) Chair, Havering CCG Dr Anil Mehta (AMe) Chair Redbridge CCG Tom Travers (TT) Chief Finance Officer, BHR CCGs Steve Rubery (SR) Director, Delivery & Performance, BHR CCGs

Attendees:

Ceri Jacob (CJ) Managing Director, BHR CCGs Rob Adcock (RA) Deputy Chief Finance Officer, BHR CCGs Mark Eaton (ME) Director of Recovery, BHR CCGs Karina Christensen (KC) Deputy Director – NEL CSU Anna McDonald (AMc) Business manager Apologies:

Khalil Ali (KA) Lay Members, PPI, Redbridge CCG Dr Ann Baldwin (AB) Clinical Director, Havering CCG Dr Mehul Mathukia (MM) Clinical Director, Redbridge CCG Ali Kalmis (AK) Director, Acute Contract Management – NEL CSU Lee Eborall (LE) Director – NEL CSU

1.0 Welcome and apologies Action

The Chair welcomed everyone to the meeting and advised that the meeting was not quorate due to not having a CD present and therefore, any papers needing agreement would need to be circulated for virtual approval to the CDs. The Chair also advised that TT had been held up but would be attending the meeting.

1.1 Declarations of interest

The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of BHR CCGs.

JJ questioned how long historic declarations need to remain on the register of interests and AMc confirmed that they need to remain on the public register for a minimum of six months after the interest has expired. ME confirmed he has completed his declaration. AMc to ensure the information is added to the register. No additional conflicts of interest were declared. The register of interests held for BHR CCGs Governing Body (GB) members and staff is available from the Company Secretary.

AMc

1.2 Minutes of the last meeting

The minutes of the meeting held on 15 March 2018 were agreed as an accurate record.

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1.3 Matters arising/actions log

‘fit notes’ and the 14 day supply of medication on discharge – KC confirmed this has been raised with BHRUT and a response from them is awaited. CSU to give an update at the next meeting – Action open.

7.3 Day cases – KC advised that a member of the CSU still needs to sit with a member of the planned care team to view the data provided at the last meeting on a PC screen as it had not transferred to paper very well. The Chair asked for this to happen as soon as possible so that the c/fwd action can be closed– Action open.

The remaining actions were either closed or appeared on the agenda.

CSU CSU

2.0 Performance

2.1 Finance risk overview report RA presented the month 12 report based on month 11 data and advised the Committee that the final year-end position for the CCGs has been submitted to NHSE. The reported deficit is £21.2m. The in-year deficit is £16.4m. The main risk remains the BHRUT contract and the position has been discussed with NHS England and the auditors. The Expert Determination (ED) process will not be concluded until the final annual accounts have been signed off. The CCGs have submitted papers in regard to ED and have posted a general acute provision of £11.5m in relation to the outstanding acute risk. In regard to Barts Health, the CCGs are reporting a forecast over spend of £9.1m which is an agreed year-end position with the Trust. The other main areas of spend are showing variances as a result of QIPP slippage, investment slippage and Continuing Health Care (CHC) packages of care and prescribing. The Operating Plan will be submitted on Monday 30 April and the underlying position moving into 18/19 is a deficit of £10.6m. RA added that the likelihood is a further Operating Plan will need to be submitted once the ED process has been completed. JJ drew attention to the forecast overspend for the Homerton of £1.1m relating to maternity and IVF cycles. RA confirmed that it is mainly due to existing patients having 3 IVF cycles. SR added that there have been Information Governance issues in terms of getting access to IVF data. JJ also queried the Mental Health underspend and RA explained that it relates mainly to the contract settlement with NELFT. AMe asked if a block contract is in place with BHRUT whilst the ED process is being undertaken and RA confirmed that to be the case. SR added that the ED process is to settle 2017/18 and in addition to that there is a separate piece of work going on in regard to quantative activity. The Chair added that ED will set out the principles of the agreement and we will agree the numbers ourselves. ME reported that a further deep dive into the independent sector providers is being carried out and he will be doing the same thing with Barts Health. JJ raised concerns about the reported CHC underspend and asked for clarity. RA explained that over the last few years CHC has been a significant pressure for the CCGs and in terms of risks going forward it is a significant risk for 18/19. JJ said he would like to understand the financial risk in regard to CHC and to know what the legacy issues are. The Chair said we need to look at why CHC is underspent and requested a deep dive on CHC for the next meeting.

CSU

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The Committee noted the remainder of the report.

2.2 Update on draft accounts RA confirmed that the draft accounts were presented to the Audit & Governance (A&G) Committee on Monday 23 April in time to meet the deadline. The timescale is very tight again, with the final accounts needing to go to the A&G Committee on Tuesday 22 May and then signed off by each individual Governing Body on Thursday 24 May for submission on Friday 25 May. The Chair gave his thanks to TT and his team for all their hard work and for meeting the tight deadlines. The Chair also advised the Committee that there is a risk of an adverse audit opinion on the accounts and value for money conclusion from the auditors because the BHR CCGs’ had not met their financial targets for 2017/18 and had ongoing financial challenges. He stressed that to mitigate these risks, the CCGs would need to demonstrate that they have robust plans in place to bring the financial position of the CCGs back into balance’. 2.3 Expert Determination update

The last of the information has been submitted, we have submitted 4 of the 8 items and BHRUT has submitted the other 4. Originally there were 10 items on the list but two were removed following the first meeting. Tom Travers joined the meeting. There is a 20 working day time period and at the end of that we will receive the resolution and a set of principles. CJ added that a lot of work has been done to get to this point, we just have to wait for the outcome now. 2.4 Integrated Performance Report

SR advised that the on-going concern is BHRUT achieving the A&E 4 hour performance standard. There is a lot of scrutiny from NHSE and NHSI and a slight improvement has been seen recently. The A&E delivery board meets fortnightly and weekly reports are given to the regulators. The Trust is performing well in regard to cancer with all 8 standards being met in February. RTT is a big concern, performance in December was at 90.6% which is below the trajectory of 91%. CJ added that Havering is flagging in regard to dementia so an action plan has been put in place and there will be an expectation to improve this as quickly as possible. AMe raised his concerns about the fact that the same problems with A&E continue despite the alternative put in place. A discussion followed that included some of the reasons why people go to A&E such as patients not being able to get an appointment with their GP. The level of contact the CCGs have with colleagues in A&E was also discussed. SR reported that the A&E plan is being refreshed and gave an overview of the four stands that are being looked at. There is a lot of focus on the Trust getting the Urgent Treatment Centre (UTC) functioning efficiently and CJ added that the UTC is the immediate solution and then primary care access will be built in to support GPs. CJ asked for the A&E plan to be circulated. JJ raised his concerns about some of the practices at the Trust that he is aware of and said that he hoped that the CDs leading on this would be able to provide an update on all of the issues after their meeting this week with A&E consultants. JJ added that Ambulatory for frailty doesn’t exist in our area and that’s one of the things that will be looked at. It was agreed that the A&E issue are well recognised and the Chair added that the meeting with A&E consultants is a positive step forward. LAS activity was referred to and

SR

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TT advised that there will be opportunities at the new Joint Commissioning Committee to discuss the contract. In regard to NELFT, TT reported that data cleansing is being carried out following receipt of service line reporting (SLR) data and a report will be brought to the Committee once the process has been completed. JJ referred to how IAPT performance is deteriorating across the 3 boroughs and questioned what NELFT is doing to try to improve it. ME said this is one of the reasons why SLR data is so important. JJ also referred to the additional money put into IAPT. AMe reminded members that there is a MH clinical lead working across the 3 boroughs and CJ added that a commissioning manager is now in place who will be working with the clinical lead. The Chair suggested the new MH commissioning manager could attend a future F&D Committee meeting. AMc to agree which month with TT. JJ referred to PELC and how the contract was a financial risk last year. TT explained that the 2018/19 contract issues have been managed. The Chair requested that a finance tracker/dashboard on constitutional targets is included in the IPR reports going forward. The Chair requested two additional deep dives on mental health and LAS. The Committee noted and agreed the actions being taken. 2. 5 System Delivery Plan SR drew particular attention to 2018/19 plan included in the slide pack and explained that ME is working with the SROs on a detailed analysis and the plan is to represent the schemes showing more granular detail. ME added that the work he is doing is identifying around £17m FYE which will leave a gap of approximately £13m. CJ added that there is a huge incentive to deliver and that she is keen to link this to transformation. JJ asked for clarification on the planned care pathway scheme. ME confirmed it will be coming out and replaced as we are now in a position where we can take schemes out and put new ones in. He added that he is creating an unplanned care and planned care data pack and the plan will be refreshed accordingly. The Chair referred to the brain storming sessions involving CDs and Consultants and said they need to happen as soon as possible. CJ suggested they could be discussed at the development session that was scheduled to follow the F&D Committee meeting. The Committee noted the progress of the System delivery Plan.

