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NHS Barking and Dagenham Clinical Commissioning Group Governing Body meeting 28 January 2014

2.00 – 5.00pm Committee rooms 1&2, Barking Town Hall, 1 Town Square

Barking, IG11 7LU Item Time Lead 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 meetings held on 24 September 2013 Matters/actions arising

2.00 Chair Chair Chair

Verbal Attached Attached

2.0 2.1 2.2

Chair and chief officer’s reports Chair’s report Chief officer’s report

2.05 2.10

Chair CB

Attached Attached

3.0 3.1

Governing body assurance Governing body assurance framework

2.15

SM/CB

Attached

4.0 4.1 4.2

Corporate strategy and planning CSPP/Operating Plan Contracting development process 14/15

2.25 2.35

SM SM/MS

Attached Attached

5.0 5.1 5.2

Service transformation and development Trialling of community services Tier 3 weight management service

2.45 2.55

SM/JJ SM

Attached Attached

6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7

Quality and performance Continuing healthcare development plan and assurance report Urgent care board and winter resilience CQC and special measures at BHRUT CQC at Barts Healthcare Patient experience report Finance and activity report Contracting report

3.05 3.15 3.25 3.35 3.45 3.55 4.05

JH CB JH JH SW MS MS

Attached Attached Attached Attached Attached Attached Attached

7.0 7.1 7.2 7.3 7.4 7.5

Development/governance Gifts and hospitality, whistle blowing, anti-fraud and bribery policies CSU contract 2014/15 and beyond OD plan progress report Clinical director elections Minutes of sub – committees and relevant fora:

• Executive committee • Audit and governance committee • Quality and Safety committee • Patient engagement forum • Joint executive team committee

4.15 4.25 4.35 4.45 4.55

SA MS SA SA Chair KP TV SW CB

Attached Attached Attached Attached Attached Attached Attached Attached Attached

8.0 AOB Chair Verbal

1

Item Time Lead Attached,

verbal or to follow

9.0 Questions from the public

5.00 Chair

10.0 Next meeting: 25 March 2014 The public are asked to indicate to the company secretary any points of enquiry or questions they would wish to address with the governing body at least three days before the meeting by e-mail to [email protected]

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mailto:[email protected]

Register of interests 2013/14

Declaration of governing body member interests ITEM 1.1

Name Role Organisation Nature of interest

Dr Waseem Mohi

Chair Markyate Surgery Remedy Health Care plc

Salaried GP Director –(not currently active)

Dr Raj Kumar Vice chair/Clinical director

Laburnum Health Centre NELFT Team

GP Partner Independent contractor

Dr Arun Sharma Clinical director Laburnum Health Centre Primary Clinical Partnership Ltd Primary Clinical Partnership Services Ltd Partnership of East London Co-operative Council

Partner Director/ownership or part ownership/shareholder Director/ownership or part ownership/shareholder Elected member

Dr Chandra Mohan

Clinical director Urswick Medical Centre Primary Clinical Partnership Ltd

GP Principal Director/ownership or part ownership/shareholder

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Primary Clinical Partnership Services Ltd

Director/ownership or part ownership/shareholder

Dr Jagan John Clinical director King Edwards Medical Group LMC Department of Health Royal College of GP’s NELFT NHS Improving Quality /NHS England NHS England

GP Principal Chair National health and wellbeing partnership champion Expert panel of the care planning programme member GPwSI in Cardiology BD CHS team National clinical associate for domain 2 London clinical senate member

Dr Rami Hara Clinical director Urswick Medical Centre GP Principal

Dr Gurkirit Kalkat

Clinical director Thames View Health Centre Primary Clinical Partnership Ltd Apex Healthcare Ltd

GP Director/owner or part owner Director/shareholder

Dr Richard Burack

Clinical director North Street Medical Care & Lawns Medical Care

GP Principal

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Siam Care UK (charity supporting HIV affected families in Thailand Partnership of East London Co-operative B&D PCT (likely to be transferred to NCB)

Chair of trustees Part time medical director/Executive committee member Named safeguarding GP lead

Tan Vandal Secondary care consultant

Essex Urology Services

Spire Hartswood Hospital

Havering, Tower Hamlets, Bromley & Greenwich CCG Governing Bodies

Co-Director and shareholder

Consultant Urological Surgeon

Secondary Care Doctor Member

Sahdia Warraich

Lay member The Forum for Health and Wellbeing The Forum for Health and Wellbeing Trading Ltd (social enterprise arm of above) East London NHS Foundation Trust Healthwatch Newham

Healthwatch Waltham Forest

Employee Director Governor Director Director

Kash Pandya Lay member Hillcroft College Surbiton

Council Member and Audit Chair

5


Ministry of Justice Essex Advisory Committee Health & Safety Executive Her Majesty’s Inspector of Constabulary Brentwood Citizen’s Advice Bureau Redbridge CCG Havering CCG

Lay Member Independent Audit Committee Member Associate Inspector Advisor Lay Member Lay Member

Conor Burke Accountable officer Your business works (not trading) Redbridge college

Director Audit committee member

Sharon Morrow Chief operating officer None

None

Martin Sheldon Chief finance officer Novus Generation Limited Somerset Sight

Director/shareholder Trustee

Jacqui Himbury Nurse director Nursing & Midwifery Council Fitness to practice panellist

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1

Draft Barking & Dagenham Clinical Commissioning Group Governing Body Meeting 24 September 2013

2.00 - 4.00pm Civic Centre, Dagenham

Present: Dr Waseem Mohi Clinical Director and Chair Dr Jagan John Clinical Director Dr Arun Sharma Clinical Director Dr Ramneek Hara Clinical Director Sharon Morrow (SM) Chief Operating Officer Conor Burke (CB) Accountable Officer Tam Vandal (TV) Secondary care consultant Kash Pandya (KP) Lay member - governance Sahdia Warraich (SW) Lay member – patient and public involvement Martin Sheldon (MS) Chief Finance officer Jacqui Himbury (JH) Nursing director

In Attendance: Sue Assar (SA) Interim Director of Corporate Services Anne-Marie Keliris Company secretary Graham Simpson BHR Commissioning support Director CSU Anne Bristow (AB) Corporate director – adult and community services Matthew Cole (MC) Public Health director Apologies: Dr Rajesh Kumar Clinical Director Dr Richard Burack Clinical Director Dr Gurkirit Kalkat Clinical Director Dr Thota Mohan Clinical Director

Item Action 1.0 Welcome and apologies

The Chair welcomed members to the meeting. Apologies for absence were received from Drs Kumar, Burack, Kalkat & Mohan. The Chair requested that clinical directors prioritise governing body meetings as their attendance and input is crucial.

Item 1.2

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1.1 Declarations of conflicts of interest There were no additional conflicts of interest declared.

An updated declaration of interests will be presented at the next meeting.

1.2 Minutes of the last meeting

The minutes of the meeting held on 21 June 2013 were agreed as a correct record.

1.3 Matters/Actions arising The committee noted the actions taken since the last meeting and

the following were also discussed: Further to minute 5.4 JH reported that the maternity network had a successful first meeting. SW questioned if the network had patient representation, JH responded that it did not but was working closely with the maternity services liaison committee.

2.0 Chair & Accountable Officer’s Reports 2.1 Chair’s report

The Chair presented his report covering the following areas: • Authorisation • Commissioning strategy • Urgent care next steps • Locality development • Quality in commissioned services

The governing body noted the report. 2.2 Chief Officer’s report The chief officer presented his report covering the following areas:

• BHRUT performance • CCG performance • CCG development • Health and wellbeing board update • Official opening of Barking community hospital • Meeting attendance

The governing body noted the report.

3.0 Governing body assurance 3.1 Governing body assurance framework

SM presented a report which outlines the key risks to the clinical commissioning group in achieving its corporate objectives that are identified in the governing body risk assurance framework. It was noted that the risk rating to validation of non contracted

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activity has increased, this is being kept under review by CSU and reported via audit and governance committee, locality risk registers are being developed partly to provide assurance with the issues identified by the Francis report. AS commented that it was worth reflecting on the locality risk register, at a time when localities are not very clear about their goals and felt this may create a level of additional bureaucracy. He felt it was important to monitor local risks but was concerned a locality model would create additional work that the borough team do not have time for and was also concerned that the governing body was devolving its responsibility. He felt the issue needed further thinking. SM agreed that it was important not to create additional bureaucracy but felt it was important the localities understand risks and would want to work with the clinical directors to achieve this in a practical way. CB suggested the governing body reflected on what it was trying to achieve. He added the aim is that members have ownership of risks and the locality model would be used to help achieve this. It was important that members view this as a bottom up process, not delegation by the governing body and suggested a separate conversation to work through the issue raised. KP agreed that if there is lack of clarity on the locality model a further discussion is required. He added that internal audit had reviewed the governing body assurance framework and on the whole they believed the process to be robust but still had some concerns around risks turning green by April and the inconsistencies between appendix 1 and 2. TV commented that it was vital to keep bureaucracy to a minimum but felt that ownership of clinical and financial risks need to be held locally and communication needs to be robust to achieve this. JJ stated that the governing body is the main reporting mechanism for practices, adding that the Francis Report specifically highlighted poor management and questioned if the CCG have a mechanism that practices are able to access. He added that it was clinical directors responsibility to share and challenge practices and questioned if this is the wrong delivery model for risk. AS agreed, adding it was vital that practices had the ability to raise risks and the importance of a clear process that works to support this. The Chair agreed with the issues raised and suggested a meaningful discussion is arranged to develop and deliver a locality model. He added that the RAG rating end summary does not give assurance. CB responded that most of the actions are framed within the governing body agenda and assurances will be given throughout the meeting and will address gaps if they arise.

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Discussion ensued on best way to gain assurance at the governing body meeting and it was agreed to have an indicative column to show how risk has changed and a column referring to a particular report within the governing body agenda. It was also noted that the quality and safety committee and finance and delivery committee review assurances in more detail and this would also be referenced within the report. The governing body noted the report. 3.2 Francis report – update on implementation JH presented a report which updated on the progress that has been made in implementing the recommendations from the Francis Report. SW questioned if there was a patient representative on the task and finish group. JH responded that the group was currently looking at the best way of achieving community representation and agreed to discuss this further with SW outside the meeting. JJ asked what the process will be in deciding what the patient experience measure will be. JH responded that the actions came from the recent Francis workshop but the details of the process and measures need to be agreed and would discuss this further with SW and JJ outside the meeting. The governing body noted the report. 3.3 BHRUT A&E services clinical review CB presented a report which updated on the external review into A&E services. It was noted that initial feedback recommends not to close King George A&E overnight as this would be a risk to Queens Hospital although the CCG were still committed to the health for NEL vision. It was noted that the final report is expected to be available on 30 September and the quality and safety committee will take responsibility to review its recommendations. CB added that the initial findings recommended that services needs to be run on both King George and Queen’s sites. SW questioned if there had been flow of patients between sites, CB acknowledged there had been where services are no longer provided on one site but there was not redirection of patients between A&E services currently. KP reported that he attended the BHRUT AGM where A&E was raised and recognised as a risk. He added that the board were questioned on how long it expected to take to resolve problems

SM JH JH

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within A&E and reduce the associated risk, the response was possibly 2 years due to staffing and recruitment problems. AS felt there were some conflicting messages as the report states that A&E is safe but was not coping with current pressure and change needs to be demonstrated. He added that he also felt concern because there were difficult times ahead with increased demand and austerity. CB summarised the issues raised around the immediate risk, wider implementation plan, accountability if no improvement is demonstrated and assurance gateway process for the Secretary of State’s decision. He added that the CCG would require an independent external review team to ensure that the closure of King George is safe. It was noted that the gateway assurance process did improve maternity services but there is a long process to follow and a clear decision making process will be presented at the next governing body meeting. The governing body noted the report and agreed that a full report on the implementation of the A&E review findings will be considered by the quality and safety committee.

4.0 Corporate strategy and planning 4.1 2014/15 commissioning planning cycle

SM presented a report which advised on the commissioning planning cycle process for 2014/15. It was noted that the process had the potential to change when national planning guidance is published in October. Patients will be involved in refreshing the plan initially through the patient engagement forum and a stakeholder group. AB expressed concern that the commissioning planning cycle timetable set does not fit with local authority timetable. She noted the progress that had been made to reflect local priorities in the high level commissioning intentions but felt that they could have a better flavour of integration and suggested working together to improve this. RH expressed concern that clinical directors who are involved in contract negotiations would not have sufficient time available to be fully involved. The Chair agreed and suggested discussing this further at the next executive committee.

The governing body noted the progress and agreed to receive the

commissioning plan for 2014/15 at the next meeting.

4.2 JSNA update SM presented a report which provided a progress update in relation

SM WM

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to the refresh of the JSNA for 2013 along with a summary of the content of the existing document provided by public health. SM added that the CCG needs to be mindful of demographic changes and economic climate. MC agreed adding the welfare reforms will have a clear impact. He added that there are some gaps in terms of the engagement process but this will be discussed further at the health and wellbeing board. The governing body noted this progress report. 4.3 Commissioning intentions SM presented a report which advised on the process for developing commissioning intentions for 2014/15 both at borough and health economy level and detailed the high level commissioning intentions which will be subject to ongoing review and evaluation throughout September 2013. It was noted that there was some clinical engagement but it was recognised that this needed to be extended through stakeholder engagement. KP highlighted the need to bear in mind governance risks and the importance of linking to the JSNA in the future. AB commented that there had been a lack of joint commissioning posts and urged the governing body to think about eliminating duplication and developing joint working. Discussion ensued on the responsibility to develop the workforce and concerns were raised that there had been poor communication from providers on this issue. MS reported that he was working with CSU colleagues to develop a resource to focus on this important issue. The Chair concluded that the governing body need to agree and understand what the CCG want to do differently and suggested a review and focus at a future executive committee meeting. The governing body noted the progress report and the Barking & Dagenham executive committee will receive a further report in one month.

SM/WM

5.0 Service transformation and development 5.1 Development of intermediate care community services

SM presented a report which provided an overview of the proposals submitted by NELFT for the development of an intermediate care community service including reprovision of bed based rehabilitation services and support in the community. CB clarified that the decision being asked of the governing body is to support the trialing of a new model of care and not to a reduction

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in beds, this would only take place after a full and robust public consultation and no decision to reduce bed numbers would be taken without taking into account any responses received. Discussion ensued on the impact of community services and CB confirmed that any proposals would be developed with partners and any decision to end or extend the service would require governing body approval. SW reported that the patient engagement forum questioned why the service is only being extended from 8-10pm and has had feedback that members would like the service extended as much as possible. SM responded that activity has been extended within these hours as these matched peak activity times at A&E but this will continue to be reviewed. KP supported the pilot but suggested the need to set success criteria now. AS commented that the model did not show closer working with the locality and asked if this can be discussed in further detail. JJ agreed the diagram did not show the detail of closer working and this will be revised once further testing on the models is undertaken. MC commented that within the report it was not clear how primary care is supporting 7 day working. CB agreed, but reported on the Havering CCG scheme trialing weekend working, if this has an impact it could be rolled out across Barking & Dagenham. It was agreed the next executive committee would receive a detailed breakdown of contract costs. The governing body approved the proposals to develop a trial for the reprovision and development of an intermediate care services. 5.2 Urgent care board: urgent and emergency care and winter planning CB presented a report which provided an update on the role of the urgent care board and its focus over the coming months. He highlighted the following areas:

• Clear focus on urgent care centre, lead by CCGs • Focus on 7 day working for wider system • Focus on primary care improvement generally led by

Havering CCG but will encompass all 3 CCGs • Frail elders project audit will report next week • Winter planning to continue

He added a demand and capacity plan has been submitted which

SM

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was co-created with partners and has been amber rated for confidence of delivery. The Secretary of State formally allocated £7m to BHRUT directly and the CCG has been in discussions with the Trust on how these funds are allocated, 50% is being allocated to schemes including the intermediate care service, with allocations being overseen by the urgent care board. JJ expressed concern at the decision to allocate funds directly to BHRUT and lacked confidence in the urgent care board overseeing proposals decided on by BHRUT and questioned governance arrangements. CB shared the concerns around allocations to BHRUT but gave assurance that the urgent care board clearly accounts into integrated care coalition and governing bodies. AS welcomed the allocation of winter monies but agreed with CB that direct allocations undermines the purpose of local commissioners and expressed concern that the system is becoming more hospital centric and therefore the urgent care board should also focus on what needs to happen within the community. AB commented that it should not be underestimated what CB has done to bring the local health economy together and congratulated CB on the work to date. The Chair acknowledged the work of urgent care board but agreed with concerns raised on the allocation of funds directly to BHRUT. CB agreed but added that the CCG does have influence around major contracts and reiterated the importance to stay focused on getting these right. The governing body noted the progress report.

6.0 Quality and performance 6.1 Quality in commissioning report

JH presented a report which provided high level assurance of actions in place to mitigate quality risks that directly impact the delivery of the CCG objectives. JH highlighted the two priority areas,

• continuing healthcare – position continues to improve with the discharge process and assessment continuing to be a priority to improve.

• commissioning of care home services – all providers with front line nursing element have been visited.

It was noted that since the report was written the CQC have informed the CCG that it will be undertaking inspections at BHRUT and Barts Healthcare in the October and November which the trusts are now preparing for. JH reported that she and CB will be meeting with the CQC compliance manager and expect information will be

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requested. JJ reported that he had been informed that the trust are reporting they are not supported by the CCG and felt this was not helpful and highlighted the need to ensure CQC understand that CCG are fully engaging and supportive of the trust. CB agreed this was disappointing to hear as the CCG are supporting and challenging the Trust to get the right outcome for patients. JH agreed and reported that at the clinical quality review meeting the trust are always asked how the CCG can help or support them and the CCG have also arranged for CCG staff to help with specific projects. SW reported that Healthwatch may be able to help around quality of care home services. AB added that Healthwatch have recently presented their 6 month work plan and it was well received. SM agreed to share this will the governing body adding that it will also being presented to the patient engagement forum. The governing body noted the report. 6.2 Patient experience report SW 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:

• complaints and MP/councillor queries • commissioned services • CCG patient engagement forum • Patient participation group audit • Engagement with children and young people • Results of GP patient survey • The NHS belongs to the people “a call to action”

TV asked whether patient stories could be included in the report. The governing body noted the report. 6.3 Finance and activity report MS presented the month 5 finance and activity report and apologised for its lateness. He added that performance is on plan with the main pressure being the quality of Barts Healthcare data with significant challenge to the trust and negotiation to make sure the contract is good enough. It was noted that QIPP was operating well but still behind on plan but gave assurance that the borough team are working hard to bring back to plan level. JJ questioned if Barking & Dagenham have an issue with non weight bearing patients as he understood this was a problem across London but not in Barking & Dagenham and this had the potential to create a significant pressure. JH responded that

SM

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Barking & Dagenham do not have significant issue but this is monitored. CB commented that some information within the report was inaccurate and did not provide adequate assurance. He had requested that the standard and quality of the report improves. The governing body noted the report. 6.4 Contracting report MS presented a report which provided an update with the position on the 2013/14 contracts and highlighted quality issues that have been identified with the Redbridge CCG main providers for acute and community services. The governing body noted the report.

7.0 Development/governance 7.1 Executive committee terms of reference and area

prescribing SA presented a report which set out sound governance arrangements to establish an area prescribing committee. The governing body approved the proposal as set out within the report. 7.2 S256 agreements MS presented a report which described the proposed process to be followed for the completion and agreement of section 256 arrangements. Discussion ensued on the governance arrangements to monitor S256 and KP added that it was not a unique problem and he would ask internal audit to recommend good practice. The governing body approved the process detailed in the report subject to clarification of governance arrangements to monitor the S256 agreement. 7.3 Business continuity plan SA presented a report which requested the governing body to delegate responsibility to the CCG executive committee to enable it to approve the business continuity plan. KP supported the delegation of responsibility adding that once finalised the plan should be tested. The governing body noted the work underway to finalise the

KP

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business continuity management policy and plan and agreed to delegate responsibility to the executive committee to enable these to be approved by the end of October 2013. 7.4 Minutes of sub committees: The governing body noted the minutes of:

• Executive committee held on 23 July & 27 August 2013 • Audit and governance committee held on 3 September 2013 • Quality and safety committee held on 6 August 2013 • Patient engagement forum held on 9 July 2013 • Joint executive team committee held on 13 June 2013 & 4

July 2013

6.0 AOB There was no other business

7.0 Date of the next meeting

28 January 2013.

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1

Actions arising from the Barking and Dagenham Clinical Commissioning Group Governing Body

24 September 2013, Part I

Action reference Action required Lead Progress

3.1 Governing body assurance framework

It was agreed to have an indicative column to show how risk has changed and a column referring to a particular report within the governing body agenda. It was also noted that the quality and safety committee and finance and delivery committee review assurances in more detail and this would also be referenced within the report.

SM Appendix one shows the change in risk rating from previous month to current month and there is reference to specific GB papers that relate to risks on the GBAF within the paper. This is within 2.2 of the GBAF report.

3.2 Francis report

SW questioned if there was a patient representative on the task and finish group. JH responded that the group was currently looking at the best way of achieving community representation and agreed to discuss this further with SW outside the meeting. JJ asked what the process will be in deciding what the patient experience measure will be. JH responded that the actions came from the recent Francis workshop but the details of the process and measures need to be agreed and would discuss this further with SW and JJ outside the meeting.

JH

JH

Completed A meeting with lay members and healthwatch had taken place in December and there will be a follow up meeting to this in January.

4.1 2014/15 Commissioning planning cycle

AB expressed concern that the commissioning planning cycle timetable set does not fit with local authority timetable. She noted the progress that had been made to reflect local priorities in the high level commissioning intentions but felt that they could have a better flavour of integration and suggested working together to improve this.

SM

The Integrated Care Coalition is overseeing the development of the 5-year strategic plan. Planning guidance has been received and the operating plan and Better Care Fund timelines are aligned. Joint work is progressing

Item 1.3

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2

Action reference Action required Lead Progress

RH expressed concern that clinical directors who are involved in contract negotiations would not have sufficient time available to be fully involved. The Chair agreed and suggested discussing this further at the next executive committee.

WM

through the H&WB Board subgroups. Verbal update.

4.3 Commissioning intentions

The Chair concluded that the governing body need to agree and understand what the CCG want to do differently and suggested a review and focus at a future executive committee meeting.

SM/WM High level commissioning intentions were approved at the October Executive Committee. A brainstorming session was held with Clinical Directors and Clinical Champions on 31st October to discuss strategic plans.

5.1 Development of intermediate care community services

It was agreed the next executive committee would receive a detailed breakdown of contract costs.

SM Will be presented as February Executive as part of Better Care Fund plan.

6.1 Quality in commissioning report

SW reported that Healthwatch may be able to help around quality of care home services. AB added that Healthwatch have recently presented their 6 month work plan and it was well received. SM agreed to share this will the governing body adding that it will also being presented to the patient engagement forum.

SM Attached with papers.

7.2 S256 agreements

Discussion ensued on the governance arrangements to monitor S256 and KP added that it was not a unique problem and he would ask internal audit to recommend good practice.

KP Verbal update.

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HEALTH AND WELLBEING BOARD

17 SEPTEMBER 2013

Title: Summary of Healthwatch Work Programme (2013/14)

Report of Healthwatch Barking and Dagenham

Open For Information

Wards Affected: NONE Key Decision: NO

Report Author: Marie Kearns, Chief Executive Officer, Harmony House

Contact Details: Tel: 020 8526 8200 E-mail: [email protected]

Sponsor: Frances Carroll, Chair of Healthwatch Barking and Dagenham

Summary: This paper provides an overview of a programme of key projects identified and agreed by the Healthwatch Barking and Dagenham Board. They are to be carried out and completed by Healthwatch Barking and Dagenham for the operating year 2013/14.

Recommendation(s)

The Health and Wellbeing Board is recommended to:

(i) Note the work programme of Healthwatch Barking and Dagenham which identifies issues affecting the provision of Health and Social Care services to local people. The reports and outcomes of the work programme will represent the voice of people from the local community.

Reason(s) To ensure that the Health & Wellbeing Board are informed in advance of the Healthwatch work programme for the year.

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1. Background 1.1. This report provides an overview for the Health & Wellbeing Board of the work

programme from Healthwatch Barking and Dagenham for the remainder of this year. The topics have been chosen for their interest to the borough. They include services for both older and younger residents representing health and social care activities.

2. Enter and View 2.1. Where pieces of work include an Enter & View visit, all volunteers will be

appropriately trained. All Enter & View visits will be announced, with service providers having 20 days’ written notice. This notice will clearly state the defined purpose of our visit. Our aim is to build a good rapport; reassuring them that we are not inspectors, but a critical friend. We can however, conduct unannounced visits if thought necessary.

3. Capturing and Sharing Outcomes 3.1. Each piece of work will generate a Healthwatch report with recommendations. As all

changes require the combined influence of a range of health and social care organisations and statutory bodies; our reports will be distributed to:

• Health & Wellbeing Board

• Health and Adult Services Select Committee

• Barking & Dagenham Clinical Commissioning Group

• Local Authority Commissioners

• NHS England

• Healthwatch England

• Care Quality Commission

• Feedback to the public will always be given in an appropriate way through a variety of media.

4. Further Public Engagement Work

4.1. This work programme is not exhaustive, as we have allowed time to undertake work on other issues that become apparent through general consultation with the public. Along with this work programme, Healthwatch volunteers and staff have arranged 15 days of public consultations to be conducted at diverse venues in the borough. Healthwatch is also undertaking two further public launch events in September and October 2013.

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5. Mandatory Implications

5.1. Joint Strategic Needs Assessment

5.1.1. The Work Programme is reflective of the issues highlighted in the Joint Strategic Needs Assessment. For example, Board Members will note that Healthwatch will be investigating dental services for children. It is hoped that the findings of this investigation can inform future editions of the JSNA as oral health is a key indicator of health inequality.

5.2. Health and Wellbeing Strategy

5.2.1. The Work Programme has been developed to reflect strategic themes and priorities from the Joint Health and Wellbeing Strategy 2012-15.

• Care and Support – Dental Care Services for Children, Services for Young People with Additional Health and Social Care Needs (Post Education), Children’s Diabetes Services, Discharge of Elderly Patients, Hospital In-Patient Services Frail & Elderly People and Duty of Candour

• Protection and Safeguarding – Discharge of Elderly Patients and Duty of Candour

• Improvement and Integration of Services – Children’s Diabetes Services, Urgent Care Appointments, Hospital Discharge Stroke Services and Discharge of Elderly Patients

• Prevention – Children’s Diabetes Services and Duty of Candour

5.3. Integration 5.3.1. The findings and recommendations arising from Healthwatch activities will be

reported back to commissioners to help to drive improvements in local health and social care services. The views of patients, service users, and residents generally will be especially valuable to understand how services can become more integrated and seamless, thus improving the patient experience.

5.4. Financial Implications

5.4.1. The commitments outlined in the Work Programme will all be met through existing budgets and resources.

5.5. Legal Implications

5.5.1. The work programme has been developed to assist Healthwatch in fulfilling its duties and functions as set out in the Health and Social Care Act 2012 and locally agreed contractual obligations.

5.6. Risk Management

5.6.1. The Council, as the commissioner of Healthwatch Barking and Dagenham, regularly monitors Healthwatch’s performance; the delivery of the Work Programme is included in this.

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6. Non-mandatory Implications

6.1. Customer Impact

6.1.1. The Work Programme is wholly reliant on engaging with local people to bring forth their experiences and views about health and social care services. The information collected from Healthwatch activities will be shared with stakeholders and used to drive improvements.

6.1.2. The Work Programme underlines Healthwatch’s commitment to engage with all types of service user and different, sometimes hard to reach, sections of the community. Young people with special needs and elderly and frail people illustrate this range.

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APPENDIX A

HEALTHWATCH BARKING AND DAGENHAM – WORKPLAN 2013/14

WORKSTREAM/ TASK/LEAD

REASON METHOD OUTCOMES DATE FINALISED

DATE TO HEALTH & WELLBEING BOARD

Complete the Healthwatch Barking and Dagenham Workplan Lead Officer: Richard Vann

It is a duty of the local Healthwatch to produce a work plan that reflects accountability to the local community, the local authority and Healthwatch England.

The Healthwatch Board met on 9th July 2013 and agreed a programme of projects to be undertaken during the current operating year.

Experiences of local people using health and social care services will be heard and they will know where to go to raise concerns about health and social care services. The public will influence decisions about local services. Scrutiny of health and social care services will be improved.

12th August 2013

17th September 2013 (to be with the Board administrator by 12th August 2013)

Childrens Diabetes Services Consultation Lead Officer: Manisha Modhvadia

Diabetes is a priority in the Barking and Dagenham Health & Wellbeing Strategy. Healthwatch want to look at Diabetic services for young people and children and how those services are meeting their needs.

Healthwatch will undertake research, 1 to 1 interviews, group discussions and a survey with local young people and children.

Produce and publish a report with any appropriate recommendations. This will be shared with the public and stakeholders.

7th October 2013 (to Healthwatch Board 30th September 2013)

5th November 2013 (to be with the Board administrator by 8th October 2013)

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APPENDIX A

Hospital In-patient Services – Frail & Elderly People (Enter & View) Lead Officer: Richard Vann

With the increasing population of older people and the likelihood of an increasing need for in-patient hospital services, Healthwatch wants to look at the quality of services being provided.

Healthwatch will carry out Enter & View visits on hospital wards for elderly and frail people. We will gather the views of patients and their relatives.

A report will be produced and published. This will be made available to the public and stakeholders.



Dental Care Services for Children Lead Officer: Manisha Modhvadia

Healthwatch want to find out about Dental services for children in the borough.

Healthwatch will carry out 1:1 interviews, group discussions and a survey to gather information about patient and parent experience of services.

A report will be produced and published. This will be made available to the public and all stakeholders.



Services for Young People with Special Needs (post education) Lead Officer: Manisha Modhvadia

Healthwatch want to find out from young people with special needs what their experiences of using services are - what is and is not working well.

To carry out 1:1 interviews, group discussions and a survey to gather patient experience of services.

A report will be produced and published. The report will be made available to the public and will be shared with all stakeholders.

11th November 2013 (to Healthwatch Board 4th November 2013)

10th December 2013 (to be with the Board administrator by 12th November 2013)

25

APPENDIX A

Urgent Care Appointments Lead Officer: Richard Vann

Barking and Dagenham CCG have agreed to deliver a minimum of an additional 25,000 GP appointments from August 2013. Healthwatch want to ask patients for their views on the impact the additional services have made.

Healthwatch will undertake a survey to ask patients for their views and to give feedback about their experiences of existing services.

A report will be produced and published. The report will be made available to the public and will be shared with all stakeholders.

13th January 2014 (to Healthwatch Board on 7th January 2014)

11th February 2014 (to be with the Board administrator by 14th January 2014)

Discharge of Patients from Hospital Stroke Services (Enter & View) Lead Officer: Richard Vann

Healthwatch would like to find out from stroke patients, their experiences of using discharge services from hospital.

Healthwatch will carry out an Enter & View visit to find out patients’ experiences of this.


13th January 2014 (to Healthwatch Board on 7th January 2014)

11th February 2014 (to be with Board administrator by 14th January 2014)

Discharge of Elderly Patients (Enter & View) Lead Officer: Manisha Modhvadia

Healthwatch wants to find out the experiences of elderly patients who use the discharge service from hospital and from those using the new services being provided in Barking and Dagenham.

Healthwatch will carry out an Enter & View visit to look at the discharging service and engage with patients to gather their views about using existing and new services.


24th February 2014 (to Healthwatch Board on 17th February 2014)

25th March 2014 (to be with Board administrator by 25th February 2014)

26

APPENDIX A

Duty of Candour (Enter & View) Lead Officer: Richard Vann

People expect their concerns over services to be acted upon and that any complaint is dealt with in an open, honest and sensitive manner. Healthwatch want to find out how well this works in the borough.

1:1 interviews and group discussions with service users and staff to ascertain how confident people are to report concerns about services. Undertake Enter & View visits to health and social care providers.

A summary report will be produced and published using feedback from service users and staff of In-patient, social care and community services. This will be made available to the public and stakeholders.

24th February 2014 (to Healthwatch Board on 17th February 2014)

25th March 2014 (to be with Board administrator by 25th February 2014)

27

Item

2.2 To: Meeting of the Barking & Dagenham Clinical Commissioning Group

Governing Body From: Dr Waseem Mohi Date: 28 January 2014 Subject: Chair’s report Executive summary The report provides an overview of key activities undertaken by myself and the CCG over the past four months including:

• Urgent action to approve the process for electing clinical directors to the governing body

• A commissioning update • An update on locality development • Key engagement activities

Recommendations

The governing body is asked to note the progress report and the urgent action taken regarding the Clinical Director election process.

1.0 Purpose of the Report 1.1 To provide an update on my activities since the September meeting and

update on CCG progress. 2.0 Urgent action 2.1 An urgent action group, which was attended by Kash Pandya, Martin Sheldon,

Jacqui Himbury, Dr Burack and Dr Mohan, reviewed a report which proposed a process to elect governing body clinical directors. The group proposed changes to the assessment panel and formally approved the process. Further details are contained within item 7.6.

3.0 Commissioning update 3.1 31 practices started a six month pilot for an urgent care surge scheme in

October and a further three have been recruited in January. In the first three months of the pilot an additional 7800 urgent care appointments have been offered through general practice.

28

3.2 As part of the BHR Planned care workstream, Barking and Dagenham led a

diabetes workshop at the beginning of October. The purpose of this event was

3.3 to agree objectives for a collaborative diabetes project. The event was well attended with clinicians from primary and secondary care in attendance, as well as NELFT and the Local Authorities. A project plan for delivering improvements in the diabetes pathway will be taken forward by the diabetes project group.

3.4 The BHR CCGs hosted a market engagement event in November to inform the market of CCG commissioning intentions. This was attended by a range of NHS and private providers.

3.5 The BHR CCGs have recently established a Collaborative Cancer Commissioning Group that will focus on the prevention and early detection of cancer. This is chaired by Matthew Cole, Director of Public Health LBBD and will meet for the first time in January.

3.6 The BHR CCG chairs and Chief Officer met with Sir Ian Carruthers on 16th January to discuss the capability and governance of BHRUT, following the announcement that the trust is in special measures.

4.0 Locality development 4.1 The CCG has been successful in securing funding to provide a range of

training and development opportunities in primary care from the Local Education Training Board (LETB) and in collaboration with Public Health. This includes a programme of clinical skills development for practice nurses covering immunisation, cytology screening, safeguarding, coil fitting, ear syringing, wound management and mental health as well as specific programmes for wider primary care teams. The BHR CCGs were also successful in securing a significant amount of funding for end of life care training and support.

4.2 The CCG has also been successful in securing funding from the Macmillan

Partnership to recruit three GPs to work with the localities and CCG delivery groups to support education and development to improve health outcomes in relation to cancer.

4.3 On the 3rd of December a special PTI meeting was held on GP provider

development with presentations Newham GPs and Hempsons solicitors informing local discussion on the development of a GP provider unit across barking and Dagenham.

29

5.0 Engagement 5.1 I attended the Health and Wellbeing Board away day on 13th January which

considered how the bard could further develop over the next year. Officers also attended an obesity summit in January which was co-ordinated through the Health and Wellbeing Board.

5.2 Healthwatch hosted a stakeholder engagement session on 16th January for

the CCG and council to engage with the public on commissioning plans for 14-16. NELFT also presented the pilot for community rehabilitation services.

5.3 I met with the Margaret Hodge, MP for Barking on 17th January to discuss

local health issues and proposals to improve access to primary care.

Author: Sharon Morrow Date: 18th January 2014

30

www.southwark.gov.uk

ITEM 2.2 To: Meeting of the Barking and Dagenham Clinical Commissioning Group Governing Body From: Conor Burke, Chief Officer Date: 28 January 2014 Subject: Chief Officer’s Report

Executive summary This report provides an overview of key activities undertaken by the Chief Officer and the CCG since the last meeting.

Recommendations The governing body is asked to: • Note the progress report

1.0 Purpose of the report 1.1 To provide an update on my activities since the last meeting in September 2013.

2.0 BHRUT performance 2.1 As Governing Body members are already aware, following long-standing concerns about the

performance of emergency care at Barking Havering and Redbridge University Hospitals Trust (BHRUT) and the recent CQC report, the Trust has been placed into special measures. A full report is provided on this later on the agenda.

3.0 CCG performance 3.1 Monthly assurance meetings with NHS England (NHSE) continue with the most recent one held

on 15 January where the discussion focused on A&E performance and quality assurance around winterbourne view and continuing healthcare. NHSE were reassured and satisfied of our progress in these areas.

4.0 CCG Development 4.1 For those members who attended the Governing Body development session on 5 December, I

am sure you will agree that it was extremely useful. Together we identified a number of key areas for development and a full report on how this will be taken forward is provided later on the agenda.

5.0 Health and Wellbeing Board update 5.1 I attended the Health and Wellbeing Board (HWBB) on 5 November where a summary was

provided on the proposed 14/15 commissioning intentions for Public Health, the Integration Transformation Fund (ITF), the Francis report and the Care Bill. At the HWBB on 10 December agenda items included progress reports on Healthwatch in its first six months of operation, the work of the Urgent Care Board and the CCG’s 14/15 commissioning strategy plan.

31

On 13 January a HWBB development day was held which focused on strengthening partnerships and plans for the future.

6.0 New appointments 6.1 I am pleased to announce that Tom Travers has been appointed to the post of Chief Financial

Officer and will join the BHR CCGs in May. We also recently appointed a Primary Care Improvement Director on a secondment basis for nine months, to work across the BHR CCGs. Sarah See will take up the post shortly. Both Tom and Sarah have extensive NHS experience and I am happy to have secured their services.

7.0 Prime Ministers Challenge Fund: Extending Access to General Practice 7.1 We are currently working with our GPs to put together a BHR CCGs’ bid for the Prime Minister’s

Challenge Fund and also engaging with all of our local MPs to support the bid.

8.0 Meeting attendance 8.1 On 14 November I attended the HSJ Summit event, where the main focus of the day was on

quality. Speakers at the event included Professor Sir Mike Richards, Chief Inspector for Hospitals and Stephen Dorrell MP, Chair, House of Commons Health Select Committee.

8.2 On 21 November the BHR CCGs held a market engagement event which allowed the CCGs to

engage and inform all current and potential providers of our commissioning intentions for 2014/15 and beyond. The event was well attended by providers who have given positive feedback about the session.

8.3 The Urgent Care Board met on 28 November and 19 December. Both meetings focused on system wide performance as well as monitoring of the winter planning schemes in place to help improve A&E performance. At the most recent meeting on 27 January we discussed the progress of winter monies and system resilience.

8.4 On 29 November UCL Partners hosted a Quality Forum on behalf of BHRUT and North East London Foundation Trust (NELFT). The forum focused on the work we are doing locally on frail elderly to reorganise care and build capacity for innovation and improvement in the local system.

8.5 On 2 December I attended a Health Education North Central and East London (HE NCEL) and

UCL Partners jointly held event focused on emergency and urgent care where activities all partners are undertaking to improve care across the system were discussed.