TT AMc SR/CSU CSU

3.0 Financial Delivery and Performance Risk report

It was agreed that the main risks had been discussed earlier during the meeting so the Chair asked if anyone had any observations to make on the content of the register itself. CJ commented on the number of risks included and that some appear to be the same. She suggested that a piece of work needs to be carried out internally to refresh the register and the Chair agreed. The Chair also commented that the mitigating actions column makes reference to CJ in her previous role. SR said more would be done to cleanse and update the register. AA asked for an additional column to be added called ‘date last reviewed’.

SR

4.0 Deep dives / analysis

4.1 RTT backlog update

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The Committee had raised concerns about BHRUT’s RTT at the last meeting and requested a report on the backlog position which was circulated after the March meeting. Following that, a further update was requested for this meeting which KC presented. Members were informed that for week ending 1 April 2018, the backlog was primarily in ‘non-admitted’, totalling 76% and the backlog for ‘admitted’ totalled 24%. Committee members were very concerned and agreed that the Trust’s RTT performance will continue to deteriorate if the RTT backlog is not cleared. AMe questioned how the backlog in ENT could have occurred as it had been working well. KC advised that Louise Mitchell (LM), SRO for Planned Care is having those conversations with the Trust. CJ said there could be a few reasons and gave the referral criteria into the community as an example. CJ tasked the planned care group to look into all of this. Concerns were raised about the methodology that is being followed as demand continues to increase regardless of all the initiatives put in place such as the hubs. TT noted that the report did not include demand and capacity. As part of the discussion, reference was made to the recent ENT procurement and it was agreed that this would be picked up outside of the meeting. AA referred to the data cleansing work that was undertaken in regard to RTT previously and suggested the same needs to happen again but this time on the 40 week wait instead of the 52 week wait. AA said he would take all the issues raised under this item to the Planned Care Clinical Leads Programme meeting. 4.2 C&B slot issues

KC gave a verbal update explaining that a work plan has been agreed to reduce the level of Appointment Slot Issues (ASIs) which will be actioned through the E-Referral Service (ERS) working group attended by both CCG staff and BHRUT. JJ said GPs are still experiencing issues with the system and said he would like a timeframe for when the issues will be resolved. ME commented that the system as a whole, has a relatively low number of out-patient appointments that result in discharge which indicates there could be a high number of patients in the system who should have been discharged which draws capacity from the people to really need to be in the system. The Chair suggested this is included in the discussions that take place with the Trust. 4.3 Follow-up on referrals from GPs to the independent sector A follow-up report was presented to provide the Committee with additional analysis to identify specific specialities where independent sector referrals are taking place at diagnostic centres and also analysis to determine why there is activity for suture removal. The report demonstrated that audiology is by far the most significant diagnostic service provided by ‘In-health, Hornchurch Diagnostic Centre and Broad Street. The CSU will be contacting each of the providers to ask what is driving the re-referrals. In regard to suture removals, the data showed that the majority of patients that have been called in for suture removal are from the cardiology speciality. A discussion took place about patient choice and the need to take control of the referral criteria. The Chair suggested this all needs to be included in future contract negotiations.

AA AA CSU

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Ceri Jacob left the meeting. ME reported that a ‘like for like’ comparison is being carried out on the three major independent sector providers and letters will be going out to them about reducing activity. It was acknowledged that patient choice plays a big part in this. SR added that as part of the 3 year strategy, we will be working with the Trust to keep as many services in the community as possible. The Chair requested an update on this in 3 months. JJ gave his view that real transformation is about advice, guidance and using technology in the practices. GPs need to be supported to be able to have guided conversations with patients who must in turn feel confident in the opinion and expertise of their GP.

CSU

5.0 Procurement Oversight Group report

SR presented the report which advised the Committee of the progress made to date on the procurement pipeline. The three main areas of concern are: the possible risk involved in tranche 3 in terms of the resource pressure on the CCGs and CSU staff; the significant number of single tender waivers (STWs) and SR acknowledged the concerns of the Chair who is also the Audit Committee Chair, regarding the number of STWs; non Purchase Order (PO) compliance across the 3 CCGs on which more focussed work is being done to increase PO compliance. The Chair added that he has discussed the number of procurements with CJ.

6.0 Items for noting

6.1 Draft F&D Committee effectiveness review

The Committee noted the extract that will appear in the annual reports. 6.2 Procurement Oversight meeting minutes The committee noted the minutes. 6.3 BHR local Estates Forum minutes The Committee noted from the minutes that it had not been possible for decisions to be made at the February Estates meeting as it had not been quorate due to adverse weather conditions.


None.

8.0 Date of the next meeting Thursday 28 June 2018 at 10.00am – 12.00pm

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge

CCGs

From: Kash Pandya, Chair of Audit & Governance Committees

Date: 24 May 2018

Subject: Feedback from the April 2018 Audit & Governance Committee meetings

The attention of the BHR Joint Commissioning Committee (JCC) is drawn to the following key

matters considered at the BHR Audit & Governance (A&G) Committee meeting on 23 April 2018:

The Director of Delivery outlined the progress made to strengthen the CCGs procurement processes and the risks involved in achieving the planned procurements for Tranche 3 i.e. those to be completed by 31st March 2019. The Committee shared these concerns and requested a capacity plan at their July meeting to demonstrate how these procurements were to be completed as planned and, if not, the alternative mitigations being put in place. The Committee stressed that further single tender waivers to address these challenges needed to be avoided, unless there were very exceptional circumstances. The Committee also recommended that all procurements should take account of the patients’ perspective.

Subject to no new audit concerns emerging, Internal audit are proposing to issue an unqualified Head of Internal Audit Opinion for 2017/18 but with some areas requiring improvement i.e. improvements to QIPP delivery and the GP Alerts system. Internal Audit have also issued a substantial assurance for the CCGs arrangements for managing conflict of interests. The draft internal audit plan for 2018/19 was agreed in principle, subject to further discussions about potential audit work at the STP and the NEL level and jointly with BHRUT about the arrangements for the delivery of savings and transformation plans.

External audit reported that their audit was on track. The Local Counter Fraud Service (LCFS) Plan for 2018/19 was approved. The LCFS

were asked to feedback to the NHS Fraud Protection Authority that the current requirement for CCGs to satisfy themselves that providers had effective arrangements for mitigating frauds and conflict of interests was not practical and needed to be reviewed.

The Committee considered the annual accounts and reports for 2017/18 and the financial outturn position for each CCG, in particular that the expenditure for each CCG had exceeded the annual resource limit. The Committee thanked officers for having produced the annual accounts and reports for audit in a timely manner.

The Committee noted the progress made in resolving the contractual dispute with BHRUT through the Expert Determination process and the development of the operating plan for 2018/19 and required QIPP savings. The Committee asked for a report of the process being followed to ensure that all possible efforts were being made to secure the required savings.

The Committee considered its annual report for 2017/18 and feedback on the review of its effectiveness. The report was agreed and also action to implement the learning from the effectiveness review.

The 2018/19 annual workplan of the Committee was circulated to members for consideration and comment.

Kash Pandya Audit Chair, BHR CCGs 14th May 2018

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Draft Minutes BHR Audit Committee 23 April 2018 v1

DRAFT Minutes of the Joint Barking & Dagenham, Havering and Redbridge CCGs

Audit &Governance Committee held on 23 April 2018 9.30-12.00

Present –Members

Kash Pandya (KP) BHR audit chair, lay member for Audit & Governance

Khalil Ali (KA) Lay member PPI Redbridge CCG

Charles Beaumont (CBe) BHR co-opted member for Audit & Governance

Sahdia Warraich (SW) Lay member PPI Barking & Dagenham

In attendance-Officers

Tom Travers (TT) BHR chief financial officer

Rob Adcock (RA) BHR deputy chief financial officer

Steve Rubery (SR) for item 19/18

Director of Delivery and Performance

Marie Price (MP) BHR directorate corporate service

Anne-Marie Keliris (AMK) BHR company secretary

In attendance-auditors

Neil Thomas (NT) External auditor, KPMG

Satinder Jas (SJ) External auditor, KPMG

Richard Hewes (RH) Internal auditor, RSM

John Elbake (JE) Internal auditors , RSM

Charlie Nicholl (CN) LCFS (RSM)

Apologies

Richard Coleman (RC) Lay Member PPI Havering CCG

Nick Atkinson (NA) Internal auditors, RSM

Action

9.00- 9.30

Committee Members held a short private meeting and then held a brief meeting

with internal audit and LCFS leads from RSM.

15/18 Welcome and Apologies for absence Apologies for absence were received from Nick Atkinson and Richard Coleman.

16/18 Declaration of Interests (DOI)

No further declarations of interests were declared other than those on the three registers presented.

17/18 Minutes of meeting held on 13 February 2018

The minutes of the previous meeting were agreed subject to minor typographical error on page 4 and change of Richard Hewes organisation to external audit in the attendance list. These would be signed by the Chair as a correct record.

18/18 Matters Arising

34.5.1 Complaints Policy - A survey will be undertaken before the end of 2018/19. Action open

MP

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37.1 IG Steering Group – AMK agreed to follow up meeting dates. Action open Risk management for governing body members will be included in action log, Action open.

AMK AMK

19/18 Directorate Risk Briefing

SR attended to outline the key risks facing the delivery and performance directorate and to report on the work of procurement oversight group (POG). The Chair questioned who POG is accountable to. SR confirmed that POG reports to the finance and delivery committee. SW requested clarity on the difference between the number of purchase orders (POs) for each CCG.. SR reported that all corporate expenditure is channelled through Redbridge CCG therefore they have the highest number of POs. SW questioned the level of involvement of patients in the procurement process as she was unaware of what procurements are coming up. MP reported that the procurement policy includes patient engagement and will review how to circulate information and how we include patients in the procurement process. KA referred to single tender waivers and how further improvements can be made. He also referred to patient engagement as there are a number of willing volunteers and suggested it would be useful to have a programme to support individual involvement in procurements. MP agreed to meet with SW/KA/RC to discuss this further. The Chair referred to tranche 3 and the associated risks. He suggested a review of capacity and if there is a shortfall this will need to be presented to the finance and delivery committee for their view. The Chair reported that any requests for single tender waivers that are more than a year should be presented to the committee for discussion and approval. The Chair requested that a report on tranche 3 procurements is presented to FRPB in May 2018. The Chair questioned where procurement of care homes is reviewed. SR confirmed that CSU manage non clinical procurement and acknowledged that all procurements should be under one structure and was currently reviewing this. SR agreed to review why care home procurements were not included within the report. KA highlighted the importance of planning the urgent care procurement to ensure that the contract is not extended again through a single tender waiver. The committee noted: • the progress made to date on the procurement pipeline; • the risk assessment of Tranche 1 & 2 & 3 pipeline; • the forecasted position relating to STWs required; • the number of procurements in Tranche 1 & 2 RAG rated as “Amber” and “Red” have been reduced following actions by the responsible SROs and should further risks be identified following further scoping of Tranche 3, these

MP MP SR SR SR

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will be escalated to the responsible SROs who will report back to the next POG on the mitigations they have put in place. The committee agreed the following:

FRPB would receive a report on resourcing needs for procurement in particular for tranche 3

A review of patient engagement in procurements with lay members

Supported the approach to purchase orders

Review the management structure for clinical and non-clinical procurements

Ensure planning of the urgent care procurement is timely to avoid a further contract extension.

The Chair requested an update report on GP alerts for the meeting in July.

SR

20/18 Internal Audit

20.1 BHR progress report

JE presented the internal audit report which covered the following:

CCG Internal Audit Progress Report-Conflicts of Interest (7.17/18) – substantial assurance.

Work in Progress - Procurement and Contract Registers

Follow up of management actions

CSU Quality Assurance Progress Report

2017/18 Draft Head of Internal audit opinions

Planning for Internal Audit plan 2018/19 and three-year strategy 2018 – 2021 The Chair congratulated RSM on their reappointment. The Chair welcomed the progress report and was pleased to note the substantial assurance of the conflict of interest review. The Chair requested the specifications for the procurement and contract registers audit. SW expressed concern that some staff feel disengaged with the STP and questioned whether any concerns were raised through staff surveys. MP agreed to explore how to review this and suggested that the quality and safety committee might be the right forum. The Chair also agreed to raise with audit chairs at provider trusts. 20.2 NELCSU Quality Assurance Plan Progress Report

The Chair welcomed the report and highlighted the need to review the plan for 2019/20 to see how this will work across 12 CCGs. The Chair questioned whether there were any lessons to be learnt from the continuing health care review. It was noted that Sharon Morrow would be able to share these.

JE MP KP SM

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The Chair reported that all CCG audit chairs were concerned about the future of Capita. The committee noted the report. 20.3 Draft internal audit strategy 2018-21 incorporating 18/19 plan

TT reported that he would provide comment and feedback from the committee to include in the redraft to be presented at the May meeting. KA commented that the framework was good and suggested linking audit opportunities to objectives. He added that despite the financial problems there are an increasing number of interventions and it is not clear what has been achieved over the last five years. The Chair commented that the annual report does give a view on achievements but we could consider if a stock take should be undertaken. The Chair agreed to review this with Ceri Jacob. MP reported that the corporate objectives had been updated and would share these with JE. The Chair commented that the strategy covers the broad areas expected. He suggested that governance issues with NEL need to be explored. The Chair also commented that he would like to see how joint PMO arrangements are working and will be discussing this with the BHRUT Chair. The Chair suggested that PMS may need a rigorous audit in 18/19.to accord with new draft NHSE guidelines. It was also noted that scale of the procurement pipeline will need to be monitored along with GP alerts. KA commented that it would be helpful to review any BHRUT audits on service improvement plans. The Chair reported that he was meeting with the BHRUT Chair to discuss this along with how QIPP and CIPs will be achieved. NT commented that it is difficult for auditors to work across commissioner and provider and will require a collaborative approach. The committee noted the draft plan. 20.4 BHR HoIAOs - update on changes

JE presented the BHR HoIAOs which is subject to change. It was noted that there had been no material change since the last meeting. The committee noted the update.

KP AMK

21/18 External Audit

21.1 Update on accounts review NT updated members on the accounts review. He reported that there had been good progress on the primary care audit and there is still a need to understand the outturn position with BHRUT. KA questioned whether reporting from BHRUT had been resolved. TT reported that the CCG accounts include our view of the contract position. He added that the national exercise around consolidation is awaited.

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The Chair commented that early discussions in 18/19 were critical to avoid a similar situation next year. CB questioned whether the CCG largely agree with the Trust subject to dispute items. TT reported that there is £14m disputed. The committee noted the update.

22/18 LCFS

22.1 18/19 draft work plan

CN presented the 18/19 draft LCFS work plan. KA welcomed the comprehensive work plan and suggested that the LCFS annual report includes effectiveness of the fraud and bribery awareness sessions. He also suggested that members committees and learning events could be used as an opportunity for raising awareness. MP/CN to discuss. The Chair welcomed the plan but requested that the self-assessment review completed by the LCFS should be circulated to the Committee as an urgent priority. CN said he would do so and would include its findings in the annual LCFS report. The Chair commented that he would like to feedback to the NHSE counter fraud team a requirement that CCGs should comment on the effectiveness of provider conflicts of interests arrangements was not practical and CN agreed to raise this concern with NHS Protect. The committee noted the draft work plan. 22.2 Three year case summary

CN presented the three year case summary. The Chair welcomed the helpful summary and requested that an outcome of each case in included to ensure that appropriate follow up had taken place for each case. MP/CN agreed to discuss the best way to achieve this. The committee noted the summary.

MP/CN CN MP/CN

23/18 Governance

23.1. Draft Audit Committee Review of Effectiveness

The committee noted the audit committee review of effectiveness and agreed to include opportunities for learning. 23.2 Draft Annual Reports - for each CCG

MP presented the draft annual reports for review and comment. SW questioned why attendance at meetings had changed from a percentage figure. MP reported that due to changes in committee membership it was felt that the proposed format would reflect these changes. The committee noted the draft annual reports and agreed to provide comment and feedback by 2 May 2018.