9.0 Equalities 9.1 There are no equalities implications arising from this report.

10.0 Risk 10.1 There are no risks arising from this report.

32

ITEM 3.1 To: Meeting of NHS Barking and Dagenham Commissioning Group Governing Body From: Sharon Morrow, chief operating officer Date: 28 January 2014 Subject: Governing body risk assurance framework report Executive summary This report outlines the key risks to the clinical commissioning group (CCG) in achieving its corporate objectives that have been escalated to the governing body assurance framework (GBAF). The GBAF has been reviewed and the key risks to the CCG, aligned to the corporate objectives, are as follows: 1. Inherited PCT continuing health care (CHC) assessment backlogs and delays 2. Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) emergency care

performance 3. Quality monitoring of care home concerns 4. Concerns with provider data 5. Transition of GP contracts to NHS England and delegation of unanticipated responsibilities. Although the key risks remain the same as last time in September 2013 the severity of the risk rating for some of the risks has decreased. Although the risks related to BHRUT has increased given their move into ‘special measures’ as shown at appendix 1 and 2 in the governing body assurance framework and summary. The Borough and locality risk registers are now well established with the locality risks feeding into the Borough risk register. A risk report is presented to our CCG Executive Committee meetings, with significant risks escalated through to the GBAF. Our internal auditors, Baker Tilly carried out a review of our governing body assurance framework, in July 2013 to assess the effectiveness of the controls we have in place to manage the framework. The majority of the recommendations have been implemented and are reflected in appendices 1 and 2. Recommendations The governing body is asked to: • Note and comment on the current risks escalated to the GBAF and levels of assurance in the

controls and mitigating actions being taken • Note that the recommendations from our internal auditors review of our GBAF have been

implemented to improve the process and effectiveness of the GBAF. 1.0 Purpose of the report

33

1.1 The purpose of the GBAF is to outline the strategic risks to the CCG in achieving its corporate objectives and the controls in place to provide assurance. This report presents the current high level risks to the organisation detailed within the GBAF.

2.0 Background/Introduction 2.1 The CCG’s governing body has a responsibility to maintain sound risk management and ensure

that internal control systems are appropriate and effective. 2.2 The CCG has established both locality and borough risk registers. The locality risk registers are

reviewed monthly with the clinical director of the locality and updated. Appropriate risks are then fed into the borough risk register which are also reviewed monthly. A report is then presented at our Executive Committee meetings. Based on criteria set out in the risk management framework and the current risk rating, significant risks are escalated from the borough risk register to the GBAF where appropriate.

2.3 The strategic risks have been aligned to the corporate objectives and are shown in the GBAF and

the summary at appendices 1 and 2. The GBAF summary details for each risk, the initial risk rating at the start of the financial year, the subsequent risk ratings presented to each governing body meeting and include the year end forecast and the target risk level that the CCG is aiming to achieve.

2.4 Our finance and delivery committee and our quality and safety committee also review our risks

and assurances as relevant and suggest recommendations to the risk lead to ensure our risk management and GBAF process is robust and effective.

3.0 Report content 3.1 The CCG risk register consists of risks that are local to the borough and risks that the CCG has in

common with its collaborative partners, Havering and Redbridge CCGs. The register is reviewed as outlined above within in the borough and the common risks are reviewed across the three CCGs via discussion at the joint management team meeting each month. The risk register informs the GBAF presented at appendix 1.

4.0 Current risks on the GBAF 4.1 There are currently five risks that have been escalated to the GBAF. Please refer to appendix 1

for the full details. These fall under three of the six corporate objectives (COBs) and are as follows:

COB 3: Continue to focus on the development and success of our new organisation – our members, governing body and staff. Risk 3.2: Operational pressures on CCG GP members due to the transition of GP contracts to NHS England and some issues with resolving issues affects focus on/delivery of QIPP. Delegation of unanticipated functions to CCGs from NHSE impacts on existing scarce CCG resources – staff and finance. Mitigation: Working closely with NHSE and establishing regular arrangement for two way dialogue on issues. The CCG is in close liaison with our CSU to identify contract management resource to manage the contracts in order to deliver QIPP. Joint meetings with NHSE primary care lead and improved engagement and communication with clusters. Risk 3.3: Commissioning organisations are not able to run patient level validations for the first quarter to validate non contract activity which will present a financial risk

34

Mitigation: Our current control is we have issued instructions to the CSU not to pay un-validated invoices. Where we have a contract we will pay in line with the contract and monitor activity. Where there is no contract we will develop an alternative validation process. Until the process is developed we will not pay the invoices. Formal contract notices, challenges and claims letters have been issued on existing contracts. We implemented a project to enable the CCG to attain accredited safe haven (ASH) status which was achieved in October 2013. The new validation system is now being developed which will enable us to run patient level validations. COB 4: Improve the quality of care from all the services we commission Risk 4.1: Continuing health care assessments – ongoing backlog and delays. Mitigation: Weekly monitoring of North East London Foundation Trust (NELFT) rectification plan continues. External investigation completed and presented at the quality and safety committee on 9th January 2014 for decision and approval of the recommendations for improvement. Formal review of operating processes with a view to transferring functions to Barking and Dagenham, Havering and Redbridge (BHR) CCGs. Weekly monitoring continues by the management team and a CHC executive meeting has been established with the first meeting held on 3 January. Risk 4.2: Quality assurance of care in care homes – process for monitoring contracts not yet finalised. Mitigation: Escalation to CSU leads, nurse director and team working with CSU to prioritise and identify the process and nurse directorate meeting with care quality commission (CQC) and dealing with any immediate risks. The quality reporting metrics have now been finalised and are being implemented. There is a plan in place for local quality visits to all nursing care homes across BHR CCGs in conjunction with the local authority and Barking and Dagenham visits have commenced. COB 5: Failure to deliver quality improvement in urgent and emergency care at BHRUT. Risk 5.1: Continued concerns with urgent and emergency care at BHRUT - risks to patient care and viability of trust. Mitigation: Revised governance and performance management arrangements as agreed at all BHR CCG governing body meetings. Arrangements approved by NHS Trust Development Agency (NTDA). NHS E updated and informed. CCGs progressing local improvements to increase access to primary/out of hours care. System wide priorities agreed at urgent care board. BHRUT is being held to account through weekly performance monitoring meetings reporting to our CCG governing body, quality and safety committee and CCG executive committee. A revised draft improvement plan and trajectory which is aligned to winter monies is being implemented. The CQC inspection has been completed and the trust put into ‘special measures’ with a paper on this being presented to this governing body meeting.

5.0 De-escalated risks from the GBAF The following risk has been removed from the GBAF as the risk to the organisation has reduced significantly with the rating reduced from 12 (likely 3 x severity 4) down to 3 (likely 1 x severity 3) Risk 3.1: Specialised commissioning costs – impact on CCG running costs and financial risk.

35

This issue had been raised with NHS England (NHSE) and BHR CCGs’ chief finance officer (CFO) leading the process with London CFOs to ensure robust system for agreeing costs and has agreed a reconciliation process. Agreement has been reached with NHS E and the other London CCGs on the opening adjustments. The original gap of £18m across BHR CCGs has been reduced to £4.4m and the in year exercise to ensure the budget and actuals are in the correct place is continuing.

6.0 Internal Audit Review of the GBAF

Our internal auditors, Baker Tilly, (formerly RSM Tenon), assessed our GBAF and risk management framework in July 2013 to ascertain that the appropriate controls are in place to effectively manage the GBAF. To provide assurance to the GB of the efficacy of the controls indentified to mitigate the principle risks that threaten the achievement of our strategic objectives. The auditors, in an advisory capacity, put forward a number of suggested changes and amendments for the CCG to consider in developing its GBAF document and process further. The CCG has implemented the majority of the recommendations and these are reflected in the GBAF and summary at appendices 1 and 2.

7.0 Resources/investment 7.1 There are no additional resource implications/revenue or capital costs arising from this report.

The cost of operating effective risk management arrangements has been met from within existing resources.

8.0 Equalities 8.1 There are no equalities considerations arising from this report. 9.0 Risk 9.1 This paper relates directly to risk. The key risk to making this process work well is a lack of

engagement and over-complication. This is being mitigated by good support from the corporate team, closely linking with the borough teams. This report also links to the following GB papers also being presented at this January meeting:

• Continuing healthcare development plan and assurance report • Urgent care board and winter resilience • The CQC and special measures at BHRUT

Attachments:

1. Governing body assurance framework 2. Governing body assurance framework summary

Author: Pam Dobson, deputy director, corporate services, BHR CCGs Date: 20 January 2014

36

1 3.1.2_Apendix 1_B&D GBAF January 2014_v0.1

Appendix 1 – Barking and Dagenham CCG Local objective 3: Continue to focus on the development and success of our new organisation – our members, governing body and staff

Ris

k R

ef

Lead

D

irect

or

Risk Description

Initial Risk

Rating (June 13)

Controls Assurances I = internal

E = external

Current risk

rating

Gaps Proposed

actions

Target Risk – 1/4/14 Control Assurance

3.2 SM

Issue: Changes in NHS system regarding primary care and concerns from practices regarding responsibilities and engagement with NHS England (NHSE), and proposed delegation of responsibilities to CCGs for a number of unanticipated areas. Risk: financial and operational pressures on practices associated with the transition of GP contracts to NHSE will impact adversely on practice engagement in QIPP delivery The key risk is that we will fail to deliver our QIPP plan as a result of the issues. Delegated responsibilities that are unplanned for, and without budget/ resources will add to pressure on current budgets and workforce.

Like

lihoo

d (3

) x

Impa

ct (5

) = S

ever

e 15

1. CCG assurance meetings

with NHS England (NHS E) where a number of concerns have been raised.

2. Discussion at London CCGs

Chief Officer meetings

3. NHSE attendance at our joint executive meetings (JET)

4. Proactive communication to

practices about respective roles and responsibilities of CCG and NHS England. • Day to day support to CCG

practices with signposting to NHSE (or to CCG) dependent on responsibility.

• Cluster/locality and practice engagement on QIPP schemes

.

1. Minutes and feedback

from assurance meetings. (E)

2. Minutes and feedback

from assurance JET (I)

3. Minutes and feedback from pan London CCGs meetings (E)

4. Communication to

practices – monthly newsletter. (I)

Like

lihoo

d (3

) x Im

pact

(2) =

Med

ium

6

1. Joint meetings with NHSE Primary Care Commissioning lead.

2. Joint meeting with

NHS E Primary Care Lead at senior level with the Chief Operating Officers across BHR CCGs for common issues

For both controls Minutes and feedback from meetings.

Initiate monthly meeting/ teleconference with NHSE Primary care Commissioning Lead by end of February 2014

Like

lihoo

d (1

) x Im

pact

(3) =

Low

3

37


Ris

k R

ef

Lead

D

irect

or

Risk Description

Initial Risk

Rating (June 13)


E = external

Current risk

rating

Gaps Proposed actions


3.3 MS

Commissioning organisations are not able to run patient level validations for the first quarter to validate non contract activity which will present a financial risk

Like

lihoo

d (3

) x

Impa

ct (5

) = S

ever

e (1

5)

1. We have issued instructions to the CSU not to pay un-validated invoices. Where we have a contract we will pay in line with the contract and monitor activity.

2. Where there is no contract we will

develop an alternative validation process and will not pay the invoices until the process is developed.

Issued formal contract notices, challenges and claims letters on existing contracts

Formally written to non-contracted activity providers if cannot provide validation information we will not pay the invoices

3. Agreed a quarterly close down

process with main providers BHRUT and NELFT

4. Project commenced to achieve

accredited safe haven (ASH) status which will enable us to receive patient identifiable data

5. Agreed process for non contract

invoicing developed and has commenced.

1. A regular weekly report is being

developed with the CSU to report on the progress. (I)

2. The audit committee will be

updated on performance to only pay validated invoices. (I)

3. CFO will review the outcome

of the 1st quarter for effectiveness. (I)

4. Achieved accredited safe

haven (ASH) status in October 2013 (E)

5. New documentation for the agreed process to ensure compliance with the information requirements received (contractual and non-contractual). (E)

Like

lihoo

d (3

) x

Impa

ct (3

) = H

igh

(9)

6. Redesign of our existing contractual invoice validation process in line with the received new documentation

1. A regular

report will be produced for the audit and governance committee to monitor progress

1. Develop/redesign

contractual validation process to enable us to receive patient identifiable data by 28 February 2014

Like

lihoo

d (1

) x

Impa

ct (3

) = L

ow (3

)

38


Collaborative objective 4: Improve the quality of care from all the services we commission

Ris

k R

ef

Lead

D

irect

or

Risk Description

Initial Risk

Rating (June 13)


E = external

Current risk

rating

Gaps Proposed

actions

Target Risk

– 1/4/14 Control Assurance

4.1 JH

A backlog of continuing health care (CHC) reviews and outstanding initial assessments, inherited from the PCT, does present a clinical and financial risk to the CCG.

Like

lihoo

d (4

) x

Impa

ct 4

) = s

ever

e 16

1. Escalation to the CCG

accountable officer and managing director of the CCU

2. Detailed action plan signed off

by the CCG.

Additional team to deal with the business as usual work (care brokerage) managed by the BHR CCGs

Programme Board established and weekly project group meetings to monitor progress

Fortnightly reporting presented to the BHR CCGs Joint management team meeting

3. Extra resource to ensure the

project plan is implemented effectively

4. Governance and escalation

framework in place

1. Minutes of the fortnightly CHC

executive meetings (I) 2. Plan presented to our joint

management team (JMT) and quality and safety committee (Q&SC) (I)

3. Minutes of our finance and

delivery committee (I) 4. Minutes of the quality and

safety committee (I) For all controls: • Bi-monthly report to the

governing body (I) • Monthly report on progress,

issues and risks to the BHR CCGs audit and governance committee (I)

• Weekly reports showing

movement and progress to reduce the back log to Nurse Director (I)

Like

lihoo

d (4

) x

Impa

ct 4

) = S

ever

e 16

5. Broadcare data to

be validated 6. Review of the

financial impact via our commissioning support unit (CSU).

5. External CHC

review commissioned and recommendation agreed on 9th January 2014

6. Minutes of contract

monitoring meetings (I)

The recommends from the external review to be implemented by 31 March 2014

Like

lihoo

d (1

) x

Impa

ct (2

) = L

ow 2

NB: The continuing health care development plan and assurance report on the governing body agenda relates to this assurance.

39


R

isk

Ref

Lead

D

irect

or

Risk Description

Initial Risk

Rating (June 13)


E = external

Current risk

rating

Gaps Proposed actions


4.2 JH

Issue: Quality Assurance process of care homes (related to process of quality monitoring of all providers) Risk: as the CCG has not inherited a robust system for assuring quality of all providers the risk is that there is not a culture of sound monitoring. Li

kelih

ood

(3)

x Im

pact

(5) =

Sev

ere

(15)

1. Quality assurance framework

for self assessment developed 2. 6 weekly meetings between the

nurse director and the CQC regional manager

Monthly meetings between the deputy nurse director and CQC inspectors

3. Implement quality assurance

performance framework 4. Action plan developed to quality

assure care homes 5. Strengthened collaboration with

the local authority

1. Feedback intelligence from

nurse director meetings (I)

Self assessment tool submitted to CSU (E)

CSU analysis and report to BHR CCGs quality and safety committee (I)

2. Cross referencing with CQC

reports (E)

Alignment with quality surveillance groups (E)

3. JMT and Q&SC (I) 4. Summary report of serious

incidents presented to Q&SC (I) 5. Safeguarding adults board (E)

Like

lihoo

d (3

) x

Impa

ct (4

) = M

ediu

m (1

2)

6. Unable to assure achievement of quality metrics until metric reporting completed

Project plan in place to develop metrics and reviewed weekly at CHC project group meeting

7. Hold quality

review meeting with individual provider where shown to be a ‘red outlier’ by the KIPs/Dashboard.

6. Report from CSU

due 31 March 2014 (E)

7. Minutes of the

quality review meetings with providers (I)

Formal escalation to CSU director of contracting and quality. Formal escalation through our JMT

Like

lihoo

d (1

) x

Impa

ct (

3) =

Low

(3)

40


Collaborative objective 5: Improve the performance of urgent care and emergency care, with a particular focus at BHRUT

Ris

k R

ef

Lead

D

irect

or

Risk Description

Initial Risk

Rating (June 13)


E = external

Current risk

rating

Gaps Proposed

actions

Target Risk – 1/4/14

Control Assurance

5.1 AS

Failure to deliver quality improvement in urgent and emergency care at BHRUT could: 1. Threaten the

long-term validity of the Trust

2. Put patients at risk, cause reputational damage and delay the implementation of acute reconfiguration programmes

3. BHRUT raised potential overnight closure of KGH to address safety and resource issues at Queens Hospital

Like

lihoo

d (4

) x

Impa

ct (

4) =

Sev

ere

(16)

1. Agreed BHRUT

improvement plan with TDA/ NHSE monitoring of the plan via the weekly emergency care standards performance group (ECSPG)

2. Tri-partite Panel (NHSE /

TDA / Monitor) reviews progress each week

3. Contractual meetings –

SPR / CQRM – and levers used fully

4. Monthly Strategic review meetings with senior leadership for overarching assurance and escalation of risk

5. Urgent Care Board focused on six priorities for action, A&E recruitment, 7 days working, urgent care centres, joint discharge, primary care support and frail elders

− Winter plan with additional resource agreed and invested on priority areas

6. Daily Dashboard reviewed by CCG during winter

1. Minutes of the weekly

ECSPG (E)

2. Minutes of Tri-Partite Panel escalation meetings (E)

3. Minutes of contractual

meetings – SPR / CQRM (I)

4. Minutes of strategic

review meeting (I)

5. Minutes of the monthly

urgent care board (I) 6. Weekly performance

reports (I) Li

kelih

ood

(5)

x Im

pact

(4)

= S

ever

e (2

0) 7. Special

Measures Governance, arrangements and support to be finalised

7. Updated improvement Plan, associated governance and performance trajectory

(NB turnaround Director appointed)

Continued liaison with NHS England and TDA to agree arrangements and leading role for CCG by

Like

lihoo

d (4

) x

Impa

ct (

3) =

Hig

h (1

2)

41


NB: The urgent care board and winter resilience paper and the CQC and special measures at BHRUT paper on the governing body agenda relate to this assurance. De-escalated risk: Local objective 3: Continue to focus on the development and success of our new organisation – our members, governing body and staff

Ris

k R

ef

Lead

D

irect

or

Risk Description

Initial Risk

Rating (June 13)

Controls Assurances Current

risk rating

Gaps

Proposed actions


3.1 MS

Issue: Central allocation funding issue / specialised commissioning The specialised commissioning group (LSG), using a set of specified identification rules (IR), agreed the transferred activity and cost with NHS provider trusts Risk: Since the exercise started (December 2012) there have been unexplained changes to the LSG calculations resulting in potential additional financial pressure to CCG

Like

lihoo

d (3

) x

Impa

ct (5

) = S

ever

e (1

5)

1. Chief finance officer (CFO) attending weekly London wide CFO/DOF group targeted at specialist commissioning to set up reconciliation process.

2. CCG budget position assumes a

cost neutral position between activity taken out of contracts and funding transferred to NHS England.

3. Analysis of the monthly acute

data set via the commissioning support unit (CSU), to ensure specialist commissioning activity is not included

4. Reconciliation and consolidation

process agreed

For all controls • Bi monthly review at finance

and delivery committee (I) • Issue discussed within the

finance paper presented to the governing body (I)

• Regular review of progress

at contract monitoring meetings (I).

Like

lihoo

d (1

) x

Impa

ct (

3) =

Low

(3)

• As NHS England has the allocations routed through them, they can withhold the disputed element.

• Output of

reconciliation and consolidation process due 30 September

• CFO

continues to lead process across London to ensure robust process to agree current costs

Like

lihoo

d (1

) x

Impa

ct (

3) =

Low

(3)

Key: Lead Directors MS – Martin Sheldon, Chief finance officer SM – Sharon Morrow, chief operating officer AS – Alan Steward, chief operating officer JH – Jacqui Himbury, Nurse Director

42


43


44


How to interpret the CCG governing body assurance framework (GBAF):

Risk refThis is a risk identifier attributed to the risk by the CCG risk lead

Lead directorThis is the executive lead with responsibility for:- managing the risks to the corporate objectives and- liaising with the risk lead to ensure the GBAF is up to dateReporting 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 GBAF.- 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 descriptionFor 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

ControlsWhat is being done to reduce the likelihood and severity of the risk.One specific risk may be mitigated by a number of controls

AssuranceAssurances are inevitably ‘bits of paper’ that act as evidence the controls are in place. Examples include:Job descriptions /organisation chartsRegular reportsContracts / service level agreementsPolicies and proceduresMinutes / agendas / terms of reference

Gaps in controlsWhat more can be done to control the risk and what controls could be improvedGaps in assuranceWhat 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

Risk Ref

Lead Director

Risk Description

Initial Risk

Rating (June 13)

Controls Assurances Current

risk rating

Gaps Proposed

actions

Target Risk – 1/4/1

4

Control Assurance

3.3 MS


15 • Our current control is we have issued instructions to the CSU not to pay un-validated invoices. Where we have a contract we will pay in line with the contract and monitor activity.

• Where there is no contract we will develop an alternative validation process. Until the process is developed we will not pay the invoices.

• A regular weekly report is being developed with the CSU to report on the progress.

• The audit committee will be updated on performance to only pay validated invoices.

15 • A detailed process for non contract invoicing requires urgent development.

• A regular report will be produced for the audit and governance committee

• Develop new validation process

3

45

Appendix 2

3.1.3_Appendix 2_B&D GBAF summary_January 2014_v0.1 1

NHS Barking and Dagenham CCG Governing Body Assurance Framework - Overall Summary

Lead

GBAF Ref. Risk Description

Initial Risk Rating

(June 2013)

Current risk Rating End Year Forecast Target risk

level September 2013

January 2014

March 2014 This time Last Time

MS

3.1 (4)

De-escalated: Central allocation funding issue / specialised commissioning unexplained changes to the LSG calculations resulting in potential additional financial pressure to CCG

Possible (3) x Severe (5) = Extreme (15)

possible (3) x Severe (5) = High (15)

Rare (1) x Moderate (3) = Low (3)


Possible (3) x Severe (5) = Extreme (15


SM 3.2 (21)

Financial and operational pressures on practices associated with the transition of GP contracts to NHSE will impact adversely on practice engagement in QIPP delivery. The key risk is that we will fail to deliver our QIPP plan as a result of the issues.



Possible (3) x Minor (2) = Medium (6)


Possible (3) x Major (4) = High (12)


MS 3.3 (22)



Likely (4) x Severe (5) = Extreme (20

Possible (3) x Moderate (3) = High (9)


Possible (3) x Moderate (3) = Medium (9)


JH 4.1 (2)

A backlog of continuing health care reviews and outstanding initial assessments, inherited from the PCT, does present a clinical and financial risk to the CCG.

Likely (4) x Major (4) = Severe (16)



AMBER net Unlikely (2) x Minor (2)= Medium (4)

Rare (1) x Minor (2)= Low (2)

Rare (1) x Minor (2) = Low (2)

JH 4.2 (10)

Assurance process of care homes (related to process of quality monitoring of all providers) as the CCG has not inherited a robust system for assuring quality of all providers the risk is that there is not a culture of sound monitoring.

Posible (3) x Severe (5) = Extreme (15)



Unlikely (2) x Minor (2)= Medium (4)

Rare (1) x Minor (2)= Low (2)


AS 5.1 (13)

Failure to deliver quality improvement in urgent and emergency care at BHRUT



Likely (4) x Severe (5) = Extreme (20




NB: risk register reference is denoted in brackets ( )

Risk Summary Number

Total risks last report 6 New risks added 0 Risks de-escalated 1 Total GBAF risk this report 5

46


ITEM 4.1 To: Meeting of the Barking and Dagenham Clinical Commissioning Group Governing

Body From: Sharon Morrow, Chief Operating Officer Date: 28 January 2014 Subject: Strategic and Operational Planning 2014 - 2019 Executive summary

The purpose of this report is to provide the Governing Body with:

• A briefing on the strategic and operational planning process following the release by NHS England on 20 December 2013 of Everyone Counts: Planning for Patients 2014/15 to 2018/19

• Update on proposed governance through the BHR Integrated Care Steering Group to co-ordinate the strategic planning process on behalf of the Coalition/BHR system.

• Description of proposed content of operating plan and Better Care Fund plan in advance of first submission of both on 14 February for agreement in principle.

Recommendations The Governing Body is asked to:

• Note the briefing on the strategic and operational planning process for 2014/15 to 2018/19 • Approve the proposal to use the Integrated Care Steering Group to co-ordinate the strategic

planning process on behalf of the Coalition/BHR system. • Agree headline content of the Operating Plan and Better Care Fund Plan in advance of first

submission.

1.0 Purpose The purpose of this report is to update the Governing Body on the development of the CCG

strategic plan, operating plan and Better Care Fund Plan following the publication of national planning guidance on 20 December 2013.

2.0 Background

Prior to the formal guidance being issued on the 20 December, NHSE had advised CCGs of the outline planning requirements which included a five year strategic plan at BHR level and two year operating plans (supported by detailed financial plans) at CCG level.

The Integrated Care Coalition has been identified as the local vehicle for driving an ambitious five year plan forward. The BHR Integrated Care Steering Group has been used to take forward

47

2

system wide discussions on the planning process, including the co-ordination of the Better Care Fund Plan (previously known as the Integration Transformation Fund).

NHSE colleagues attended the BHR Integrated Care Steering Group in December and an outline strategic plan based on the local work that has taken place over the last two years was discussed along with and how NHSE might be better engaged with our local system. Leads from primary care, public health and specialised commissioning attended and lead details for engagement at borough and Health and Well Being Board level are being identified through this route.

3.0 Introduction

This report includes: o a briefing on the strategic and operational planning process following the release on 20

December 2013 of Everyone Counts: Planning for Patients 2014/15 to 2018/19 o a proposal to use the BHR Integrated Care Steering Group to co-ordinate the strategic

planning process on behalf of the Coalition/BHR system o a description of proposed content of operating plan and Better Care Fund plan in advance

of first submission of both on 14 February for agreement in principle.

4.0 Everyone Counts: Planning for Patients 2014/15 – 2018/19

4.1 Everyone Counts: Planning for Patients 2014/15 – 2018/19 was released on 20 December 2013. It builds on the 2013/14 planning guidance and sets out a framework within which commissioners need to work with partners in local government and providers to develop strong, robust and ambitious five year plans to secure sustainable high quality care for all.

4.2 A full version of the guidance can be found at (http://www.england.nhs.uk/wp-

content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf). A summary briefing is attached in Appendix 1.

4.3 The implications of the guidance are still being worked through but the following is evident from

an initial review: a) The strategic direction of the BHR plans, supporting governance framework and the initial

development of the Better Care Fund plans are consistent with the aims, framework and service characteristics set out in the planning guidance. A draft BHR Strategic Headline plan on a page (Appendix 2) co-produced with the BHR Integrated Care Steering Group and NHS England in December prior to the formal release of the planning guidance demonstrates this.

b) It is clear, however, that further work is required to strengthen the improvement in

outcomes expected as a result of the changes being made (work to date has focussed on the activity and financial impact).

c) Further consideration should be given to stronger citizen engagement as we move into

this next phase (taking into account initial feedback from local Call to Action responses); extending the scope of integrated care at the same time reviewing how we align the frailty and end of life programmes, and implement new clinical leadership and accountability models (for example in regard to changes in the GP contract securing specific arrangements for all patients aged 75 and over to have an accountable GP and for those who need it to have a comprehensive and co-ordinated package of care. CCGs are expected to provide additional funding to practices for this with practice plans being

48

http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf

3

complementary to the Better Care Fund. There is an expectation that similar arrangements will apply to an increasing number of people with long term conditions in future years); and the use of personal health budgets and technology as enablers to the changes.

d) The guidance calls for the development of new models of primary care, which are more

proactive, holistic and responsive particularly for frail older people and those with complex health needs. There have been some initial local discussions on the development of a primary care improvement programme.

e) Whilst the BHR Urgent Care Board (UCB) operates largely as described in the guidance,

a review of membership in the 2014 is proposed. The UCB will need to ensure there is a refresh of plans before summer 2014 and reach agreement on investment plans to be funded by the retained 70% from the application of the marginal rate rule.

f) Procurement plans for urgent care will also need to take account of the national work to

develop a new specification for NHS111 g) The BHR CCGs will need to work closely with Specialised Commissioning to understand

the local implications of the developing national strategy.

5.0 Co-ordination of strategic planning process

The five year strategic plan is seen as the starting point for the whole planning process. Given the role of the Integrated Care Coalition and the work it has already set in train, it was agreed at its meeting on 10 January that the Coalition will lead the process and formally delegate authority to the BHR Integrated Care Steering Group to co-ordinate on its behalf the production of the five year strategic plan with changes to terms of reference and membership.

5.1 B&D local arrangements for development of operating plan and Better Care Fund Barking and Dagenham CCG is required to submit a two year Operating Plan and (with LBBD) the Better Care Fund plan first draft submission on 14 February. The Health and Wellbeing Board is required to sign off the Better Care Fund draft plan at its February meeting. The final submission for both of these plans is 4 April 2014.

Work has been ongoing on both, cognisant of the need to align this work to wider system strategic plan development described above. The Integrated Care sub-group of the Health and Wellbeing Board has been overseeing the development of the Better Care Fund for Barking and Dagenham.

5.2 Operating Plan

5.2.1 Taking the planning guidance into account, the emerging priorities for Barking and Dagenham CCG’s two year operating plan are summarised below:

Priority Proposed Changes

Integrated care

• Implement Integrated Care Strategy. Better care through - Joint Assessment and Discharge, Integrated Health and Social Care Teams, frail elders and falls prevention. Better care in nursing homes and at end of life.

49

4

• Further focus on integrating mental and physical health services

• Better Care Fund as key tool to support integration

Urgent care • Implement urgent care strategy - people seen at the right place first time, improved access to primary care, changes to walk in centres and more effective hospital based urgent care/A&E services.

• Improved access to mental health urgent care services

Planned care

• Improved productivity in elective care

• Care as close to home as possible, better join up between primary care, community care and hospital care, getting the right tests/right care first time.

Primary care improvement

• Take forward a primary care improvement plan focused on setting quality standards and improving outcomes at practice, locality and CCG level

• Support primary care provider development in line with NHSE England “Call to Action” transformation plans

Children and young people

• Joint planning and commissioning services for children with Special Educational Need and Disability including: Education, Health and Care Plan (EHCP) and personal budgets

• Improving children’s mental health through implementing Children’s Improved Access to Psychological Therapies (IAPT)

• Quality improvements to the maternity pathway and the care of women with complex social factors

Learning disabilities and mental health

• Implementation of the Winterbourne concordat and the development of a Section 75 for learning disabilities service with LBBD

• Ongoing focus on meeting access and recovery rate improvement for Improved Access to Psychological Therapies (IAPT)

• Implementation of the mental health tariff in shadow form

• Improved dementia diagnosis rates and access to memory clinics

Cancer • Early detection – particularly lung cancer in B&D

• Improved screening

• Improved primary care management at end of life (Macmillan GPs)

• Better post-treatment pathways

5.2.2 In completing the two year operating plan, work is ongoing to:

50

5

• complete the development of QIPP savings and associated modelling

• agree the level of aspiration against the measures set out in Appendix 1 – in particular the 7 ambitions which are both challenging but deliverable.

• continue to engage with stakeholders on priorities and aspirations. A stakeholder engagement event, hosted by Healthwatch, was held on the 16th January to engage with patients and the public on operating plan and Better Care Fund priorities.

5.3 Better Care Fund 5.3.1 The Better Care Fund plan is required to set out overarching integration aims and objectives of

the plan along with a description of how those aims and objectives will be met and the impact of changes on acute providers. The following aims and objectives and change schemes are proposed as follows:

Aims and objectives Planned changes to deliver

• Delivery of the Integrated Care Commissioning Strategy.

• Integrated Health and Social Care working that improves arrangements for admission avoidance and discharge

• Supporting a joint and strengthened commissioning role with provider services

• Improvements in primary care improving access to support and interventions in people’s own homes with less reliance upon acute services.

• Improvements in prevention, keeping people well and healthy for longer and protecting support for carers.

• Improving End of Life Care which enables greater numbers of people to be effectively cared for at home or in the place of their choice.

• Protecting Social Care Spending and services.

• Commission a Joint Assessment and Discharge service within the acute setting

• Implementation of 7 day working across health and social care

• Enhancement of integrated care clusters following testing of Intensive Rehabilitation Service and Community Treatment Team services and concurrent productivity improvements in use of intermediate care beds

• Integration of mental health social worker support into integrated health and social care teams

• Development of integrated health teams and consolidation of long term conditions services

• Further development of year of care funding model

• Implementation of pooled budgets and a detailed joint commissioning plan with appropriate joint commissioning support arrangements

• Delivery of improved pathways and delegation for access across the system

• Greater integration of dementia services and community equipment

• Supporting carers • Supporting end of life care including

through training initiatives

5.3.2 Alongside the promotion of integration through the creation of a pooled budget there will be a strong focus on performance against agreed outcomes measured by the following metrics with levels of aspiration to be set locally:

51

6

• Delayed Transfers of Care; • Reducing avoidable emergency admissions; • Effectiveness of reablement; • Admissions to residential and nursing care; • Patient and Service User experience – to be locally agreed • Locally identified metric

5.3.3 Further work is needed to agree whether funds over and above those stipulated in the guidance could be included in the fund. Governance arrangements for the management of the pooled budget in 2015/16 through section 75 arrangements will need to be determined. In 2014/15, funds will be transferred through S256 agreements and an element of the NHS to social care transfer in year 1 has been identified to support preparation for full pooling of the BCF.

6.0 Resources/investment

The CCGs financial allocations were issued alongside the planning guidance. The Barking and Dagenham financial plan is being refreshed to take into account the planning guidance and forecast full year spend on 13/14 budgets. A more detailed briefing is in the finance report.

7.0 Equalities There are no specific equalities implications within this progress report although individual strategy areas either have or will need to assess impact on equalities.

8.0 Risk 8.1 Due to the late publication of the planning guidance, the timescale for completing the strategic

and operating plan within the national timescales in challenging, in particular the interface with NHS England commissioning plans, QIPP and contract negotiations with providers. A proportion of the Better Care Fund in 15/16 will be performance related and there is a risk that if outcomes are not achieved then funding will be removed from the local health and social care system.

Attachments: 1. Summary of the Strategic and Operational planning process for 2014 to 2019.

2. The system narrative ‘plan on the page’ that was submitted on the 18 December 2013.

Author: Sarah D’Souza/Gemma Hughes, Senior Locality Lead – Planning and Integration

Date: 14 January 2014

52


Appendix 1 –Everyone Counts: Planning for Patients 2014/15 to 2018/19 NHS England published Everyone Counts: Planning for Patients 2014/15 to 2018/19, the new planning guidance for NHS organisations. The document describes NHS England’s ambition for the NHS over the years ahead. It describes a series of changes to the way health services are delivered that NHS England considers are required to deliver improved outcomes within the resources that will be available to the NHS.

Part 1: Our ambition The first section of the document:

• Sets out vision: high quality care for all, now and for future generations

• Reiterates the 5 domains of outcomes to be delivered for patients (in turn delivering the Government’s mandate)

• Translates those into a set of 7 practical measurable ambitions which describe the progress we want to see in delivering

• Identifies a further 3 vital measures

• Signals 6 patterns of service/characteristics, emerging from early Call to Action work, identified as necessary to deliver transformation

• Identifies 4 essential elements for delivery of service

Domains/Improvement outcomes Measurable ambitions Vital measures

Prevent people from dying prematurely, with an increase in life expectancy for all sections of society

Make sure those people with long term conditions, including mental health, get the best possible quality of life

Ensure that patients are able to recover quickly and successfully from episodes of ill health or following an injury

Ensure patients have a great experience of all their care

Ensure patients in our care are kept safe and protected from avoidable harm

Securing additional years of life for the people of England with treatable mental and physical health conditions

Improving the health related quality of life of people with one or more long-term condition, including mental health conditions

Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital

Increasing the proportion of older people living independently at home following discharge from hospital

Increasing the number of people having a positive experience of hospital care

Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community

Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care.

Improving health, which must have just as much focus as treating illness. NHS England will work closely with Public Health England (PHE) at a national level to ensure that the key elements of Commissioning for Prevention are delivered and at a local level all stakeholders should work on improving health through Health and Wellbeing Boards (HWB).

Reducing health inequalities, to ensure that the most vulnerable in society get better care and better services, often through integration, in order to accelerate improvement in their health outcomes.

Moving towards parity of esteem for mental health, making sure that the NHS is just as focused on improving mental as physical health and that patients with mental health problems don't suffer inequalities, either because of the mental health problem itself or because they then don't get the best care for their physical health problems.

Delivering transformation/characteristics of sustainable health and care systems • New approach to ensuring that citizens are fully included in all aspects of service design and change and that patients are fully empowered

in their own care

• Wider primary care, provided at scale

• A modern model of integrated care

• Access to the highest quality urgent and emergency care

53

8

• A step-change in the productivity of elective care

• Specialised services concentrated in centres of excellence

Essential elements: access, quality, innovation, value

Part 2: How we are going to achieve these ambitions This section sets out the proposed planning process which aims to take a longer term view of planning than previous approaches. The table below summarises the key elements:

Plans required Due date for submission

Level and Lead Requirements Assurance lead

5 year Strategic Plan First draft 4/4/14

Final submission 20/6/14

(Years 1 and 2 fixed per the final operating plan submitted on 4/4/14)

BHR system

Proposed: Integrated Care Coalition lead with co-ordination delegated to Integrated Care Steering Group

At CCG level co-ordinated by Director of Strategic delivery/PMO

Sets vision, ambitions and framework against which operational and financial planning will be determined. Whole system needs to buy into plan.

The plan should be short and focussed, and describe to those outside the system, what the system plans to achieve in a way that informs and engages.

Detailed template provided (see below) that requires:

-system narrative plan on a page and

-organisation specific key highlights

It will be tested against the characteristics described above

NHSE Regional Team

Operating plan First draft 14/2/14

Refresh post contract sign off 5/3/14


CCG level

Lead: Chief Operating Officer

The operational plan will include the key operational metrics needed to support the assurance of, and measure performance against, strategic plans. It will be structured around 4 headings:

-outcomes

-NHS constitution

-Activity

-Better Care Fund

Detailed template provided to CCGs

NHSE Area Team

Better Care Fund Plan First draft 14/2/14


Health and Well Being Board

Detailed template provided, Plan will need to show how it meets national condition.

Ministers, NHSE Area Team, LGA

Financial plan First draft 14/2/14

Refresh post contract sign off 5/3/14


CCG level

Lead; BHR CCGs CFO

Will provide detailed financial breakdown of each plan, and be explicit in dealing with any financial gap.

Detailed template and assumptions provided to CCGs

NHSE Area Team

Direct Commissioning Plan

NHSE area Team NHSE will produce strategic and operational plans for services they commission on the same basis as CCGs.

NHSE Regional Team

The planning guidance is accompanied by a suite of support tools intended to assist commissioners with

their planning considerations to maximise the best possible outcomes for their local communities.

54

Appendix 2 – System narrative – Plan on the Page (submission 18 December)

55


56

ITEM 4.2 To: Meeting of NHS Barking and Dagenham Clinical Commissioning Group

Governing Body From: Martin Sheldon, Chief Finance Officer, BHR CCGs Date: 28 January 2014 Subject: 2014/15 Contracting Round

Executive summary

This paper sets out the current progress with the negotiation of the contracts for which the BHR CCGs are the host in the 2014/15 round. Progress in broadly in line with plan with minor delays in the baseline setting process and with preparation and agreement of CQUINs and Quality Requirements.

2014/15 Contract Round Plan

The contract round plan can be presented in a number of stages each of which will need to be completed in order for agreement to be reached on the contracts for the next financial year. There are more detailed plans behind each of the large stages identified below. These detailed plans form the basis of the planning for the negotiations between the providers and the CCG that is acting as the host commissioner for all CCGs across London for that contract.

The governance arrangements for the negotiation round have been agreed and are in place with regular Contract Negotiation Steering Group meetings taking place where progress against plan for each of the negotiations is monitored. Key critical path items are identified within the plan for each provider and escalation steps have been identified in the event that these are not delivered in line with plan to ensure that the negotiations progress to a successful conclusion. Negotiation meetings have been scheduled for each of the BHR hosted providers and these meetings have commenced. The recent decision by the NHS TDA to place BHRUT in special measures may influence the commissioners’ approach to the negotiations. The key stages of the negotiations are listed below with current status identified for each of the provider contracts.

57

BHRUT NELFT PELC Baselines First cut baselines showing the

impact of the revised tariffs for 2014/15 on the unadjusted activity for the first six months of the year has been completed. This is being adjusted for known elements before sharing with the provider.

Block contract arrangement in 2013/14 so baseline not required.

Block contract arrangement in 2013/14 for Out of Hours Baseline being set based on projections for 111 and UCC

QIPP / CIP CCG QIPP schemes are being developed to identify activity transfers expected and consequent financial impact. CIP schemes to be provided by providers.

Acute Productivity Metrics Productivity metric proposals shared with CCGs for review and agreement. Definitions and methodology being shared with provider w/c 13th January.

Not applicable

Quality Requirements (KPIs) KPI long list shared with CCGs for review and agreement before issuing to provider as part of negotiations.

NELFT KPI being worked up in technical and quality work-streams with CCG input to inform first draft.

PELC current KPI set being reviewed

CQUINs Local CQUINs initial proposals developed through workshop. With CCG currently for review and agreement.

NELFT further development through Quality work-steam of CQUIN.

PELC proposal to incentivise UCC activity being developed with CCG

Information Requirements Refresh to reflect PBR changes underway and resultant draft to be shared with CCGs.

NELFT being reviewed through Technical work-steam

Activity Planning Assumptions These will be developed as outputs of the productivity metrics, adjustments to baselines and non PBR pricing

NELFT baselines being set. PELC 14/15 proposals being developed

58

BHRUT NELFT PELC elements of the negotiations.

Non PBR Pricing (e.g. pathway tariffs)

Pricing will be part of the negotiations around trust implementation of pathways of care (e.g. ambulatory care, cardiac rehab, etc.) and any additional services being implemented.

NELFT non-tariff MH values being negotiated. Intent to explore non-block payment in part for CHS signaled to provider

Expected Contract Value (LTFM) Triangulated from the baseline, QIPP, metrics, and pricing adjustments against the CCG affordability.

59

1. Summary

The contract negotiations are currently progressing broadly to plan. There has been a slight delay in issuing the first draft baseline / impact of tariff changes for BHRUT as a result of late amendments to the tariff. This is now completed and the adjustments for non-recurrent items and adjustments relating to a successful / agreed challenges / claims are being made before this is shared with the Trust week commencing 13th January. KPIs and CQUINs for BHRUT are in draft stages and currently with CCGs for review and agreement before being issued to providers in the negotiation process. NELFT KPIs are with Quality work-stream to develop options with view to short list proposals. Productivity metrics have been assessed by the CSU on behalf of CCGs using national peer groups and benchmark data to evaluate likely improvements and financial consequence. These are with CCGs currently for review and agreement before being introduced into the negotiations with BHRUT. Non PBR pricing will be raised with providers as appropriate as part of the challenge around block elements of the existing acute provider contract and various cost and volume services under consideration. The information requirements schedules in the contracts are being refreshed currently to reflect the PBR changes this year and additional requirements as a result of new CQUINs or KPIs being introduced.

2. Actions

The Governing Body is asked to note the progress report and status of the key elements of the negotiations to date and a further update will be presented to the March governing body meeting

Martin Sheldon, Chief finance officer

22 January 2014

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ITEM 5.1 To: Meeting of Barking & Dagenham Clinical Commissioning Group Governing Body From: Sharon Morrow, Chief Operating Officer Dr Jagan John Date: 28 January 2014 Subject: Development of Intermediate Care Services Executive summary This paper provides an update on the progress of the development of a new model of intermediate care for the Barking and Dagenham, Havering and Redbridge (BHR) economy. It provides an overview of the trial of the expanded Community Treatment Team (CTT) and new Intensive Rehabilitation Service (IRS) and their performance since services commenced in November 2013.

It details the comprehensive engagement work which has taken place since November and provides an overview of the key themes to inform further development of the model.

It recommends that following the completion of the trial period in March 2014 that the CCGs continue to commission the trial of CTT and IRS with a view to gathering further evidence on service effectiveness and finalising the proposed model of intermediate care in 2014/15. Agreement is sought from the Governing Body for this recommendation. Recommendations Based on the performance of the IRS and CTT services and the outcomes from the engagement work to date, it is recommended that:

1. The CCG continues to commission the trial of CTT and IRS 2014/15 with a view to: - reviewing the model in year following further evidence regarding service effectiveness

and development of plans to improve links with social care; - finalising the proposed model of intermediate care in partnership with the local authority, and; - consulting on any significant service changes for 2015/16.

Agreement is sought from the Governing Body for this recommendation.

In agreeing the above, CCGs can be assured that:

1. Service performance, and more specifically, King George Hospital acute hub pathways and activity will be monitored via the weekly performance dashboards and through local intermediate care development project groups, and the local Integrated Care Steering Group (subgroup of HWBB) in B&D.

2. Contract Key Performance Indicators (KPIs) will be revised in line with the Better Care Fund and with a specific focus on outcomes.

3. The activity modelling for CTT (new referral to follow up ratio) will be revised in line with the audit findings of 1 new referral:3 follow up contacts on average (modelled 1:6) and that released capacity is transferred to new patient referral activity.

4. In line with feedback from engagement work, to continue with further focussed communications regarding the new service and model and to feedback formally regarding service performance and effectiveness.

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1.0 Purpose of the Report

This paper provides an update on the progress of the development of a new model of intermediate care for the BHR economy. It provides an overview of the trial of the expanded Community Treatment Team and new Intensive Rehabilitation Service and their performance since commencement November 2013.

2.0 Background

In September 2013, CCG Governing Bodies approved the trial of a community model for the provision of intermediate care. The trial, to run November 2013-March 2014, included the establishment of a new home based intensive rehabilitation service (IRS) and expansion of Community Treatment Team (CTT) to establish a new service in Redbridge and operate 8am - 10pm in all three boroughs. It was agreed the trial would ‘double run’ with the existing community bed based intermediate care services to provide opportunity to test the effectiveness of the new model and to ensure the continuity of service provision was not adversely impacted upon during the trial period. These developments are a key part of the delivery of the agreed Integrated Care programme, and are therefore a key component of the strategy to reduce pressure and reliance on the acute hospital, building local community service infrastructure to deliver care closer to home in the BHR economy. The trial of the new model of intermediate care therefore demonstrates good progress in delivery of this strategy. Given this, CCGs working with Local Authorities are considering the use of the Better Care Fund to ensure the financial sustainability of these services.

The position of intermediate care in each individual CCG prior to the trial was varied, fragmented and inconsistent. The community treatment team has been in operation in Barking and Dagenham and Havering since January 2013 (8am-8pm/7days). This service was established through redirection of existing investment in rapid response and the primary care discharge facilitation team, to complement the Integrated Case Management planned care approach, providing an urgent care response and avoidance of inappropriate hospital admission. No such service was in operation in Redbridge prior to the trial. There was an overreliance on institutional (bed based) services with respect to rehabilitation in all three boroughs.

The approval of the trial was subject to two conditions: 1. That intensive engagement with service users and the public would be undertaken during

the trial period to understand their experience of the new services and thoughts on the proposed model

2. That a follow up paper was submitted to Governing Bodies in January 2014 providing early messages from this engagement work, oversight of performance of the new services, and recommended next steps following the trial.

This paper will detail the above.

3.0 Trial of expanded Community Treatment Team and new Intensive Rehabilitation Service From November 2013 the new Intensive Rehabilitation Service rolled out across the three BHR boroughs and the Community Treatment Team expanded to establish a new service in Redbridge and began operating 8am - 10 pm in all three boroughs. These services are provided by North East London Foundation Trust (NELFT).

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The CTT provides short term intensive, urgent care and support to people experiencing health and/or social care crisis to help them be cared for in their own home, rather than be referred to hospital.

The CTT works with, and complements, the Integrated Case Management planned care approach, providing the urgent care response and pathway for these patients as well as out of hours cover. The CTT also provides early supported discharge, supporting people to return home as soon as possible following an acute/community inpatient stay where this is required/appropriate. The CTT is the single point of access to the rehabilitation pathway, navigating patients to intensive rehabilitation or a bed in a community inpatient unit as is most appropriate for their needs.

The Intensive Rehabilitation Service aims to provide an alternative to community bed rehabilitation to enable the support of people in their own homes as appropriate. Intensive, in home support is provided by the team with between one and four visits per day depending on the needs of the patient. The team works closely with CTT and the community bed inpatient units to ensure a smooth and seamless patient journey to recovery. The service is open 8am-8pm, seven days a week and is accessed via CTT.

Three project groups (one per borough) were established to set up and oversee the new services and included representation from NELFT, each BHR CCG and the local authorities to ensure clear, integrated pathways with social care. Social care engagement and integration is key to providing holistic care to support people to stay at, or return home. At present there are different models of operation in each Borough. In Barking and Dagenham, an arrangement of delegated authority to arrange/restart care packages within an agreed limit is in place. Havering local authority currently provides funding for social workers as part of the CTT. In Redbridge, there are agreed pathways in place to access social care support. The merits of each approach are subject to ongoing discussion as a component of the trial, with cross borough learning and feedback being shared via project groups.

In order to understand service performance and effectiveness, comprehensive monitoring reports were developed to capture CTT and IRS performance. NELFT submits these reports weekly to the CCGs. In addition, a retrospective audit to review two weeks of CTT referrals was completed to capture additional information regarding activity modelling, acuity and service effectiveness. A summary of the performance of both services is detailed below.

Community Treatment Team Performance data to 29/12/13 identifies that the service is currently achieving target for new referral performance year to date (YTD) with 4423 referrals received by the service against a target of 3463. The Queen’s acute hub and community spoke are consistently over performing against new referral targets week on week. Additional service demand above the anticipated target is currently being offset by follow up contact activity, the ratio of which is less than originally modelled (see audit findings below). Further work is required to embed pathways to CTT in the KGH acute hub.

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Service performance is summarised as below:

Queen’s Acute Hub

KGH Acute Hub

Community Spoke

Total YTD

New referral target

1092 62 2309 3463

Achieved YTD 1723 9 2691 4423

Note: KGH Acute Hub has only been operational since November 2013, whereas Queen’s Acute Hub is more established with CTT operational since January 2013

- The Queen’s acute hub has received 1723 new referrals YTD against a target of 1092.

The service is averaging 47 referrals per week YTD against original modelling of 28.The data supports the view that that the pathway to CTT within Queen’s is well established and well utilised.

- The community spoke is also performing well against target for new referral activity, with 2691 referrals YTD against a target of 2309. The service averaged 123 referrals per week November-December against a target of 73. For Redbridge, the newest service established, the majority of referrals received to date have been from GPs, followed by friend/family/carers. 214 Redbridge patients have been referred YTD, with utilisation circa that of Havering and B&D at the same phase of implementation. To continue to embed and increase the use of the Redbridge service, further targeted communication and promotional activities are scheduled in January 2014 which include visits to specific nursing homes and GPs.

- For the period November-December, underutilisation of the KGH acute hub is evident in performance data with 9 referrals YTD against a target of 62. Feedback indicates there may be several reasons for this variance. A recent review of the patient cohort attending this site identified that many were children or adults presenting acutely unwell. NELFT is therefore considering a focus on early supported discharge on this site and has based a senior member of staff on the KGH site with a view to relationship building and to embed pathways to CTT both within A&E and the wards. In addition, during the winter period where pressure may be evident in other parts of the system e.g. Queen’s acute hub or community spoke, NELFT is utilising the KGH hub staffing resource flexibly in order to meet this demand.

- 94% of patients that utilise CTT are aged 65+ - Strong pathways have been established with LAS to divert patients to CTT, where

appropriate since November, averaging 12 referrals per week over the last five weeks. - To date, 76%1 of people seen in the acute hub do not go on to be admitted to hospital

and 93% of people seen in the community remain at home. This means that more people are being cared for in the community and at home and are not being admitted to hospital unnecessarily.

- 92% of staff are currently in place, with rolling recruitment programme in place to appoint to those posts still outstanding

A retrospective audit to review two weeks of CTT referrals was completed to capture additional information regarding activity modelling, acuity and service effectiveness. Key findings from the audit are as follows: - Patients referred to CTT by a professional tend to self-refer back to the service or have

a carer refer them on the second occasion - Service activity was initially modelled on an assessment to follow up ratio of 1:6. The

review identified that in current practice this is too high with a majority of patients seen/stabilised on a 1:3 ratio.

1 Note that in some cases a decision to admit had already been made prior to a referral to CTT and the referral was made by

BHRUT with a view to therapy assessment to support this admission. As of Dec 13, data is now being specifically collected and

monitored on the above.

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- 60% of the patients referred were managed successfully within 72 hours. - The number of interventions per visit shows a high number of interventions carried out

on average in both the initial assessment appointment (six interventions) and follow up with an average of five interventions. The acute hub carried out fewer interventions when compared to the community spoke as many were already completed by A&E prior to referral. This high level of intervention per appointment confirms that the service is seeing patients with complex needs and co-morbidity.

In 2014/15, it is anticipated this service would contribute to the Better Care funding ambitions to: - reduce the amount of time people spend avoidably in hospital through better and more

integrated care in the community, outside of hospital. - increasing the number of people with mental and physical health conditions having a

positive experience of care outside of hospital, in general practice and the community Intensive Rehabilitation Service Trial of the new intensive rehabilitation service went live in all three CCGs from November 2013 allowing people to be rehabilitated at home rather than in a non acute bed. Performance data to 22/12/13 indicates: - All boroughs are achieving target for new referrals to date: B&D 15 against a target of

10, Havering 24 against target of 18, Redbridge 14 against a target of 14. - Good evidence of referrals to the service to ‘step down’ from acute/community beds and

‘step up’ from the community and prevent hospital bed admission. - Data indicates that all patients referred to date have been seen/transferred within 48

hours, this is in line with transfer rates for non acute beds. - Improvement in patient outcome scores is being measured routinely for the service,

however at this stage of service implementation it is not possible to provide a commentary on this metric. This should be available as more people complete their treatment with the service.

- Rolling recruitment programme in place, current staff in place to meet demand In 2014/15, it is anticipated this service would contribute to the Better Care funding ambitions to: - reduce the amount of time people spend avoidably in hospital through better and more

integrated care in the community, outside of hospital. - increasing the proportion of older people living independently at home following

discharge from hospital. - increasing the number of people with mental and physical health conditions having a

positive experience of care outside of hospital, in general practice and the community.

Non Acute Beds

- During the winter pressure period, there is evidence of improved performance with respect to non acute bed utilisation. 8 additional ‘winter pressure beds’, which opened at the end of December 13, are currently in use within the system. This is in significant contrast to the same time last year when 32 additional beds were commissioned to meet demand from October 12 to April 13. In addition, demand for inpatient rehabilitation is less than was predicted as being required through winter pressure capacity modelling (11 on average). The capacity and approach provided through IRS and CTT, and additional productivity improvement implemented in year, are arguably offsetting additional winter demand.

- Data on non acute bed performance to the 26/12/13 identifies that referral to transfer rates continue to meet the 72 hour target (43 hours on average).

- Significant improvement in quality and productivity has been achieved through 2013/14 within the three inpatient unit sites. As of quarter three, average length of stay has improved to 18 days (baseline av 29 days 2012/13) across the three sites, in line with national guidance (21 days). The capacity of IRS to support discharge from the non

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acute beds and provide intensive rehabilitation at home, and the support offered through CTT to avoid admission at the front end of the pathway has arguably contributed to this improvement.

In addition, to the service specific performance and benefits detailed above, there are arguably a number of other benefits which have been realised through the course of these developments including: - Improved information available to commissioners to measure and track progress - Improved working relationship between commissioners/provider established through

engagement in a co-development approach to development of the new model - The BHR health and social care system being in a stronger position this winter with

regard to capacity and joint working arrangements. 4.0 Service User Engagement

The agreement by Governing Bodies in September 2013 to the trial of the expanded CTT and new IRS was conditional on the understanding that intensive engagement with service users and the public would be undertaken during the double running period. Each CCG undertook comprehensive engagement of potential service users, and those who had been supported by the CTT and IRS. This engagement, sought to understand patient views about the proposed model and their experience of using the new services to inform further development. Engagement was jointly undertaken by NELFT and the BHR CCGs. Engagement work is summarised as follows: - NELFT Patient Engagement Forum - Exit surveys completed by patients who have been through IRS and CTT services - Patient satisfaction survey - Follow up phone calls to patients post discharge from IRS/CTT- a standardised ‘script’

was used to elicit information regarding patients’ experience of the new services - CCG Patient Engagement Forums in each of the three boroughs - Healthwatch public workshops in each of the three boroughs

4.1 Overview of engagement outcomes

A total of 123 people have been engaged during November/December 13, using the different methods detailed above, to understand their thoughts about the proposed model/services and experience of using the new services (where applicable). This included 18 people from Barking and Dagenham, 50 from Havering, and 55 from Redbridge. The Healthwatch workshop took place in Barking and Dagenham 16 January 2014, and hence participant numbers for this session are not included in the above. From the engagement work five key themes have emerged: 1. Support for the new services and model All those asked were overwhelmingly positive about the new services and model being trialled. People were particularly supportive of the focus on home based treatment and care. ‘A really good thing and a very good idea’ ‘Everybody wants to go home from hospital - as soon as they are ready and able to’ ‘Sounds like a great idea in principle’

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‘I couldn’t have got a better service if I went private’ 2. Operational detail Participants were keen to understand the operational detail of the new services such as the referral process and criteria and how to make sure the right people use the right services at the right time (avoiding inappropriate cases). Participants also wanted to understand how many people could be seen by the service and the detail regarding the numbers, and training, of staff available to support them. Joint working together with other services was also considered key. Participants responded positively to discussion regarding engagement with social care to date. Participants were assured by the detail and responses provided by NELFT presenters regarding the operational detail of the new services and model. 3. Sustainability Many participants raised concern about the trial nature of the new services with no guarantee of further funding and expressed some scepticism regarding the ability to deliver the service as described. 4. Communication/publicity Participants were keen to ensure that all those who may benefit from support of the new services were made aware of them and how they could be accessed and made some helpful suggestions to feed into future communication regarding the new services and model. 5. Monitoring and review Participants were clear that the purpose of the trial of the new model and services was to ‘test’ the approach and services with a view to developing an evidence base and refining/developing the services and approach. Weekly performance dashboards to capture service performance effectiveness and outcomes were discussed and participants responded positively to the focussed emphasis on patient experience of the new services. Participants were keen to have future updates regarding service performance and effectiveness. 4.1.1 Patient experience of the new services As a component of the engagement work focussed strategies were undertaken in order to understand the experience of patients who had actually used the new services. Patients expressed a high level of satisfaction for both CTT and IRS, scoring CTT an overall average of 9.5/10 and scoring IRS an overall average of 9.6/10. All were supportive of the services offered and 100% of patients were likely to recommend it to others, saying without it they would have ended up being admitted to hospital or in A&E. For those patients that accessed CTT, conditions such as shortness of breath, musculoskeletal/pain, and falls were the most common. Those that had used CTT made particular comment about feeling the service was responsive, efficient and provided them with the right type of care. ‘ Excellent level of care, efficient’ ‘Level of care, got everything needed’ ‘Response, level of care’

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Only one comment was received about how the service could be improved, this centred on communication if visits were delayed. For those patients that accessed IRS, post-surgical support, falls/fractures was the primary reason for access. Those that had used the service made particular comment about the supportiveness, approachability and reliability of the staff, and positive outcomes achieved. ‘Felt free to say what I wanted and speak freely with the physiotherapist. Felt it was a better service to receive treatment’ ‘Found it to be very intensive treatment. When physiotherapists attended appointments they always attended when arranged and were extremely nice’ ‘Patient getting about now, and able to go up and down the stairs, can go the length of his footpath and manage a big step with little difficulty, something he could not do previously’ ‘Gave her back a lot of confidence’ ‘Husband felt he would not have been able to cope. Classed the persons giving the service as lifesavers’ As with CTT, patients were generally satisfied with the service, however when asked how the service could be improved a couple of patients commented about the duration of the service and wanting some further treatment. These comments will be picked up via local project groups to ensure clarity in the service average length of treatment requirement and ensure interface with generic therapy support should longer term treatment be required.

5.0 Recommendations

Based on the performance of the IRS and CTT services as detailed above and the outcomes from the engagement work to date, it is recommended that: 1. The CCGs continue to commission the trial of CTT and IRS 2014/15 with a view to: - reviewing the model in year following further evidence regarding service effectiveness

and development of plans to improve links with social care; - finalising the proposed model of intermediate care in partnership with the local

authority, and; - consulting on any significant service changes for 2015/16.

Agreement is sought from the Governing Body for this recommendation.

In agreeing the above, CCGs can be assured that: 1. Service performance, and more specifically, King George Hospital acute hub pathways

and activity will be monitored via the weekly performance dashboards and through local intermediate care development project groups, and the local Integrated Care Steering Group (subgroup of HWBB) in B&D.

2. Contract Key Performance Indicators (KPIs) will be revised in line with the Better Care Fund and with a specific focus on outcomes

3. The activity modelling for CTT (new referral to follow up ratio) will be revised in line with the audit findings of 1 new referral:3 follow up contacts on average (modelled 1:6) and that released capacity is transferred to new patient referral activity

4. In line with feedback from engagement work, to continue with further focussed communications regarding the new service and model and to feedback formally regarding service performance and effectiveness.

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6.0 Finance

Arrangements for the ongoing commissioning of the trial of CTT and IRS will be picked up via the NELFT contract negotiation process depending on the Governing Bodies decision. Given this work is a core priority of the Integrated Care Strategy overseen by the Integrated Care Coalition, CCGs working with Local Authorities are considering the use of the Better Care Fund to ensure the financial sustainability of these services.

6.0 Risk Failure to agree to the ongoing commissioning of the trial may result in reputational risk to the CCGs given the high level support and patient satisfaction reported via the engagement work to date.

Attachments: 1. Intermediate Care Patient Engagement Report- January 14 2. Healthwatch Redbridge Report- December 13 3. Healthwatch Havering Report- December 13 4. Healthwatch Barking and Dagenham Report to be tabled

Author: Tara-Lee Baohm, Strategic Delivery Project Manager Andy Strickland, Head of Communications Date: 21st January 2014

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Development of intermediate care services Engagement report Barking and Dagenham, Havering and Redbridge (BHR) CCGs are working closely with health and social care partners, including the three local councils, providers and clinicians, to improve how intermediate care is provided and delivered. This involves putting people at the heart of service delivery, and ensuring they receive the best quality care, experience and outcomes by caring for them in their own homes or closer to home, shifting activity away from hospitals and into the community. In order to provide patients with the best care and support, from November 2013 – April 2014, two new or expanded intermediate care services are being trialled for a six month period:

• community treatment team (CTT)

• intensive rehabilitation at home

BHR CCGs’ governing bodies agreed to the trial of new services on the condition that intensive engagement with service users and the public would be undertaken during the trial period. As a result, each CCG undertook comprehensive engagement of the public, patient representatives, and those who had been supported by CTT or IRS. This engagement sought to understand people’s thoughts about the proposed model and their experience of using the new services to inform further development. The public, patients and patient representatives were spoken to to find out what they think of the new services provided. A total of 123 people were engaged with during November/December 2013, to understand their thoughts about the proposed model/services and experience of using the new services (where applicable). This included 18 people from Barking and Dagenham, 50 from Havering, and 55 from Redbridge. (The Healthwatch workshop took place in Barking and Dagenham on 16 January 2014, and participants’ numbers for this session are not included in the above). Engagement was jointly undertaken by NELFT and BHR CCGs to find out what the public, patients, carers and patient representatives think about the new services. Their thoughts and whether their needs have been met will be key when considering how to take forward any further development of intermediate care services. Engagement involved a number of different methods: Phone interviews Thirty patients or their representatives were interviewed about their experience of the new services – ten patients from each borough, five from each service. Patients were selected at random, and the interviews, undertaken by NELFT staff, took place in the first two weeks of December 2013 following their discharge from the service. The following questions were asked:

1. How did you come to know about this service? 2. How quick was the service in responding to you? 3. What do you think was best about the service? 4. How do you think we could make it better? 5. On a scale of 1-10 how satisfied were you with the service – 1 being not satisfied, 10 being

very satisfied. Can you explain why you chose that? 6. What do you think would have happened if you didn’t get support from the service?

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7. Would you access this service again? Recommend this service to a friend or family member? Patient engagement forums Each of the three boroughs held a patient engagement forum to engage with patients and patient representatives about the new services. NELFT staff and clinical staff presented on the changes and answered questions from the forum members. Healthwatch workshops Each of the three boroughs has an active Healthwatch organisation and each was commissioned to host a workshop on improving intermediate care services through the trial of new services, in partnership with their local CCG. Attendees included the public, patients, patient group representatives and local councillors. The meetings were promoted by Healthwatch through their usual stakeholder networks with support from the CCGs. The workshops involved a presentation on the trial of the new services, and a question and answer session with NELFT staff. The Redbridge workshop had 25 attendees and the Havering workshop had 35. N.B. a workshop in Barking and Dagenham is scheduled for 16 January. Patient satisfaction surveys Upon discharge, patients from each borough and across both services, were asked to fill in a short patient satisfaction survey asking them questions such as ‘how likely are you to recommend our service to friends and family if they needed similar care or treatment?’ along with questions about waiting times, being treated with dignity and respect and being communicated with in a confidential manner. Every patient will be asked to complete the survey when they are discharged for the rest of the trial period. Summary of findings All those asked were overwhelmingly positive about the new services being trialled and five key themes have emerged:

1. Support for the new services and model

All those asked were overwhelmingly positive about the new services and model being trialled. People were particularly supportive of the focus on home based treatment and care. ‘A really good thing and a very good idea’ ‘Everybody wants to go home from hospital - as soon as they are ready and able to’ ‘Sounds like a great idea in principle’ ‘I couldn’t have got a better service if I went private’

2. Operational detail

People were keen to understand the operational detail of the new services such as the referral process and criteria and how to make sure the right people use the right services at the right time (avoiding inappropriate cases). They also wanted to understand how many people could be seen by the service and the detail regarding the numbers, and training, of staff available to support them. Joint working together with other services was also considered key and discussion regarding engagement with social care to date was responded to positively. Forum and workshop participants were assured by the detail and responses provided by NELFT presenters regarding the operational detail of the new services and model.

3. Sustainability

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Some people raised concerns about the trial nature of the new services, with no guarantee of further funding, and expressed some scepticism regarding the ability to deliver the service as described.

4. Communication/publicity

People were keen to ensure that all those who may benefit from support of the new services were made aware of them and how they could be accessed and made some helpful suggestions to feed into future communication regarding the new services and model.

5. Monitoring and review

People were clear that the purpose of the trial of the new model and services was to ‘test’ the approach and services with a view to developing an evidence base and refining/developing the services and approach. Weekly performance dashboards to capture service performance effectiveness and outcomes were discussed and participants responded positively to the focussed emphasis on patient experience of the new services. People were keen to have future updates regarding service performance and effectiveness.

Borough-specific feedback Barking and Dagenham

“I couldn’t have got better service if I went private’ Asking people from Barking and Dagenham about CTT, they gave an average satisfaction rate of 9.2 out of 10, saying that without the CTT service they would have gone to A&E or been admitted to hospital. Respondents were extremely likely (60%) or likely (40%) to recommend the CTT service to friends and family.

‘The support was friendly and it was easy to consult with the physiotherapists. Felt it was a good service. When agreed appointments were made they were kept and always on time’

Asking people from Barking and Dagenham about IRS, they gave an average satisfaction rate of 9.5 out of 10. Comments included that they were very satisfied and had no trouble with the service and that they felt the service suited the needs required. 100% of patients were responded to within 24 hours. Attendees at the patient engagement forum were extremely positive, but wanted to see the services promoted more widely so the right people were referred to it and inappropriate cases were avoided. N.B. Barking and Dagenham Healthwatch workshop is scheduled for 16 January. Havering

‘Level of care, got everything I needed’ Asking people from Havering about CTT, they gave an average satisfaction rate of 10 out of 10, saying that without the CTT service, they would have gone to, or been readmitted to hospital and their health would have deteriorated. Respondents were extremely likely (80%) or likely (20%) to recommend the CTT service to friends and family.

‘The physiotherapist and occupational therapists were very caring and helpful’ Asking people from Havering about IRS, they gave an average satisfaction rate of 9.6 out of 10. Comments included that they found the IRS team to be more supportive, could not praise them more, and felt they did all they could. 60% of Havering IRS patients were responded to within 24 hours and 40% within 48 hours.

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Attendees at the patient engagement forum were very positive about the services, but wanted to make sure that staff had the appropriate skills and capacity, and that the service ran at the right times for patients. The Healthwatch workshop attendees felt the introduction of the services were long overdue and saw them as a positive step, but that it was important to involve social care colleagues, communicate about the service and clarify the referral criteria. Redbridge

‘Excellent level of care, efficient’ Asking people from Redbridge about CTT, they gave an average satisfaction rate of 9.2 out of 10, saying that without the CTT service, they would have been admitted to hospital, or gone to A&E. One respondent felt nothing would have happened. 100% of respondents were extremely likely (80%) or likely (20%) to recommend the CTT service to friends and family.

‘The service was all good, found nothing to complain about’ Asking people from Redbridge about IRS, they gave an average satisfaction rate of 9.6 out of 10. Comments included that they were very satisfied, got back their confidence and ‘so far so good’. 80 of patients were responded to within 24 hours and 20% within 48 hours. Attendees at the patient engagement forum were positive about the services, raising issues regarding communication, quality and responsiveness, continuity of care, self-referral and patient choice. One member noted that she has two patients who were picked up by the team and have already benefitted from these services, meaning admission to hospital was avoided. The Healthwatch workshop attendees wanted to see the service promoted, and asked about staffing, continuity of care, how the services work with the community and voluntary sectors and the referral process. Service-specific feedback CTT Patients expressed a high level of satisfaction for CTT, scoring it an overall average of 9.5/10. All were supportive of the services offered and 100% of patients were likely to recommend it to others, saying without it they would have ended up being admitted to hospital or in A&E.

For those patients that accessed CTT, conditions such as shortness of breath, musculoskeletal/pain, and falls were the most common. Those that had used CTT made particular comment about feeling the service was responsive, efficient and provided them with the right type of care.

‘Excellent level of care, efficient’

‘Level of care, got everything needed’

‘Response, level of care’

Only one comment was received about how the service could be improved, this centred on communication if visits were delayed.

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IRS Patients expressed a high level of satisfaction for IRS, scoring IRS an overall average of 9.6/10. All were supportive of the services offered and 100% of patients were likely to recommend it to others, saying without it they would have ended up being admitted to hospital or in A&E. For those patients that accessed IRS, post-surgical support and falls/fractures were the primary reasons for access. Those that had used the service made particular comment about the supportiveness, approachability and reliability of the staff, and positive outcomes achieved.

‘Felt free to say what I wanted and speak freely with the physiotherapist. Felt it was a better service to receive treatment’ ‘Found it to be very intensive treatment. When physiotherapists attended appointments they always attended when arranged and were extremely nice.’ ‘Patient getting about now, and able to go up and down the stairs, can go the length of his footpath and manage a big step with little difficulty, something he could not do previously’ ‘Gave her back a lot of confidence’

As with CTT, patients were generally satisfied with the service, however when asked how the service could be improved a couple of patients commented about the duration of the service and wanting some further treatment. These comments will be picked up via local project groups to ensure clarity in the service average length of treatment requirement and ensure interface with generic therapy support should longer term treatment be required. Next steps The trial of the services continues until the end of March. Patients, public, patient representatives, and those who had been supported by CTT or IRS will continue to be surveyed using a number of different methods to make sure we understand what they think about the new services and what their experience has been like. What they say about the services and whether their needs have been met will be key when considering how to take forward intermediate care services.

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Care Closer to Home Integrated Care in Redbridge

Healthwatch Redbridge December 2013

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2

This report is available to download from our

website, in plain text version, Large Print, and can be made available in Braille

or audio versions if requested.

Please contact us for more details. www.healthwatchredbridge.co.uk

020 8553 1236 [email protected]

If you have a Smart Phone©, scan here to go to our website.

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http://www.redbridgelink.net/


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‘Care Closer to Home’ Integrated Care Meeting

3 December 2013 Introduction The Case for Change for Integrated Care for Barking and Dagenham, Havering and Redbridge (BHR) (August 2012) identified that too many people are being admitted to hospital for entirely preventable causes. This has resulted in an over reliance on institutional (bed based) services as the default option rather than considering individual needs, choice and ability to return home. The Barking, Havering and Redbridge University Trust (BHRUT) has more rehabilitation/reablement beds than other similar parts of the country, high occupancy and long lengths of stay. This is related to poor procedures and an inability to move service users in and out of these facilities in an appropriate and timely manner.

Healthwatch Redbridge was commissioned by Redbridge Clinical Commissioning Group (RCCG) to facilitate a workshop whereby people would be given the opportunity to find out more about the services (the Community Treatment Team (CTT) and Intensive Rehabilitation Service (IRS)) and discuss any concerns they may have.

25 people attended the event and were given the opportunity to listen to a presentation from the service provider; North East London Foundation Trust (NELFT) and to ask questions before breaking into small groups to consider a number of posed questions. Workshop After listening to a brief presentation on the proposed changes presented by Carol White, Director of Adult Services at NELFT; attendees were invited to comment on the following questions:

What do you think of the changes?

Do people want to get home quicker with the right support in place?

Do the new services sound like the right ones?

Are there any other suggestions? Summaries of those discussions are detailed on the following pages.

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4

Executive Summary: Recommendations

Redbridge Clinical Commissioning Group are recommended to:

Ensure the services are publicised and promoted through all GP Practices, Social Care Services and Community and Voluntary Organisations

Ensure appropriate levels of staffing are maintained as the service becomes more popular

Ensure that there is continuity of carers for

users to ensure they are not seeing different

faces every time

It is essential that contact with the voluntary

and community sector is part of the care

package to ensure continuity of service may

be maintained

Users of the service must be given access to

ongoing support and information in

reasonable time and not left without

appropriate service at the end of the respite

Review the pilot and provide updates to

interested organisations and individuals

Consider a further engagement event in

March 2014

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5

What do you think of the changes?

Summary: On the whole, most respondents were happy with the new services being proposed. Some felt it was too soon to know if the services would be effective but that ‘it looks good on paper’. Some raised concerns about staffing capacity and there was an assurance from both RCCG and NELFT that staff had not been recruited or transferred from existing hospital based services. They wanted to be assured that GP’s and Accident and Emergency departments were aware of the new services and understood how to access them. NELFT responded that most referrals were through local GPs, A&E admissions and via Community Teams. Few referrals were seen from patients and carers but it was hoped that the levels would improve as people began to use the service. All respondents felt there was need for more information and publicity to be made available to patients and carers. There were concerns raised when it became clear that this was a six month pilot project funded through ‘winter pressures’ money and there was no guarantee that the services would be commissioned in the future. Respondents suggested that a further meeting be held in March to update them on whether the service will continue.

Recommendations: Healthwatch would recommend that the service is promoted widely through GP Practices, Social Services, Community and Voluntary Sector organisations. Healthwatch would be pleased to assist in the design and promotion of accessible leaflets. Redbridge CCG should consider inviting respondents to a meeting in March to update them on the service.

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Do people want to get home quicker with the right support in place?

Summary: Respondents felt it important that people were treated closer to home and could definitely see the benefits of staying out of hospital when it was practicable. They wanted assurances though that the right level of support would be available further on in regards to ongoing support needs being supported adequately. Concerns were raised regarding the length of time taken for referrals for Occupational Health or equipment services. Although users of these services were given assurances that patients would receive appropriate referrals. Respondents were content that staff were available at the moment but this could be due to the service not being widely known of or used at present. They asked for assurances that staff would continue to be recruited to ensure patients were not waiting for services. NELFT confirmed that they would not sub-contract the service to other care providers; they were confident the service could be provided appropriately. They also confirmed that there will be 17 new staff for the expanded CTT and 42 new staff for IRS to ensure the service could manage calls from Redbridge, Barking and Dagenham and Havering boroughs. Recommendations: RCCG must make sure that enough staff are available as the service becomes more popular. They must also make sure that there is continuity of carers for users to ensure they are not seeing different faces every time. It is essential that contact with the voluntary and community sector is part of the care package to ensure continuity of service may be maintained. Users of the service must be given access to ongoing support and information in reasonable time and not left without appropriate service at the end of the respite.

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Do the new services sound like the right ones?

Summary: Respondents were interested to hear how the services had been rolled out in Havering and Barking and Dagenham since January this year. They were pleased to hear that the services were showing excellent results but would like to see further reviews and local reports. It was also clear that users were responding favourably. Currently 96% of users were happy with the services being provided. They also discussed the need for culturally appropriate services. RCCG responded that they would try and ensure appropriate services were available. They confirmed that translators are available via telephone if required. There were a number of staff that spoke community languages. Again, it was clear that respondents wanted to see more publicity and events (such as the one they were attending) to ensure local people were aware of the services that could be provided. Recommendations: Review the pilot and provide updates to interested organisations and individuals. Ensure stakeholders such as users and carers are kept informed of the progression of the pilot and consider holding a further engagement event in March 2014.

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Any other suggestions?

Summary: Respondents felt the changes were a positive approach to ensuring people had the right support at a critical time and could afford people the option of staying out of hospital, which was the right approach. They felt that for the changes to work in the long term, they had to be sustainable. In response to a question, RCCG confirmed that the service covered the whole of Redbridge, including patients who would use Whipps Cross Hospital. Concerns were raised regarding confidentiality and there was an assurance that all information is stored safely and that NELFT would work with what the patient wanted. It was explained that both CCT and IRS use handheld secure mobile devices therefore no information was left at the patient’s home. So far, 90% of patients seen within this service remain at home and out of hospital. Some respondents asked whether this serviced covered people with mental health (MH) conditions. NELFT replied that the service would not cover people who were presenting with specific MH conditions if was the primary reason for the call. There are home treatment teams who work in similar ways to this service but have specialist MH staff. If the patient has a health condition such as Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and Asthma for example, but also has a mental health condition; NELFT confirmed that the CCT/IRS would be available.

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Report compiled by Cathy Turland CEO, Healthwatch Redbridge December 2013 Healthwatch Redbridge 5th Floor, Forest House 16-20 Clements Road Ilford IG1 1BA

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Healthwatch Havering is the operating name of Havering Healthwatch Limited A company limited by guarantee Registered in England and Wales No. 08416383

New Services:

Putting Care Closer to Home

New intermediate care services in Havering

A workshop held by Healthwatch Havering

in partnership with Havering CCG

Wednesday 11 December 2013

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New Services: Putting Care Closer to Home

Introduction

On 11 December 2013, Healthwatch Havering held a workshop, in

conjunction with Havering Clinical Commissioning Group, to introduce the

new Community Treatment Team service being commissioned by the CCG

in association with the North East London Foundation NHS Trust.

The participants were an invited group including Members and Officers of

Havering Council, of the Clinical Commissioning Group and Directors,

Lead and Active Members of Healthwatch Havering.

This is a report of the presentation and the comments of the workshop’s

participants about what they heard.

The service proposals

This is a new community service to help people get care in their own homes rather

than in hospital.

People had said that they would prefer to be supported at home rather than stay in

hospital, where possible: hospital wasn’t always the best place to be – people could

contract infections, suffer loss of independence etc. The simple fact is that too many

people are in hospital when they don’t need to be; people are in beds when they

don’t need to be.

The plan is to trial a new service, and expand an existing service, in Havering to help

these patients.

Too many people in Havering end up in hospital when they don’t need to and are

being admitted too quickly to a hospital bed without consideration for their needs,

choice and when and how they will be able to return home.

The borough has more ‘rehabilitation’ beds than other similar parts of the country,

with too many people in them, for too long. There had been a lack of investment in

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health and social services that support people to get out of hospital and back home

sooner.