All

24/18 Finance

24.1 Risk overview report

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TT reported that the 17/18 expert determination is expected to conclude in June and will not assign a financial value, therefore it is expected that regulatory intervention will be required. It was noted that 18/19 block contract arrangements are in place to cover Q1 with BHRUT while expert determination concludes and contract negotiations continue. CB referred to risk share on finance and questioned whether there will be controls on quality. TT confirmed that quality needs to be included. The committee noted the report. 24.2 Draft Annual Accounts – for each CCG

TT thanked the finance team for their work to produce the draft annual accounts. Members will review and give feedback by 2 May 2018. An updated version of the accounts would be emailed to members following the meeting. 24.3 Single Tender Waivers

The committee noted the following single tender waivers:

Waiver for Finevalley Communications Ltd / GP Practice infrastructure

GP access hub and Loxford contracts 2018/19

Community anticoagulation (warfarin) service

Redbridge Community Glaucoma Service and Havering Community Ophthalmology Service

SW expressed concern that patents were unaware that the Loxford clinic was open. TT agreed to review this and feedback. The Chair commented that the increasing number of appointments being offered needs to be recorded when requesting single tender waivers. RA confirmed that this modelling is part of the process in place.

TT

25/18 Any Other Business

25.1 Audit committee annual work plan

The Chair agreed to circulate the annual work plan following the meeting. AMK

26/18 Items for information

26.1 NAO briefing and newsletter – The committee noted the briefing and

newsletter.

27/18 Key Messages for GB

The key message will be provided at the next meeting.

28/18 Date of Next Meeting

22 May 2018 (Sign off of Annual Reports/Accounts pre GB meeting)

Signed………………………………………………..Date………………………….

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DRAFT Q&S Committee Minutes 3 April 2018 v3 final 1

DRAFT Minutes of the BHR CCGs Quality & Safety Committee – Part 1

Tuesday 3rd April 2018 at Becketts House 1.30 – 3.30pm Members:

Ah Fee Chan (AFC), Secondary Care Consultant Steve Rubery (SR), Director of Delivery & Performance Jacqui Himbury (JH), Nurse Director Dr S Heyes (SH), Clinical Director Dr A Bhatia (AB), Clinical Director Dr K Rai (KR), Clinical Director Sahdia Warraich (SW), Lay Member Attendees: Kate Byrne (KB), Designated Safeguarding Children & LAC Nurse, BHR CCGs Sue Nichols (SN), Designated Safeguarding Children & LAC Nurse, BHR CCGs Anna Bjorkstrand (ABj), Quality Manager, BHR CCGs Belinda Krishek (BK), Chief Pharmacist, BHR CCGs Keeley Chaplin (KC), Business Manager, BHR CCGs Apologies

Mark Gilbey-Cross (MGC), Designated Adult Safeguarding Manager, BHR CCGs Dr R Hara (RH), Clinical Director

Action

1.0 Welcome and apologies

The Chair welcomed everyone to the meeting. Apologies were noted as above.

1.1. Declarations of interests

The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of BHR CCGs. No additional declarations of interest were declared. The register of interests held for BHR CCGs Governing Body (GB) members and staff is available from the Company Secretary.

1.2. Minutes of the last meeting

The minutes of the meeting held on 27 February 2018 were agreed.

1.3. Matters Arising Action Log

The action log was noted, with the additional comments: 8.2 Ms A Safeguarding Adult Review

SH advised the provision for adolescent children is poor and asked if NELFT have feedback what they are doing. Patients are sent back to primary care and children can wait 9 months for an appointment, schools provision is reduced and advise to send them to their GP and when they are referred to NELFT are often rejected for not meeting the criteria. JH advised that CAMHS investment is part of the contract negotiations. The NELFT performance data does not highlight any issues, only be exception. KR added there is also an issue with children near to turning 18 are not

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Action

accepted by CAMHS and told to refer to adult services. JH asked all to keep reporting these issues on the GP alert system and will invite Sharon Morrow to the meeting. AFC said the Committee will need to seek assurance on referrals and access into the service.

JH

2.0 Meadow Court Nursing Home Mortality Review

JH presented the mortality review of Meadow Court Nursing Home in Goodmayes. In November 2017 the CCG agreed to end the contract with Care UK for this home. Two patients had died following their move out of the care home and a review to identify if there was any correlation between the transfer of two residences and their subsequent deaths was undertaken. Since the contract ended a further patient has died, and the designated adult safeguarding manager is conducting a review into this too. The Committee noted the briefing and that a final report will be presented to the June Quality & Safety Committee.

3.0 Safeguarding Section

3.1. Organised and Complex Abuse (Child Sexual Exploitation and Gang Related Activity)

In November the Barking & Dagenham MASE meeting highlighted a young person in Dagenham disclosed child sexual exploitation (CSE) and harmful sexual behaviours in a letter to the school indicating the involvement of a number of young people. 52 young people have been identified to date as being at risk of CSE with most attending Barking and Dagenham schools. The establishment of a strategic management group chaired by the Deputy Chief Executive of LBBD and an Investigation Management Group have been arranged. The investigation is ongoing and this is a complex and fairly unique situation as the children are potential victims and perpetrators. The Committee noted the content of the report and would like to receive further updates as the investigation progresses.

3.2. Redbridge Serious Case Review briefing

In October 2017 the death of a baby was reviewed at a Rapid Response Meeting and the nature of the injury was thought to be consistent with shaken baby syndrome. The child was in the care of the mother’s friend who was subsequently arrested and their own child removed from her care into the care of the local authority. A pre SCR meeting was held on 14 March 2018 and the independent chair will write to Ofsted to advise that a SCR will be undertaken. This will be in parallel to the police investigation. The Committee noted the contents of the report and assured that representatives of Redbridge CCG are actively participating in the SCR process and noted a further update will be given following the publication of the SCR report.

4.0 AABIT Action Plan

The NELFT Access, Assessment and Brief Intervention Team (AABIT) Suicide Cases Thematic Review Action Plan was presented to the Committee. This was produced following the high number of serious

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Action

incidents of unexpected deaths in NELFT. A number of actions have been achieved and CQRM have been assured the plan will deliver what was asked and decrease the number of deaths. SH and AB had noticed a difference in primary care to the level of service received. The Committee noted the report and accepted assurances that the action plan continues to be monitored via the CQRM process. If the situation changes a further report will be brought back.

5.0 Review of Effectiveness Quality & Safety for Annual Report

The committee noted the draft that is being prepared for submission into the Annual Report 2017/18.


6.1. Barts RTT SH said it would be useful to receive RTT information and see how it relates to quality. This will be added to the agenda.

JH/KC

6.2. Discharge summaries AFC asked if the discharge summaries are now being received by practices. CDs advised that some of the summaries received do not have enough detailed information. KR will send an example to JH.

KR/JH

7.0 Items for information

7.1. PELC CQRM minutes

The minutes of the meeting held on 22 February 2018 were noted.

7.2. BHRUT CQRM minutes The minutes of the meeting held on 12 February 2018 were noted.

7.3. BHRUT Maternity CQRM Minutes

The draft minutes of the meeting held on 8 March 2018 were noted.

7.4. NELFT CQRM minutes The draft minutes of the meeting held on 21 February 2018 were noted.

7.5. WX CQRM minutes

The minutes of the meeting held on 15 February 2018 were noted.

7.6. Q&SC draft forward plan The forward planner was duly noted.

8.0 Future Meeting Dates

Noted meeting dates arranged for year 2018/19: Tuesdays at 1pm. 19 June,14 August, 9 October, 11 December, 12 February An additional date in May will be arranged if required

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1

Barking and Dagenham Patient Engagement Forum 23 March 2018 Maritime House, Barking

Attendees

David Elliott Ken Humphries Dorothy Stokes Mary Parish Nicholas Hurst Manisha Modhvadia (Healthwatch representative) John Craig (Care City representative)

CCG staff in attendance

Zoe Anderson Sam Brooker

Apologies

Ron Wright Sahdia Warraich (lay member) Youth forum Natalie Keefe (CCG) Val Shaw Miriam Greenwood Jacqui McLeod

Items

1. Introduction

Nicholas discussed his concerns over the new arrangements for the PEF.