This applied generally to older people, but all adult age ranges have similar

experiences. The types of injury or illness affected include

• Injury as a result of a fall

• Dementia/delirium/confusion

• Diabetes

• UTIs - e.g. cystitis or bladder infections

• People requiring short term, intensive nursing intervention after surgery to

support their return home

• Worsening of respiratory conditions e.g. chronic obstructive airways disease,

emphysema and chronic bronchitis.

Improvements have already been made to services in 2013/14, including:

• The same admission criteria and medical cover on all sites

• Care tailored to the needs of the patient with a clear rehabilitation focus

• Moving to 7 day working for therapy teams to improve recovery times and

help people to return home sooner

• Making it easier for community services and GPs to ‘step patients up’ if they

need a period of more intense support, thereby potentially reducing the

need for going into hospital

• Improved average length of stay and transfer rates from hospital so that

people can access services more quickly

To improve things further, a new service is being trialed in Havering to provide an

expanded rapid response/community treatment team and intensive rehabilitation at

home.

The Community Treatment Team (CTT) will comprise doctors, nurses, occupational

therapists, physiotherapists, social workers and support workers, providing short-term

intensive care and support to people experiencing health and/or social care crises to

help them to be cared for in their own home, rather than hospital; and to support

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people to return home as soon as possible following a hospital/community inpatient

stay where this is required/appropriate.

The CTT will provide a single point of access to the Intensive Rehabilitation Service or

inpatient community beds if necessary.

There is no specified time limit for support from the team but most patients will be

supported for between 1 and 7 days. The CTT will operate between 8am and 10pm

seven days a week, responding to service requests within two hours.

Anyone can refer: self, family/friend/carer, GP, nursing home etc. by a simple

telephone call (to 020 3644 2799).

Complementing the CTT is the Intensive Rehabilitation Service (IRS)

This team includes nurses, occupational therapists, physiotherapists and rehabilitation

assistants. There is also access to a geriatrician through the CTT if required.

The CTT aims to provide an alternative to community bed rehabilitation and to

support people in their own homes as appropriate. It will offer an average of three

visits a day to a patient but the actual service provided will naturally vary depending

on needs of the patient.

The IRS team will work closely with CTT and community beds to ‘step people up’ and

down if required; so that, for example, if someone had been supported by IRS but

their condition worsened, they could be transferred into a community bed.

The IRS will be open 8am-8pm seven days a week and accessed through the CTT.

The aim is to provide easier access and choice about how care is received by patients

and improved patient experience. More people will receive care in their own homes

and there will be better packages of care tailored to a patient’s specific needs rather

than providing same care to all.

There will also be fewer potential risks from bed based provision e.g. risk of infection,

loss of independence etc. and a reduction in inappropriate admissions to hospital: but

it is stressed that anyone who needed a bed will still be able to have one.

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The discussion

The general view of participants was that the CTT/IRS initiative is long overdue but

that there had been a positive start. As always, communication would be the key: patients

and carers needed to know about the service and be clear about how they could access and

use it, and what its benefits would be for them. Moreover, it would be important to ensure

that carers felt supported.

The focus of the presentation was on health outcomes but it would be important to ensure

that social care was involved too. The inclusion of a social worker in the CTT was welcome

but there would need to be social care back up for people whose primary need is not medical.

There was concern about screening of service users: it would be necessary to ensure that CTT

interventions did result in greater strain on the other aspects of service, on managing clinical

need and in managing social care nor lead to an avoidable increase in the burden on social

services funding.

There was also concern that forthcoming changes in direct payments to service users could

have an unforeseen impact on the provision of the service.

The view overall, however, was that in principle the changes should provide a major

improvement to current services, provided that capacity and finance was capable of meeting

demand now and in the future.

Clarification was needed about self-referral mean. For best effect, patients, carers and

professionals needed to be informed about service and how it worked. The service number

needed to be very widely advertised, with clarity about what it is for, but protocols had to be

in place to ensure that important contact with GPs is not cut out. It was suggested that, for

Havering residents, a 01708 number should be available.

The criteria should be explained in full to the caller and then the CTT should decide who to

assist, based on those criteria. Care was needed to ensure that all available diagnostic

information was obtained during the initial call so as to avoid misdiagnoses. It would be

important to use plain language when speaking with people who had no specific medical

knowledge and to dig deeply into what they were saying in order to bring out the true facts,

without giving any impression that callers were “being a nuisance”.

It would be necessary also to overcome the developing cultural assumption that only the GP

or A&E held the answers to medical problems.

The new service would meet the need, at least in principle but only if it did not duplicate or

confuse what is there already and continued once a need had been created. Ongoing

monitoring and review would be needed and complaints dealt with quickly and effectively.

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There was agreement that there should be a further workshop event, with the same

participants, in about 6 months’ time to hear feedback from the CCG and NELFT as to

progress thus far, to review the outcomes and to consider what (if any) changes may be

required.

Specific questions and answers

Haven’t we heard all this before?

There have been similar schemes before, but this is the first time that CCGs have put these

services in place and are really committed to making it work – it is definitely not “lip service”.

How will demand be managed – what planning has been done on that?

There will be weekly and daily monitoring, peaks identified and the service will be fitted around

those times. There could come a saturation point when it will be necessary to go back to the CCGs

for more resources.

How does referral work? Can LAS refer into it? How do you know if people self-referring are doing

so appropriately?

There are close links with the London Ambulance Service, who can refer patients to CTT: there

have been referrals from paramedics/LAS already. All calls are triaged by the most senior nurse on

the team to make sure that the CTT is appropriate route for treatment. If it is not, they are told

where best to get a service elsewhere.

Are referrals coming from the Queen’s Hospital?

The IRS has had 3 referrals this week from Queens – we see that as a breakthrough.

What do A&E staff say about the service?

We’ve had referrals – they support it.

The clinical side is sorted out – how will the interface between clinical and social care be managed?

Social workers are part of the team and involved from day one so the team is working in an

integrated way

Are these teams being asked to do additional work as well as current roles?

No: they are funded as new resourced service with new funding.

It’s a good idea and everybody wants to go home from hospital quicker – but what about isolated

people - are they ready?

We work with the local voluntary sector – e.g. Age UK in Havering – to make sure that support is at

home. No one will be sent home if it is not appropriate to do so.

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Will CTT support carers to help with discharge?

A main function of the CTT is to support carers. Community pharmacy is part of the scheme too.

Our nurses are also prescribers.

What information is there for patients about treatment and care?

Self-referral care plans are signed off by the patient and family. Calls are screened by a clinician

and CTT staff are at A&E to identify appropriate patients.

Publicity is all – do GPs know about this?

Absolutely. Similar presentation events had been held for GPs to introduce the service.

Is 111 aware of the service?

Yes, it’s part of their Directory of Services.

It’s all about communication and letting people know about these services.

Many people already know about and use the service; we are seeking to roll it out more widely.

How will the service be financed? By extra resources or recycled from elsewhere?

There will be investment from CCGs to support these services.

What about mental health (MH)?

The whole concept for these services comes out of MH services at NELFT. Dementia patients get

infections which often end in A&E as they are harder to care for. Older people’s MH teams work

closely with CTT to deal with physical illness and home treatment team works around the

behavioural aspects. We support everyone, without the need to go to A&E.

What about out of hours drugs dispensing? What happens after 10pm?

The CTT is working with care homes on this. By 10pm a patient will have a care plan to cover this.

Is there a password system for house callers/security?

Yes. Protocols are in place for that.

Will the team have ID so people can be assured who they are?

Yes they will.

Are community pharmacists involved?

Yes. A pharmacist is part of the team.

Will the service go 24 hours in future?

There is no evidence showing a demand for that. The service is currently framed around the peaks

in demand.

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ITEM 5.2 To: Meeting of the Barking and Dagenham Clinical Commissioning Group Governing

Body From: Sharon Morrow Chief Operating Officer Date: 28 January 2014 Subject: Commissioning of a tier 3 weight management service Executive summary Since April 2013, the commissioning of services across the adult weight management pathway, which was formerly the responsibility of the PCT, has been devolved to the Local Authority, the CCG and NHS England.

NHS England is responsible for commissioning Severe and Complex Obesity Surgery and follow up care (tier 4). However, in order to access surgery patients must first have received a local specialist obesity service weight loss programme (tier 3). Currently, this is a gap in service across the BHR CCGs. NHS England is leading a programme of work nationally and in London to review the weight management pathway and make recommendations for the definition of Tier 3 services. This programme will take some months to report and in the interim patients who potentially could benefit from obesity surgery are not able to enter the service. It is proposed therefore that the BHR CCGs proceed to commission a tier 3 weight management service and prioritise this for investment in 2014/15. A wider project is recommended through the Health and Wellbeing Board to review local prevalence and map the obesity pathway. Recommendations The committee is asked to: • Approve the commissioning of a tier 3 weight management services • Authorise the Executive Committee to sign off the service specification and budget • Request the Health and Wellbeing Board to review the adult obesity pathway


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1.1 The purpose of this paper is to make the commissioning case for a tier three weight management service, that complies with the NHS England commissioning policy: complex and specialised obesity surgery and to seek board approval for procuring a service.

2.0 Background/Introduction 2.1 Obesity is a growing epidemic nationally and locally and reducing adult and children’s

obesity levels is a health and wellbeing priority. Obese people are more likely to have co-morbidities and they are also at greater risk of developing cancer. Their morbidity, mortality and utilisation of healthcare resources are much greater than those who are not obese.

2.2 In 2006, NICE published guidance on prevention and management of obesity and

recommended medical treatment and life style & behaviour change (through multi-disciplinary approach) as the non surgical treatment of obesity and bariatric surgery as the surgical intervention.

2.3 NICE Criteria for bariatric surgery

NICE recommends bariatric surgery as a treatment option for adults with obesity if all of the following criteria are fulfilled:

• they have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other

significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight.

• All appropriate non-surgical measures have been tried but have failed to achieve or

maintain adequate, clinically beneficial weight loss for at least 6 months. • The person has been receiving or will receive intensive management in a specialist

obesity service. • The person is generally fit for anaesthesia and surgery. • the person commits to the need for long-term follow-up.

Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate.

2.4 Since April 2013, the commissioning of services across the adult weight management pathway,

which was formerly the responsibility of the PCT, has been devolved to the Local Authority, the CCG and NHS England.

2.5 The pathway of care recommended for the management of obesity includes the following:

• Tier 1 – Primary Care and Community Advice • Tier 2 – Primary Care with Community Interventions • Tier 3 - Primary/Community Care based multi-disciplinary team (MDT) to provide weight

loss programme support • Tier 4 – Specialised Complex Obesity Services (including obesity surgery)

2.6 NHS England is responsible for commissioning Severe and Complex Obesity Surgery and

follow up care (tier 4). The NHS England Clinical Reference Group (CRG) for Severe and Complex Obesity developed the clinical commissioning policy for this service. The policy was implemented in April 2013 and is based on 2006 NICE guidance. The national position is that

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the commissioning policy, based on the NICE guidance, and the expert opinion of clinical leaders in this field should be applied as providing the best service model to deliver the best possible outcomes to patients.

2.7 Prior to April 1st 2013, Primary Care Trusts (PCTs) commissioned obesity surgery and access to

this was determined at a local level. As NICE guidance was not mandated a number of PCTs in London did not commission a tier 3 weight management service and did not specify this as a requirement for access to bariatric surgery. Now that the national commissioning guidance has been implemented this has identified a gap in service for the BHR CCGs.

2.8 NHS England has set up a national working group to review the weight management pathway

and make recommendations for the definition of Tier 3 services. The London region has also established a work stream to map weight management programmes across London, discuss collaborative commissioning arrangements with CCGs and Councils for the weight management pathway and developed proposals for addressing this. A tier 3 service model is being piloted in City and Hackney which potentially could be rolled out across London.

2.9 Should a London model be recommended for local implementation there will inevitably be a time

lag in procuring and mobilising a service which means that it will be some considerable time before any surgical treatment can commence for patients in the BHR CCGs. It is proposed therefore that the BHR CCGs plan to commission a tier 3 weight management service in advance of any national and London model being developed.

3.0 Modelling the need for a tier 3 service 3.1 Information on patterns of obesity in adults is drawn from a range of different sources, including

general practice records. In 2011, it was estimated that there were 618 people with a BMI over 50kg/m2 across the BHR boroughs (Redbridge – 237, Barking and Dagenham – 163, Havering – 218).

3.2 Referrals for bariatric surgery have increased year on year (Table 1). This number is a small

proportion of the number of people who could be eligible for surgery according to local obesity prevalence rates.

Table 1 - Number of bariatric surgery procedures by PCT

B&D Havering Redbridge Total 2008/09 20 18 25 63 2009/10 35 15 24 74 2010/11 42 32 16 90 2011/12 35 32 54 131

3.3 In order to determine future demand for a tier 3 service it will be necessary to review obesity

prevalence and also map services across the obesity pathway to ensure that appropriate interventions are available at all tiers of the pathway. Public Health input will be required to undertake a more detailed modelling exercise.

4.0 Commissioning a tier 3 service 4.1 Subject to governing body approval to commission a service, it is proposed that a small project

group is established across the BHR CCGs to take forward the commissioning and procurement of a tier 3 weight management service.

4.2 The British Obesity and Metabolic Surgery Society (BOMSS) has produced a draft

commissioning guide for weight assessment and management clinics which includes standards

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for clinical services and guidance on commissioning. Model specifications have also been developed by CCGs across the country, which may be modified for local use.

4.3 It is proposed that the project group reports to the Joint Management Team and that the service

specification and budget for 14/15 is agreed by the CCG Executive Committees 5.0 Resources/investment 5.1 The service is not currently commissioned therefore new investment is required to establish a

service. 6.0 Equalities 6.1 Subject to approval of the recommendations by the governing body an equalities impact

assessment will be undertaken prior to commissioning community based multi-disciplinary weight management service.

7.0 Risk 7.1 Obese patients who meet the NICE criteria for bariatric surgery will be unable to access the

procedure unless they have received support from a tier 3 weight management service. A delay in commissioning a service could have an adverse impact on health outcomes for this cohort of the population.

Author: Sharon Morrow Date: 18th January 2014

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ITEM 6.1 To: Meeting of the Barking & Dagenham Clinical Commissioning Group Governing Body From: Jacqui Himbury, Nurse Director Date: 28 January 2014 Subject: Continuing healthcare future options and assurance report Executive summary This report presents the outcome of the Continuing Healthcare (CHC) options appraisal that was undertaken to consider build, buy or share models that would enable CHC services to be stabilised and delivered in the immediate future to a high quality standard. The approach that was taken to conduct the appraisal is detailed, with the core principles and underpinning factors listed. A recommendation on the future model is made for the governing body to consider and agree. The monitoring arrangements for ongoing service delivery and quality improvement plans are also detailed to provide assurance that the current risks are being managed effectively and all potential new risks identified early with mitigating actions put in place where required. Recommendations The governing body is asked to: • Note current position and assurance process • Agree to option 1 as the future delivery model for continuing healthcare services.

1.0 Purpose of the Report 1.1 To seek governing body agreement to the recommendations for all patient facing continuing

healthcare (CHC) services to be repatriated to the Clinical Commissioning Group (CCG). The intention is that non-patient facing transactional functions, such as contract monitoring and invoice payments remain with the North and East London Commissioning Support Unit (NELCSU).

2.0 Background 2.1 Following the presentation of a paper to the November CCG Executive Committee it was agreed

that notice was to be given to North East London Foundation NHS Trust (NELFT) for the provision of a clinical assessment and review service for adult patients who require or are in receipt of NHS funded CHC. This included NHS funded nursing care (FNC).

2.2 It was also agreed that an options appraisal was to be undertaken that fully considered buy, build or share models and made a recommendation to the Governing Body on the way forward. The options appraisal has now been completed.

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2.3 Prior to the options appraisal being completed the scope of the service was defined, outcomes

were agreed and the required functions necessary to deliver the service were identified. The overall outcomes that we are aiming for is that patients report a positive account of their care and experience of using the service, that care is provided and put in place within twenty eight days of a potential care need being identified and that we follow the patient pathway stipulated in the National Framework for NHS Continuing Healthcare & NHS Funded Nursing Care. The service can be divided into three defined and separate functions: Clinical functions - direct patient contact to undertake assessments, reviews, care coordination and management, safeguarding and supporting patient discharge. These are commissioning functions because the assessment forms the basis for the direct commissioning of care packages. Brokerage functions - once eligibility for CHC has been confirmed, or if following a review the patients needs change, a package of individual care must be negotiated and the cost agreed with a provider. This is the micro commissioning of care or placement into a nursing home. Contracting functions - these are back office functions and involve the placing and monitoring of a contract, invoice payments and taking contractual action if care falls below the expected quality or performance. These functions were outside the scope of the review as the review focused on patient facing functions. The North and East London CSU currently provide these transactional services.

3.0 Option Appraisal 3.1 The options appraisal was approached using a set of core principles that were developed to

ensure the short and long term quality and performance improvements. These principles were: • The patient pathway must be a continuous seamless process • Patients require a single point of contact and personalised service • The future pathway must meet the 28 day standard stipulated in the “National Framework

for NHS Continuing Healthcare and NHS–funded Nursing Care (Revised) 2012” • The CCG must make the decision on eligibility for CHC and agree the funding • All patients must receive high quality care that is appropriate to their needs and enables

them to meet their health and wellbeing goals. 3.2 There were also underpinning factors that were taken into account and considered when

reviewing the options. These factors were based on the learning from the past ten months, the conclusion and recommendations from the jointly commissioned CCG/NELCSU external review and the serious incident investigation completed by NELFT.

3.3 The underpinning factors were: • Continuing with the current model is not an option; the patient pathway has inbuilt delays.

Patients have complained that “they do not know what is happening to their application or care”. Listening to and responding to patient feedback is critical to improving the service

• On reviewing and evaluating the concerns, issues and risks that all three organisations have encountered over the past ten months, the paramount reason for change is, that any future model must improve the overall quality of the service for patients, their families and carers by addressing the current quality issues

• The current model involves three separate organisations, the CCG, NELCSU and NELFT. The impact of this is a fragmented patient pathway due to numerous members of staff across different organisations being involved in the process. Patients have reported they experience a disjointed service and “get passed from person to person”.

• The future model must be able to support the implementation and delivery of personal health budgets (PHBs). The CCG must be in a position to offer PHBs by April 2014.

• Systematic and robust quality monitoring and assurance process must be in place supported by clear governance arrangements. This will involve specifying how the model

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will deliver the functions mandated in the National Framework (especially care coordination), reporting requirements and organisational roles and responsibilities

• The future model must be financially viable and provide value for money • The new model must be capable of operational delivery by 1 April 2014 • There will need to be medium and long term potential for integration with the Local

Authority once the service has been stabilised • The model will support the implementation and delivery of the joint assessment and

discharge service. 3.4 The options considered were:

Option 1 - Build To build an internal CCG team, with the capability and capacity to provide an assessment, brokerage and care management service.

Option 2 - Buy To buy the complete service from an external organisation such as a private provider, a CSU or NHS provider.

Option 3 - Share To develop a model similar to the current approach whereby functions are shared across different organisations.

3.5 The approach taken was to fully consider the advantages and disadvantages of each option including the impact on patients their families and carers, the implications for staff currently providing the services and the financial impact. Scenario planning and risk assessment was also used to work through the options.

3.6 This analysis is available on request and has not been made publicly available due to the

potential sensitivity and possible patient identifiable information contained in the report. 4.0 Recommendation 4.1 To agree to option 1. The build option of repatriating clinical functions and permanently

establishing the brokerage functions will respond to the quality issues of the elongated and fragmented pathway that patients have raised. If all these functions are undertaken by one organisation patients will have one point of contact and an identified care manager who can lead the brokerage of a care package or placement. As the CCG must retain the decision making for CHC eligibility and agree to funding, the build option simplifies and streamlines this process. This option is the only option that enables a one organisation patient facing service.

Options 2 and 3 meet some of the outcome requirements, although not all, and this is mainly related to the twenty eight day requirement, ongoing case management and the implementation of PHB's.

5.0 Ongoing Assurance of Service Delivery 5.1 The current governance and delivery monitoring arrangements will continue until the new model

is operational. The high risks that have been captured on the CCG governing bodies’ assurance framework and are reviewed monthly by the Joint Executive Team.

5.2 Ongoing delivery of clinical services including reviews and assessments will continue to be monitored weekly. NELFT have formally reported to the CSU that all overdue reviews and outstanding assessments have been completed and they are in a business as usual position.

6.0 Resources

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The existing resources will be used to fund the model recognising that there is a requirement to undertake further detailed financial analysis to determine the exact cost. The outcome of this analysis will be presented to the February Executive Committee.

7.0 Equalities 7.1 There are no equalities implications arising from this report. 8.0 Risk 8.1 All risks relating from the recommendation contained in this report are already captured on the

CHC risk register. This includes the risks of implementing the required changes by 1 April 2014. 8.2 If the recommendation is not agreed by the governing body this will have an impact on the

implementation of the service and the planned quality improvements for patients.

Author: Jacqui Himbury, Nurse Director Date: 15 January 2014

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ITEM 6.2 To: Meeting of Barking and Dagenham Clinical Commissioning Group

Governing Body From: Conor Burke, Chief Accountable Officer, BHR CCGs Date: 28 January 2014 Subject: Urgent Care Board and Winter Resilience

Executive summary The purpose of this report is to provide Governing Body members with a progress update on the Urgent Care Board (UCB) and winter resilience: The paper sets out:

• To provide an update on the activities of the Urgent Care Board.

• To outline the projects agreed using the winter pressure funds allocated to BHR system.

• To provide an update on progress of the schemes, including impact on A&E performance.


• Note the progress of the Urgent Care Board.

• Note the progress against the winter pressure funded schemes and its monitoring approach.

1.0 Purpose of the Report 1.1 The purpose of this report is to provide members with an update on the progress of

the Urgent Care Board. The paper also outlines the projects agreed to improve overall A&E performance, winter pressure funding and the monitoring arrangements in place.

2.0 Background/Introduction 2.1 The Barking and Dagenham, Havering & Redbridge (BHR) Urgent Care Board was

established in June 2013. The Board was established as an advisory Board to drive improvement in urgent care at a pace across the BHR system. The Board brings together senior leaders across health and social care in Barking & Dagenham, Havering and Redbridge to support consistent and sustained improvements in services delivered to local residents with a clear focus on achievement of 95% A&E 4 hour target. The UCB meets on a monthly basis. Terms of reference setting out membership and purpose is attached as Appendix One.

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2.2 The UCB agreed at its meeting in June that a key task was the planning and identification of schemes to ensure that the A&E performance improved over the next 12 months.

2.3 NHS England and the NHS Trust Development Agency (NTDA) announced on the 02 September 2013 that national winter monies were being targeted at systems considered to be at greatest risk of being unable to sustain performance of the A&E 4 hour operational standard.

2.4 A sum of £7m was allocated to the BHR system and UCB members were requested to produce proposals for the use of winter monies to enable the health economy covered by Barking, Havering and Redbridge University Hospitals NHS Trust to deliver sustained performance on the A&E 4 hour standard across quarters 3 and 4.

2.5 A range of projects aimed at improving performance were agreed by the UCB and submitted to NHS England. The UCB monitors the progress against these at the monthly meetings.

3.0 Report Content 3.1 This paper provides Governing Body members with an update on the following areas:

• Progress of the Urgent Care Board

• A summary of the schemes agreed and allocated funding

• Progress on the delivery of the schemes and next steps

3.2 Progress of the Urgent Care Board 3.3 The Urgent Care Board was established in June 2013. It was established as an

advisory Board to drive improvement in urgent care at a pace across the BHR system. The clear focus of the Board is on the achievement of the 95% A&E 4 hour target.

3.4 The UCB agreed at its meeting in June that a key task was the planning and identification of schemes to ensure that the A&E performance improved over the next 12 months. To do this, the UCB undertook the following process:

• Reviewed the outputs from the stakeholder Urgent Care workshop held on the 24 May 2013 where the key issues / metrics were divided into pre hospital; in hospital and post hospital pathways.

• Mapped the metrics into a combined urgent care dashboard showing the performance of each care pathway.

• Reviewed the metrics for each pathway and identifying underperforming areas across the pathways.

• Agreed the priority areas / workstreams to deliver improved A&E performance.

3.5 Six priority areas were identified and approved at the UCB meeting held in July. These were:

• A&E recruitment – one of the key issues is the lack of medical and nursing staff in the emergency department and the availability of key senior decision makers. The short term plan is to use temporary agency staff and the medium term solution involves recruitment planning looking at overseas recruitment. This workstream is led by BHRUT.

• 7 day working – this workstream focuses on removing bottlenecks to A&E flow by smoothing & accelerating discharges. The workstream involves the Trust and Local Authorities working over weekend. In the medium term, the aim will be to reduce average length of stay for patients and a reduction in the number of beds. This workstream is led by BHRUT.

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• Urgent Care utilisation (UCC) – to review the working practices of the urgent care centres located on the KGH and Queens hospital sites. This would consider utilisation, opening hours to increase the proportion of activity that is seen in the UCC to reduce pressures on emergency department activity. The medium term aim to increase the utilisation of urgent care centres. This workstream is led by Havering CCG.

• Primary care improvement – a programme of clinically led projects to manage more patients in primary care and reduce the winter pressures on A&E. These projects will increase the capacity of primary and community care and enable people to have their condition assessed and resolved wherever possible within primary care. The projects cover GP surge schemes offering additional GP appointments, GP weekend opening and GP alignment to nursing homes. This workstream is led by Havering CCG.

• Joint Assessment and Discharge service – project to facilitate the safe and timely discharge of patients from acute settings by providing integrated health and social care support required to discharge patients with social and/or complex medical needs. This workstream is led by London Borough of Barking and Dagenham.

• Frailty project – the aim of the workstream is to create efficient and seamless care for frail and older people across our three dimensions of urgent care – care at home, acute hospital care and getting people home. This workstream is led by BHR CCGs.

• London Ambulance Service - a further initiative was agreed in September that focused on more effective ambulance use and conveyancing

The UCB agreed a process to deliver the projects through an agreed set of project workbooks and highlight reports to monitor against the deliverables. The UCB dashboard incorporates the metrics from the projects which is monitored at each meeting.

3.6 A summary of the projects agreed and the allocated funding 3.7 Further to this, NHS England and the NTDA announced on the 02 September 2013

that national winter monies were being targeted at systems considered by the tripartite panel to be at greatest risk of being unable to sustain performance of the A&E 4 hour operational standard.

3.8 A sum of £7m winter pressure fund was allocated to the BHR systems and organisations were requested to produce proposals that would deliver sustained performance on the A&E 4 hour standard across quarters 3 and 4.

3.9 The winter pressure monies were seen as additional money for winter over and above those already committed on existing projects. The UCB agreed that the winter funds would be used to accelerate the delivery of pre existing plans where possible and provide additional resource to manage increased winter pressure and demands.

3.10 Additional projects were identified using the winter monies received and majority of these were aligned with the six priorities identified by the UCB.

3.11 The list of the key projects agreed to improve A&E performance is attached at Appendix Two. The total funds allocated for each project is also attached. The UCB also agreed to monitor spending against allocation and to review at future meetings. Members also agreed that funds would be used flexibly if there were slippages within projects.

3.12 Progress on the delivery of the projects 3.13 To ensure that the UCB was able to monitor projects, each project has an agreed set

of metrics to show the outcomes to be achieved. The metrics are then linked into an

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overall dashboard which is presented to the UCB meetings. The UCB reviews progress of each project through the use of RAG ratings and agree mitigating actions for areas that are underperforming.

3.14 The UCB dashboard categorised delivery of projects into the three pathways:

• Demand and Pre-hospital Care

• Hospital Response

• Getting People Home

3.15 The latest performance reports show that the A&E target has not been achieved. Although the target remains challenging, there has been significant progress in the implementation of the projects. A number of projects commenced in December and the impact of these is yet to be realised. In addition to the projects, there has also been much improved partnership working and relationships between all organisations in the system to tackle the challenges. The latest UCB dashboard shows the following results:

Demand and pre-hospital care

• A&E attendees – a reduction of 6.59% in overall attendances in quarter 3, particularly a reduction of 7.01% reduction in type 1 attendance compared to a similar period last year.

• Community Treatment Teams - service currently achieving target for new referrals (YTD) with 4423 referrals received against a target of 3463. 76% of people seen in the acute hub do not go on to be admitted and 93% of people seen in the community remain at home.

• Integrated Case Management – service currently achieving a greater number of admissions avoided than planned.

• Intensive Rehabilitation Service – new service rolled out in all boroughs which allows people to be rehabilitated at home rather than in non acute bed.

• Primary care surge schemes – increasing coverage by offering up to 30,000 additional appointments to patients across the system during October to March.

Hospital Response

• A&E recruitment - successful for middle grade doctors, but recruitment of consultants remains a challenge.

• Non elective admissions – a reduction of 14.35% in quarter 3 2013/14 compared to the same position last year.

• KGH Non-Elective Length of stay has now dropped below target.

• Improving trend on discharges by 11am – both now above the originally set target based on a 4 week average.

• LAS interface – LAS presence now on site at Queen’s and introduction of revised care pathways.

Getting people home

• Delayed transfers of care – a reduction of 25.5% in quarter 3 compared to previous year.

• Discharges, referrals and assessment process – referral to assessment and referrals to transfer activities meeting targets set.

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• 7 day working – improvement in the percentage of discharges happening on Mondays/Tuesdays and Fridays/Saturdays. Weekend discharges in Nov-Dec accounted for 18% of total.

• Joint Assessment and Discharge service – on track to deliver an integrated ward based discharge service by the spring / summer of 2014.

• Non acute beds - improvements have seen steady reduction in beds utilisation.

3.16 At the last UCB meeting in December, leads reported that all projects were now being implemented with no reported slippage.

3.17 Whilst acknowledging the successes achieved so far, there remains areas where further work is required to assess impact on performance. These include:

• Urgent Care Centre utilisation. The service, provided by the Hurley Group was expected to increase utilisation rates to 50% through extended working hours, funded using winter pressure funds. The latest weekly dashboard shows performance at approximately 30%.

• Primary care surge scheme. The service to provide additional GP urgent appointments is still being rolled out. The service at Redbridge commenced in mid December. It is still too early to review performance against target.

3.18 In addition to the projects identified to improve performance, additional bed capacity has been negotiated with the Trust, to be opened during the winter period. A sum of £897k of the winter funds has been allocated and to be paid through activity generated by these beds. The CCGs are also currently working with the Trust to explore additional step down facilities to enable timely discharges.

3.19 The January UCB meeting will review the status of the projects against A&E impact and the funds used to date. Members will be required to make an informed decision on the effectiveness of the projects that are slipping and reallocate funds to other priority areas where there is slippage.

4.0 Resources/investment 4.1 The UCB has agreed the recommendations for the use of the winter pressures

monies to deliver improvement to A&E performance.


6.0 Risk 6.1 The risk associated with non delivery of the A&E target is described through the

progress update of schemes to the UCB.

Attachments: 1. Urgent Care Board Terms of Reference

2. List of projects funded using winter monies.

Author: Ramesh Rajah, BHR CCGs Programme Management Office


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Appendix One – Urgent Care Board Terms of Reference

Terms of Reference Urgent Care Board

June 2013

These terms of reference were approved by: Insert name ……………………………………………………

These terms of reference will be reviewed by: Insert date ………/…………/…… 6 months

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Members

Organisation Name and Role

BHR CCGs Conor Burke, Accountable Officer (Chair)

LB Barking and Dagenham Anne Bristow, Corporate Director Adult and Community Services

Barking and Dagenham CCG Dr Richard Burack, urgent care lead

LB Havering Cheryl Coppell, Chief Executive London Borough Havering (Chair of ICC)

LB Havering Joy Hollister, Director Children, Adults and Housing

Havering CCG Dr Alex Tran, urgent care lead

LB Redbridge John Powell, Director of Adult Social Services and Housing

Redbridge CCG Dr M Mathukia, urgent care lead

Barking & Dagenham, Havering, Redbridge University trust (BHRUT)

Averil Dongworth, Chief Executive BHRUT

Barking & Dagenham, Havering, Redbridge University trust (BHRUT)

Dr Mike Gill, Medical Director

NHS England Amelia Howard, Assurance Manager

NHS England Nafeesah Mian, Senior Assurance Manager

North East London Foundation Trust (NELFT)

John Brouder, Chief Executive NELFT

North East London Foundation Trust (NELFT)

Jacqui Van Rossum, Executive Director Integrated Care (London) and Transformation

Patient Representative Anne-Marie Dean, Chair HealthWatch Havering

PELC Jacqui Niner, Head of Services

London Ambulance Service Katy Millard, Assistant Director Operations (East)

Members are permitted to send deputies in their place when they are not able to attend.

In attendance

BHR CCGs Jane Gateley, Director of Strategic Delivery BHR CCGs

Havering CCG Alan Steward, Chief Operating Officer, Havering CCG

MEMBERSHIP

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The group will be considered quorate when 4 members are in attendance, with at least one NHS Commissioner and one Local Authority Commissioner present.

Admin functions will be undertaken by CCGs PMO:

• Agreement of the agenda with the Chair. Once agreed and circulated no further agenda items, without prior warning or discussion with the Chair, will be raised or presented at the meeting.

• The circulation of papers, with papers being circulated within a minimum of three working days in advance of the meeting date.

• Taking action notes/issues to be carried forward.

Action notes from each meeting will be taken and approved at the subsequent meeting of the Urgent Care Board. They will be forwarded to all members for them to circulate/report as appropriate within their respective organisations and will be included as a standing item on the Integrated Care Coalition agenda.

They will also be forwarded to the contract leads so that relevant actions can be taken through the performance management arrangements where appropriate.

The urgent Care Board has been established as an advisory Board to drive improvement in urgent care at a pace across the BHR system.

It is being established in context of current poor performance and recognition of the criticality of getting this part of the system fit for purpose for local residents. Whilst it is recognised that formal contractual governance arrangements are in place to performance manage providers of services, it is also recognised that interdependencies exist across the system requiring strong partner and interface working.

The Urgent Care Board brings together senior leaders across health and social care in Barking & Dagenham , Havering and Redbridge to support consistent and sustained improvements in services delivered to local residents. (with a clear focus on outcomes, a key measure being achievement of 95% A&E 4 hour target).

Through the use of a system wide consolidated urgent care dash board (that will report agreed KPIs) the Board will at every meeting:

• Review current and projected performance of urgent care

• Focus discussion on the areas not delivering and agree actions/ responsibilities

QUORUM

ADMINISTRATION & HANDLING OF MEETINGS

REPORTING / COMMUNICATIONS

PURPOSE OF GROUP

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across the system to address

• This process will need to ensure the integrity of the contract management framework is maintained. Where relevant, actions agreed at the Urgent Care Board will be reported into the provider relevant contractual group to ensure alignment.

• Agree process for production of demand and capacity plan across the system that takes account of CIP, QIPP and elective workload, and gives the system assurance that it can deliver 95% target during 13/14 winter period.

• Strategic oversight: The review of current performance will also highlight how services/pathways can be developed together between commissioners and providers. The Urgent Care Board will make recommendations for future changes to the Integrated Care Coalition. These will inform the 2014/15 plan (these should be reviewed and agreed by the Coalition in September/October to inform commissioning intentions).

• To ensure performance improvement is informed by application of best practice and the consistent application of evidence based practice. This includes having mechanisms in place to share knowledge, learning and best practice across the local health economy.

• Any recommendations impacting on acute reconfiguration will be reported back to the Acute Reconfiguration Implementation Group.

The Urgent Care Board will be responsible for ensuring all partners deliver their contribution and developing recommendations for system wide change.

The group will meet monthly from June 2013.

The Urgent Care Board will be accountable to the Integrated Care Coalition

FREQUENCY OF MEETINGS

ACCOUNTABILITY

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Appendix Two – List of projects funded using winter monies

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ITEM 6.3 To: Meeting of NHS Barking & Dagenham Clinical Commissioning Group Governing

Body From: Conor Burke, Chief Accountable Officer Date: 28 January 2014 Subject: CQC and special measures at BHRUT

Executive summary The Care Quality Commission (CQC) identified Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) as a top priority acute provider to be inspected in the first wave of the new CQC hospital inspection programme, as it had been shown to be at “high risk” on several indicators in the new Intelligent Monitoring tool. Over recent years the trust has faced significant quality challenges including:

• Poor results on the CQC inpatient survey and on the cancer patient experience survey • Achievement of the four-hour accident and emergency waiting time standard • Poor results on the national staff survey • High weekend mortality in some areas • Non-compliance with regulations recorded on several CQC inspections since it was

registered especially in the A&E departments.

The CQC inspected the Trust from 14 - 17 October 2013 and held a Quality Summit on 17 December 2013 where the final reports were shared. It was also announced at the Quality Summit that the trust was being placed in “Special Measures” as it was recognised given the scope and scale of the challenges faced by the Trust additional support was required. This report sets out the initial actions taken by the local and national organisations to address the key issues identified within the CQC report.


• Note the CQC report and the action being taken by the Trust Development Agency and BHRUT under the ‘Special Measures’ framework

• Review the action being taken to date by the CCG advising on any additional activities

• Agree to receive a further report on the Trust Improvement plan at its next meeting

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1.0 Purpose of the Report 1.1 To advise the Governing Body on the publication of the CQC inspection report of

BHRUT and assure the members on action being taken to address key quality issues

2.0 Background/Introduction

2.1 The Care Quality Commission (CQC) identified Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) as a top priority acute provider to be inspected in the first wave of the new CQC hospital inspection programme, as it had been shown to be at “high risk” on several indicators in the new Intelligent Monitoring tool. Over recent years the trust has faced significant quality challenges including:

o Poor results on the CQC inpatient survey and on the cancer patient experience

survey o Achievement of the four-hour accident and emergency waiting time standard o Poor results on the national staff survey o High weekend mortality in some areas o Non-compliance with regulations recorded on several CQC inspections since it

was registered especially in the A&E departments.

2.2 The CQC inspected the trust from 14 -17 October 2013. It was also announced at the Quality Summit that the trust were being placed in “Special Measures” as it was recognised that given the scope and scale of the challenges faced by the Trust additional support was required.

3.0 CQC report summary

3.1 A full copy of the CQC inspection report is available at http://www.cqc.org.uk/public/news/our-latest-reports

3.2 The key findings from the report are as follows:

• Many initiatives to improve quality and safety have only started very recently and it is too early to tell if they will deliver the required improvements quickly.

• The lack of support and engagement to drive improvements and address the Trust challenges from all senior clinical staff has meant progress has been slow

• Issues with record keeping were identified and need to be addressed

• The longstanding history of the problems and lack of progress indicates that the

leadership is inadequate to address the scale of the challenges that the trust is facing and additional support is required

3.3 A CQC/TDA Quality Summit took place on 17 December 2013 where the final reports

were shared and discussed. This was attended by senior CCG clinicians and officers.

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http://www.cqc.org.uk/public/news/our-latest-reports

4.0 Special Measures

4.1 Given the scale and scope of the challenges faced by the Trust it was placed in special

measures by the CQC and TDA on the 18 December 2013. 4.2 The special measures are intended to be supportive of the Trust and are in recognition

of the scale and scope of the challenges faced by the organisation 4.3 There is an immediate requirement for the Trust to produce an improvement plan to

address the following key issues:

• Ensure the Chief Operating Officer has clinical and management support to deliver improvements to patient safety and quality. The improvement plan should be agreed at Board level with progress monitored at each Board meeting.

• Ownership for improvement must be embedded at every level of the trust and the visibility of the Executive Team at Queen’s Hospital and King George Hospital must be improved.

• The trust needs to urgently focus on resolving problems in the A&E departments of King George and Queen’s Hospitals which are resulting in unsafe care. A clear and unambiguous protocol must be put in place for the transfer of patients between trust locations. All care must be documented.

• The trust must also address its discharge planning and patient flow problems which will require improved working with local partners.

• Infection control procedures must be implemented consistently in every ward and theatre across the trust.

• A clear and unambiguous protocol must be put in place for the transfer of patients between trust locations. All care must be documented.

4.4 The Special Measures include:-

• The requirement for the Trust to develop an improvement plan. • That an organisational capability review be conducted by Sir Ian Carruthers over the

15 and 16 January 2014. • A Board to Board meeting in February • The TDA will appoint an Improvement Director. • The Trust will receive support from the TDA Special Measures Director. • The Trust is buddied with a Foundation Trust for peer support.

5.0 CCG Action

5.1 The CQC report and Special Measures makes little reference to the wider health and social care system. However as the statutory bodies responsible for commissioning safe and sustainable health services across the BHR system, we are clear that we have a fundamental role to play in this process and take this very seriously.

5.2 Given the full scale of the challenges, the improvements cannot be made in isolation and BHRUT will require our full support. To this end the CCGs have already taken the early action:

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5.3 The CCG secured involvement in the Trust capability and governance review. The three BHR CCG Chairs and Chief Officer were interviewed by Sir Ian Carruthers last week.

5.4 The Chief Officer has had a very positive initial meeting with the TDA’s Improvement

Director, and they have agreed to work closely together to support the development of the Trust improvement plan alongside and aligned with a system-wide support programme.

5.5 The Chief Officer and Cheryl Coppell, LBH CEO have written to the TDA proposing

arrangements to further support the development of the Trust and work more closely to align respective planning, governance and assurance processes.

5.6 BHR CCGs will need to lead improvement across what is a very challenged system.

The collaborative is working intensively with partners to co-develop CCG operating plans and system-wide strategic plans. In parallel, we are making good progress negotiating 14/15 contracts and as the Trust and system improvement plans develop, we will ensure all agreed targets are aligned with and actively managed through provider contracts.

5.7 The implementation of a major transformational change and acute reconfiguration

programme will also support improvement and it is critical that we maintain momentum and secure all available support during this time.

5.8 Further and rapid development of primary care is critical to improving outcomes for local

people and the future of this health economy. The CCG is developing a primary care improvement plan to drive this forward at pace. We have agreed that the support from the NHS England Local Area Team will be critical and that our teams will need to work closely together to make sure this continues.

6.0 Resources/investment 6.1 The Trust will scope its investment/resource requirements as part of the development of

its improvement plan. 7.0 The CCG CFO has started to work with NHSE colleagues on our approach to

transitional funding which will be fundamental to delivering the required changes. 8.0 Equalities 8.1 The implementation of the Trust improvement plan will improve quality and reduce

health inequalities.

9.0 Risk 9.1 Patient quality and safety concerns continue. 9.2 The Trust may be placed into Special Administration should services not improve.

Author: Conor Burke, Chief Accountable Officer Date: 21 January 2014

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ITEM 6.4 To: Meeting of the Barking & Dagenham Clinical Commissioning Group Governing Body From: Jacqui Himbury Nurse Director Date: 28 January 2014 Subject: Care Quality Commission report for Barts Health NHS Trust Executive summary The Care Quality Commission (CQC) identified Barts Health NHS Trust as a Trust to be inspected in the first wave of the new CQC hospital inspection programme, as it had been shown to be at “high risk” on several indicators in the new Intelligent Monitoring tool. Over recent years the Trust has faced significant financial challenges and has been a persistent outlier on some key quality of care indicators, including:

• Poor results on the cancer patient experience survey • Non-achievement of the four-hour accident and emergency waiting time standard • Poor results on the national staff survey • A high number of never events (events so serious they should never happen) • Non-compliance with regulations recorded on several CQC inspections since it was registered,

especially in maternity services and wards caring for older people.

The CQC inspected all the Trust’s sites, including Barking Birthing Centre, in November 2013 and shared the outcome of the inspection at a Quality Summit on 10 January 2013. During the inspection the CQC checked that the Trust had met the requirements of the Warning Notices issued to Whipps Cross Hospital (WXH). They had, so the warning notices were removed. This report focuses on WXH because of the proximity to Barking and Dagenham and the care provided to our residents. The CQC issued 15 compliance notices to the Trust and they must now develop a quality improvement plan to demonstrate how they will address the concerns and improve the quality of care. They have taken immediate action where required.

Recommendations The governing body is asked to: • Note the next steps set out in section 4 of the report • Receive a further report in 2 months

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1.0 Purpose of the Report 1.1 This report is to advise the governing body of the outcome of the CQC inspection conducted in

November 2013 into Barts Health NHS Trust and to confirm the ongoing monitoring arrangements.

2.0 Introduction 2.1 Barts Health is the largest NHS trust in the country, having been formed by the merger of Barts

and the London NHS Trust, Newham University Hospital NHS Trust and Whipps Cross University Hospital NHS Trust on 1 April 2012. Barts Health is a large provider of acute services, serving a population of 2.5 million in North East London.

2.2 The Trust has three acute hospitals; the Royal London, Whipps Cross University Hospital and Newham University Hospital, three specialist sites and two birthing centres.

2.3 All the Trust sites were inspected in November 2013 using the new CQC inspection framework which asks five questions to undertake the inspections and to form a judgement on the performance of the provider. These are:

• Are services safe? • Are services effective? • Are services caring? • Are services responsive to people’s needs? • Are services well-led?

2.4 The inspection team methodology covers 8 core services; accident and emergency, medical care (including older people’s care), surgery, intensive/critical care, maternity and family planning, children’s care, end of life care.

3.0 Inspection outcome 3.1 The CQC report (available on the website)) is very detailed and highlights areas of good

practice and positive practice in addition to areas that require improvement. Overall, fifteen compliance notices were issued, the services are generally safe, effectiveness varies across the sites, examples of poor care were described and cultural concerns identified as there is a lack of openness and staff feel bullied and unable to raise safety issues without fear. Positive practice was also highlighted.

3.2 For WXH specifically the CQC found some areas of good practice. Patients held staff in high regard and felt them to be committed, compassionate and caring. The intensive care unit was safe, met patients’ needs and demonstrated how improvements could be made through learning from incidents. Improvements have been made in both accident and emergency and maternity services since the last CQC visit in June 2013, and some good practice was observed in these departments. Palliative care was compassionate and held in high regard by staff, patients and their friends and family. Good practice in children’s services was also highlighted, particularly in relation to education and activities for children while in hospital. Lastly, the hospital was clean and staff adhered to good infection control practice.

3.3 However, a number of improvements need to be made and four compliance notices were issued for diagnostic and screening procedures, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.

3.4 Action the trust must take includes ensuring staffing levels meet people’s needs on all medical and surgical wards; address delays to providing care that have a negative impact on patients discharge from hospital; ensure equipment is always available on medical and surgical wards (the Trust has taken immediate action to address this concern); improve staff morale and address the hospital culture; make changes to the hospital environment; ensure patients know how to make a complaint; strengthen governance arrangements and ensure that the hospital’s risk register is managed more effectively.

3.5 The report was shared at a quality summit held on 10 January 2014. The summit was led by the CQC and the Trust Development Agency. It was very well attended by all commissioners, TDA, CQC, Local Authorities, trust executives and NHS England.

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3.6 The trust responded positively to the report and confirmed the leadership team were committed to improvement and change and that immediate action had been taken were necessary. They welcome the support of partners and intend to hold follow up events to develop the improvement plans in collaboration and partnership.

4.0 Next steps 4.1 The Trust must submit a draft improvement plan to the CQC by 7 February with a more detailed

and comprehensive plan submitted at the end of February 2014. 4.2 A second quality summit is planned for 6 February 2014 to further develop the improvement

plan in collaboration with partners. Redbridge CCG is attending as lead commissioner for BHR. 4.3 Monitoring of the quality of services delivered will continue formally through the clinical quality

review meetings. 5.0 Resources/investment 5.1 There are no additional resource implications/revenue or capitals costs arising from this report. 6.0 Equalities 6.1 There are no equalities implications arising from this report. 7.0 Risk 7.1 No new risks have been identified from this report. The quality risks highlighted in the CQC

reports are already captured on the governing body assurance framework. Author: Jacqui Himbury Nurse Director Date: 18 January 2013

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ITEM 6.5 To: Meeting of NHS Barking and Dagenham Clinical Commissioning Group (CCG) Governing Body From: Sahdia Warraich, lay member, Patient and Public Involvement (PPI) Date: January 2014 Subject: Patient experience report

Executive summary As part of the CCG’s focus on ensuring that patient experience of services is considered throughout all that we do, this paper provides a summary of feedback and insight available since the last meeting. Recommendations The governing body is asked to:

• Note the results of recent CQC inspections into BHRUT and Barking birthing centre • Note the progress on the development of the CCG Patient Engagement Forum (PEF) • Note the wider engagement work taking place in conjunction with local Healthwatch • Note the CCG’s work with the local Community Voluntary Sector (CVS) forum.

0.0 Purpose of the report

0.1 To provide a summary of the range of feedback that has come through to the CCG from patients

and stakeholders. 1.0 Complaints and MP/councillor queries

1.1 The CCG is responsible for complaints received about the services that we commission.

1.2 For quarter two we have received one complaint via an MP, which related to an Individual

Funding Request (IFR). The patient complained about being refused funding for keyhole surgery. The investigation has shown that the treatment was refused as the clinical evidence submitted did not meet the criteria for a Procedure of Limited Clinical Effectiveness (POLCE) and the MP was advised if the constituent’s consultant felt new evidence could be provided, then a further application could be considered for funding the treatment.

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2

1.3 The CCG also considers the trends on complaints with all our providers. Any common issues,

one of exceptions or other matters are discussed with the organisations concerned through our regular quarterly monitoring meetings with them.

1.4 There were no MP enquiries for quarter two. 2.0 Commissioned services

2.1 Care Quality Commission (CQC) report about BHRUT- Patient Safety

In December 2013 CQC published the report on their October visit to Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT). The report highlighted issues about patient safety, effectiveness, caring issues, responsiveness to people’s needs and managements of the services. In terms of patient safety, the main concern was still around the A&E departments. It appears that the A&E departments are at times unsafe because of the lack of full-time consultants and middle-grade doctors. Delays in specialist doctors seeing patients in the A&E departments are also impacting on patient safety.

The Trust is currently recruiting across many staff groups, including specialist doctors, and those from abroad. Bank and agency staff are being used to fill vacancies. Out of 21 Emergency Doctors consultants only 8 were in place in October 2013. All the wards visited were clean but in the operating theatres at King George Hospital they observed some poor practice especially relating to hand washing and staff not using stickers to show when equipment had been cleaned as per trust policy. Although the Trust are having recruitment difficulties, it was acknowledged in the report that there were no examples of patients not having their needs met due to lack of staff. However, staff did not have sufficient time to complete patient records of care. In terms of the environment, a lack of storage space was noted in the operating theatres at Queen’s site and the location of the sexual health clinic at Queen’s site was identified as unsuitable.

2.2 Barking Birthing Centre

England's Chief Inspector of Hospitals published his first reports on the quality of care provided by Barts Health NHS Trust across three acute hospitals, three specialist hospitals and two birthing centres in central and east London on 14 January 2014. As part of this inspection, the CQC inspected the Barking Birthing Centre in November.

The CQC looked at the personal care or treatment records of people who used the service, observed how people were being cared for and talked with people who used the service. Inspectors also talked with carers, family members and staff. The inspection team included a midwife and a consultant obstetrician

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3

The inspectors found ‘Staff were caring and people were treated with dignity and respect. Staffing levels enabled safe practice and people’s needs were met. People got the treatment and care they needed at the right time. There was effective leadership and governance.’

One woman using the service at the time of the inspection said she was ‘delighted’ with her care. CQC inspectors highlighted the following areas of good practice: Assessment of women at 36 weeks of pregnancy to ensure it remained appropriate for them to deliver their baby at the birthing centre.

The full report is available on the CQC website: www.cqc.org.uk/directory/r1h.

3.0 CCG Patient Engagement Forum (PEF)

3.1 The most recent meeting of the PEF was held in November 2013. The Forum had received an

overview about the CCG’s Commissioning Strategy. Carol White, Operational Director for Adult Care-North East London Foundation Trust (NELFT) provided an update on Intermediate Care Services proposed changes and Gemma Hughes, Senior Locality Lead, gave an update on work to simplify the discharge processes for complex patients. The members agreed to receive a more comprehensive update on BHRUT at their January meeting.

3.2 On 21 October 2013 a joint meeting was held between all three PEF Chairs from Havering, Redbridge and Barking and Dagenham, Vice Chairs and lay members. These meetings will continue in 2014 and will be organised by the Patient and Public Engagement (PPE) Advisor. Terms of Reference will be developed and discussed at their March meeting.

4.0 The Community and Voluntary Sector (CVS) Forum meeting 4.1 The CCG attended the CVS Forum meeting which was held in December 2013.

There was a presentation about CCG strategy presented by Sarah D’Souza, Senior Locality Lead.

5.0 Francis report meetings 5.1 Local Healthwatch organisations from all three boroughs, Havering, Barking and Dagenham and

Redbridge, commenced joint meetings with all three lay representatives to discuss steps forward in relation to the Francis report. Sahdia Warraich attended the meeting which was held on the 6 December 2013.

6.0 Barking and Dagenham Stakeholder event - 16 January 2014 6.1 Barking and Dagenham Healthwatch organised this event, which aimed to engage stakeholders

in the commissioning strategies of the CCG and the local authority and to discuss how intermediate care services are developing in Barking and Dagenham as a key component of improved community based care.

7.0 Patient stories

No patient stories have been submitted for this patient experience report. We are currently

considering how best to present patient experience stories to the governing body

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http://www.cqc.org.uk/directory/r1h

4

8.0 Resources/investment

8.1 The only resource implication arising from this report is potential funding to enable the umbrella voluntary sector organisation to do mailouts on our behalf and to organise sessions with wider target community groups.

9.0 Equalities

9.1 It is anticipated that the process being adopted will help to improve access to and engagement in

NHS commissioning activities.

10.0 Risk

10.1 The keys risks to the CCG are not considering and actively addressing the concerns of patients – the CCG must be, and be seen to be, adopting a far more patient centred and responsive approach.

Author: Boba Rangelov, Patient and Public Engagement Advisor, BHR CCGs Date: January 2014

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ITEM 6.6 To: Meeting of Barking & Dagenham Clinical Commissioning Group Governing Body From: Martin Sheldon, Chief Finance Officer Date: 28 January 2014 Subject: Finance Reporting Month 9 Executive Summary

As at the end of December (Month 9) the CCG achieved a surplus of £3.58m, a £1.79m higher surplus compared to the planned year to date surplus of £1.79m. It is estimated at year end that the CCG will achieve a 2% surplus, of £4.77m. As reported last month the additional 1% surplus will be carried forward into the next financial year.

A number of risks and overspends remain for the CCG. Clearly it is very important that the CCG mitigates these pressures to help ensure the financial stability of the organisation.

There is significant year to date pressure within acute contracts. This variance amounts to £7.1m. This month a non recurrent revenue transfer was actioned for specialist commissioning for £2.5m which is offsetting this pressure. As previously reported, most of the variance continues to relate to the Barts Health contract, which is over performing by £2.9m at month 9. An activity variation notice has been issued to the trust and an action plan is in place. A number of claims and challenges have been raised against acute contracts; a risk assessed position of the likely outcome of these claims is included within the year to date and Predicted Year End Value outturn financial position. This month the BHRUT activity schedule has included a £2m accrual with no backing data. This has been challenged and the position was reported using the last complete month of costed activity (October). The Barts Health contract offer has been agreed by all of the commissioning CCGs and issued to the Trust. However, this has not yet been signed due to issues with the Information Schedule. The closedown of quarters 1 and 2 is still outstanding for BHRUT and Barts Health. BHRUT have not accepted the CCGs Q1/Q2 offer, the CCG’s are therefore, preparing papers for mediation. The Trust has being placed in special measures and this may impact on further discussions. Furthermore, no response has been received from Barts Health with regard to fixing the Q1 and Q2 position to Heads of Terms values. The CCG has requested the Commissioning for Quality and Innovation (CQUIN) payment to be being withheld for contracts that have not been signed. The significant contract this affects

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is Barts Health. Special measures have been imposed on Barts Health and BHRUT this means the trusts are in financial turn around and are being scrutinised by the National Trust Development Authority (NTDA). This may impact on contractual arrangements for this year and next year, resulting in cap and collar arrangements or a block contract in preference to a full Payment by Results contacts being enforced which have not been agreed at a local level.

The QIPP projects are currently £719k below plan at month 9. The borough team are working to address this variance.

Some of the CCG reserves (For example the 0.5% contingency) have been utilised within the year to date position to partially offset some of the acute overspends. However a number of risks remain;

Key financial risks;

1. Specialist Commissioning – The specialist commissioning reconciliation is now complete and the revenue transfer actioned in month 9. There is a negative budget left in Barking and Dagenham CCG of £2,929k.

2. Barts Health Contract – Significant levels of over performance has been built into the reported position. A risk remains with regard to the agreement of challenges and specialist commissioning activity that may not have been attributed to the CCGs. A London wide project is reviewing the misattributions and meetings are currently ongoing with the Provider to triangulate the position.

3. Activity Information – As previously reported there continues to be a number of problems with acute data. The new PAS means that BHRUT activity is incomplete for November and the Trust included an accrual line in the data. There are ongoing issues with data within the Barts contract. This increases the risk of inaccurate reporting. There is a further inherent risk of activity increase across all cost and volume contracts, in excess of the projected levels.

4. Associate Contracts – There are still a few unsigned contracts, the value totalling £2.7m. Until the contracts are signed the CCG has taken a decision to withhold the payment of CQUIN.

5. Invoices – A high level of unpaid invoices remain which impact directly upon the CCG’s cash flow. All invoices that relate to the CCG have been included in the reported position. The CSU continues to work with the CCG to clear the backlog.


• Agree the financial position and the actions being undertaken to manage the key risks.

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Finance and Activity Report Purpose of the Report The purpose of this report is to brief the Governing Body on the financial risks inherent as at 15th January 2014 and report on the overall financial position for financial year 2013/14. Resource limit The CCG has an anticipated resource limit of £243,981k. This month’s anticipated adjustments include adjustments for Specialist commissioning funding transfer, Prop Co., GP collaborate fees and Walk-in centres. The resource limit for 2014-15 has recently been announced it is £8.2m, 3.55% increase on the recurrent funding for Barking and Dagenham CCG. Cash Draw Down The CCG is required to draw down cash from the DoH on a monthly basis to pay invoices and staff salaries. To date £146,633k of a full year Predicted Year End Value of £204,906k has been drawn down. The CCG is predicting to utilise all cash made available by year end, this is in Appendix 1. The closing cash position as at 31st December 2013 was £3,396k. A summary of Predicted Year End Value receipts and payments for the year is provided for information at Appendix 2. The cash to income and expenditure reconciliation at appendix 5 reconciles the actual cash received and paid out by the organisation to the total charge within the income and expenditure account. Throughout December the CCG continued to operate within its expected cash envelope and was not overdrawn on any of its bank accounts at any time. The CCG is working closely with the CSU to ensure accurate and robust cash predicted year end values are in place, and that there continues to be appropriate cash and treasury safeguards.

Opening Resources 2013-14 £'000

Recurrent Programme Baseline Allocation 233,034Growth Uplift 5,360Anticipated Adjustments 747Programme Resources 239,141Running Costs Allocation 4,840Total Resources 2013-14 243,981

Barking and Dagenham CCG

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Monthly Reported Position The CCG revenue financial position is summarised in the table below. A more detailed summary can be viewed in Appendix 4. Total expenditure year to date for Barking and Dagenham CCG is underspend by £1,788k this has results in the predicted year end value of £2,383k as per last month. Acute contracts The total acute budget is £116,436k in month 9. The specialist commissioning reconciliation is now complete and a non recurrent revenue transfer was actioned in month 9. The specialist commissioning transfer has increased the acute budget by £2,542k. Additionally £300k non recurrent support was transferred to Waltham Forest CCG. The budgets were adjusted on individual contracts and NCAs to reflect the impact of the specialist commissioning reconciliation. The year to date performance shows an over spend against budget of £7,131k with an anticipated predicted year end value over spend of £10,061k. The detail against individual contracts is shown in the table below:

Commissioner Function Annual YTD YTD YTD Predicted Year Predicted Year Predicted Year End Allocation Budget Actual Variance End Value End Value Variance Value In Month Movement

£000's £000's £000's £000's £000's £000's £000'sAcute

Acute Clinical SLA 105,071 79,425 82,990 (3,565) 110,649 (5,577) 530Acute Other 11,364 8,523 12,088 (3,565) 15,848 (4,483) (3,080)

Acute sub-total 116,436 87,948 95,079 (7,131) 126,496 (10,061) (2,550)

Mental Health & LD 28,313 21,235 21,229 6 28,247 66 208Community Healthcare 30,970 23,228 23,499 (272) 31,316 (346) (74)Continuing Care 11,970 8,978 8,978 (0) 11,970 0 0Programme Spend 20,063 11,141 2,835 8,306 7,426 12,637 2,035Services Provided in a Primary Care Setting 29,005 21,917 21,039 879 28,917 88 381

Healthcare Provision sub-total 120,321 86,498 77,579 8,919 107,877 12,444 2,550

CCG Running Costs 4,840 3,630 3,630 (0) 4,841 (1) (2)Non Healthcare 0 0 0 0 0 0 0

(2)Running Costs & Non-Healthcare Provision sub-total 4,840 3,630 3,630 (0) 4,841 (1) (2)

Total Expenditure 241,597 178,076 176,288 1,788 239,215 2,383 (2)

Barking and Dagenham CCG Financial Position 2013/14

Month 9 - 31st December 2013

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Provider Annual YTD YTD YTD YTD YTD In month In month In month In Month Predicted Year Predicted Year Allocation Budget Actual Variance Variance Challenges Budget Actual Variance Movement End Value End Value Variance

£000's £000's £000's £000's % £000's £000's £000's £000's £000's £000's £000's

BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST 82,869 62,802 62,167 635 1% (183) 6,912 6,649 263 (109) 82,989 (120)BARTS HEALTH NHS TRUST 13,439 10,079 12,997 (2,918) -29% (70) 1,120 1,257 (137) (6) 17,310 (3,871)MOORFIELDS EYE HOSPITAL NHS FOUNDATION TRUST 1,810 1,346 1,498 (152) -11% 0 151 166 (15) (16) 2,003 (193)MID ESSEX HOSPITAL SERVICES NHS TRUST 1,150 863 1,045 (182) -21% 0 96 130 (34) 6 1,385 (235)UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST 1,001 751 846 (95) -13% 0 27 68 (40) (14) 1,120 (119)GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 982 734 733 0 0% 0 82 34 48 71 975 7HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 950 708 1,013 (305) -43% (12) 88 160 (72) (71) 1,350 (400)BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 520 390 370 20 5% 0 43 57 (13) (6) 493 27KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST 317 237 230 7 3% 0 26 17 10 13 307 10ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST 290 216 564 (348) -161% 0 24 114 (90) (79) 730 (440)CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST 292 219 163 55 25% 0 24 3 21 6 209 82ROYAL FREE HAMPSTEAD NHS TRUST 304 227 345 (118) -52% 0 38 89 (51) (39) 451 (147)IMPERIAL 316 236 244 (8) 26 23 3 2 326 (10)THE WHITTINGTON HOSPITAL NHS TRUST 121 91 47 44 48% 0 10 5 5 2 62 58THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST 80 60 45 15 25% 0 7 2 4 8 60 20GREAT ORMOND STREET HOSPITAL FOR CHILDREN NHS TRUST 259 194 331 (137) -70% 0 114 16 98 119 443 (184)ST GEORGE'S HEALTHCARE NHS TRUST 105 72 113 (41) -57% 0 9 0 8 8 116 (12)

ROYAL BROMPTON AND HAREFIELD NHS FOUNDATION TRUST 74 55 55 (1) -1% 0 -6 2 (9) (14) 74 (0)THE ROYAL MARSDEN NHS FOUNDATION TRUST 55 41 22 19 46% 0 -13 (2) (11) (16) 30 25NORTH WEST LONDON HOSPITALS NHS TRUST 70 52 55 (2) -5% 0 9 3 6 5 73 (3)NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST 69 51 106 (54) -105% (4) 6 6 (1) 10 140 (71)

ACUTE CLINICAL SLA SUB-TOTAL 105,071 79,425 82,990 (3,565) -4% (268) 8,793 8,800 (7) (120) 110,649 (5,577)

LONDON AMBULANCE SERVICE 6,867 5,150 5,150 0 0% 0 572 572 0 0 6,867 0NCAs 2,192 1,644 1,889 (245) -15% 0 -42 195 (237) (243) 2,518 (327)COMMUNITY SPECIALIST SERVICES 809 607 1,139 (532) -88% 0 67 37 30 1 1,248 (439)URGENT CARE CENTRE 0 0 0 0 0% 0 0 0 0 0 0 0INDEPENDENT SECTOR 4,331 3,248 3,839 (592) -18% 0 361 518 (157) (40) 5,119 (789)ACUTE OTHER (INCL IFR) 94 71 71 (0) -0% 0 -187 (387) 200 400 94 0SPECIALIST COMMISSIONING REDUCTION (2,929) -2,196 0 (2,196) 0% 0 -2,196 0 (2,196) (2,196) 0 (2,929)

ACUTE OTHER SUB-TOTAL 11,364 8,523 12,088 (3,565) -42% 0 -1,425 934 (2,360) (2,079) 15,848 (4,483)

TOTAL ACUTE 116,436 87,948 95,079 (7,131) -8% (268) 7,368 9,735 (2,367) (2,199) 126,496 (10,061)



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Key issues

BHRUT: The reported position shows an under spend of £635k in month 9 compared to a reported under spend of £372k in month 8. The Trust submitted costed activity data for November (month 8 SLAM) within the required timescales. However, the month 8 SLAM included a Trust accrual for just over £2m at month 8 with £3m predicted at year end. The Barking and Dagenham CCG share of this is £565k at month 8 and £847k predicted at year end. The impact of the Trust accrual is that the Trust has reported a fairly stable position compared to the previous month. However, the inclusion of an accrual with no detail behind it means an in depth analysis of data cannot be carried out. The CSU have raised a query with the Trust about the accrual and as part of the claims management process have requested that the sum is moved from the freeze position pending discussions with the Commissioners. For reporting purposes a decision was taken to use the last full month of costed data which was the month 7 (October) data extract. This was extrapolated to month 9 and the year end. There were several adjustments made to the data to arrive at the reported position. Firstly, the data used was adjusted to take into account the offer made by the CCGs to the Trust for Quarters 1 and 2. This equates to a £4m over plan at month 6.This position is yet to be agreed so may be subject to change. Further adjustments were made to the month 7 to 12 data for claims, emergency threshold, maternity prepayment, readmissions and CQUIN.

Barts Health: The contract was signed by the CCGs last month and issued to Barts Health. However, Barts Health hasn’t signed the contract, citing issues with the information schedule. The reported position shows an over spend of £2,918k compared to £2,781k in month 8. The position is based on the latest information received which is the month 8 SLAM data. The WELC CSU team lead on this contract and make a series of financial adjustments to the activity data. As with previous months the largest adjustments are for challenges, contract penalties, CQUIN, productivity, readmissions, incorrectly assigned activity (specialist and renal transplants) and the emergency threshold. Claims have been adjusted for quarter 1 outstanding claims and an estimate for the remainder of the financial year. This results in a year to date claims figure of £70k. Contract penalties are reported at quarters 1 and 2 with a run rate of 75% assumed for the remainder of the financial year. It has been assumed that the CQUIN payment to the Trust will be 92% of the target. CQUIN has been included for reporting purposes. However, the CCG have advised that theTrust shouldn’t receive payment for CQUIN until the contract is signed. The adjustments for productivity and readmissions have been

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updated in month 9 to reflect actuals and the emergency threshold adjustment is based on the Trust offer for quarter 1 and plan for the remainder of the financial year. Activity incorrectly assigned to the CCG contracts relates to specialist activity and renal transplants. The total predicted year end cost of this activity is £1,130k. As with previous months the financial adjustments made to the cost of the data submitted are significant which means that this contract has a risk of financial volatility. The unadjusted predicted year end value position shows an over spend of £6,742k. The adjustment to the predicted year end value outturn resulted in a reported year end position of £3,871k over plan. Other Acute Trusts: Budget adjustments were made to the Homerton, UCLH, Royal Brompton and Harefield, Royal Marsden, Royal Free, Great Ormond Street and North West London Hospital contracts. This was as a result of the specialist commissioning reconciliation. At the time of writing these contracts remain unsigned. The contract spend is, therefore, monitored against the CCG budget rather than the Trust version of the contract plan. Based on the current budget the contracts representing the biggest financial risk to Barking and Dagenham CCG at month 9 are Great Ormond Street (£137k over plan), Royal Free (£118k over plan) and the Homerton (£305k over plan). This position may change when the contracts are signed. Additionally Royal National Orthopaedic Hospital is £348k over plan. The over spend is against planned activity (high cost, low volume spinal surgery). Further detail will be given about the variances against plan in the contract report. NCA’s: The annual NCA budget has reduced by £337k in month 9. £300k relates to the revenue transfer to Waltham Forest and £37k relates to the specialist commissioning reconciliation. The backlog of NCA invoices are in the process of being cleared. The CSU is following the CCG approved procedure to do this. The backlog built up over the first six months of the financial year. Whilst progress is being made there are still a large number of invoices outstanding. For the purposes of reporting invoices paid and those waiting for validation are accrued. Community Specialist Services: As reported in previous months the CATs service (Care UK and Primary Clinical Partnership Ltd) is over plan. The majority of the budget was removed at the beginning of the financial year for QIPP. The scheme has now stopped but it overran by 3 to 4 months. The predicted year end value over spend against this budget is £439k. Independent Sector: The contracts reported in this section are Care UK, In Health, Holly House, BMI and Spire Healthcare. The reported position has been based on data received to date with a straight line used for the predicted year end value outturn. This budget is £592k over plan at month 9 with a predicted year end value of £789k. The majority of the over spend relates to the ISTC (Care UK and In Health). The over spend is largely due to a budget setting issue but there is also an increase in the cost of activity compared to the last financial year.

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Specialist Commissioning Reduction: The specialist commissioning reconciliation is now complete and the revenue transfer actioned in month 9. There is a negative budget left in Barking and Dagenham CCG of £2,929k. In previous months it was assumed that this budget would break even and represent no financial risk to the CCG. As the reconciliation is now complete the financial position has been adjusted to show the impact of the negative budget. The reported year to date over spend against plan is £2,196k and £2,929k over plan at year end. Acute risks and recommendations BHRUT: Risk – In the month 8 activity data submitted by the Trust there is £2m coded to an accrual line. The Trust implemented a new PAS at the end of November and indicated that the accrual was raised to pick up the cost of activity manually recorded at the end of November. There is a risk that the PAS implementation will have an impact on data recording in future months. Additionally the quarter 1 and 2 reconciliation and financial payment to the Trust is not agreed. The financial position is based on the CCGs offer to the Trust. There is a risk that this position is different to the final performance payment agreed with the Trust and that the predicted year end value is under reported. Recommendation – The CSU claims team have raised a query about the accrual with the Trust and asked that it be removed from the freeze position. By the freeze date the activity needs to either be coded correctly or removed. The CSU contracts team will work with the Trust to assess whether the Trust are able to do this and the likely timescales. The CSU contracts team will also work with the Trust to assess any likely impact on future months reporting. Barts Health: Risk – There is a significant financial risk associated with this contract. The reported position has been consistently above plan. There is a risk that the adjustments made to the contract have been overly ambitious and that the contract position worsens. The predicted year end value position has remained fairly even at £3,871k over plan but the underlying data suggests that the predicted year end value position could be significantly higher. Recommendation – Further analysis of the main areas of over spend are detailed in the contracts report. It is recommended that the BHR CSU contracts and finance teams work with the WELC CSU teams to further understand the data submitted by Barts Health and the adjustments made to the data. Adjustments to the financial position: Risk – There is risk that the challenge process will not yield the expected benefit built in to the reported position. For the two largest contracts there are a range of financial adjustments made to the reported position. These adjustments are not currently agreed by the Trust. The CCGs are in discussion with BHRUT and Barts Health about the quarter 1 and 2 closedown. The basis of any agreement reached will impact on the future reported position. Recommendation - Use the quarter 2 reconciliation process to inform the reported position. The CSU teams will continue to monitor the success of claims and amend the reporting accordingly.

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NCA’s: Risk – There are a large number of NCA invoices that remain un-validated and unpaid. The NCA budget has being adjusted to remove the element of budget relating to specialist activity. Until the invoice backlog is cleared there is a risk that the reported position is either over stated or under stated. There is a risk that the reported position contains an element of specialist costs. Additionally there is lack of clarity about whether CCGs should be charged for Walk in Centres, Urgent Care Centres and Minor Injury Units. Recommendation – The CSU and CCG have agreed a NCA validation process. The CSU contracts team have started to clear the backlog of invoices in the system. Until the invoicing process for Walk in Centres, Urgent Care Centres and Minor Injury Units is agreed the invoices will remain on hold, although they will be accrued into the financial position to ensure the full cost is reflected. NCA spend will be closely monitored and the contracts team will notify the CCG of any emerging financial risks.

Healthcare Provision

Community Health Services: The position shows a month 9 reported cost pressure of £272k and a yearend variance of £346k overspend. The predicted year end value is made up of cost pressures of £199k against phlebotomy costs, £30k against counselling services, £105k charge for locum costs above an agreed threshold and £95k for the Community Treatment Teams contract variation being charged outside of the NELFT community block contract. The £95k contract variation is against winter pressures and the funding is within the acute portfolio so overall this is not an over spend. Further pressures are predicted of £35k against the Richard House budget with £2k against other budgets within this area. These pressures are partially offset by a £36k rebate from NELFT for a missed first quarter KPI against average length of stay and a predicted underspend of £84k against the termination of pregnancy budgets. Service provided in a primary care setting: GP Prescribing - The October data was available in December from the Prescription Pricing Authority (PPA) and this also includes a predicted year end value. The cash report from the Business Services Authority has also been received. Figures have also been finalised for October amounts against Non-Discretionary drugs and Centrally Held Drugs costs. These have been factored into the M9 position which is based on the 7 months (April to October) data. A full review by the CCG’s medicine management team along with CCG and CSU finance teams has resulted in a predicted value at year end of a £453k overspend being reported. This is an increase of £137k from the month 8 position and is believed to be due to a spike in the Non-Discretionary spending caused by GP prescribing of seasonal flu vaccinations. Non-Discretionary cost is forecast with the PMD predicted year end figures provided by the PPA.

Healthcare Provision Annual Budget £000s

YTD Budget £000s

YTD Actual £000s

YTD Variance £000s

In Month Budget £000s

In Month Actual £000s

In Month Variance

£000s

Predicted Year End

Value £000s

Predicted Year End

Value Variance

£000sCommunity Healthcare 30,970 23,228 23,499 (272) 2,581 2,685 (104) 31,316 (346)Services Provided in a Primary Care Setting 29,005 21,917 21,039 879 2,366 1,341 1,025 28,917 88Mental Health & LD 28,313 21,235 21,229 6 2,414 2,328 86 28,247 66Programme Spend 20,063 11,141 2,834 8,307 1,474 (33) 1,507 7,426 12,637Continuing Care 11,970 8,978 8,978 0 898 898 1 11,970 0Healthcare Provision Total 120,321 86,498 77,578 8,920 9,732 7,219 2,514 107,877 12,444



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A further overspend in this area against Primary Care IT is also predicted to be £45k at year end. Predicted underspends of £5k against Out Of Hours services, £14k against Oxygen services and £567k against Walk In Centres services leave this area with an overall predicted year end underspend of £88k. Mental Health Services: The reported position shows a month 9 overspend of £6k and a predicted yearend pressure of £66k. A yearend pressure of £299k is predicted against costs for charge exempt overseas visitors from NELFT. The NCA pressure has been removed this month as the patient has been discharged when previously the costs had been predicted until the end of the financial year. Further pressures of £18k against the CAB budget and a £10k adverse various against the remaining budgets have also been identified. These are offset by £165k predicted year end underspend in the Care UK contract due to higher than expected voids within spot placements being made at their Cherry Orchard site. A further £135k has been released due to the high costs area budget, £59k against the TIS Service budget and a £34k underspend is predicted against the collaborative budget. Programme Spend: This contains the CCGs reserves which are being used to offset the projected over spends in both acute and non-acute. Within this area a pressure of £381k is shown against Cardiac Nurses. This funding was expected to be received by the CCG as an additional allocation but NHS England has stated that as networks ceased on the 1st April so has the funding. This issue will be resolved within the 2014/15 contract round. Continuing Healthcare: The Broadcare system, which is designed to support the reporting of continuing care, is currently being reviewed by the central NEL CSU continuing care team. The work to cleanse the system is underway and regular meetings are being held between the CSU continuing care team and the BHR CCGs central management team. The invoice backlog is also being addressed and the two issues are very much interlinked. An analysis of all available information was carried out by the CSU finance team. After review by the CCG finance team a predicted year end value of breakeven was agreed and this has been reflected in the predicted year end value.

Healthcare Provision risks and recommendations

Continuing Care:

Risk: This area continues to be a concern and therefore a risk. Continuing care is historically a volatile area which has been susceptible to adverse variances.

Recommendation - The area continues to be closely monitored with all available tools utilised. The completion of the rectification work will further assist the understanding of the in year position and the predicted year end value.

Continuing care provision: Risk - A provision for previously un-assessed (retrospective) care claims has been made in B&D PCT’s annual accounts. Latest notification from NHS England has stated that the provision, and related responsibilities against this, will be passed to B&D CCG in 2014/15. Therefore any costs incurred in 2013/14 will be paid by NHS England. Full clarity around this and the impacts on 2014/15 is being sort and it is expected full guidance will be issued shortly. Ongoing costs against successful retrospective claims will also need to be closely monitored and factored into this year’s forecasts and future

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years planning. A provision will also need to be made to cover any retrospective claims that may be received in future years relating to 2013/14. Cost and volume contracts: These areas are 111, Out of hours, Walk in Centres (WICs) and Termination of Pregnancies (TOPs). Currently the 111 service is under performing and a small claw back could be due if this trend continues. Under spends are predicted within the TOPs and WIC budgets as detailed above. Due to information governance issues and confusion caused by the Who Pays guidance the recharging of WIC services hosted by Barking and Dagenham CCG has not occurred so far in 2013/14. Recommendation - Solutions to information governance issues are continued to be sort from NHS England. This will enable the risks, particularly around WICs, to be identified and mitigating plans, if required, can be put in place as soon as possible. The CCG also needs to take a view of the impact of the finalised Who Pays guidance on the recharging of services once the IG issues are resolved.

Running Cost Barking and Dagenham CCG are currently showing a breakeven position against plan.

Corporate non-pay budgets have been split as per the CCG request.