Group reminded the CCG representatives that one PEF member doesn’t have email

Action: Zoe Anderson to call Val Stokes re PEF dates and advise Nicholas when actioned.

2. General NHS update

Zoe Anderson presented on general NHS updates. This included changes to the Managing Director at the CCGs, and the continued financial challenge faced by the CCGs. Zoe set out new NHS arrangements including the role of North East London (NEL) Commissioning Alliance and their Joint Commissioning Committee. She will share the papers and details of their first meeting with the group.

Zoe provided information on a new Citizens’ Panel which is being set up by the East London Health and Care Partnership (NEL STP) across NEL and confirmed that engagement with the panel will be primarily online, but it is expected members would also be invited to focus groups, workshops or events.

Updates on the local health providers were provided, and the challenge faced across the health system during winter. She confirmed that ELHCP would provide updates on King George Hospital’s A&E work when relevant.

3. Online GP consultations

Sam Brooker presented on the CCGs’ plans for online GP consultations. She set out that BHR CCGs had received funding to commission services for people to be able to access their GP online, and the CCGs were looking into the best way to do this.

Sam confirmed that the service would be optional, and was aimed at patients who use the internet and can feel too busy to visit their GP. The service aims to free up more appointments for those with complex or more urgent needs.

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2

The group provided their views on the service and areas for the CCG to consider when commissioning, or practices in delivering. This included suggesting training people so they were confident to deliver, how to triage, how to access website, and how practices would respond to patients. Healthwatch commented that from their recent engagement with the public many people said they would be interested in such a service, although the group felt older people would be less likely to use it.

Action: on agenda for future meeting

4. Care City update

John Craig presented on Care City, describing the organisation as an innovation partner for local health and social care services. Its aim is to build the area into a centre of excellence by attracting people, resources and innovation.

He provided an example of their pilot introducing new technology which made it quicker and easier to identify heart conditions, and reduced the time taken to speak to a consultant. He expressed an aim for the organisation to improve its engagement with patients, working with their partner UScreates.

Projects they are working on include:

Carers education

Community health service efficiencies

Healthy new towns - Barking Riverside

Health and care recruitment and retention

NHS England test bed.

John Craig, Chief Executive – [email protected], 0300 555 1201.

5. CCG Lay member’s report

This item was not discussed as the lay member was unable to attend the meeting.

6. Healthwatch report

Manisha Modhvadia provided a verbal update. Healthwatch are soon publishing a report on the public’s views on their service. A link to the report will be circulated to the group. As a result of the findings Healthwatch will be undertaking more engagement with the public and has already started this.

Healthwatch is planning their workplan for 2018/19 and asked for suggestions on areas to focus on. It will be recruiting 17 champions to provide advice, signposting and engagement with local people.

7. Youth Forum update

This item was not discussed as the youth forum representatives were unable to attend the meeting.

8. AOB

Possible items for future meetings:

Youth forum presentation and video (as unable to attend March meeting)

BHR CCG finances update

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mailto:[email protected]

3

Online GP consultations project

Meet new CCG chair (if new chair elected)

Information from BHRUT on its IT systems – Dave Elliott to advise on specifics of what this item should cover.

No other AOB.

9. Next meeting

Next joint PEF meeting – Tuesday 22 May 2018, 6pm at Becketts House in Ilford.

Agenda items:

Ceri Jacobs, Managing Director for BHR CCGs

Community urgent care review

Next B&D PEF meeting - The group suggested mid-June for their next meeting.

Action log

Action Lead

Phone Val following meeting, and ensure she is contacted ahead of each meeting

ZA

CCG to provide update on latest financial position at next B&D PEF ZA

Share the papers for and date of NEL Commissioning Alliance first Joint Commissioning Committee

ZA

Provide an update on the ELHCP Citizens’ Panel when it has progressed further

ZA

CCG to share examples/feedback from other areas which have online GP service

NK

CCG to update on online GP consultations when the project has progressed

NK

Healthwatch to share its annual survey results MM

Identify someone from BHRUT to present on IT systems at Queen’s and any plans for better system integration.

DE/All

Identify date for next B&D PEF and advise members AS

215

Havering PEF: 21 March 2018

Action Lead

Ceri Jacob, the new Managing Director of BHR CCGs, to attend the Joint PEF in May

Ceri Jacob

Update PEF members, as able, on the progress of the frailty service being delivered by providers

AS

Update PEF members, as able, on the progress of the NEL Citizen’s Panel

AS

Share Healthwatch report on urgent and emergency care engagement with PEF members, once available

AS

Contact Care UK re: concerns over lack of refreshments/treatment of patients waiting for appointments at their care centre

AS

Share contact details of the GP hubs with PEF members

AS

Contact BHRUT re: possibility of establishing a “drunk bus” in Romford town centre

AS

Contact Havering Volunteer Centre re: possibility of volunteers accompanying vulnerable patients traveling into central London for treatment

AS

PEF members to volunteer themselves or someone else for the position of Chair

PEF members

Date for the next Havering PEF to be confirmed AS

Future meetings:

Next Joint PEF to be held at Becketts House in Ilford on 22 May

Possible iItems for future meetings:

o Mental health update (adults and children)

o Medicines wastage

216

Redbridge Patient Engagement Forum (PEF) Tuesday 13 March 2018 Becketts House, Ilford

Attendees Lorraine Silver, Chair Vivien Nathan, Vice-Chair Khalil Ali, Lay member Howard Clarke-Melville David Lyon Dee Datta David Hall Stuart Bellwood Naina Thaker Raina Gee Swati Vyas Kishan Sharma

CCG staff in attendance Marie Price Lima Khanom Natalie Keefe

Apologies

Harjit Sangha

Filiz Zaman

Agenda items

2. Minutes, PEF log and matters arising.

Minutes - Some members raised issues with not being able to print minutes. Action:

Andy Strickland to send future meeting papers as PDFs. Matters arising – member raised an issue that was covered as an agenda item in the last

meeting, and requested information that had previously been provided to members. A

member also requested to add mental health on the agenda for the next meeting, as this is

an area of interest for them.

Action:

CCG to recirculate Meadow Court consultation document/ and all care homes to

members by email.

Andy Strickland at the request of a member to put mental health on the next

meeting’s agenda.

3. NHS update

Marie Price presented updates on BHR CCGs. This included recent changes to the Managing Director of the CCGs, with Conor Burke moving on, and the new Managing Director will be Ceri Jacobs who begins her role on 1 April. Ceri previously worked at NHS England and will attend a future PEF meeting.

4. Online GP consultation

Natalie Keefe from the CCG primary care team presented on implementing the General Practice Forward View, and how NHS England have allocated £45million to support more GP practices with providing online GP consultations. The presentation talked about how BHR CCGs were planning to provide this service, getting the public’s views on how it could

217

work, working with local GP practices to offer consultations by email/online, for those who would find it useful or didn’t have time to come into the practice. Action: Andy Strickland to circulate a survey with questions to capture views about GP

online consultation from members.

5. CCG Lay members report

Khalil Ali updated members on patient engagement in Redbridge. Action: Marie/Lorraine to invite two GPs leading each locality to a future PEF meeting.

6. Healthwatch update (engagement on urgent and emergency care) Healthwatch provided an overview on work they did with BHR CCGs on urgent care. They reached out and spoke to 4,000 people about urgent care services locally back in 2016. This research is being used to scope options for how community urgent services could work in BHR. Action: CCG to present about proposals on the future of community urgent care services at the next meeting.

7. Virtual groups for PEF members to ‘meet’

Marie Price presented a paper on future PEF meeting options. The paper outlined potential

options for an online forum in addition to the current face to face meetings. The online forum

would provide another way for members to raise and discuss topics in between scheduled

meetings with the CCG.

Action: Members to review the online forum paper and let the CCG know if they would like

to proceed with any of the options.

8. AOB - including tabled items and local issues: King George Hospital land, Whipps Cross stakeholder event

Youth Council representatives updated members on their work.

CCG provided a handout with an update on King George Hospital land and Whipps Cross.

Member raised confusion over GP referral advice and guidance.

Action: Swati Vyas to circulate the Whipps cross update.

Action: Andy Strickland to circulate more information on GP referral advice and guidance to

members.