Cost Centre Description

Annual Allocation in £000's

YTD Budget £000's

M9 Ledger YTD Actual

Costs £000's

M9 Accruals £000's

YTD Total £000's

YTD Variance

£000's

In Month Budget £000's

In Month Actual £000's

In Month Accruals £000's

In Month Total £000's

In Month Variance £000's

In Month Movement

£000's

Predicted Year End

Value £000's

Predicted Year End Variance

£000'sBarking & Dagenham CCG - 07LNCEO/ Board Office 289 217 175 26 201 16 24 10 -4 6 18 20 292 -3Chair and Non Execs 369 277 271 4 275 2 31 36 -8 29 2 2 383 -14Clinical Support 75 56 17 32 49 7 6 0 -1 -1 7 7 65 10Corporate Costs & Services 317 238 112 78 190 48 26 17 -26 -8 35 22 301 17Finance 330 247 199 81 280 -32 27 -1 68 67 -39 -49 319 11Innovation Fund 70 53 25 13 38 15 6 0 4 4 1 -12 72 -1Nursing Directorate 20 15 47 20 67 -52 2 1 53 53 -52 -51 23 -3Operations Management 614 460 529 -81 448 13 51 49 -27 22 29 47 610 4Recharges 2,708 2,031 2,041 5 2,046 -15 226 677 -450 227 -2 12 2,728 -20Strategy & Development 47 36 24 13 37 -1 4 0 4 4 -1 0 47 0Total Running costs 4,840 3,630 3,440 190 3,630 0 403 789 -385 404 -1 -2 4,840 0

Barking and Dagenham CCGStatement of CCG Running CostsPosition as at 31st December 2013

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QIPP Barking and Dagenham CCG has achieved £4.41m of £5.13m QIPP savings required to M8 - 79% of the targeted total. Performance is below target for: Outpatient Demand Management, which has significantly underachieved YTD, creating nil savings against a targeted £400k saving. The CCG is focussing on increasing practice ownership and understanding of the QIPP targets, as this is the key driver for delivery. Jointly developed enhanced action plans are being created with practices in Cluster 6. This should enable delivery of the target. Review and expansion of POLCV has created nil savings YTD. A review of the savings target suggests that it was set unrealistically high and is unlikely to achieve any savings in-year. ICM has continued to lose much of the savings reported against it in M8 as M7 saw increased spend against EM admissions in the ICM top 10 conditions. The project has shifted focus towards looking at how ICM can be used to support admission avoidance through supporting primary care, based on the admission avoidance audits practices have completed - some key processes will be signed off in mid Nov. Contract Novation The slight shortfall relates to a single contract that the CCG was unable to decommission at the start of the year. Decommissioning of CATS Discussions are in place to review the savings CCG is now expecting to deliver. M9 report will detail this. Diagnostics Demand Management - The CCG has enjoyed another month of low utilisation at InHealth in M8, which continues the trend of reduction, particularly in MRI. A focus on Ultrasound will assist in creating further savings towards the target. YTD achievement currently sits at 64% of target, Acute reconfiguration. Performance is on/above target for the following QIPP projects: Community Services Development, Acute reconfiguration, Medicines Management, Medicines Management budget

8

QIPP schemes - by commissioner function Full year YTD YTD YTD In month In month In monthsaving target saving target actual savings variance saving target actual savings Variance

£000's £000's £000's £000's £000's £000's £000's

AcuteOutpatient Demand Management 680 461 0 -461 61 0 -61Diagnostic Demand Management 180 122 98 -24 15 -3 -19Review and expand POLCV 100 61 0 -61 10 0 -10Integrated Case Management 350 156 148 -8 34 148 114Medicines Management 920 678 678 0 60 297 237Medicines Management - budget removal 400 267 267 0 33 33 0Acute Reconfiguration - A&E/UCC and redirection to Primary Care 170 81 58 -23 17 1 -16BHRUT Productivity measures - DC to OP, FA:FU, C2C 790 523 523 0 65 65 0Barts Health risk share 880 587 587 0 73 73 0

Acute schemes sub-total 4,470 2,937 2,359 -578 370 615 244

Non-AcuteDecommissioning of CATS 240 122 0 -122 30 0 -122Community Services Development 460 304 304 0 38 38 -84Walk in centre review at Barking 140 0 0 0 0 0 -122Contract Novation/Decommissioning inc. Local Authority 1,490 922 902 -20 142 140 18NELFT Community Services efficiencies 600 500 500 0 63 63 -60NELFT Mental Health cluster efficiencies 600 333 333 0 42 42 -80Local Enhanced Services 20 13 13 0 2 2 -120

Non-Acute scheme sub-total 3,550 2,194 2,052 -141 317 284 -570

Total position 8,020 5,131 4,411 -719 687 899 -326

Barking and Dagenham CCG QIPP Financial Position 2013/14

Month 8

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removal, BHRUT productivity measures, Barts Health Risk Share, Local Enhanced Services, NELFT No savings are yet expected from the following schemes/The following schemes are no longer being pursued: Walk-in Centre Review Statement of financial position The statement of financial position (SoFP) summarises the CCG’s assets, liabilities and tax payers’ equity at a specific point in time. The CCG’s statement of financial position as at 31st December 2013 can be seen at Appendix 1. The Barking and Dagenham CCG SoFP currently shows a negative non-current asset value of £74k with a Predicted Year End Value position of £99k positive. This is due to an expected depreciation charge to month nine of non-current assets which have not yet been transferred to the CCG as part of the legacy balance transfer from Primary Care Trusts. The Predicted Year End Value position takes into account expected transferred Net Book Value of assets from legacy organisations and the predicted year end value of the depreciation charge. The cash and cash equivalent balance within the statement of financial position as at 31st December 2013 was £3,258k. This was £138k less than the cash position shown within the actual cash and Predicted Year End Value cash position (Appendix 2) due to the release of a bacs run on 27th December which cleared the bank account on 3rd January. The statement of financial position shows the general ledger balance based upon un-cleared cash items, whereas the actual cash and the predicted year end value cash position only shows cleared items. Trade and other payables totalling £19,134k include £8,925k worth of outstanding invoices to NHS and Non NHS Organisations, as well as £10,209k worth of net manual adjustments most noticeably £3,801k in terms of Prescribing which contribute to the estimated financial position as at 31st December 2013. Predicted Year End Value of closing balances are based upon expected working capital balances including one quarters worth of the predicted year end value for over performance to NHS Providers, as well as 50% in year utilisation of the retrospective continuing health care provision being transferred from legacy organisations. Invoice payment performance measure – Better Payment Practice Code (BPPC) The BPPC requires the CCG to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. A summary of the year to date results can be found at Appendix 3. BPPC figures for the CCG as at the end of December show that 74.6%% was achieved on the number of invoices paid and 94.1% was achieved on the value of invoices against the target of 95% on both indicators. The CCG is working closely with the CSU to ensure all valid invoices are being cleared in line with this target.

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Financial Summary The data received for month 9 reporting has improved slightly apart from Barts Health, which is of great concern and is a key risk to the reported position. There are also a number of other unsigned acute contracts. There is regular liaison between the Trusts and associate contract leads to sign off contracts and analysis is ongoing to validate the financial position for month 1 to month 7 activity data where it is being submitted. The handover of legacy issues from Barking and Dagenham CCG is currently ongoing and the full financial impact of this will not be understood until it is completed. A further update will be provided when available. Due to the reported acute overspend the use of reserves has been required to deliver the current Predicted Year End Value position. The year to date position at month 9 highlights a £719k QIPP variance, which will need to be recovered to enable the full £8m QIPP programme to be delivered.

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Appendix 1

135

Appendix 2

136

Appendix 3

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Appendix 4

Commissioner Function Annual YTD YTD YTD In month In month In month In Month Predicted Year Predicted Year Predicted Year End Allocation Budget Actual Variance Budget Actual Variance Movement End Value End Value Variance Value In Month Movement

£000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's

Acute Healthcare

Acute Commissioning 105,071 79,425 82,990 (3,565) 8,793 8,800 (7) (120) 110,649 (5,577) 530Acute Commissioning Other 110 83 2,961 (2,878) (2,028) 174 (2,202) (2,214) 3,677 (3,567) (2,958)High Cost Drugs 10 8 8 0 (110) (110) 0 0 10 0 0Ambulance Services 6,867 5,150 5,150 0 572 572 0 0 6,867 0 0Clinical Assessment and Treatment Centres 2,185 1,639 2,081 (442) 182 303 (121) (22) 2,775 (589) (108)NCA 2,192 1,644 1,889 (245) (42) (5) (37) 157 2,518 (327) (14)

Acute sub-total Acute sub-total 116,436 87,948 95,079 (7,131) 7,368 9,735 (2,367) (2,199) 126,496 (10,061) (2,550)

Mental Health & LD sub-total

IAPT 34 25 12 13 3 0 3 (9) 16 18 2Mental Capacity Act 22 16 0 16 2 0 2 0 0 22 38Mental Health Contracts 24,988 18,741 18,741 0 2,082 2,082 0 0 24,988 0 0Mental Health Services - Adult 1,633 1,225 1,303 (78) 136 106 30 18 1,682 (49) 136Non Acute NCA 300 225 98 127 25 8 17 16 131 169 5Mental Health Services - Older People 135 101 1 100 11 1 10 (80) 0 135 0Mental Health Services Other 1,201 901 1,073 (172) 155 131 24 213 1,430 (229) 26

Mental Health & LD sub-total 28,313 21,235 21,229 6 2,414 2,328 86 159 28,247 66 208

Community Healthcare

Community Services 29,959 22,469 22,635 (166) 2,497 2,586 (89) (85) 30,187 (228) (94)Hospices 819 615 685 (71) 68 77 (9) 37 899 (79) 13Long Term Conditions 164 123 143 (20) 14 18 (4) (6) 182 (18) 7Wheel chair service 28 21 36 (15) 2 4 (1) 2 48 (20) 0

Community Sub-total 30,970 23,228 23,499 (272) 2,581 2,685 (104) (52) 31,316 (346) (74)

Continuing Care

CHC Adult 9,256 6,942 7,634 (692) 671 885 (214) (12) 9,988 (732) (198)CHC Adult Full Fund Pers Hlth Bud 0 0 35 (35) 0 4 (4) (20) 31 (31) (8)CHC Children 1,508 1,131 535 597 126 (104) 229 67 730 778 245Funded Nursing Care 1,206 905 775 130 101 112 (12) (35) 1,221 (15) (40)

Continuing Care Sub-total 11,970 8,978 8,978 (0) 898 898 (0) (0) 11,970 0 0

Programme Spend

Commissioning - Non Acute 372 290 580 (290) 27 30 (3) 226 779 (407) 144Reserves - Commissioning (0) 0 1 (1) 0 0 0 1 0 (0) 0Counselling services 138 104 104 0 12 12 0 0 138 0 0GP IT/Levies 0 (0) 0 (0) (66) (221) 155 166 0 0 241Programmes Projects 99 74 322 (247) 74 250 (175) (175) 384 (285) (285)Reablement 17,722 9,373 967 8,407 1,282 200 1,082 89 4,981 12,741 1,348NHS 111 353 265 265 0 29 29 0 0 353 (0) 0NHS Prop.Co 385 288 299 (11) 32 32 (0) 11 396 (11) (11)

994 745 297 448 83 (366) 448 449 396 598 598Programme Spend Sub total

20,063 11,141 2,835 8,306 1,474 (33) 1,507 766 7,426 12,637 2,036Services Provided in a Primary Care Setting

Out of Hours 1,133 850 845 4 94 94 1 0 1,127 6 0Commissioner Schemes 2,718 2,038 722 1,316 226 (1,023) 1,250 1,247 2,028 690 587Primary Care Payment 459 344 344 0 38 38 (0) (0) 459 0 (0)Medicines Management 745 116 135 (19) 13 32 (19) (29) 158 (4) (4)Primary Care GP IT 155 559 591 (32) 62 94 (32) (32) 787 (42) (42)GP Prescribing 23,796 18,011 18,401 (391) 1,932 2,106 (174) 88 24,358 (562) (160)

Services Provided in a Primary Care Setting Sub total 29,005 21,917 21,039 879 2,366 1,341 1,025 1,274 28,917 88 381

Sub-total Health Sub-total Healthcare provision 236,757 174,446 172,658 1,788 17,100 16,953 147 (52) 234,374 2,384 0

Corporate and non healthcare costs

CCG Running Costs 4,840 3,630 3,630 (0) 403 404 (1) (2) 4,840 (0) (1)Education And Training 0 0 0 0 0 (5) 5 5 0 0 0CCG Levies 0 (0) 0 (0) 0 (47) 47 47 0 (0) (0)

Corporate Sub-total 4,840 3,630 3,630 (0) 403 352 52 51 4,840 (0) (1)

Gross Expenditure 241,597 178,076 176,288 1,788 17,503 17,305 198 (1) 239,214 2,384 (1)



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Appendix 5

139

ITEM 6.7

To: Meeting of Barking & Dagenham Clinical Commissioning Group Governing Body

From: Martin Sheldon, Chief Financial Officer


Subject: Contract Report

Executive Summary The purpose of this report is to brief the Governing Body on the contract performance as at M9 (December 2013) for the four main providers of Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT), Barts Health NHS Trust (BH), North East London Foundation Trust (NELFT), PELC and contracts for whom the CCG are an associate. Overall financial performance of these four main contracts against plan is above plan performance of £2.515m Year to Date (YTD), with a predicted year end variance of £4.539m (based on the adjusted position). The main provider over performance relates to Barts Health NHS Trust (BH). The contract with this provider is still not agreed between the Barking and Dagenham, Havering and Redbridge (BHR) CCGs and the Trust. Drivers of over performance vary between the two main acute providers of Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) and BH, with the main area where expenditure is highest above plan at BHRUT being planned admissions and at BH emergency admissions. This report provides information based on the Provider raw data (SLAM) and the adjustments made to that position (which have been agreed with the CCG) to give the assessed position. BHRUT implemented a new Patient Administration System in late November, with the impact that activity for the last three days of November isn’t properly reported. To address this, the Trust included an ‘accrual’ value of £2m in the November SLAM report. No further detail for this value has been provided, with the consequence that the individual points of delivery are under reported. The trust have stated that this issue will be resolved by the data freeze point of the week commencing 20th January. Challenges and queries are being raised where appropriate and there is a quarterly reconciliation process being undertaken with each Trust. These are expected to at least partially mitigate the above plan costs to date. Performance against standards and contractual quality requirements is showing that one red RAG rating is in place for at least one area in each standard and for the A&E standard performance is predominantly red rated across both acute Providers. There are breaches of specific requirements or standards that are identified within the report. Where these have occurred contract mechanisms have been applied to address the performance issue and where appropriate penalties are being applied. Details of the particular areas of concern are highlighted in the summary for each provider and full performance details are provided in the appendices to this report.

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Recommendations The Barking and Dagenham CCG Governing Body is asked to:

• To note and discuss the current position for each of the four main contracts and associates;

• To agree any further actions to be taken in respect of managing the contracts and mitigating the risk of over performance;

• Note any risks that are to be added to the Governing Body Assurance Framework • To note the implementation of mitigation actions

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CONTENTS

1.0 Purpose of the Report 3 2.0 Background/Introduction 3

2.1 Overview for Provider Contracts 3 3.0 YTD Overview (£000,%) (Over)/Under Spend 4

3.1 YTD Adjustments 4 3.2 YTD Performance 4 3.3 Monthly Provider Performance (raw data) 5 3.4 Predicted Year End Position 5

4.0 Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) - Contract Summary 6

4.1 Commentary 6 4.2 POD Analysis 6 4.3 Contractual Performance Summary Error! Bookmark not defined. 4.4 National Quality Requirements 9 4.5 Financial Mitigations 8

5.0 Barts Health NHS Trust (BH) - Contract Summary 11 5.1 Commentary 11 5.2 POD Analysis 12 5.3 Contractual Performance Summary 13 5.4 National Quality Requirements 14 5.5 Financial Mitigations 15

6.0 North East London Foundation Trust - Contract Summary 15 6.1 Overview 15 6.2 Mental Health Contract B&D (£25m) 16 6.3 Community Services Contract B&D (£29m) 16

7.0 PELC - Contract Summary 17 7.1 Overview 17 7.2 Urgent Care Centre (UCC) 18 7.3 111 18 7.4 Out of Hours (OOH) 18

8.0 Continuing Health Care (CHC) 19 9.0 Summary of Associate Clinical Services Contracts 19

9.1 Associate Contracts Summary 19 9.2 Signed Contracts 19 9.3 Unsigned Contracts 20 9.4 Commentary 20

10.0 2014/15 Contract Negotiations Update 21 10.1 BHRUT 21 10.2 Barts Health 22

11.0 Appendices 23

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1.0 Purpose of the Report The purpose of this report is to brief the Governing Body on the contract performance Year to Date (YTD) as at M9 (December 2013). 2.0 Background/Introduction The following section describes the basis of the contract values and the reporting methodology used throughout this report. 2.1 Overview for Provider Contracts

2.1.1 Contract Value Methodology: BHRUT The contract value is based on the 2012/13 M6 Freeze reported activity and finance data for the Trust net of challenges extrapolated to full year effect and then net of NHS England (NHSE)/Local Authority (LA) transfers. QIPP deductions were made with no growth applied. No additional capacity was purchased in respect to planned Referral to Treatment (RTT) backlog clearance programmes. 2.1.2 Contract Value Methodology: BH The contract value is based on 2012/13 actual outturn with agreed adjustments, net of NHSE/LA transfers. No QIPP deductions were made however growth was applied. No additional capacity was purchased in respect to planned RTT backlog clearance programmes. 2.1.3 Predicted Year End Outturn Methodology for 2013/14 The predicted year end value outturn is calculated using the predicted year end value data generated by the North East London Information Exchange (NELIE). This is based on a straight line, calendar days or working days depending on the type of activity. The adjustments made to the position are also made to the predicted year end value position. The claims figure included in the position is based on an estimate for M8 at M9 and is based on the CSU risk adjusted claims figure. CQUIN is built into the prediction on the basis of a 75% achievement for BHRUT and 92% achievement for BH for quarters 3 and 4. At the request of CCGs QIPP delivery is not built into the predicted year end position. 2.1.4 Drivers of Predicted Year End Over-performance There is evidence that NHSE activity is being incorrectly misattributed to CCGs by most providers. This can only be adjusted where known and is being challenged with providers as part of the monthly claims process. The output of this will be picked up as part of the M6 Reconciliation Project currently underway. 2.1.5 Provider Performance Analysis of the movement in the BHRUT position is not possible because of the data issues due to the PAS implementation. Barts Health reported activity figures are being queried due to data quality and accuracy concerns.

Other acute contracts are not all yet agreed as the offers include NHSE activity transfer values that are at variance to CCG assumed values. These variances should reduce as these final negotiations conclude.

2.1.6 Actions to Address Performance Position Additional challenges have now been raised with all Providers. PbR and pricing queries are being raised with Providers and work is underway to address key areas of specialist attribution queries.

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3.0 YTD Overview (£000,%) (Over)/Under Spend Note: For reporting purposes the convention adopted is that an over performance is described as a negative value (i.e. (£196k) is a £196k above plan performance). The tables below identify the total adjustments that have been made to the provider raw reported activity and finance data. These adjustments reflect the changes that are made to the provider reported figures resulting from challenges raised, productivity metric adjustments and performance penalties etc., which result in the final values that are presented in the Budget Report. The raw figures are used here as this is the data used to analyse provider performance. Details of the adjustments that have been applied are identified in the Budget Report. 3.1 YTD Adjustments The table below shows the YTD position based on the Provider’s actual position (SLAM), the total of the adjustments made and the reported budget (ledger) position.

Provider YTD ActualYTD

Adjustments

YTD Adjusted Actual in Budget Report

£'000 £'000 £'000BHRUT 62,813 (646) 62,167 Barts Health 15,150 (2,153) 12,997 NELFT 40,281 40,281 PELC 1,134 - 1,134

Barking and Dagenham CCGDecember (M9)

3.2 YTD Performance The information below identifies the financial performance against expected contract plan levels for each provider post the application of any contract penalties, challenges or other adjustments.

Provider YTD PlanYTD (Over) / under spend

Full Year Plan

FOT (Over) / Under spend

£'000 £'000 £'000 £'000BHRUT 62,802 635 82,869 (120)Barts Health 10,079 (2,918) 13,439 (3,871)NELFT 30,968 (232) 41,291 (621)PELC 3,085 0 3,656 73Total 106,935 (2,515) 141,255 (4,539)

Barking and Dagenham CCGDecember (M9)

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YTD performance for four main contracts (contained within the table above) for Barking and Dagenham CCG shows an overall predicted year end overspend of £4.539m. An accrual value of £2m is included within the BHRUT values, included because the implementation of a new patient administration system meant that BHRUT have not been able to report for the activity for the last 3 days of November. 3.3 Monthly Provider Performance (raw data) The chart below shows the monthly financial performance by Provider for each month of the year to date using the raw SLAM data i.e. prior to any financial adjustments being made. This identifies that the BHRUT plans are broadly representative of the levels of activity expected in year although there are variations month to month. The position for BH is relatively stable. NELFT and PELC are block contracts therefore no variation is shown. The £2m accrual value is included in the BHRUT profile below. N.B. Data was not available in M1 and that caution should be used in respect of M2 and M3 due to the embedding of new reporting systems.

3.4 Predicted Year End Position The predicted year end position is an overperformance of £4.539m. This has been based on a series of financial adjustments which are detailed further in the Budget Report. BHRUT implemented a new Patient Administration System in late November, with the impact that activity for the last three days of November isn’t properly reported. To address this, the Trust included an ‘accrual’ value of £2m in the November SLAM report. No further detail for this value has been provided, with the consequence that the individual points of delivery are under reported. The trust have stated that this issue will be resolved by the data freeze point of the week commencing 20th January.

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4.0 Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) - Contract Summary

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4.1 Commentary After risk assessed adjustments for mitigations, agreed with the CCG, the BHRUT contract is performing over the contract value. Detail on these mitigations can be found in section 4.5. The predicted year-end position is £82.989m. Under delivery of QIPP is a key risk to achieving the planned financial values set in the contract. Contract process is being followed in respect of the financial closedown for quarter 1 and quarter 2, with the potential that the financial position will be referred to mediation and arbitration. Penalties are being levied for performance breaches and joint actions set out to understand and address variances in activity levels. Further actions are being addressed through the Service Performance Review Group and appropriate escalation processes. Adjustments will be made to the mitigated financial position once these items are resolved. 4.2 POD Analysis

4.2.1 Planned Admissions and Daycases Activity consists of Day Case (DC), Planned Admissions, Regular Day Attenders and the related Excess Bed Days

The top 5 areas where YTD spend has been worse than expected are:

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Specialty YTD Price Plan

YTD Price Actual

YTD Price Variance

YTD Activity Plan

YTD Activity Actual

YTD Activity Variance

ENT £629,065 £944,258 (315,193) 498 755 (257)Trauma & Orthopaedics £1,432,964 £1,624,785 (191,821) 555 647 (91)Urology £1,061,999 £1,203,121 (141,121) 1,625 1,782 (157)Gynaecology £661,848 £792,457 (130,609) 590 623 (33)Neurosurgery £240,861 £363,679 (122,817) 68 89 (22)

Barking and Dagenham CCG Financial Position 2013/14Planned Admissions and Daycases - top 5 specialties where expenditure is worse than planned

4.2.2 Emergency Admissions Activity consists of Emergency Admissions, Non-Elective Non-Emergency and the related Excess Bed Days. The top 5 areas where YTD spend has been worse than expected are:

SpecialtyYTD Price

PlanYTD Price

ActualYTD Price Variance

YTD Activity Plan

YTD Activity Actual


Gastroenterology £320,222 £688,724 (368,502) 169 354 (184)Urology £369,455 £434,787 (65,332) 272 330 (59)Cardiology £706,334 £768,788 (62,454) 529 549 (20)ENT £191,647 £239,503 (47,856) 185 344 (158)General Medicine £9,532,184 £9,569,739 (37,555) 7,268 6,681 587

Barking and Dagenham CCG Financial Position 2013/14Emergency Admisions - top 5 specialties where expenditure is worse than planned

4.2.3 Outpatients The Outpatient POD consists for first and follow–up attendances, non-face to face activity and outpatient procedures. The top 5 areas where YTD spend has been worse than expected are:

SLAM POD YTD Price Plan (000's)

YTD Price Actual (000's)

YTD Price Variance (000's)

YTD Activity Plan

YTD Activity Actual


First Attendances £4,345 £4,506 (161) 24,680 25,622 (942)Follow Up attendances £3,946 £4,007 (62) 42,713 44,828 (2,116)Outpatient Procedures £1,134 £1,169 (36) 7,175 7,109 66Total £9,425 £9,683 (259) 74,567 77,560 (2,992)

Barking and Dagenham CCG Financial Position 2013/14Outpatient Attendances by Point of Delivery

4.2.4 Maternity The antenatal maternity pathway expenditure YTD is £3.813m, an overperformance of £412k. A range of checks are being run, including checks on the potential for double bookings across Trusts and both a clinical and non-clinical check of coding practice. Two briefing papers have been produced setting out the position for both BHRUT and BH in terms of Maternity Deliveries.

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4.3 Contractual Performance Summary A summary of the achievements and issues in relation to BHRUT up to November (where data is available) are set out below, the full Provider Scorecard is available at Appendix 1. 4.3.1 18 weeks Referral to Treatment Times In October, BHRUT achieved on the waiting times standards for Non-admitted (97.7%) and Incomplete (93.2%). There were no over 52 week waiters for BHRUT in October. Diagnostic waiting times were also achieved at 99.9%. October BHRUT was under the waiting time standard for Admitted (89%). Specialty level underperformance remains in the Admitted and Incomplete cohorts. BHRUT reduction of the 18weeks backlog has impacted on admitted performance. 4.3.2 Cancer Waiting Times Figures for October show BHRUT has achieved the 2WW standard, 31 day subsequent surgery standard and 62 day screening standard every month this year so far – eight months in a row. After breaching the 2ww breast symptomatic standard for five months in a row (May-Sept 2013), BHRUT have achieved a performance of 93.2% against the standard of 93% for October. Although there has been an improvement in performance in regard to the 62 day GP referral standard this month, the Trust have still failed to meet the standard, making it the fourth month this year. The year to date position is just under the 85% standard at 84.5%. This was discussed at the December SPR and a Contract Query Notice was issued on 21 January 2014. A remedial action plan was requested and a meeting will be arranged to review the plan within 10 operational days from the date the CQN was issued. 4.3.3 Summary Hospital Mortality Indicator (SHMI) Trust wide SHMI score below 100. 4.3.4 Venous Thromboembolism Achieved 95.2% in September. 4.3.5 Mixed Sex Accommodation In October, BHRUT reported 5 further MSA cases, bringing the YTD total to 86. 4.3.6 Cancelled Operations In quarter two, BHRUT cancelled 4 elective patients at short notice, who were not re-booked within 28 days. 4.3.7 Quality of Services CCGs have raised concerns regarding the quality of Radiology and Ophthalmology services and cancellation of Outpatient services. A Radiology Working Group has been set up and will provide a forum for focused discussions regarding quality of radiology services.

4.4 National Quality Requirements

4.4.1 Never Events and Serious Incidents No Never Events reported in current month (YTD= 1 Wrong Site Surgery-April 2013). No Grade 2 SIs reported in current month (YTD=2: including above Never Event & Maternal death-April 2013). The CSU and Trust continue to meet monthly to review SI status.

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4.4.2 MRSA & C. Diff Up to end of October, no MRSA cases were reported by BHRUT in 2013-14, however one has been reported in November and a further instance in December. Three C. Diff cases reported for BHRUT in October, this is within the monthly tolerance. The Trust is well within their annual tolerance of 40 cases, having reported 14 YTD. 4.4.3 Friends and Family Test (FFT) The total number of eligible inpatients and A&E patients decreased between May and September; during October there was an increase in number of eligible inpatients. It is noted that BHRUT continues an upward trend in the overall percentage response rates, where in October 27.18% of all eligible patients responded to the FFT questionnaire – compared to other London Trusts reporting on FFT, BHRUT was placed tenth highest out of 31 organisations in London. BHRUT met Q1; Q2, with response rate of 11.93%, BHRUT is likely to achieve Q2 - to be validated in December. 4.4.4 Ambulance Handover Times There were no reported 60 minute handover breaches in November. There were 115 over 30 minute handover breaches in November. 15 minute handover performance remains a cause for concern at both sites. 4.4.5 CQC The CQC visited BHRUT during week commencing 14 October 2013 under Professor Mike Richards new hospital inspection programme. As a result of the visit, BHRUT have been placed in special measures.

4.5 Financial Mitigations Challenges are raised each month where there are perceived inaccuracies in the information provided by the Trust. These are raised and responded in accordance with the monthly claims timetable. Any unresolved claims at the end of each month are retained and money withheld until the underlying issue has been resolved or the claim is addressed as part of a quarterly reconciliation exercise. Performance penalties are applied each month in respect of breaches where a financial penalty is defined in the contract. These penalties are included in the quarterly reconciliation process. Remedial action plans are in place as a consequence of the Deep Dive meetings with the CCG that have been taking place and these are being developed to address performance issues as they arise. Performance against the agreed CQUIN targets in the contract is assessed and any financial penalty or benefit applied as required. A summary of the mitigations applied is shown below. Please note, these adjustments are included within the adjustments contained within the tables above and there are a number of other areas e.g. emergency threshold that are not included within this table.

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Value M8 (£000's)

Claims 753Performance Penalties 231CQUIN Withholding 610Total 1,594

Contract Mitigation Values

5.0 Barts Health NHS Trust (BH) – Contract Summary The 2013/14 contract for Barts Health has not yet been signed off, although the contract has now been signed by Commissioners and issued to the Trust. The figures in the table and graph below are based on the Finance and Activity Tables provided by the NELCSU Finance Team.

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5.1 Commentary After adjustments for mitigations agreed with the CCG, the contract is over performing by £2.918m YTD for Barking and Dagenham CCG. Detail on these mitigations can be found in section 5.5. The predicted year-end position is £3.871m worse than plan. The main areas of over-expenditure relate to the Emergency POD. Maternity deliveries are captured within Non Elective Non-Emergency (NELNE activity) in the Emergency POD. For Barking and Dagenham CCG maternity deliveries are above planned levels at BH, although it is worth noting that below plan performance continues at BHRUT. There is also above plan performance within the Outpatient POD, but to a far lesser extent.

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As is the case for BHRUT, formal queries are raised with the Trust via the monthly Claims process and are addressed through the Technical Sub Group (TSG) and if necessary as part of the quarterly reconciliation process.

5.2 POD Analysis

5.2.1 Emergency Admissions Activity consists of Non-Elective, Non-Elective Non-Emergency and the related Excess Bed Days. The top 5 areas where YTD spend has been worse than expected are:

SpecialtyYTD Price

PlanYTD Price


YTD Activity Plan

YTD Activity Actual


Obstetrics £19,011 £1,669,771 (£1,650,760) 15 945 (930)Cardiology £238,606 £786,113 (£547,507) 115 238 (123)Well Babies £12,619 £197,772 (£185,153) 11 168 (157)Neurology £8,892 £99,259 (£90,367) 10 258 (248)Gynaecology £45,293 £115,565 (£70,272) 44 81 (37)

Barking and Dagenham CCG Financial Position 2013/14Emergency Admisions

5.2.2 Outpatients The various elements of Outpatient activity are set out within the chart above, however the specialties with the greatest above plan performance financially are shown in the table below: There is no plan for Nephrology and Cardiothoracic Surgery outpatient activity and this is currently being investigated as part of the SCG misattribution work ongoing across NELCSU. In terms of the Maternity pathway YTD, expenditure is better than plan by £38k. However activity is above plan and as such a range of checks are being run, including checks on the potential for double bookings across Trusts as well as an assessment of the amount of “pre-paid” activity.

5.2.3 Planned Admissions and Daycases Activity consists of Day Case (DC), Elective, Regular Day Attenders and the related Excess Bed Days The top 5 areas where YTD spend has been worse than expected are:

SpecialtyYTD Price

PlanYTD Price


YTD Activity Plan

YTD Activity Actual


Nephrology £0 £170,848 (£170,848) 0 1,017 (1,017)Gynaecology £101,120 £150,265 (£49,145) 746 983 (237)Cardiothoracic Surgery £0 £43,078 (£43,078) 0 189 (189)Paediatrics £109,739 £143,911 (£34,172) 520 682 (162)Clinical Haematology £5,074 £38,656 (£33,582) 224 276 (52)

Barking and Dagenham CCG Financial Position 2013/14Outpatient Attendances by Specialty

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Specialty YTD Price Plan

YTD Price Actual

YTD Price Variance

YTD Activity Plan

YTD Activity Actual


Cardiology £147,463 £441,705 (£294,242) 85 144 (59)Gynaecological Oncology £55,480 £78,970 (£23,490) 19 24 (5)Breast Surgery £0 £18,536 (£18,536) 0 4 (4)Urology £72,986 £83,902 (£10,917) 77 86 (9)Hepatobiliary & Pancreatic S £26,170 £34,484 (£8,314) 15 8 7

Barking and Dagenham CCG Financial Position 2013/14Planned Admissions and Daycases

5.3 Contractual Performance Summary A copy of the Provider Scorecard for BH is attached at Appendix 2. A summary of the achievements and issues in relation to BH during September and October (where data is available) are set out below.

5.3.1 Referral to Treatment (RTT) Waiting Times In October Barts Health was under the waiting time standard for Admitted (82%), Non-Admitted (92.4%) and Incomplete (84%). There were 58 patients waiting over 52 weeks at the end of October.

5.3.2 A&E Waits Barts Health achieved the All Types standard for the second consecutive month in November with 95.6%. The YTD position has improved to 94.8% at the end of November. Whipps Cross YTD position is 93.3%.

5.3.3 Cancer Waits Figures for October show Barts Health has achieved the 31 day 1st treatment cancer waiting times standard and the 62 day GP referral cancer waiting time standard. The Trust failed to meet the 2 week cancer waiting time for GP referral standard and the two week cancer waiting time for breast symptomatic standard in October for the third consecutive month. The Trust failed to meet the 31 day cancer waiting time for subsequent surgery in October.

5.3.4 Mixed Sex Accommodation (MSA) Barts Health had 14 breaches in November 2013. Of these 14, 10 occurred at The Royal London, 2 at Newham General Hospital, 1 at Whipps Cross and 1 at St Bartholomew’s.

5.3.5 Venous Thromboembolism The Trust continues to achieve the target to undertake a VTE risk assessment, with performance at 96.2% in September.

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5.4 National Quality Requirements

5.4.1 Serious Incidents Barts Health reported 56 SIs in October, a slight decrease from the previous month, and 180% increase from the same month last year. Serious Incidents form a subset of all patient safety incidents reported and the increase in SI numbers reflects an overall increase in patient safety incidents from 4.9 per 100 admissions to 6.5 in the data published in September 2013. The Trust has provided a response to the letter CCGs sent in regard to missed and delayed SI reporting, including an outline of its governance arrangements.

5.4.2 Infection Control In October, no MRSA cases were reported by Barts Health, the YTD position is 4 cases to the end of October. Four C.Diff cases reported for Barts Health in October are within the monthly tolerance. The Trust is well within their annual tolerance of 75 cases, having reported 41 YTD.

5.4.3 Friends and Family Test (FFT) The overall performance for Barts Health in October was 19.34% (combined inpatient and A&E). This is measured against a 15% target. This represents significant improvement on previous months. Performance for inpatient areas has risen from 24.22% in September 2013 to 32.54%. Significant improvement has been sustained in Barts Health A&E response rate from 6.64% in August to 14.54% in September with only a marginal decrease to 14.40% in October. Whipps Cross A&E declined from 22.04% down to 12.49%. However, The Royal London and Newham both increased to above 15%.

5.4.4 Ambulance Handovers There were six 60 minute handover breach reported in November for Barts Health, all at Whipps Cross. Whipps Cross Hospital failed the KPI 1 15 minute handover with (38.3%) and underperformed against KPI 2 (89.9%).

5.4.5 CQC Care Quality Commission (CQC) have a new inspection process was carried out at Barts Health in early November during which the CQC visited all sites. The formal feedback has recently been given and briefing sessions are planned to ensure that stakeholders are briefed. All restrictions on the Trust have now been lifted and in general the Trust was deemed to be providing “safe” services.

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5.5 Financial Mitigations Challenges are raised each month where there are perceived inaccuracies in the information provided by the Trust. These are raised and responded to in the monthly claims timetable. Any unresolved claims at the end of each month are retained and money withheld until the underlying issue has been resolved, or the claim is addressed as part of a quarterly reconciliation exercise. Performance penalties are applied each month in respect of breaches where a financial penalty is defined in the contract. These penalties are included in the quarterly reconciliation process. Remedial action plans are in place as a consequence of the Deep Dive meetings that have been taking place and these are being developed to address performance issues as they arise. Further to the Activity Query Notice (AQN) issued in October a meeting has now taken place between the CCGs and Trust with a draft action plan developed. An update against the actions was received in December 2013 and the CSU will continue to work with the Trust in close liaison with the BHR CCGs CFO on this. Performance against the agreed CQUIN targets in the contract is assessed and any financial penalty or benefit applied as required. A summary of the mitigations applied is shown below. Please note, these adjustments are included within the adjustments contained within the tables above but there are also a number of other areas not listed out specifically in this table e.g. Emergency Threshold. It should also be noted that due to the poor data quality issues being experienced with the BH contract, it is not possible to quantify all of the challenges being raised and as such this table only includes those elements which can be quantified at the current time.

It should be noted that a proposal has been made to BH on behalf of the 12 NELCSU CCGs to have a block contract arrangement for Q1 and Q2 based on the Heads of Terms value. A response to this proposal is still awaited. 6 North East London Foundation Trust - Contract Summary

6.1 Overview The NELFT block contract is on budget at M9 with no major provider disputes or issues. NELFT is supportive of BHR plans to deliver the BHRUT improvement programme. Quarter 2 close down with validated performance data took place at SPR on 25 November 2013. Quarter 3 closedown is due to commence via SPR on 27th January 2013.

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6.2 Mental Health Contract B&D (£25m)

• Mental Health Tariff (PBR) Summary reports on cluster activity, themes and accuracy now being provided to SPR. Areas for improvement identified with required actions agreed. First cut price per cluster is now also available and is being refreshed monthly as cluster and clinical activity data accuracy improves.

• Issues with access to mental health services have been identified especially in Havering. NELFT has prepared a detailed action plan to resolve these issues. Action plan is being monitored by CQRM, with detailed report by NELFT presented to CQRM on 2nd December 2013. Given that most of the action plan’s deadlines are for end December, CQRM has requested further update in January. CSU is advising CCG on action plan. Access is an issue that is recommended for more active performance management in 2014-15 contract.

• NELFT Q2 reports have been received and presented to SPR on 25 November. There are no KPI failures requiring financial penalty.

• There is one partial failure of a CQUIN relating to missing the threshold for response rate of Inpatient satisfaction survey. Non-recoverable withhold is £15K.

• SDIP good progress and additional stronger evidence is being provided by NELFT. • Essential operational service continuity maintained during Christmas and New Year

period.

6.3 Community Services Contract B&D (£29m) The £36k budget underspend is due to a penalty applied against NELFT not meeting the Average Length of Stay KPI for Q1

6.3.1 Key Headlines • Contract Variation in place for up to 11 ‘Winter Beds’ and daily sit-rep report in

place; • 4 KPIs meeting target; • 1 KPI failure (KPI 3 - ICM red and amber caseloads at 70% against target); • Bed occupancy reducing in line with BHR strategic plans; • Success in meeting targets set against assessment days, transfer days and

the Average Length of Stay for general rehabilitation • Contract variation in place for an enhanced Community Treatment Team

Service and new Intensive Rehabilitation Service. Revised budgets for these services and operational models signed off by all Clinical Commissioning Group (CCG) Governing Bodies;

• DQUIP requirements met (including financial service line reporting for wheelchair services); and

• In recognition of improvements, noted at SPR, in both the number of patients on ICM caseload and quality of crisis plans, the penalty to be applied for Q2 failure against ICM caseload targets will be £48,731. This reflects the progress that has been made during Quarter 2 and is based on applying a penalty against the percentage of target not achieved (30%). The penalty per CCG is set out below:

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ICM – BHR CCG withholding based on Q2 performance (recoverable if year-end target met)

CCG Budget Spend on

NELFT CHS

% of Total NELFT Budget Spend

Potential full

amount that can

be withheld

Closedown position withholding based on Q2 Performance (based on %

not achieved against target)

Barking and Dagenham – at 68%

against target

£28,748,913 40% £72,789 £23,292

Havering – at 91% against target

£24,984,743 34% £61,870 £5,568

Redbridge – at 58% against target

£19,055,291 26% £47,313 £19,871

Total £72,788,947 100% £181,972 £48,731

6.3.2 Contract Query - Clostridium Difficile (C. Dif) • Contract Management meeting held on Friday 6 November. The Deputy

Director of Nursing and Clinical Quality was assured by NELFTs detailed report on how the 6 reported C Diff cases were managed. An action plan is in place to improve format of the Root Cause Analysis form and process for reporting C Diff to CCGs and CSU.

• A new case of C. Dif (7th YTD) was reported in December 2013. A 2nd contract query has been issued with contract query meeting to be held on Friday 31st January.

6.3.3 Safeguarding training (Levels 1-3) and supervision The NELFT dashboard shows that further work is required to achieve compliance with levels 1, 2 and 3 safeguarding children’s training in CHS and MHS. NELFT provides regular updates to CQRM regarding progress of their action plans. 7 PELC - Contract Summary

7.1 Overview The PELC contract covers UCC at Whipps Cross and King George Hospital (KGH), GP Out of Hours (OOH) and 111. The PELC contract performs with no significant financial risks at the end of Q2. Underperformance in the UCC contract will result in overall cost saving against plans across all CCGs. This is being managed through the quarterly closedown process, which is yet to be completed for Q1 and Q2.

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NHSE have required all providers of 111 services to report daily and submit weekly exception reports if the call answering falls below 95% standard in 60 seconds. Overall PELC’s performance has been within or very close to the contracted target except for couple of occasions when PELC’s performance was below target. PELC was required to submit an exception report, explaining the reasons for deterioration in performance and mitigation to ensure continuity of safe, quality service. On those occasions PELC mobilised other resources including supervisors and clinical directors to ensure patient safety was not put at risk. A daily SITREP on 111 performance, staffing and demand has been instigated within a more rigorous daily performance management regime and PELC’s performance is included in daily dash board report produced by performance. The first phase of Joint Investigation under the contract query into the allegations made by PELC “working doctors” has been completed. The investigation found no significant safety, quality or contractual failings but the interim report makes a number of recommendations. The second phase of the investigation will test some of the findings further to establish to full facts and at the end of it a final report will be produced. The contract negotiations process for 2014/15 for all three contracts has begun. Project plans to include the contract negotiations time table, strategy and key issues have been developed. A meeting is scheduled for 16 January and subsequent meetings have also been planned.

7.2 Urgent Care Centre (UCC) The KGH UCC activities have underperformed by 13.25% against the planned activity, which was increased by 11,000 attendances (37%) in 2013/14. In comparison to 2012/13 the UCC activities at KGH has gone up. The activity against plan is being rigorously monitored to ensure increased targets are met. The overall number of patient number at KGH UCC has increased compared to 12/13 for the corresponding period. However the overall aim of achieving 50% of appropriate attendances being directed through the UCC is not being met. PELC have been asked to come up with proposals to improve the uptake and increase the patient numbers. Walk in patients to UCC continues to perform well against target with no significant risks.

7.3 111 In M8 the 111 service achieved 63% of the planned activities level. It is largely because the planned national campaign to promote 111 has not been driven through. 15% of the 111 contract value is linked KPIs. These KPIs are banded and the provider will be entitled to full payment only if achieves the maximum target. Whilst PELC has generally performed well but failed to attain the maximum target to qualify for full KPI payments.

7.4 Out of Hours (OOH) The 2013/14 plan is based on 2012/13 outturn figures. There has been an overall reduction in activities in 2013/14 for the comparable period from 2012/13, which is likely to be a result of the impact of the 111 initiative as it was anticipated during the modelling of 111.

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8 Continuing Health Care (CHC)

The CHC project group led by Jacqui Himbury (Director of Nursing, BHR CCGs) continues its work to develop the CHC pathway and address quality requirements. NELFT are proceeding with reviews of the backlog of CHC patients. The contract for the clinical assessment team is now with NELFT for their consideration, further negotiation is continuing to achieve agreement on the contract but commissioners are pressing for this to be completed before concluding financial reimbursement to NELFT on the CHC work completed to date. 9 Summary of Associate Clinical Services Contracts

9.1 Associate Contracts Summary

Total Number Contract Value2013/14 Predicted Year End Position as at M9

£000s £000sSigned Contracts 14 £7,328 £8,369Unsigned Contracts 5 £1,751 £1,978Total 19 £9,079 £10,347

Barking and Dagenham CCGAssociate Contract Summary (excluding Bart's Health)

9.2 Signed Contracts

Provider Name Contract Value2013/14 Predicted Year

End Position£000s £000s

Moorfields £1,810 £2,003Mid Essex £1,150 £1,385Guy's And St Thomas's £982 £975RNOH £290 £730Basildon & Thurrock £520 £493Imperial £316 £326King's £317 £307Chelsea & Westminster £292 £209North Middlesex £69 £140St George's £152 £116Princess Alexandra £80 £60The Whittington £121 £62GOSH £284 £443UCLH £945 £1,120Total £7,328 £8,369

Barking and Dagenham CCGAssociate Signed Contracts

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9.3 Unsigned Contracts

Barking and Dagenham CCG Associate Unsigned Contracts

Provider Name Latest Trust Offer to

CCG CCG Envelope Value 2013/14 Predicted Year End Position

£000s £000s £000s The Homerton £1,115 £936 £1,350 The Royal Free £404 £285 £451 North West London £70 £66 £73 Royal Brompton £101 £93 £74 The Royal Marsden £61 £81 £30 Total £1,751 £1,461 £1,978

9.4 Commentary

9.4.1 Signed contracts

• Moorfields: Expenditure is worse than planned in outpatient procedures, day cases, outpatient follow up appointments and high cost drugs. The main drivers for over spend are procedures for medical retina and Lucentis for wet age related macular deterioration.

• Royal National Orthopaedic Hospital: Activity levels have increased this month (was 134% now 161% over). Expenditure is worse than planned in elective procedures, in particular Spinal Surgery, trauma and orthopaedics. Several high cost elective procedures earlier this year are continuing to impact on the financial position.

• North Middlesex: Expenditure is worse than planned in Accident & Emergency and emergency admissions, in particular for the general medicine and trauma and orthopaedics specialties.

• Mid Essex: Expenditure is worse than planned for adult critical care, day cases and planned admissions. Plastic surgery and reconstructions following mastectomies stand out.

• UCLH. Expenditure is worse than planned, this adverse variance is being driven primarily by activity in outpatients (General Medicine and Audiological Medicine Specialties); Drugs and Devices and Elective activity. The CSU has queried the drugs activity reported in M8 data with the Trust as there was an increase from M8 to M9. UCLH have confirmed an error was made in the M8 data around attribution of a specific high cost drug. A favourable adjustment for this of £37k should be made to the CCG position in hard close numbers.

9.4.2 Unsigned contracts Particular delays are being experienced in agreeing contracts with providers where NHSE is a significant commissioner. For Barking and Dagenham these include The Royal Marsden and Royal Brompton Provider Trusts face penalties from NHSE for specialised commissioning contracts that were not agreed before 23 October 2013.

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• Homerton: The provider has yet to reach agreement on the contract. Over performance against provisional plans is seen across a number of PODs and across various specialities. Most noticeably, overspend is noted in elective admissions and outpatient follow up attendances and neuro-rehab sessions. Maternity related activity is also slightly higher than expected.

• The Royal Free: Awaiting counter offer from the Trust as gross offer variances are still too high.

• Royal Brompton: Overall contract not yet agreed with host. Barking and Dagenham offer within envelope.

• The Royal Marsden: Currently waiting on a response to a query around the value of NHSE activity transfers. The host commissioner for Royal Marsden is reviewing.

10 2014/15 Contract Negotiations Update

10.1 BHRUT

10.1.1 Governance A meeting structure has been agreed, with fortnightly Contract Setting meetings between the CCGs / CSU and the Trust. There are clinical and financial sub groups reporting into this group. In addition, there is a CCG/CSU internal Contract Negotiation meeting which reports into an overall CCG Contract Steering Group which is chaired by the CCG Chief Financial Officer. This group is responsible for setting the direction and strategy for all contract negotiations.

10.1.2 Performance Measures • CQUINs: A CQUIN workshop was held on the 19 December 2013. This was

an internal CCG/CSU meeting with clinical engagement, and was responsible for considering the CQUINS required across both acute and non-acute providers. An outcome of this is a longlist of CQUIN priorities, which will now be refined to a smaller number of key local priorities, with national CQUINs already set. The standards for each area, the measure to be used and the proportion of funding against each area also needs to be agreed. The longlist is due to be shared with Trust at the next Contract Setting meeting on the 13 January 2014, with further detail to be provided in advance of the following meeting on the 30 January 2014.

• KPIs: A draft list of KPIs has been circulated to CCGs. This draft will be shared with BHRUT on the 13/01/14, and an indication given to the Trust that the CCGs are intending to attach financial penalties to a small number of these, for example A&E and Length of Stay. These are being considered in conjunction with CQUINS to ensure all quality and performance priorities will be addressed in the contract.

10.1.3 Finance and Technical issues

• Baseline setting: The CSU have produced a draft baseline for 2014/15, which shows activity up to Month 6 at 2014/15 prices. Once adjustments have

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been made for a range of areas, e.g. 18 week activity, this will be sent to BHRUT, with the aim of completing this within the next week.

• QIPP: A further QIPP workshop is planned for the 17/01/14. All CCGs have developed a long list of options, but more work is required to develop these at HRG level. This is a key priority and needs to be completed by the end of January.

• Productivity metrics: A draft document has been circulated to CCGs which shows savings against three key areas of outpatient first to follow up ratios, consultant to consultant referrals and daycases procedures that could be undertaken as outpatient. Further work is required to agree the standard to be achieved by area, e.g. upper quartile or upper decile. This piece of work needs to be clinically led, and it has been agreed that the CCG Planned Care representatives will take the lead for this.

10.1.4 Contract documentation The CSU will lead on contract documentation, with the first milestone to be achieved signing of Heads of Terms by the 28 January 2014. Service specifications will need to be included in the contract, with a list of priorities agreed, for example the Urgent Care Centre at Queens Hospital. In addition the CCGs may decide to approve service developments put forward by BHRUT. To date the only business case received by the Trust, against a deadline of mid December, has been cardiac rehabilitation.

10.2 Barts Health

10.2.1 Governance A meeting structure has been agreed, with fortnightly Internal Contract Negotiation meetings between the CCGs and CSU which reports into an overall CCG Contract Steering Group which is chaired by the CCG Chief Financial Officer. This group is responsible for setting the direction and strategy for all contract negotiations.

10.2.2 Performance Measures • CQUINs: A CQUIN workshop was held on the 19 December 2013. This was

an internal CCG/CSU meeting with clinical engagement, and was responsible for considering the CQUINS required across both acute and non-acute providers. An outcome of this is a longlist of CQUIN priorities, which will now be refined to a smaller number of key local priorities, with national CQUINs already set. The standards for each area, the measure to be used and the proportion of funding against each area also needs to be agreed. The Central NELCSU team is currently producing the collated longlist which will be shared initially with Tower Hamlets CCG as the Lead for Quality matters. There is a WELC Quality Meeting scheduled for 21 January 2014 to which the BHR CCGS Quality Lead for the Barts Health contract has been invited.

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10.2.3 Finance and Technical issues Baseline setting: The NELCSU have produced a draft baseline for 2014/15, which shows activity up to Month 6 at 2014/15 prices. This is currently being reviewed by the NELCSU BHR POD and CCGs.

10.2.4 Contract documentation The WELC POD of the NEL CSU will lead on contract documentation and there is a CSU workshop planned for 15 January 2014 with the objective of producing a detailed timescale for contract negotiation.

11 Appendices

Appendix 1 BHRUT Provider Scorecard

Appendix 2 BH Provider Scorecard

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Appendix 1

BHRUT Provider Scorecard

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Appendix 2

Barts Health Provider Scorecard

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ITEM 7.1 To: Meeting of Barking and Dagenham Clinical Commissioning Group Governing Body From: Sue Assar, Interim director of corporate affairs Date: 28 January 2014 Subject: Anti-Fraud and Bribery, Whistleblowing and Gifts, Hospitality, Sponsorship (non-

pharmaceutical), Rewards or Inducement policies.

Executive summary In conjunction with the internal auditors, Baker Tilley, three polices have been developed in relation to Anti-fraud and Bribery, Whistleblowing and Gifts, Hospitality, Sponsorship, Rewards and Inducement. The policies have been reviewed and amended by the Audit and Governance Committee. The Whistleblowing policy has also been reviewed by the Remuneration and Workforce Committee. In view of the importance of these policies to the CCG’s governance arrangements they require formal approval by each the Governing Bodies. Once approved each of the policies will have the names changed so that they are individualised to each of the CCGs. Currently the policies do not apply to member practices. Should member practices wish to adopt them this can be reflected in the final version of each of the policies. Recommendations The Governing Body is asked to approve the following policies subject to name change

• Anti-Fraud and Bribery • Whistleblowing • Gifts, Hospitality, Sponsorship (non-pharmaceutical) Rewards or Inducement


To obtain Governing Body approval of three key policies which support the CCG’s governance arrangements. These policies apply to all CCG employees, members of the Governing Body and its committees, working groups and any person working on behalf of the CCG e.g. agency staff.

2.0 Background/Introduction

In conjunction with the Internal auditors, draft policies have been produced covering Anti-Fraud and Bribery, Whistleblowing, Gifts, Hospitality (non-pharmaceutical),

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Rewards or Inducement. The Anti-fraud and Bribery and Whistleblowing policies were initially considered by the Audit and Governance committee at its September meeting and a number of amendments agreed. The Committee also recommended that the policies were formally approved by the GBs rather than responsibly for sign off being delegated to officers. The Whistleblowing policy has also been reviewed by the Remuneration and Workforce committee at its November meeting. At the meeting there was discussion as to the amount of support and protection to be given to a member of staff who “whistleblows”. Further advice has been taken on this and the wording in the policy is considered to be in line with our auditor’s advice and with good practice across government departments. The Gifts and Hospitality policy was considered by Audit and Governance at its November meeting. This policy does not cover pharmaceutical sponsorship and working with the pharmaceutical industry which is the subject of a separate policy still in development.

3.0 Report Content

The final drafts of the following policies are attached to this report for formal approval: • Anti-fraud and Bribery • Whistleblowing • Gifts, Hospitality, Sponsorship (non-pharmaceutical), Rewards or Inducement.

The policies apply to all CCG employees, members of the Governing Body and its

committees, working groups and any person working on behalf of the CCG e.g. agency staff. They do not apply to member practices. Should member practices decide to adopt the policies then this will be reflected in the final versions.

Once the policies have been formally approved the names will be changed so that they

are individualised for each CCG

4.0 Resources/investment Training in relation to the whistleblowing policy will be required for the named contacts

in the policy. The costs will be met from the training budget


6.0 Risk 6.1 The CCG’s governance arrangements will be less robust without these policies in place.

Attachments: 1. Draft Anti-Fraud and Bribery policy 2. Draft Whistleblowing policy 3. Draft Gifts, Hospitality, Sponsorship (non-Pharmaceutical) Rewards and Inducement policy

Author: Sue Assar Interim Director of Corporate Services Date: 17 January 2014

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BHR Anti-Fraud and Bribery Policy v2

1

ANTI-FRAUD AND BRIBERY POLICY

Version 1 Supported by Audit & Governance Committee 3 September 2014, subject to some amendment

Version 2 For agreement by the Governing Body meetings January 2014*

For Review For review by the Audit & Governance Committee January 2015

*Following Governing Body approval an individualised policy will be provided for each of the three Clinical Commissioning Groups

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CONTENTS 1. INTRODUCTION ........................................................................................................................ 3

2. SCOPE ....................................................................................................................................... 3

3. PROTOCOL WITH HEALTH COUNCIL POLICY ...................................................................... 4

4. FACILITATION PAYMENTS ...................................................................................................... 5

5. GIFTS AND HOSPITALITY ........................................................................................................ 5

6. POLITICAL AND CHARITABLE CONTRIBUTIONS .................................................................. 6

7. SPONSORING ........................................................................................................................... 6

8. DEFINITIONS ............................................................................................................................. 6

9. PUBLIC SERVICE VALUES ...................................................................................................... 7

10. ROLES AND RESPONSIBILITIES ......................................................................................... 8

10.1. ROLES .............................................................................................................................. 8

10.2. EMPLOYEES .................................................................................................................... 8

10.3. MANAGERS ...................................................................................................................... 9

10.4. LOCAL COUNTER FRAUD SPECIALIST (LCFS) ......................................................... 10

10.5. DIRECTOR OF FINANCE............................................................................................... 11

10.6. SENIOR COMPLIANCE OFFICER ................................................................................. 11

10.7. INTERNAL AND EXTERNAL AUDIT .............................................................................. 11

10.8. HUMAN RESOURCES ................................................................................................... 11

10.9. INFORMATION MANAGEMENT & TECHNOLOGY ...................................................... 11

10.10. EXTERNAL COMMUNICATIONS .................................................................................. 12

10.11. TRAINING ....................................................................................................................... 12

11. REPORTING FRAUD, BRIBERY OR OTHER ILLEGAL ACTS .......................................... 12

12. DISCIPLINARY ACTION ...................................................................................................... 12

13. POLICE INVOLVEMENT ...................................................................................................... 13

14. RECOVERY OF LOSSES INCURRED BY FRAUD OR BRIBERY ..................................... 13

15. MONITORING EFFECTIVENESS ....................................................................................... 14

16. ADDITIONAL INFORMATION .............................................................................................. 14

17. RELATED POLICIES ........................................................................................................... 14

Appendix A What to Do

Appendix B The Fraud Act 2006

Appendix C The Bribery Act 2010

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1. INTRODUCTION

1.1. This document sets out the CCG policy and advice to employees in dealing with fraud or suspected fraud. This policy details the arrangements made in the CCG for such concerns to be raised by employees or members of the public.

This policy applies to all CCG employees, members of the Governing Body and its committees, sub-committees and working groups and any person working on behalf of the CCG e.g. agency staff. It also applies to consultants, vendors, contractors and any other parties who have a business relationship with the CCG.

It will be brought to the attention of all employees and form part of the induction process for new staff. It is incumbent on all those above to report any concerns they may have concerning fraud and bribery.

1.2. The CCG does not tolerate fraud and bribery within the NHS. The intention is to eliminate all NHS fraud and bribery as far as possible. The aim of the policy and procedure is to protect the property and finances of the NHS and of patients in our care.

1.3. The CCG is committed to taking all necessary steps to counter fraud and bribery. To meet its objectives, it has adopted the seven-stage approach developed by NHS Protect:

1) The creation of an anti-fraud culture

2) Maximum deterrence of fraud

3) Successful prevention of fraud which cannot be deterred

4) Prompt detection of fraud which cannot be prevented

5) Professional investigation of detected fraud

6) Effective sanctions, including appropriate legal action against people committing fraud and bribery, and

7) Effective methods of seeking redress in respect of money defrauded.

1.4. The CCG will take all necessary steps to counter fraud and bribery in accordance with this policy, the NHS Counter Fraud and Bribery Manual, the policy statement ‘Applying Appropriate Sanctions Consistently’ published by NHS Protect and any other relevant guidance or advice issued by NHS Protect.

1.5. This document sets out the CCG’s policy for dealing with detected or suspected fraud and bribery, incorporated in the Secretary of State for Health’s Directions to NHS Bodies on Counter Fraud Measures that were issued in November 2004.

2. SCOPE

2.1 This policy relates to all forms of fraud and bribery and is intended to provide direction and help to employees who may identify suspected fraud. It provides a framework for responding to suspicions of fraud, advice and information on various aspects of fraud and implications of an investigation. It is not intended to provide a comprehensive approach to preventing and detecting fraud and bribery. The overall aims of this policy are to:

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improve the knowledge and understanding of everyone in the CCG, irrespective of their position, about the risk of fraud and bribery within the organisation and its unacceptability

assist in promoting a climate of openness and a culture and environment where staff feel able to raise concerns sensibly and responsibly

set out the CCG’s responsibilities in terms of the deterrence, prevention, detection and investigation of fraud and bribery

ensure the appropriate sanctions are considered following an investigation, which may include any or all of the following:

- criminal prosecution

- civil prosecution

- internal/external disciplinary action(including professional/regulatory bodies)

2.2 In implementing this policy, managers must ensure that all staff are treated fairly and within the provisions and spirit of the CCG’s equal opportunities arrangements. Special attention should be paid to ensuring the policy is understood where there may be barriers to understanding caused by the individual’s circumstances, where the individual’s literacy or use of English is weak, or where the individual has little experience of working life.

3. PROTOCOL WITH HEALTH PROFESSIONAL COUNCIL POLICY 3.1 All employees have a personal responsibility to protect the assets of the CCG, including all

buildings, equipment and monies from fraud, theft, or bribery.

3.2 The CCG is absolutely committed to maintaining an honest, open and well-intentioned atmosphere, so as to best fulfil the objectives of the CCG and of the NHS. It is, therefore, also committed to the elimination of fraud within the CCG, to the rigorous investigation of any such allegations and to taking appropriate action against wrong doers, including possible criminal prosecution, as well as undertaking steps to recover any assets lost as a result of fraud.

3.3 The CCG wishes to encourage anyone having reasonable suspicions of fraud to report them. The CCG’s policy, which will be rigorously enforced, is that no individual will suffer any detrimental treatment as a result of reporting reasonably held suspicions. The Public Interest Disclosure Act 1998 came into force in July 1999 and gives statutory protection, within defined parameters, to staff who make disclosures about a range of subjects, including fraud and bribery, which they believe to be happening within the CCG employing them. Within this context, ‘reasonably held’ means suspicions other than those which are raised maliciously and are subsequently found to be groundless.

3.4 Any unfounded or malicious allegations will be subject to a full investigation and appropriate disciplinary action.

3.5 The CCG expects anyone having reasonable suspicions of fraud to report them. It recognises that, while cases of theft are usually obvious, there may initially only be a suspicion regarding potential fraud and, thus, employees should report the matter to their Local Counter Fraud Specialist who will then ensure that procedures are followed.

3.6 Bribing anybody is absolutely prohibited. CCG employees will not pay a bribe to anybody. This means that you will not offer, promise, reward in any way or give a financial or other advantage to any person in order to induce that person to perform his/her function or activities improperly. It does not matter whether the other person is a UK or foreign public official, political candidate, party official, private individual, private or public sector employee or any other person (including creating the appearance of an effort to improperly influence another person).

3.7 Off-the-book accounts and false or deceptive booking entries are strictly prohibited. All gifts, payments or any other contribution made under the Anti-Fraud and Bribery Policy and these guidelines, whether in cash or in kind, shall be documented, regularly reviewed, and properly

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accounted for on the books of the CCG. Record retention and archival policy must be consistent with the CCG’s accounting standards, tax and other applicable laws and regulations.

3.8 The CCG procures goods and services ethically and transparently with the quality, price and value for money determining the successful supplier/contractor, not by receiving (or offering) improper benefits. The CCG will not engage in any form of bribery, neither in the UK nor abroad. CCG employees, independent of their grade and position, shall at all times comply with the Bribery Act 2010 and with this policy.

3.9 The CCG may, in certain circumstances, be held responsible for acts of bribery committed by intermediaries acting on its behalf such as subsidiaries, clients, business partners, contractors, suppliers, agents, advisors, consultants or other third parties. The use of intermediaries for the purpose of committing acts of bribery is prohibited.

3.10 All intermediaries shall be selected with care, and all agreements with intermediaries shall be concluded under terms that are in line with this policy. The CCG will contractually require its agents and other intermediaries to comply with the Anti-Fraud and Bribery Policy and to keep proper books and records available for inspection by the CCG, auditors or investigating authorities. Agreements with agents and other intermediaries shall at all times provide for the necessary contractual mechanisms to enforce compliance with the anti-bribery regime. The CCG will monitor performance and, in case of non-compliance, require the correction of deficiencies, apply sanctions, or eventually terminate the agreement even if this may result in a loss of business.

3.11 Where the CCG is engaged in commercial activity (irrespective as to what happens to the profit) it could be considered guilty of a corporate bribery offence if an employee, agent, subsidiary or any other person acting on its behalf bribes another person intending to obtain or retain business or an advantage in the conduct of business for the CCG and it cannot demonstrate that it has adequate procedures in place to prevent such. The CCG does not tolerate any bribery on its behalf, even if this might result in a loss of business for it. Criminal liability must be prevented at all times.

3.12 Recovery of any losses will always be sought – see section 10.

4. FACILITATION PAYMENTS 4.1 Facilitation payments are small payments made to secure or expedite the performance of a

routine action, typically by a government official or agency (e.g. issuing licenses or permits, installation of a telephone line, processing goods through customs, etc.) to which the payer (or the company) has legal or other entitlement.

4.2 Facilitation payments are prohibited under the Bribery Act like any other form of bribe. They shall not be given by the CCG or it’s in the UK or any other country.

5. GIFTS AND HOSPITALITY 5.1 Courtesy gifts and hospitality must not be given or received in return for services provided or to

obtain or retain business but shall be handled openly and unconditionally as a gesture of esteem and goodwill only. Gifts and hospitality shall always be of symbolic value, appropriate and proportionate in the circumstances, and consistent with local customs and practices. They shall not be made in cash. Please refer to the CCG’s Policy on Gifts, Hospitality, Sponsorship (non-pharmaceutical), Rewards and Inducements for further advice.

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6. POLITICAL AND CHARITABLE CONTRIBUTIONS 6.1 The CCG does not make any contributions to politicians, political parties or election

campaigns.

6.2 As a responsible member of society, the CCG may make charitable donations. However, these payments shall not be provided to any organisation upon suggestion of any person of the public or private sector in order to induce that person to perform improperly the function or activities which he or she is expected to perform in good faith, impartially or in a position of trust or to reward that person for the improper performance of such function or activities.

6.3 Any donations and contributions must be ethical and transparent. The recipient’s identity and planned use of the donation must be clear, and the reason and purpose for the donation must be justifiable and documented. All charitable donations will be publicly disclosed.

6.4 Donations to individuals and for-profit organisations and donations paid to private accounts are incompatible with the CCG’s ethical standards and are prohibited.

7. SPONSORING 7.1 Sponsoring means any contribution in money or in kind by the CCG towards an event

organised by a third party in return for the opportunity raise the CCG‘s profile. All sponsoring contributions must be transparent, pursuant to a written agreement, for legitimate business purposes, and proportionate to the consideration offered by the event host. They may not be made towards events organised by individuals or organisations that have goals incompatible with the CCG’s ethical standards or that would damage the CCG’s reputation. All sponsorships will be publicly disclosed.

7.2 Where commercial sponsorship is used to fund CCG training events, training materials and general meetings, the sponsorship must be transparent, pursuant to a written agreement, for legitimate business purposes, and proportionate to the occasion. Where meetings are sponsored by external sources, that fact must be disclosed in the papers relating to the meeting and in any published minutes/proceedings. Should the sponsorship be from the pharmaceutical industry, the CCG has a separate policy advising on arrangements for accepting and registering this. . The policy on Sponsorship and Joint Working with the Pharmaceutical Industry will shortly be forwarded to the Governing Body for approval. In the interim advice should be sought from the Medicines Management Team.

7.3 Where sponsorship links to the development of guidelines and advice, this should be carried out in consultation with the Chief Finance Officer and governance lead in conjunction with an appropriate CCG working group independent of the sponsors. While it is recognised that consultation with the industry may be necessary when developing a guideline, the overall decision on what is included should lie with the relevant CCG working group.

8. DEFINITIONS 8.1 Fraud - any person who dishonestly makes a false representation to make a gain for himself or

another or dishonestly fails to disclose to another person, information which he is under a legal duty to disclose, or commits fraud by abuse of position, including any offence as defined in the Fraud Act 2006. Appendix B is a summary of the Fraud Act 2006.

8.2 Bribery - “Inducement for an action which is illegal, unethical or a breach of trust. Inducements can take the form of gifts, loans, fees, rewards or other advantages”. Appendix C provides a summary of the Bribery Act 2010.

8.3 This can be broadly defined as the offering or acceptance of inducements, gifts, favours, payment or benefit-in-kind which may influence the action of any person. Bribery does not always result in a loss. The corrupt person may not benefit directly from their deeds; however, they may be unreasonably using their position to give some advantage to another.

It is a common law offence of bribery to bribe the holder of a public office and it is similarly an offence for the office holder to accept a bribe.

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Bribery prosecutions tend to be most commonly brought using specific pieces of legislation dealing with bribery, i.e. under the following:

the Public Bodies Corrupt Practices Act 1889

the Prevention of Bribery Acts 1889–1916

the Anti-Terrorism, Crime and Security Act 2001.

8.4 The CCG has procedures in place that reduce the likelihood of fraud occurring. These include prime financial policies, documented procedures, a system of internal control (including Internal and External Audit) and a system of risk assessment. In addition, the CCG seeks to ensure that a comprehensive anti-fraud and bribery culture exists throughout the CCG via the appointment of a dedicated Local Counter Fraud Specialist, in accordance with the NHS Secretary of State’s Directions to NHS Bodies on Counter Fraud Measures that were re-issued in November 2004.

8.5 It is expected that Governing Body members and staff at all levels will lead by example in acting with the utmost integrity and ensuring adherence to all relevant regulations, policies and procedures.

9. PUBLIC SERVICE VALUES 9.1 High standards of corporate and personal conduct, based on the recognition that patients

come first, have been a requirement throughout the NHS since its inception. The three fundamental public service values are:

Accountability Everything done by those who work in the CCG must be able to stand the tests of parliamentary scrutiny, public judgements on property and professional codes of conduct.

Probity Absolute honesty and integrity should be exercised in dealing with NHS patients, assets, employees, suppliers and customers.

Openness The CCG’s actions should be sufficiently public and transparent to promote confidence between the CCG and its patients, our employees and the public.

In addition, all those who work for or are in contract with the CCG should exercise the following when undertaking their duties:

Selflessness …should take decisions solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family or their friends

Integrity …should not place themselves under any financial or other obligation to outside individuals or organisations that might influence them in the performance of their official duties

Objectivity … should, in carrying out public business, (including making public appointments , awarding contracts, or recommending individuals for rewards and benefits), make choices on merit

Accountability …are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to

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their office

Openness …should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest demands

Honesty …have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest

Leadership …should promote and support these principles by leadership and example

9.2 These standards are national benchmarks that inform our local policies and procedures. The arrangements made in this policy have been designed to ensure compliance with the national standards.

10. ROLES AND RESPONSIBILITIES 10.1. ROLES

10.1.1 The CCG has a duty to ensure that it provides a secure environment in which to work, and one where people are confident to raise concerns without worrying that it will reflect badly on them. This extends to ensuring that staff feel protected when carrying out their official duties and are not placed in a vulnerable position. If staff have concerns about any procedures or processes that they are asked to be involved in, the CCG has a duty to ensure that those concerns are listened to and addressed.

10.1.2 The CCG‘s Chief Officer is liable to be called to account for specific failures in the CCG‘s system of internal controls. However, responsibility for the operation and maintenance of controls falls directly to line managers and requires the involvement of all of CCG employees. The CCG therefore has a duty to ensure employees who are involved in or who are managing internal control systems receive adequate training and support in order to carry out their responsibilities. Therefore, the Chief Officer and Chief Finance Officer will monitor and ensure compliance with this policy.

10.2. EMPLOYEES

For the purposes of this policy, ‘Employees’ includes all CCG staff and Governing Body members (including Co-Opted Members)

10.2.1 All employees should be aware that fraud and bribery (of finances of the NHS or of patients in our care) will normally, dependent upon the circumstances of the case, be regarded as gross misconduct thus warranting summary dismissal without previous warnings. However, no such action will be taken before a proper investigation and a disciplinary hearing have taken place. Such actions may be in addition to the possibility of criminal prosecution.

10.2.2 CCG employees will not request or receive a bribe from anybody, nor imply that such an act might be considered. This means that you will not agree to receive or accept a financial or other advantage from a former, current or future client, business partner, contractor or supplier or any other person as an incentive or reward to perform improperly your function or activities.

10.2.3 Employees must act in accordance with the CCG’s Standards of Business Conduct, Gifts and Hospitality and Declaration of interest arrangements.

10.2.4 Employees also have a duty to protect the assets of the CCG including information, goodwill and reputation, as well as property.

10.2.5 Employees are expected to act in accordance with the standards laid down by their Professional Institute(s), where applicable.

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10.2.6 The CCG’s Constitution and Prime Financial Policies place an obligation on all staff and Governing Body members to act in accordance with best practice. In addition, all CCG staff and Governing Body members must declare and register any interests that might potentially conflict with those of the CCG or the wider NHS.

10.2.7 In addition, all employees have a responsibility to comply with all applicable laws and regulations relating to ethical business behaviour, procurement, personal expenses, conflicts of interest, confidentiality and the acceptance of gifts and hospitality. This means, in addition to maintaining the normal standards of personal honesty and integrity, all employees should always:

act with honesty, integrity and in an ethical manner

behave in a way that would not give cause for others to doubt that the CCG employees deal fairly and impartially with official matters

be alert to the possibility that others might be attempting to deceive.

All employees have a duty to ensure that public funds are safeguarded, whether or not they are involved with cash or payment systems, receipts or dealing with contractors or suppliers.

10.1.10 When an employee suspects that there has been fraud or bribery, they must report the matter to the nominated Local Counter Fraud Specialist. See Section 7 below.

10.3. MANAGERS

Line managers at all levels have a responsibility to ensure that an adequate system of internal control exists within their areas of responsibility and that controls operate effectively. The responsibility for the prevention and detection of fraud and bribery therefore primarily rests with managers but requires the co-operation of all employees.

10.3.1 As part of that responsibility, line managers need to:

Inform staff of the CCG ‘s code of business conduct, gifts and hospitality, declaration of interest and counter fraud and bribery arrangements as part of their induction process, paying particular attention to the need for accurate completion of personal records and forms

ensure that all employees for whom they are accountable are made aware of the requirements of the policy

assess the types of risk involved in the operations for which they are responsible

Ensure that adequate control measures are put in place to minimise the risks. This must include clear roles and responsibilities, supervisory checks, staff rotation (particularly in key posts), separation of duties wherever possible so that control of a key function is not invested in one individual, and regular reviews, reconciliations and test checks to ensure that control measures continue to operate effectively

be aware of the CCG‘s Anti-Fraud and Bribery Policy and the rules and guidance covering the control of specific items of expenditure and receipts

identify financially sensitive posts

ensure that controls are being complied with

contribute to their Director’s assessment of the risks and controls within their business area, which feeds into the CCG‘s and the Department of Health Accounting Officer’s overall statements of accountability and internal control (as it applies to CCG’s under the new legislation)

10.3.2 All instances of actual or suspected fraud or bribery, which come to the attention of a manager, must be reported immediately. It is appreciated that some employees will initially raise concerns with their manager, however, in such cases managers must not attempt to

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investigate the allegation themselves, and they have the clear responsibility to refer the concerns to the Local Counter Fraud Specialist as soon as possible. See Section 11 below.

10.3.3 Where staff have access to the Internet, managers need to ensure that any use is linked to the performance of their duties and any private use specifically agreed beforehand. Any instance of deliberate viewing of offensive material (e.g. pornography or hate material) must be reported immediately. See Section 10.28 below.

10.4. LOCAL COUNTER FRAUD SPECIALIST (LCFS)

The Directions to NHS Bodies on Counter Fraud Measures 2004 require the CCG to appoint and nominate an LCFS. The LCFS’s role is to ensure that all cases of actual or suspected fraud and bribery are notified to the Chief Finance Officer and reported accordingly.

10.4.1 Investigation of the majority cases of alleged fraud within the CCG will be the responsibility of the CG’s Local Counter Fraud Specialist (LCFS). NHS Protect will only investigate cases which should not be dealt with by the CCG.. Following receipt of all referrals, NHS Protect will add any known information or intelligence and based on this case acceptance criteria determine if a case should be investigated by NHS Protect. This list is not exhaustive.

Cases which:

have a strategic or national significance or are deemed to be of suitable national public interest;

from intelligence or information have been identified as being part of a suspected criminal trend or an area which is suspected of being targeted by organised crime and which requires a centrally coordinated investigation;

form part of a series of linked cases already being investigated or about to be by NHS Protect.

are known or likely to have a high degree of complexity either in the nature of the fraud or the investigation required;

will require a significant investigation which could include the involvement of other agencies such as the Office of Fair Trading (OFT), Financial Services Authority (FSA), or Serious Fraud Office (not day to day involvement of agencies on lower level cases);

have any factors which would determine that the case should be investigated outside of the NHS body, for example very senior management involvement, the need to use directed surveillance, obtain communications data or use powers provided to NHS Protect in the NHS Act 2006;

Extend beyond the geographical, financial or legal remit of the NHS body affected by the fraud; may be retained by NHS Protect.

10.4.2 The LCFS will regularly report to the Chief Finance Officer on the progress of the investigation and when/if referral to the police is required.

10.4.3 The LCFS and the Chief Finance Officer, in conjunction with NHS Protect, will decide who will conduct the investigation and when/if referral to the police is required. Cases, for instance, where more than £100,000 or where possible bribery is involved may be investigated by NHS Protect (though the LCFS may assist); otherwise the investigation will normally be undertaken by the CCG’s own LCFS directly.

10.4.4 The LCFS in consultation with the Chief Finance Officer will review the strategic objectives contained within the assurance framework to determine any potential fraud or bribery risks. Where risks are identified these will be included on the CCG’s risk register so the risk can be proactively addressed.

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10.5. DIRECTOR OF FINANCE

The Chief Finance Officer, in conjunction with the Chief Officer, monitors and ensures compliance with Secretary of State Directions regarding fraud and bribery.

10.5.1 The Director of Finance, in consultation with NHS Protect and the LCFS, will decide whether there is sufficient cause to conduct an investigation, and whether the Police and External Audit need to be informed.

10.5.2 The Chief Finance Officer or the LCFS will consult and take advice from the Head of HR if a member of staff is to be interviewed or disciplined. The Chief Finance Officer or LCFS will not conduct a disciplinary investigation, but the employee may be the subject of a separate investigation by HR.

10.5.3 The Chief Finance Officer will, depending on the outcome of investigations (whether on an interim/on-going or a concluding basis) and/or the potential significance of suspicions that have been raised, inform the Chair of the CCG and the Chair of the Audit and Governance Committee of cases, as may be deemed appropriate or necessary.

10.5.4 The Chief Finance Officer is also responsible for informing the Audit and Governance Committee of all categories of loss.

10.6. SENIOR COMPLIANCE OFFICER

10.6.1 The CCG has appointed the Chief Finance Officer who will be responsible for ensuring compliance with the requirements of the Bribery Act 2010, implementing anti-bribery guidelines and monitoring compliance. They will review annually the suitability, adequacy and effectiveness of the CCG’s anti-bribery arrangements and implement improvements as and when appropriate.

10.6.2 The Chief Finance Officer directly reports to the Chief Officer and once a year, the Chief Finance Officer reports the results of the reviews to the Governing Body.

10.6.3 Any incident or suspicion that comes to attention of the Senior Compliance Officer will be passed immediately to the LCFS.

10.7. INTERNAL AND EXTERNAL AUDIT

10.7.1 Any incident or suspicion that comes to Internal or External Audit’s attention will be passed immediately to the LCFS.

10.8. HUMAN RESOURCES

10.8.1 Human Resources (service provided through the Commissioning Support Unit) will liaise closely with managers and the LCFS, from the outset, where an employee is suspected of being involved in fraud in accordance with agreed liaison protocols. Human Resources (HR) are responsible for ensuring the appropriate use of the CCG’s Disciplinary Procedure. The Human Resources advisors shall advise those involved in the investigation in matters of employment law and in other procedural matters, such as disciplinary and complaints procedures. Close liaison between the LCFS and HR will be essential to ensure that any parallel sanctions (i.e. criminal and disciplinary) are applied effectively and in a coordinated manner.