9. Close and date of the next meeting Next joint PEF meeting: Tuesday 22 May 2018 Action log

218

Action Lead

Send future meeting papers as PDFs (members raised issue with

printing)

Andy Strickland

In regards to Meadow Court, members asked for the list of all care

homes by email. CCG to recirculate consultation document to

members

Andy Strickland

Request to put mental health on the next meeting’s agenda

Andy Strickland

Feedback to GP online consultation – circulate a survey with

questions to capture views from members

Andy Strickland

View to invite two GPs leading each locality to a future PEF meeting

Marie/Lorraine

Members to review the online forum paper and come back to CCG if

they require support

PEF members

Whipps cross update to be circulated

Swati Vyas

More information on GP referral advice and guidance to be circulated

to members to clear up confusion

Andy Strickland

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Part 1

Minutes of the Primary Care Commissioning Committee (a Committee in Common)

held on 14 February 2018 at Becketts House Present: B&D CCG Havering CGG Redbridge CCG

Sahdia Warraich, Lay Member (SW)

Richard Coleman, Chair & Lay Member (RC)

Khalil Ali, Vice Chair & Lay Member (KA)

Kash Pandya, Lay Member (KP)



Sarah See, Director, Primary Care (SS)



Arnold Fertig, Independent GP (AF)



Conor Burke, Interim Managing Director (CB)



Dr Gurkirit Kalkat, Clinical Director (GK)

Dr Alex Tran, Clinical Director (AT)

Dr Shabana Ali, Clinical Director (SA)

Dr Adedayo Adedeji, GP (AAd)

In attendance: Natalie Keefe (NK) Head of Primary Care Transformation, BHR CCGs Terilla Bernard (TB) LMC, Barking, Dagenham and Havering Dr Anil Mehta (AM) Chair, Redbridge CCG Dr Atul Aggarwal (AAg) Chair, Havering CCG Rob Dickenson (RD) Finance, BHR CCGs (for Tom Travers) Mark Gilbey-Cross (MGC) Designated adult safeguarding nurse, BHR CCGs (for Jacqui

Himbury) Anne-Marie Dean (AMD) Chair, Havering Healthwatch Cathy Turland (CT) Chief Executive, Healthwatch Redbridge Dr Andrew Rixom (AR) Public Health Consultant, London Borough of Havering Gladys Xavier (GX) Interim Director of Public Health, London Borough of Redbridge Tony Curtis (TC) Senior Primary Care Commissioning Manager, NHSE Gohar Choudhury (GC) Assistant Head of Primary Care, NHSE Keeley Chaplin (KC) Business Manager, BHR CCGs (Minute taker) Apologies: Dr David Derby (DD) GP, Havering CCG Dr Waseem Mohi (WM) Chair, Barking & Dagenham CCG Jacqui Himbury (JH) Nurse Director, BHR CCGs Tom Travers (TT) Chief Finance Officer, BHR CCGs Dr Shabnam Ali (SAli) GP, Redbridge CCG Matthew Cole (MC) Director of Public Health, London Borough of Barking &

Dagenham Cllr Wendy Brice-Chambers (WBC)

Councillor, London Borough of Havering

Manisha Madhvadia (MM) Chief Officer, Barking & Dagenham Healthwatch Dr Ambrish Shah LMC, Redbridge Alison Goodlad Head of Primary Care, NHSE

Draft PCC Minutes 14 February 2018 v3 Page 1 of 4 220

Item Action 1. Welcome and apologies The Chair welcomed those present and apologies for absence from those

listed above were noted.

2. Declarations of conflicts of interest The Chair reminded members of their obligation to declare any interest they

may have on any issues arising at the meeting which might conflict with the business of the primary care committee and clinical commissioning group. Declarations declared by members are listed in the CCG’s Register of Interests. The Register is available via the secretary to the Committee.

3. Minutes, action log and risk register 3.1

The minutes of the meeting held on 13 December 2017 were agreed as a correct record subject to removing Mark Gilbey-Cross as an attendee.

KC

3.2 The Committee noted the actions that had been taken since the last meeting. In addition, members noted the following update: ACT84 Five Elms – the CQC inspection report was published in December. NHSE and the primary care team have given support to the practice however there are still concerns regarding leadership; a follow up inspection will take place to review developments.

3.3 SW noted that NHS Property Services are increasing their service charges at one of the health centres in Redbridge, which could increase a practice’s rent by 20% and asked if this increase can be mitigated. SS advised there is new guidance from NHSE on what commissioners can do and the team will review these and feedback to SW. The Committee approved the risk register.

NK/RD

4. Budget update RD gave an overview of the primary care budgets for 2017/18 financial year.

The forecasts show an underspend of £50k for Havering CCG, an underspend of £1.6m in Redbridge CCG and Barking & Dagenham CCG is forecast to breakeven. Month 10 data is estimated as the reports have not yet been received from NHSE. It was noted that B&D have received a rates reduction from the local authority. RD responded to a question by GX stating that no information had been forthcoming that Havering and Redbridge were to receive rates reductions themselves but the CCG was pursuing this line of enquiry. Members asked if the underspend is carried forward into 2018/19. SS advised that as long projects or schemes, approved through the established governance process, had commenced and/or was being pump primed in 2017/18, the associated costs could be accrued. However, any budget not allocated to an approved scheme is not carried forward into 2018/19. SS confirmed that business cases are still in development for 2017/18. The Committee noted the content of the report and the level of financial risk to be reported on in future months.


5. Barking & Dagenham, Havering and Redbridge Primary Care


5.1 NHS England and Newham CCG Memorandum of Understanding A memorandum of understanding (MoU) relating to the geographical

assignment of NHSE London region’s primary care commissioning staff has been signed by Newham and NHSE London. As the lead CCG, Newham CCG will accommodate 18 staff on behalf of all seven CCGs in the STP. Costs associated are being worked through however, an estimate has been included in the budget. Newham CCG now needs to develop a MoU between itself and the other NEL CCGs, to reflect and administer the arrangements between itself and NHSE London. AAg requested that the costs associated are split proportionate to the population and not split between the number of CCGs. The BHR Primary Care Commissioning Committee noted the Memorandum of Understanding, and will await receipt of the draft Newham CCG/NEL CCG MoU.

SS

6. Barking & Dagenham, Havering and Redbridge Primary Care Commissioning Committee

6.1 Online Consultations NHSE have made funding available to BHR CCGs of £200k to help

progress GP online consultations; this will enable patients to conduct clinical consultations with their GP practice online. Each CCG will also receive indicative amounts for two additional years until 2019/20. A joint procurement will be undertaken across NEL with Waltham Forest taking the lead. AF asked if the shortlisted providers will be acceptable to local practices. NK advised a procurement panel has been set up which includes GPs, practice managers and patient engagement members from across each of the BHR CCGs. If agreed, it is hoped to complete procurement by end March. The funding will not cover all practices therefore expressions of interest will be requested. The BHR Primary Care Commissioning Committee: • Agreed to proceed to a formal NEL procurement using the National NHS

Procurement Hub for purchasing a product to enable online consultations in primary care across BHR.

• Agreed that the outcome of the procurement will be reported back to the Primary Care Commissioning Committee but that progress on the pilot will be reported back to the Primary Care Transformation Board along with the evaluation near the end of year 1.

NK

7. Redbridge Primary Care Commissioning Committee 7.1 Elmhurst Practice – change of practice boundary application The Elmhurst Practice has made application to reduce its current practice

area to within the Borough boundaries from 1 March 2018. The main purpose for this request is so that the practice can focus its efforts on patients within Redbridge. Registered patients outside of this boundary will not be deregistered. The Redbridge Primary Care Commissioning Committee: • Approved the application for Elmhurst Practice to reduce its current

practice catchment area to within the Redbridge borough boundary, with


the proviso that no mass removals can take place, and • Noted that neighbouring CCGs been advised on the changes to the

practice’s catchment area.

7.2 Dr Paul’s resignation Dr Eric Paul has submitted his notice to resign with effect from 31 May

2018, meaning that the primary medical services contract will come to an end. The practice currently provides its services from a health centre, which is owned by NHS Property Services in Seven Kings. This single-handed practice has a list size of c1800 and there is capacity in surrounding seven practices to take these patients. The patients will be given the list of practices to choose from but if they have not done so after a set date, patients will be allocated to one of these practices (although patients will still have the choice to register with another practice, if they reside within its catchment area). Notices will be put up in the waiting room and added to repeat prescriptions and these patients will be written to twice advising them of the process to register. The practice has been asked to identify vulnerable patients. Patients will be given three-months’ notice. The Redbridge Primary Care Commissioning Committee: • Approved the dispersal of Dr Paul’s Surgery patient list, and • Agreed to patient engagement events and stakeholder events to support

this transition.

8. Questions from the public There were no questions from the public.

9. Any other business The chair thanked Conor Burke for his hard work and commitment to

delegated primary care commissioning for BHR CCGs as he as he will be leaving the organisation in March 2018.

10. Dates of the next meeting Scheduled for 14 March 2018 & 14 April 2018 however, to be confirmed due

to conflicts with the newly established meeting within the NEL corporate calendar.

Signed………………………………………………..Date………………………….


Part 1

Minutes of the Primary Care Commissioning Committee (a Committee in Common)

held on 4 April 2018 at Becketts House Present: B&D CCG Havering CGG Redbridge CCG

Sahdia Warraich, Lay Member (SW)

Richard Coleman, Chair & Lay Member (RC)

Khalil Ali, Vice Chair & Lay Member (KA)

Ceri Jacob (CJ), Managing Director









Jacqui Himbury (JH) Nurse Director



Tom Travers (TT), Chief Finance Officer



Dr David Derby (DD), GP Dr Shabnam Ali (SAli), GP In attendance: Natalie Keefe (NK) Head of Primary Care Transformation, BHR CCGs Terilla Bernard (TB) LMC, Barking, Dagenham and Havering Alison Goodlad (AG) Head of Primary Care, NHSE Greg Cairns (GCa) Director of Primary Care Strategy, London wide LMC Gohar Choudhury (GC) Assistant Head of Primary Care, NHSE Keeley Chaplin (KC) Business Manager, BHR CCGs (Minute taker) Manisha Madhvadia (MM) Chief Officer, Barking & Dagenham Healthwatch Apologies: Kash Pandya (KP) Lay Member, BHR CCGs Dr Anil Mehta (AM) Chair, Redbridge CCG Dr Atul Aggarwal (AAg) Chair, Havering CCG Dr Jagan John (JJ) Chair, Barking & Dagenham CCG Dr Alex Tran, (AT) Clinical Director, Havering CCG Dr Adedayo Adedeji (AAd) GP, Barking & Dagenham CCG Dr Shabana Ali (SA) Clinical Director, Redbridge CCG Matthew Cole (MC) Director of Public Health, London Borough of Barking &

Dagenham Cllr Wendy Brice-Chambers (WBC)

Councillor, London Borough of Havering

Dr Ambrish Shah Redbridge LMC Dr Gurkirit Kalkat, (GK) Clinical Director, Barking & Dagenham CCG Anne-Marie Dean (AMD) Chair, Havering Healthwatch Cathy Turland (CT) Chief Executive, Healthwatch Redbridge Dr Andrew Rixom (AR) Public Health Consultant, London Borough of Havering Gladys Xavier (GX) Interim Director of Public Health, London Borough of

Redbridge Ah-fee Chan (AFC) Secondary Care Consultant, Redbridge CCG

Draft PCC Minutes 4 April 2018 final Page 1 of 4 224

Item Action 1. Welcome and apologies The Chair welcomed those present and apologies were noted.

2. Declarations of conflicts of interest The Chair reminded members of their obligation to declare any interest

they may have on any issues arising at the meeting which might conflict with the business of the primary care committee and clinical commissioning group. No additional declarations of interest were declared. Declarations declared by members are listed in the CCG’s Register of Interests. The Register is available via the secretary to the Committee.

3. Minutes, action log and risk register 3.1

The minutes of the meeting held on 14 February 2018 were agreed as a correct record with the exception of item 5.1, paragraph 1 amend ‘lead CCG’ to ‘host CCG’.

3.2 The Committee noted the actions that had been taken since the last meeting. In addition, members noted the following update: ACT72 – work on QOF targets is progressing but not yet finalised therefore it will be presented to the June meeting. ACT89 - NEL localised QOF; BHR will be part of any NEL group established (membership to include LMCs) to review a localised QOF, therefore ensuring a consistent approach across NEL. An update on this item will be brought back to the PCCC for further discussion at a later date. ACT94 – Property Services increase in service charges; the CCG Estates Manager is leading on this for BHR CCGs and seeking advice on how the CCG can support the practices with potential increased charges. This will be part of a NEL approach. ACT94 – GP online consultations; the procurement process for BHR and Waltham Forest CCGs has completed, the panel included a local GP and Practice Manager.

AF/GC SS SS/Carolyn Botfield

3.3 The Committee noted and approved the risk register.

4. Budget update TT advised work is ongoing on a number of schemes being delivered

during months 11 and 12. The outcome of this will be presented in the month 12 report which will be brought back to the Primary Care Commissioning Committee. Members noted the verbal update.

TT


5. Barking & Dagenham, Havering and Redbridge Primary Care Commissioning Committee

5.1 Core Opening Hours Upon review of uptake of the 2017/18 Extended Hours DES/annual

practice e-declaration/NHS Choices website, AG advised that NHS England had noted there is a discrepancy in terms of information relating to practices half day closing. For BHR, it would appear that 11 practices in B&D still close for half day, 17 in Havering and 10 in Redbridge. All practices have been written to confirm their opening hours, and if half day closing does still happen the practice need to supply details of their subcontracting arrangements and to evidence communications with their patients. Not all have responded but some practices have advised they are now open. SS added the Primary Care team believe the numbers reported are lower and are conversing with the practices and the LMC regularly. MM asked what patients should expect within core opening hours. SS clarified that practices have a responsibility for their patients from Monday to Friday from 8am to 6:30pm. This is to provide essential services that are appropriate to meet the needs of its patients and have in place arrangements to access services in case of emergency. Furthermore, GC confirmed that practice contracts do not require the practice to make a GP available in person to provide routine services to patients throughout the core hours. The Committee noted the verbal update.

5.2 Special allocation scheme – updated framework GC reported that the final draft of the framework has been submitted to

NHS England London region for review. Once this is signed off it will be shared with the Primary Care Commissioning Committee.

GC

6. Barking & Dagenham Primary Care Commissioning Committee 6.1 Five Elms update The Five Elms practice was inspected in 2016 and special measures were

put in place as it was found to be inadequate in all 5 domains. A re-inspection took place in October 2017 and was rated as ‘requires improvement’ as improvements were seen. The CQC will revisit again in May 2018 to look at the action plan and check progress is being made. KA asked if practices are still supported if they are struggling. SS confirmed that resilience funding was made available and earmarked for practices that are rated as ‘requires improvement’. There is also a review of estates through the networks linked with local authorities. KA highlighted the results of a patient experience survey raised by young people that there is a lack of confidentiality in small practices. SS noted this is being picked up via a range of CCG commissioned training being offered to practices, along with practice based sessions on maximising the use of the practice’s clinical system (as there is variation in knowledge and use of systems).

6.2 White House – additional rent – chairs action agreed The White House surgery is a two site practice. They will be redeveloping

the site but have requested support with rent reimbursement and


additional IT infrastructure for this development. The application was reviewed on 19 March 2018 by the BHR Strategic Estates Group who recommended it for approval by the Primary Care Commissioning Committee. Due to the time restraints to ensure the works commenced on 1st April 2018 Chairs action was sought and was given on 23 March 2018. The Committee noted the approval of the additional rent reimbursement and IT costs a total of £15,463.36 was given by Chairs action on 23 March 2018.

7. Questions from the public There were no questions from the public.

8. Any other business 8.1 Quality dashboard 8.1 JH asked if there was any update on the quality dashboard work being

undertaken with NHS England. NK responded that the quality dashboard developed across London is progressing at North East London (NEL) level through the Senior Management Team and QI programme board. However from a review of what information is in these reports, they focus on complaints and concerns and trends across London – so will be of limited use. However there are several other areas that are being developed. The NEL QI programme board are currently agreeing a framework that can be used to monitor quality. This will include: • CEG providing data on a set of common clinical indicators across NEL • Exploring opportunities around each CCG in NEL using Edenbridge

which provides activity and workforce data • Staff surveys and patient surveys The BHR primary care teams have also developed practice profiles that provide information about each practice including clinical outcomes on immunisations and screening and non-clinical outcomes like access and patient survey results.

9. Date of the next meeting Wednesday, 6 June 2018

10. For information 10.1 GMS Contract Changes 2018/2019 AG shared a summary of key changes to the GMS contract. These will be

shared with practices. AG added that these are minor changes but next year is likely to be far greater following completion of the ongoing negotiations between the GPC and NHS Employers.


1

Primary Care Transformation Programme Board Minutes of meeting held on 07.02.2018

Present:

Khalil Ali (KA) Lay Member, Redbridge CCG

Councillor Mark Santos (CHAIR) Cabinet Member for Health and Social Care, LBR

Dr Ann Baldwin (AB) Clinical Director, Havering CCG

Richard Coleman (RC) Lay Member, Havering CCG

Paul Olaitan (PO) Programme Manager, BHR CEPN

Mark Scott (MS) Head of Primary Care, NEL STP Primary Care

Sarah See (SS) Director, Primary Care Transformation, BHR CCGs

Dr Siva Ramakrishnan (SR) Chairman, Healthbridge Direct

Dr Rajbir Randhawa (RR) Network West Chair – Barking & Dagenham

Matthew Cole (MC) Director of Public Health, LBBD

Lucy Botting (LB) Deputy Director, Primary Care Transformation, BHR CCGs

In attendance

Nohad Hamada (NH) Business Manager, Healthbridge Direct

Natalie Keefe (NK) Head of Primary Care, BHR CCGs

Dr Sangeetha Pazhanisami (SP) QI Facilitator, W&W Network

Dr Fearzana Hussain (FH) QI Facilitator, Cranbrook & Loxford Locality

Graham MacDougall (GM) NEL Primary Care Lead, Healthy London Partnership

Jenny King (JK) (notes) Business Manager, Corporate Services, BHR CCGs

Gary Shuckford (GS) Director, Edenbridge Healthcare

John Craig Chief Executive, Care City

Apologies

Dr Atul Aggarwal Chair, Havering CCG

David Parke (DP) Head of Primary Care, Havering CCG

Dr Shabana Ali (SA) Clinical Director, Redbridge CCG

Tom Travers (TT) Chief Finance Officer BHR CCGs

Dr Daniel Weaver (DW) Chair, Havering Health Ltd

Conor Burke Chief Officer, BHR CCGs

Anne-Marie Dean Healthwatch Havering

Dr Tina Teotia Local Medical Committee Barking, Dagenham & Havering

Janaka Perera North East London Local Pharmaceutical Committee

Elspeth Paisley Communications and Acting Healthwatch Manager

Item Title

Welcome and introductions

MS welcomed all to the meeting; introductions were made and apologies noted.

1a Minutes of the meeting held on 07.02.2017 Agreed.

1b Action Log PCTB dashboard – SS provided an update. NHS England and the STP are working on a dashboard which will incorporate similar issues. Across NEL there is already a framework and dashboard in place. It was agreed that any changes were deferred until such time that the CCG were sighted on the NHSE and STP draft dashboard. MS stated that the new dashboard will include outcomes as well as activity. He is currently in consultation with local areas on this draft version of the dashboard.

Paper 1.1

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2

Action: To bring a copy of the draft dashboard to a future meeting MS STP Workforce Analysis

The BHR team with MS and his team are currently carrying out this analysis with practices. This work is on-going. MS noted the difficulty in terms of exploring capacity and vacancies. The output of this analysis will be reported back to the PCTB at a future meeting. Board Membership The 6 CDs across BHR have now streamlined their roles to take on either local focused or NEL STP focused portfolios as follows below: Local Leads Dr Ann Baldwin (Havering) Dr Shabanna Ali (Redbridge) Dr Ravi Goriparthi (B&D) NEL Leads

Dr Gurkirit Kalkat (B&D) Dr Alex Tran for (Havering) Dr Mehul Mathukia for (Redbridge) It was recognised that it was important to ensure that NEL and local leads were completely aligned in their work and strategy for the future, hence appropriate attendance at the PTCB. SS stated that HLP are refreshing the Strategic Commissioning Framework (SCF) for Primary Care. This framework may influence the Primary Care Strategy at a NEL and BHR level. SS clarified that the Terms of Reference (TOR) for the PCTB were also due to be revised. Due to changes at NEL level and with the STP footprint, In alignment with the SCF it was agreed that the Board would refresh the TOR and Strategy together in March 2018. Investment Case for Primary Care Funding

MS reported an event had been held in December 2017 attended by Robert Varnam from the National team. This is to be followed by an additional event, to refresh the investment case, identify the potential programme and obtain funding. MS will ensure there is full representation across NEL CCGs. LIS – Long Term Conditions SS welcomed LB to her first meeting. LB is leading on a LTC LIS linking with CDs where appropriate. Ben Bray would be the link with Public Health. PO stated that there have been some funds allocated from HEE for QI improvement which may lend themselves to LTC work. Action: Invite PO and DW to the Network Chairs’ meeting Action AB BHR QI Report

MS stated that the initiatives covered included support for first fives (GPs) and practice led QI projects with multi-professional representation across the system.

1c Risk Register

SS reported that the risk register has been updated.

2 Quality Improvement: Programme Update UCLP

229

3

Chiya Shikalislami and Preeti Sud from UCLP attended to give a presentation on Redbridge and Havering CCG’s QI collaborative. This was positively received and the following noted:-

New approach is much more primary care focussed

Need to break the old cycle of QI which does not work

B&D did not invest in QI last year- need to support.

QI case studies

Dr Sangeetha Pazhanisami presented a case study to the group on her findings in relation to the QI course and post QI improvement work from a practice perspective (Clayhall Clinic). This was positive and resulted in a better understanding of the QI concept; an improved culture of sharing good practice, reducing variation and confidence in her network as an ‘at scale’ provider. Dr Fearzana Hussain also had had a positive experience of QI, taking encouraging first steps with QI in practice. She felt that, in terms of the future direction for this programme, QI may benefit from supporting practice involvement.

UCLP QI Evaluation Report

Dr Baldwin went through the following summary of QI Intentions:-

We need to capture the baseline of QI developments across BHR

We need an understanding of the local needs of primary care in relation to QI

We should be Implementing a BHR dedicated QI support team in conjunction with existing NEL QI support (Team Virginia- Tower Hamlets)

Need to develop a local QI leadership group with GPS/Nurses/Practice Manager who have already undertaken the QI course and those who will do this in the future in BHR

Allocate a sustainable resource for at least 3 years, allowing the projects to mature and prove effectiveness

Produce a progress/projections chart over the next 3 years with agreed targets across BHR

Find a way to link with system-wide QI projects with NELFT (MSK/Mental Health) and BHRUT (Long term conditions such as DM, COPD, AF, CKD & CVD)

Engage with wider commissioners, providers (Networks, Federations, NELFT, BHRUT), HEE, CPEN, CCGs and NHSE by possible implementation of an MOU (to form a trusted advocate)

Aim to produce a brief proposal paper to be presented and discussed at the next PCTB meeting

MS planned to meet with B&D and Redbridge relevant CDs and Sarah See

Next Steps/Actions

Form a QI task and finish group – AB to chair

AB to attend future Clinical Cabinet meeting

Have a clear high level vision, strategy, outputs and QI next steps for the next PCTB meeting

Action:, LB to organise

3 Provider Development - Edenbridge APEX demonstration

Professor Gary Shuckford (standing in for Allison Homer) from Edenbridge Healthcare attended to demonstrate the APEX business tool for primary care. Although this was a ‘live’ demonstration, ‘dummy’ data was used. The demonstration received a very positive reaction.

230

4

The following points were noted:-

Edenbridge as a tool can be used on EMIS and System 1 (In practice soon)

The tool is useful for analysing workload against demand and for relevant specialisms i.e. nursing, GP etc.

It is useful for undertaking audits

Edenbridge have a good working relationship with Clinical Effectiveness Group (CEG)

Good feedback on this tool has already been received from GP practices in NEL

Tower Hamlets’ practices will be feeding back at the next CEG

Ensure adequate provision is in place when data sharing Action: AB to take this to the network leads meeting to discuss and come back with any further actions. LB to support.

4 Provider Alliance update Verbal update for Networks/Federations Due to lack of time, this item was deferred

5 AOB

Due to lack of time, this item was deferred

Date of next meeting: 18th April 2018

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