10.8.2 Human Resources will take steps at the recruitment stage to establish, as far as possible, the previous record of potential employees as well as the veracity of required qualifications and memberships of professional bodies, in terms of their propriety and integrity. In this regard, temporary and fixed term contract employees are treated in the same manner as permanent employees.

10.9. INFORMATION MANAGEMENT & TECHNOLOGY

10.9.1 The Head of Information Security (or equivalent) will contact the LCFS immediately in all cases where there is suspicion that IT is being used for fraudulent purposes. This includes

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inappropriate internet/intranet, e-mail, telephone and PDA use. Human Resources will be informed if there is a suspicion that an employee is involved.

10.10. EXTERNAL COMMUNICATIONS

10.10.1 Individuals (be they employees, agency staff, locums, contractors or suppliers) must not communicate with any member of the press, media or another third party about a suspected fraud as this may seriously damage the investigation and any subsequent actions to be taken. Anyone who wishes to raise such issues should discuss the matter with either the Chief Finance Officer or the Chief Officer.

10.11. TRAINING

10.11.1 The CCG will provide anti-bribery training to all relevant employees on a regular basis to make them aware of our Anti-Fraud and Bribery Policy and guidelines, including possible types of bribery, the risks of engaging in bribery activity, and how employees may report suspicion of bribery.

11. REPORTING FRAUD, BRIBERY OR OTHER ILLEGAL ACTS 11.1 This section outlines the action to be taken where fraud, bribery or other illegal acts involving

dishonesty, inappropriate Internet use, or damage to property are discovered or suspected. For completeness, it also deals with the action to be taken where theft is discovered or suspected.

11.2 If any of the concerns mentioned in this document come to the attention of an employee, they must inform the Local Counter Fraud Specialist or the Chief Finance Officer immediately. Employees can also call the NHS Fraud Reporting Line on Freephone 0800 028 40 60. This provides an easily accessible route for the reporting of genuine suspicions of fraud within or affecting the NHS. It allows NHS staff who are unsure of internal reporting procedures, to report their concerns in the strictest confidence. All calls are dealt with by experienced caller handlers.

Contact information for the above is listed in Appendix A.

11.3 The attached Appendix A is designed to be a reminder of the key “what to do” steps - as well as contact details - to be taken where fraud or other illegal acts are discovered or suspected.

11.4 Managers are encouraged to copy this to staff and to place it on staff notice boards in their department.

11.5 Anonymous letters, telephone calls etc. are received from time to time from individuals who wish to raise matters of concern, but not through official channels. While the allegations may be erroneous or unsubstantiated, they may also reflect a genuine cause for concern and should always be taken seriously.

11.6 Sufficient enquiries will be made by the LCFS to establish whether or not there is any foundation to the allegations. If the allegations are found to be malicious, they will also be considered for further investigation as to their source.

11.7 The CCG wants all employees to feel confident that they can expose any wrongdoing without any risk to themselves. In accordance with the provisions of the Public Interest Disclosure Act 1998, the CCG has produced a Whistleblowing Policy. This procedure is intended to complement the CCG’s Anti-Fraud and Bribery Policy and Code of Business Conduct and ensures there is full provision for staff to raise any concerns with others if they do not feel able to raise them with their line manager/management chain.

12. DISCIPLINARY ACTION 12.1 The disciplinary procedures of the CCG must be followed where an employee is suspected of

being involved in a fraudulent or other illegal act.

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12.2 It should be noted, however, that the duty to follow disciplinary procedures will not override the need for legal action to be taken (e.g. consideration of criminal action). In the event of doubt, legal statute shall prevail.

13. POLICE INVOLVEMENT 13.1 In accordance with the NHS Counter Fraud Manual, the Director of Finance, in conjunction

with the LCFS and NHS Protect, will decide whether a case should be referred to the police. Human Resources and line managers will be involved as necessary. Any referral to the police will not prohibit action being taken under the CCG’s disciplinary procedures.

14. RECOVERY OF LOSSES INCURRED BY FRAUD OR BRIBERY 14.1 The seeking of financial redress or recovery of losses should always be considered in cases of

fraud or bribery that are investigated by the LCFS or NHS Protect where a loss is identified. As a general rule, recovery of the loss caused by the perpetrator should always be sought. The decisions must be taken in the light of the particular circumstances of each case.

14.2 Redress allows resources that are lost to fraud and bribery to be returned to the NHS for use as intended, for provision of high-quality patient care and services.

14.3 Sections 10 and 11 of the NHS Counter Fraud Manual provide in-depth details of how sanctions can be applied where fraud and bribery is proven and how redress can be sought. To summarise, local action can be taken to recover money by using the administrative procedures of the CCG or the civil law.

14.4 In cases of serious fraud and bribery, it is recommended that parallel sanctions are applied. For example: disciplinary action relating to the status of the employee in the NHS; use of civil law to recover lost funds; and use of criminal law to apply an appropriate criminal penalty upon the individual(s), and/or a possible referral of information and evidence to external bodies – for example, professional bodies – if appropriate.

14.5 NHS Protect can also apply to the courts to make a restraining order or confiscation order under the Proceeds of Crime Act 2002 (POCA). This means that a person’s money is taken away from them if it is believed that the person benefited from the crime. It could also include restraining assets during the course of the investigation.

14.6 Actions which may be taken when considering seeking redress include:

no further action

criminal investigation

civil recovery

disciplinary action

confiscation order under POCA

recovery sought from on-going salary payments or pensions.

14.7 In some cases (taking into consideration all the facts of a case), it may be that the CCG, under guidance from the LCFS and with the approval of the Chief Finance Officer, decides that no further recovery action is taken.

14.8 Criminal investigations are primarily used for dealing with any criminal activity. The main purpose is to determine if activity was undertaken with criminal intent. Following such an investigation, it may be necessary to bring this activity to the attention of the criminal courts (magistrates’ court and Crown court). Depending on the extent of the loss and the proceedings in the case, it may be suitable for the recovery of losses to be considered under POCA.

14.9 The civil recovery route is also available to the CCG if this is cost-effective and desirable for deterrence purposes. This could involve a number of options such as applying through the

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Small Claims Court and/or recovery through debt collection agencies. Each case needs to be discussed with the Chief Finance Officer to determine the most appropriate action.

14.10 The appropriate senior manager, in conjunction with the HR department, will be responsible for initiating any necessary disciplinary action. Arrangements may be made to recover losses via payroll if the subject is still employed by the CCG. In all cases, current legislation must be complied with.

14.11 Action to recover losses should be commenced as soon as practicable after the loss has been identified. Given the various options open to the CCG, it may be necessary for various departments to liaise about the most appropriate option.

14.12 In order to provide assurance that policies were adhered to, the Chief Finance Officer will maintain a record highlighting when recovery action was required and issued and when the action taken. This will be reviewed and updated on a regular basis.

15. MONITORING EFFECTIVENESS 15.1 Qualitative Assessments (QA’s) are a self-assessment tool developed by NHS Protect to

measure the effectiveness of the Counter Fraud arrangements at the CCG. QAs require NHS organisations to make a declaration of the counter fraud work they have completed during the financial year. The declaration focuses on the importance of demonstrating effectiveness and the correlation between workplan tasks, output and impact and innovative action. A copy of the self-assessment will be included in the LCFS Annual Report.

15.2 As a result of reactive and proactive work completed throughout the financial year, closure reports are prepared and issued by the LCFS. System and procedural weaknesses are identified in each report and highlight suggested recommendations for improvement. The CCG, together with the LCFS will track the recommendations to ensure that they have been implemented.

16. ADDITIONAL INFORMATION Any abuse or non-compliance with this policy or procedures will be subject to a full investigation and appropriate disciplinary action.

This policy will be subject to regular review.

17. RELATED POLICIES Whistleblowing Policy

Gifts, Hospitality , Sponsorship, Rewards or Inducement

Standards of Business Conduct

Code of Conduct for Managers

Disciplinary Policy

Declaration of Interests

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APPENDIX A-What to Do

This includes: What to do: DO

Fraud

Any deliberate intention to make a gain for themselves or anyone else, or inflicting a loss (or a risk of loss) on another i.e. the NHS.This could be through the falsification of any records or documents or obtaining any service(s) and/or failing to disclose information.

Bribery

Anything that induces or intends to induce improper performance. This covers offering, promising or giving a bribe, requesting, agreeing to receive or accepting a bribe, and failing to prevent bribery.

Where someone is influenced by bribery, payment of benefit-in-kind to unreasonably use their position to give some advantage to another.

If any of these concerns come to light you must immediately report your suspicions and what you have discovered to one of the following:

The Local Counter Fraud Specialist:

John Always

Tel: 01908 577 450

Email: [email protected]

Chief Finance Officer

Martin Sheldon

Tel: 0208 926 5270

Email; [email protected]

The NHS Fraud Reporting Line

0800 0284060

Or online www.reportnhsfraud.nhs.uk

Confidentiality will be maintained and all matters will be dealt with in accordance with the NHS Counter Fraud standards.

You will not suffer any recriminations as a result of raising concerns – You have protection under The Public Interest Disclosure Act 1998.

Tell someone!

Confidentiality will be respected.

Any delay might cause the organisation to suffer further financial loss.

Make a note of your concerns!

Note all relevant details, what was said, the date time and names of all parties involved.

Keep a record or copy any documentation that arouses your suspicion.

DO NOT

Confront the individual(s) with your suspicions.

Try to investigate the matter yourself. Contact the police directly. Convey your suspicions to anyone other

than those with the proper authority as listed.

Do nothing!

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http://www.reportnhsfraud.nhs.uk/

Anti-Fraud and Bribery Policy v2

Appendix B

THE FRAUD ACT 2006 SUMMARY

Section 1of The Fraud Act sets out provisions for a general offence of fraud. There are several new offences created the main three being sections 2, 3 and 4. The Act also creates new offences of obtaining services dishonestly and of possessing, making and supplying articles for use in fraud, as well as containing a new offence of fraudulent trading applicable to non-corporate traders.

Section 2: Fraud by False Representation

It is an offence to commit fraud by false representation. The representation must be made dishonestly. This test applies also to sections 3 and 4 below. The current definition of dishonesty was established in R vGhosh [1982] Q.B.1053. That judgment sets a two-stage test. The first question is whether a defendant's behaviour would be regarded as dishonest by the ordinary standards of reasonable and honest people. If answered positively, the second question is whether the defendant was aware that his conduct was dishonest and would be regarded as dishonest by reasonable and honest people.

The person must make the representation with the intention of making a gain or causing loss or risk of loss to another. The gain or loss does not actually have to take place.

A representation is defined as false if it is untrue or misleading and the person making it knows that it is, or might be, untrue or misleading. A representation means any representation as to fact or law, including a representation as to a person's state of mind.

A representation may be express or implied. It can be stated in words or communicated by conduct. There is no limitation on the way in which the representation must be expressed. It could be written or spoken or posted on a website.

A representation may also be implied by conduct. An example of a representation by conduct is where a person dishonestly misuses a credit card to pay for items. By tendering the card, he is falsely representing that he has the authority to use it for that transaction. It is immaterial whether the merchant accepting the card for payment is deceived by the representation.

This offence would also be committed by someone who engages in "phishing": i.e. where a person disseminates an email to large groups of people falsely representing that the email has been sent by a legitimate financial institution. The email prompts the reader to provide information such as credit card and bank account numbers so that the "phisher" can gain access to others' personal financial information.

A representation may be regarded as being made if it (or anything implying it) is submitted in any form to any system or device designed to receive, convey or respond to communications (with or without human intervention). The main purpose of this provision is to ensure that fraud can be committed where a person makes a representation to a machine and a response can be produced without any need for human involvement. (An example is where a person enters a number into a "CHIP and PIN" machine.)

Section 3: Fraud by Failing to Disclose Information

Section 3 makes it an offence to commit fraud by failing to disclose information to another person where there is a legal duty to disclose the information. A legal duty to disclose information may include duties under oral contracts as well as written contracts.

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For example, the failure of a solicitor to share vital information with a client within the context of their work relationship, in order to perpetrate a fraud upon that client, would be covered by this section. Similarly, an offence could be committed under this section if for example an NHS employee failed to disclose to the CCG that certain patients referred by him for private treatment are private patients, thereby avoiding a charge for the services provided by that NHS employee during NHS time.

Section 4: Fraud by Abuse of Position

Section 4 makes it an offence to commit a fraud by dishonestly abusing one's position. It applies in situations where the defendant has been put in a privileged position, and by virtue of this position is expected to safeguard another's financial interests or not act against those interests.

The necessary relationship will be present between trustee and beneficiary, director and company, professional person and client, agent and principal, employee and employer, or between partners. It may arise otherwise, for example within a family, or in the context of voluntary work, or in any context where the parties are not at arm's length.

The term "abuse" is not limited by a definition, because it is intended to cover a wide range of conduct. The offence can be committed by omission as well as by positive action. For example, an employee who fails to take up the chance of a crucial contract in order that an associate or rival company can take it up instead at the expense of the employer commits an offence under this section.

An employee of a software company who uses his position to clone software products with the intention of selling the products on would commit an offence under this section.

Another example covered by this section is where a person who is employed to care for an elderly or disabled person has access to that person's bank account and abuses his position by removing funds for his own personal use.

Note: It is now no longer necessary to prove a person has been deceived in the above offences. The focus is now on the dishonest behaviour of the suspect and their intent to make a gain or cause a loss.

Section 5: (not relevant for the purposes of this document)

Section 6: Possession etc. of Articles for Use in Frauds

Section 6 makes it an offence for a person to possess or have under his control any article for use in the course of or in connection with any fraud. This wording draws on that of the existing law in section 25 of the Theft Act 1968 (These provisions make it an offence for a person to "go equipped" to commit a burglary, theft or cheat, although they apply only when the offender is not at his place of abode.

Proof is required that the defendant had the article for the purpose or with the intention that it be used in the course of or in connection with the offence, and that a general intention to commit fraud will suffice.

Section 7: Making or Supplying Articles for Use in Frauds

Section 7 makes it an offence to make, adapt, supply or offer to supply any article knowing that it is designed or adapted for use in the course of or in connection with fraud, or intending it to be used to commit or facilitate fraud. For example, a person makes devices which when attached to electricity meters cause the meter to malfunction.

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Section 8: "Article"

Section 8 extends the meaning of "article" for the purposes of sections 6 and 7 and certain other connected provisions so as to include any program or data held in electronic form. Examples of cases where electronic programs or data could be used in fraud are: a computer program can generate credit card numbers; computer templates can be used for producing blank utility bills; computer files can contain lists of other peoples' credit card details or draft letters in connection with 'advance fee' frauds.

Section 9: Participating in fraudulent business carried on by sole trader etc.

Section 9 makes it an offence for a person knowingly to be a party to the carrying on of fraudulent business where the business is not carried on by a company or (broadly speaking) a corporate body.

A person commits the offence of fraudulent trading dishonesty is an essential ingredient of the offence; the mischief aimed at is fraudulent trading generally, and not just in so far as it affects

creditors; the offence is aimed at carrying on a business but that can be constituted by a single

transaction; and It can only be committed by persons who exercise some kind of controlling or

managerial function within the company.

Section 10: (not relevant for the purposes of this document)

Section 11: Obtaining Services Dishonestly

Section11 makes it an offence for any person, by any dishonest act, to obtain services for which payment is required, with intent to avoid payment. The person must know that the services are made available on the basis that they are chargeable, or that they might be. It is not possible to commit the offence by omission alone and it can be committed only where the dishonest act was done with the intent not to pay for the services as expected.

It requires the actual obtaining of the service. For example, data or software may be made available on the Internet to a certain category of person who has paid for access rights to that service. A person dishonestly using false credit card details or other false personal information to obtain the service would be committing an offence under this section. The section would also cover a situation where a person climbs over a wall and watches a football match without paying the entrance fee - such a person is not deceiving the provider of the service directly, but is obtaining a service which is provided on the basis that people will pay for it.

Section 11 also covers the situation where a person attaches a decoder to her television to enable viewing access to cable / satellite television channels for which they has no intention of paying for.

Section 12: Liability of Company Officers for Offences by Company

This section repeats the effect of section 18 of the Theft Act 1968. It provides that company officers who are party to the commission of an offence under the Bill by their body corporate will be liable to be charged for the offence as well as the company. It applies to directors, managers, secretaries and other similar officers of a company. If the body corporate charged with an offence is managed by its members the members involved in management can be prosecuted too.

The Fraud Act 2006 repeals the following Theft Act offences:

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Theft Act 1968

Section 15 (obtaining property by deception). Section 15A (obtaining a money transfer by deception). Section 15B (Section 15A: supplementary). Section 16 (obtaining a pecuniary advantage by deception). Section 20(2) (procuring the execution of a valuable security by deception).

Theft Act 1978

Section 1 (Obtaining services by deception). Section 2 (evasion of liability).

The Act came into force on 15th January 2007 and carries a maximum sentence of 10 years imprisonment with the exception of the ‘going equipped offence’ which is five years.

Any suspicions of fraud against the CCG should be reported to the LCFS or alternatively you can telephone the NHS Fraud Reporting Line. Details are provided in Appendix A.

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Appendix C BRIBERY ACT 2010

The following business practices constitute criminal offences under the Bribery Act 2010 and are therefore prohibited:

Offences of bribing another person

Case 1 is where a employee offers, promises or gives a financial or other advantage to another person and intends the advantage (i) to induce that or another person to perform improperly a relevant function or activity, or (ii) to reward that or another person for the improper performance of such a function or activity.

Case 2 is where a CCG employee offers, promises or gives a financial or other advantage to another person and knows or believes that the acceptance of the advantage would itself constitute the improper performance of a relevant function or activity by that person.

The bribery must relate to (i) a function of a public nature, (ii) an activity connected with a business, (iii) an activity performed in the course of a person’s employment, or (iv) an activity performed by or on behalf of a body of persons (whether corporate or unincorporate). The person performing the function or activity must be expected to perform it in good faith, impartially or in a position of trust. It does not matter whether the function or activity is performed inside or outside the UK, whether the other person(s) involved is/are in the public or private sector and whether the advantage is offered, promised or given directly by a CCG employee or through a third party, e.g. an agent or other intermediary.

Offences relating to being bribed

Case 3 is where a CCG employee requests, agrees to receive or accepts a financial or other advantage intending that, in consequence, a relevant function or activity should be performed improperly (whether by him-/herself or another person).

Case 4 is where a CCG employee requests, agrees to receive or accepts a financial or other advantage, and the request, agreement or acceptance itself constitutes the improper performance by him-/herself of a relevant function or activity.

Case 5 is where a CCG employee requests, agrees to receive or accepts a financial or other advantage as a reward for the improper performance (whether by him-/herself or another person) of a relevant function or activity.

Case 6 is where, in anticipation of or in consequence of a CCG employee requesting, agreeing to receive or accepting a financial or other advantage, a relevant function or activity is performed improperly (i) by that, or (ii) by another person at his/her request or with his/her assent or acquiescence.

Again, the bribery must relate to (i) a function of a public nature, (ii) an activity connected with a business, (iii) an activity performed in the course of a person’s employment, or (iv) an activity performed by or on behalf of a body of persons (whether corporate or unincorporate). The person performing the function or activity must be expected to perform it in good faith, impartially or in a position of trust.

It does not matter whether the function or activity is performed inside or outside the UK, whether the other person(s) involved is/are in the public or private sector, whether a CCG employee requests, agrees to receive or accepts the advantage directly or through

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a third party, e.g. an agent or other intermediary, and whether the advantage is for the benefit of a CCG employee or another person.

In Cases 4 to 6, it does not matter whether a CCG employee knows or believes that the performance of the function or activity is improper.

Bribery of foreign public officials

Case 7 is where a CCG employee bribes a foreign public official and intends (i) to influence that official in his/her capacity as a foreign public official and (ii) to obtain or retain a business or an advantage in the conduct of business. A foreign public official is someone who holds a legislative, administrative or judicial position of any kind or exercises a public function of a country outside the UK, or is an official or agent of a public international organisation.

The following paragraph will apply if any part of the organisation is considered as a ‘commercial’ one.

Failure of commercial organisations to prevent bribery

A corporate or partnership is guilty of a corporate bribery offence if an employee, agent, subsidiary or any other person acting on its behalf bribes another person intending to obtain or retain business or an advantage in the conduct of business for the corporate or partnership. For a definition of bribery, please refer to Cases 1, 2 and 7 above.

It should be the policy of a corporate or partnership not to tolerate any bribery on its behalf, even if this might result in a loss of business for it. Criminal liability must be prevented at all times.

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Whistleblowing – Disclosure in the Public Interest Policy v 3

1

WHISTLEBLOWING – DISCLOSURE IN THE

PUBLIC INTEREST POLICY

Version 1

Version 2

Supported by Audit and Governance Committee 3 September 2014, subject to some amendment.

Supported by Remuneration Committee on 14 November 2014, subject to some amendments.

Version 3 For agreement by the Governing Body Meetings January 2014*

Next Review For review at January 2015 Audit & Governance Committee

*Following Governing Body approval an individualised policy will be provided for each of the three Clinical Commissioning Groups.

*

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TABLE OF CONTENTS Page No.

1. PURPOSE

2. DEFINITION OF WHISTLEBLOWING – PROTECTED DISCLOSURE 3

3. SCOPE 4

4. POLICY STATEMENT – DISCLOSURE AND PROTECTION 4

5. GENERAL PRINCIPLES AND PROCEDURE – INTERNAL DISCLOSURE 6

6. GENERAL PRINCIPLES AND PROCEDURE – DEPARTMENTAL DISCLOSURE 7

7. CONFIDENTIALITY 8

8. WHEN EXTERNAL DISCLOSURE IS REASONABLE AND APPROPRIATE 8

9. EQUALITY AND DIVERSITY MONITORING 9

10. RESPONSIBILITY 9

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1. PURPOSE 1.1 The CCG seeks to conduct its business honestly and with integrity at all times.

However, it is acknowledged that all organisations face the risk of their activities going wrong from time to time, or of unknowingly harbouring malpractice. The CCG has a duty to take appropriate measures to identify such situations and attempt to remedy them.

1.2 It is important to the CCG that any fraud, misconduct or wrong doing in the context of

the Public Interest Disclosure Act (1998) is reported and properly dealt with.

Thus the aim of this policy is to:

• Provide information about how to raise any concerns (or ‘whistleblow’) under the provisions of the Act) with regard to the conduct of others in the CCG, or the way in which the CCG is run.

• Ensure that everyone is confident that they can raise any matters of genuine concern without fear of reprisals, in the knowledge that they will be taken seriously and that the matters will be investigated appropriately.

2. DEFINITION OF WHISTLEBLOWING - PROTECTED DISCLOSURE 2.1 Whistleblowing, or public interest disclosure, occurs when a worker (see Section 3.2)

in good faith reports the actual or prospective improper actions of his /her organisation or colleagues.

2.2 The Public Interest Disclosure Act clearly defines the types of disclosure that qualify the worker disclosing them for protection against dismissal and detriment. These are known as 'protected' disclosures and cover allegations of six types of wrongdoing which may be occurring, have occurred or may occur and are: • A criminal offence • Failure to comply with any legal obligation • A miscarriage of justice • Risks to health and safety or; • Environmental damage • The deliberate concealment of information which would constitute evidence of

any of the above See 3.3 for examples of whistleblowing

2.3 For a whistle-blower to be protected under the Act, the disclosure needs to be both a qualifying and a protected disclosure. To be protected, disclosures must be made in good faith meaning that the motivation for making a disclosure should be an honest and reasonable one and made in the public interest.

2.4 Disclosures under 2.2 will be a qualifying disclosure protected under the Act unless the person making the disclosure commits an offence by making the disclosure e.g. it breaches the Official Secrets Act.

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3. SCOPE 3.1 This applies to all “workers” or staff directly employed by the CCG, anyone who

works for the CCG, anyone who works for the CCG under any type of contract, including letter of appointment e.g. any member of the Governing Body of the CCG, any contractor, consultant, agency, temporary, and casual staff. It also covers ex-employees but this does not apply to volunteers or self-employed people.

3.2 Since the legislation defines staff covered by this act as “workers” this term has been

used throughout the policy.

3.3 The whistleblowing procedure is appropriate for raising public concerns only. Where

an individual has a personal grievance, the appropriate policy (e.g. Grievance Procedure, Harassment, Bullying and Discrimination) should be consulted.

Before proceeding to raise an issue under this policy, line managers and workers should recognise that there is a difference between a grievance and a protected disclosure. A protected disclosure will concern the conduct of another person in the workplace (whether or not that conduct affects the complainant personally), in circumstances where the complainant genuinely believes e.g. that the conduct in question amounts to a criminal offence, a breach of a legal obligation, or something likely to endanger health or safety or damage the environment etc

Examples of the difference between a grievance and a protected disclosure may include, but are not limited to:

Grievance: employee complains about:

Protected disclosure – individual discloses

Tthe type of work being asked to do, e.g. if it is not covered by his/her contract.

Being instructed to carry out actions that he/she genuinely believes to be illegal, e.g. falsify tax returns.

Not receiving sufficient safety training. That safety rules within the workplace are routinely being flouted, thus endangering safety.

4. POLICY STATEMENT - DISCLOSURE AND PROTECTION 4.1 The CCG is committed to achieving the highest possible standards of service and

ethical standards in public life and recognises the value of operating a whistleblowing policy to help sustain this. Thus this policy is to ensure for instance: • Active support of the Act by management at the highest level of the organisation

• A route for workers to report wrongdoing that should be disclosed or raising genuine concerns about possible malpractice internally, without feeling intimidated

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• That any worker expressing concerns of this nature will be taken seriously and their concern investigated

• That evidence of poor or unacceptable practice or misconduct is not concealed

• That disciplinary action is taken if a worker destroys or conceals such evidence

• Liaison with the DESIGNATED OFFICIAL (see Section 6) in cases where staff report malpractice to the Department

4.2 By encouraging a culture of openness and accountability within the CCG, it is believed the CCG can help prevent such situations occurring. The CCG expects all workers to maintain high standards in accordance with all policies and procedures and to report any wrongdoing that falls short of these fundamental principles. It is the responsibility of all workers to raise any concerns that they might have about malpractice within the CCG.

4.3 The Act and CCG policy provides that workers can where appropriate disclose the

improper action, internally, to the DESIGNATED OFFICIAL, to one of a number of external regulators, or more widely if none of the other options is appropriate. The CCG has a set procedure in this policy to help workers determine the most appropriate course of action bearing in mind the provisions under Section 2 of this policy.

4.4 The CG aims to ensure that workers have confidence in the fairness and impartiality

of its procedures for registering concerns. 4.5 Workers should follow the internal procedures set down in this policy for

whistleblowing and in most circumstances raise concerns internally to an appropriate person before making a disclosure to any external body. Only if a case is exceptionally serious, and there are good reasons for doing so, should a worker bypass these disclosure procedures. The key for the worker is to ensure that any disclosure of information is “reasonable in all the circumstances” and disclosed in good faith. The worker must always comply with the CCG policy for whistleblowing - (protection of the Public Interest Disclosure Act 1998 can be lost if internal policy is ignored).

4.6 The CCG also has a duty to protect workers who raise concerns under this policy

from less favourable treatment. The CCG will make every effort to ensure any whistleblower suffers no adverse repercussions from individuals under its control as a result of making a disclosure. This will include;

• Keeping any disclosure made under this policy as confidential as possible. (See

Section 7) • Treating any victimisation of a whistle-blower as a serious matter subject to the

Disciplinary Procedure, including action up to and including dismissal (which in some circumstances may also result in criminal prosecution).

4.7 Workers who experience less favourable treatment can and should take any issues

up through the appropriate CCG adopted policies such the Bullying/ Harassment policy or the Grievance Policy and Procedure.

4.8 It should be noted that any worker who, in good faith, makes allegations that turn out

to be unfounded will not be penalised for being genuinely mistaken.

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4.9 Equally, any worker who abuses the whistleblowing process by making a disclosure in bad faith e.g. raising unfounded allegations maliciously or for personal gain may be subject to disciplinary action up to and including dismissal.

5. GENERAL PRINCIPLES AND PROCEDURE – INTERNAL DISCLOSURE 5.1 There is an obligation on every worker to report genuine concerns (e.g. possible

security incidents and losses must be reported). In majority of instances the most appropriate place to raise concerns will be with the line or more senior manager.

However, in some cases approaching the line manager may be neither appropriate nor desirable. In this case, and where the concern falls under the protected disclosure criteria (see section 2) above, workers should follow this procedure as laid out in (sections 5-7). This procedure provides a route whereby workers can raise concerns over issues of impropriety and malpractice without going through the normal management structure and with confidence that those concerns will be thoroughly investigated and dealt with as appropriate.

5.2 The worker should first ensure their concern constitutes a protected disclosure rather than a grievance (see sections 3.3) and is a public concern that is appropriate and reasonable to be raised in good faith under the whistleblowing procedure, (see section 2)

5.3 A worker wishing to raise their concern under this policy should preferably write to

the member of the CCG governing body entrusted with the duty of investigating staff concerns, who is the Chair of the Audit and governance Committee (and CCG lay member for governance), sending their letter in a sealed envelope marked ‘In Confidence” to :

Kash Pandya ,Chair of the Audit and Governance Committee See section 6.1 for contact details In the absence of the Chair of the Audit and Governance Committee, the alternative person to handle this concern will be the second governing body lay member (for patient and public involvement). The worker may alternatively request a telephone call to raise their concerns and details of the call will be recorded in lieu of the letter.

5.4 The designated governing body member will then handle this matter promptly after firstly acknowledging receipt of their letter to the worker and secondly assessing whether their concerns fall properly within the policy and his/ her remit. This acknowledgement will be in writing. It will be issued as soon as possible and within five working days unless not reasonably practicable.

5.5 If the concern falls under the policy, the governing body member will then initiate a

thorough investigation (either in person or to an appropriate member of staff), and arrange for further evidence both from the concerned worker and the CCG management as appropriate.

5.6 The governing body member will normally enlist the assistance of the Human

Resources function supporting the CCG who will nominate a member of staff

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employed by the CCG to gather evidence and in some cases e.g. when there are financial or legal implications or where senior workers are under suspicion it may be appropriate to involve the CCG Chief Officer (the Accountable Officer) and / or the CCG Local Counter Fraud Specialist, internal or external auditors. Advice in such circumstances will be sought from the Chief Financial Officer and/or the Director of Corporate Services.

5.7 The process will ensure protection of the identity of the worker concerned so far as is possible, although no absolute promise of confidentiality can realistically be made if this is to be investigated (see section 7); Any investigation may involve the worker and other individuals involved giving a written statement and they may be asked to comment on additional evidence obtained.

5.8 The member of staff carrying out the investigation will then either report to the

governing body lay member or the CCG governing body, as appropriate, who will take any necessary action, including reporting the matter to an appropriate government department or regulatory agency if required. If disciplinary action is required, HR (delivered through the Commissioning Support Unit) will need to be notified in order to initiate the disciplinary procedure.

5.9 Once assured that the investigation has been conducted properly and that all of the

concerns raised have been addressed seriously and fully, the governing body lay member will notify the individual (and the governing body if appropriate) of the outcome of any investigation and what the governing body has done, or proposes to do, about it. The level of details given will be appropriate to the circumstances and if no action is taken the reason for this will be explained.

5.10 If for any reason the worker is dissatisfied with the handling of the concern e.g.

reasonably believes the CCG has failed to make a proper investigation, take proper action or has delivered an unsatisfactory outcome, the worker may raise this in other ways (See sections 6-8).

6. GENERAL PRINCIPLES AND PROCEDURE – DEPARTMENT DISCLOSURE

6.1 The approach to the designated governing body official should be detailed either by telephone or in writing marked ‘In Confidence-Addressee only” to the designated official at the CCG who will investigate the matter further. The contact details of the official are:

Kash Pandya, Lay Member for Audit & Governance, C/0 Corporate Services Directorate, 5 Floor, Becketts House, 2-14 Ilford Hill, Ilford Essex IG1 2QX. Email: [email protected] Or if their concern is about fraud or bribery, they can also contact the Trust Local Counter Fraud Specialist or the NHS Fraud Hotline (Tel: 0800 028 40 60)

6.2 Workers should be aware that there are instances where issues of propriety and

misconduct under the Public Interest Disclosure Act (1998) may also be raised with the Secretary of State for Health. These are when the worker reasonably deems that:

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• It is inappropriate to use the internal process, (he /she may raise the issue in good faith with the Nominated Official)

• The response to the concerns raised with the governing body member is not

reasonable or satisfactory.

7. CONFIDENTIALITY 7.1 The CCG recognises that workers may want to raise a concern in confidence under

this policy and the CCG will work to sustain confidentiality in all disclosures by ensuring the anonymity / identity of the individual concerned will, so far as is possible, be kept confidential.

7.2 The worker disclosing must realise that in some circumstances, there can realistically

be no absolute promise of confidentiality following disclosure if this is to be investigated or the concern resolved.

7.3 Once a worker has made a disclosure they equally have a responsibility to maintain

confidentiality about this disclosure since this could compromise the worker and the process.

7.4 The CCG will not disclose the person’s identity without first discussing this with the

worker and outlining how this can proceed. Appropriate steps will be taken to ensure that their working environment and/or working relationship is/are not prejudiced by the fact of the disclosure.

7.5 There will be some disclosures, that once disclosed, cannot be investigated or

resolved without revealing the workers identity, and that the CCG will be obliged to continue to investigate and resolve. Workers may be required to attend a disciplinary or investigative hearing as a witness. It needs to be remembered that this was why the framework of legal protection for individuals who disclose information was required. The Public Interest Disclosure Act (1998) was devised to protect workers from suffering from detriment, discrimination, victimisation or dismissal if they criticise the working practices of the organisation which employs them (see section 4.1)

8. WHEN EXTERNAL DISCLOSURE IS REASONABLE AND APPROPRIATE

8.1 The aim of this policy is to provide a mechanism for reporting, investigating and

remedying any potential wrongdoing internally and/or with the CCG as appropriate. It is therefore hoped that it will not be necessary for workers to alert external organisations.

8.2 However, in very serious circumstances, the CCG recognises that it may be

appropriate for a worker to report their concerns to an external body such as a regulator (see 8.3 below) where the alleged wrongdoing / malpractice falls within that body's remit, especially if on the conclusion of the above process (sections 5-6), the worker reasonably believes that the appropriate action has not been taken.

8.3 The Government has prescribed a list of appropriate external bodies for reporting

certain matters, including (for example) the Environment Agency and the Health and Safety Executive. A full list is available from Public Concern at Work, an independent charity. It will rarely be appropriate to go directly to the press.

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8.4 Also, workers may make such a disclosure to the independent whistleblowing charity

Public Concern at Work, on 020 7404 6609 or by email at [email protected] if, despite the best efforts of the organisation, workers believe that disclosure within the organisation is inappropriate or has been unsuccessful. Disclosures made to worker’s legal advisors in the course of obtaining legal advice will be protected.

8.5 'Exceptionally serious' is not defined in the legislation, but is likely to be restricted to

matters where disclosure would serve the public interest. However, the worker making the disclosure must:

• Have reasonably believed, at the time of making the disclosure, that he/she

would be subjected to a detriment by the employer if disclosure was made to the employer or to a prescribed body;

• Comply with the CCG policy for whistleblowing - (protection of the Public Interest Disclosure Act 1998 can be lost if internal policy is ignored)

• Have previously disclosed his/her concerns to the employer or a prescribed body; or;

• In circumstances where there is no prescribed body, have reasonably believed that, if he/she had made the disclosure to the employer, it would have taken steps to conceal or destroy the evidence of malpractice

• The disclosure must be made in good faith.

9. DIVERSITY AND EQUAL OPPORTUNITIES MONITORING 9.1 Human Resources will compile any records required in relation to the worker who

made the disclosure in terms of race, gender, age and disabled status etc. and issues of concern. This information will be kept confidentially by Human Resources and will be used for no other purpose than to enable the CCG to fulfil its obligations for monitoring and ensuring Equal Opportunities.

10. RESPONSIBILITY 10.1 All workers / members of staff referred to within the scope of this Policy are required

to adhere to the policy. 10.2 All line managers are responsible for ensuring that this Policy is applied within their

own area. Any queries on the application or interpretation of this policy must be discussed with Human Resources prior to any action being taken.

10.3 Corporate Services are responsible for ensuring the maintenance, regular review and

updating of this Policy. A review will be undertaken at least annually by the Audit & Governance Committee.

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BHR Gifts, Hospitality, Sponsorship (non-pharmaceutical industry) Rewards or Inducements Policy v2

1

POLICY ON GIFTS, HOSPITALITY, SPONSORSHIP (NON - PHARMACEUTICAL INDUSTRY)

REWARDS OR INDUCEMENT

*Following Governing Body approval an individualised policy will be provided for each of the three Clinical Commissioning Groups.

Version 1 Supported by Audit & Governance Committee 12 November 2013 - for some amendment

Version 2 For Agreement by Governing Body Meetings January 2014*

For Review For review by the Audit & Governance Committee January 2015

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CONTENTS

1 Introduction 2

2 Definitions 5

3 Legal Framework and Principles 5

4 Policy 6

5 Procedure 8

6 Freedom of Information 11

7 Consequence of Breach 11

8 Related Policies 11

Appendix A Form to register gifts, hospitality, sponsorship (non-pharmaceutical industry) Rewards or Inducement

Appendix B Form to register Tender Declaration of Interest

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1. Introduction This policy applies to all CCG employees, members of the Governing Body and its committees, sub-committees, working groups and any person working on behalf of the CCG e.g. agency staff. This group will be referred to as employees in the remainder of the document.

This policy and procedure takes into account the requirements of;

Commercial Sponsorship - Ethical Standards in the NHS document issued by the Department of Health in November 2000;

Standards of Business Conduct for NHS Staff.

In addition the reader of this policy should be aware of the requirements for NHS Clinical Commissioning Groups to comply within relevant legislation including (and not exclusive to) Section 75 of The Health and Social Care Act and the Bribery Act 2010.

It is a long established principle that public sector bodies, which include the NHS, must be impartial and honest in the conduct of their business, and that their employees should remain beyond suspicion. Therefore employees must:

Ensure that the interests of patients remain paramount at all times; and

Be impartial and honest in the conduct of CCG business.

NHS bodies are required to have an explicit procedure for staff and the Governing Body to declare any gifts, hospitality, sponsorship (non-pharmaceutical), rewards or inducements offered by/ accepted from contractors, suppliers and others. In addition, it is good practice to declare anything offered but declined. This policy is intended to provide clear guidance to employees on the procedure to be followed, including register entries, in the event of gifts, hospitality, sponsorship, rewards or inducements being offered.

The CCG needs to have in place principles and procedures for minimising, managing and registering gifts, hospitality, sponsorship, rewards or inducements that could be deemed, or assumed to affect, the decisions made by those involved in the CCG business. These decisions could include funding decisions, research assessment, awarding contracts, procurement, policy, employment and other decisions.

This policy and procedure sets out to allow the CCG to demonstrate probity in its commercial activity and protect the CCG from potential criticism. The process is intended to be open and transparent and provide the required separation of responsibilities when awarding commercial contracts.

This policy should be read together with the CCG’s Standards of Business Conduct and Managing Conflicts of Interest Policy and the CCG’s policy on Sponsorship and Joint Working with the Pharmaceutical Industry.

This policy respects the revised Appointment Commission’s Code of Accountability, fourteenth report published January 2013, and Code of Conduct for NHS Boards and the seven principles of public life promulgated by the Nolan Committee.

The seven principles are:

Principle Description

Preamble The principles of public life apply to anyone who works as a public office-holder. This includes all those who are elected or appointed to public office, nationally and locally, and all people appointed to work in the civil service,

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local government, the police, courts and probation services, NDPBs, and in the health, education, social and care services. All public office-holders are both servants of the public and stewards of public resources. The principles also have application to all those in other sectors delivering public services.

Selflessness Holders of public office should act solely in terms of the public interest.

Integrity Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests and relationships.

Objectivity Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias.

Accountability Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to ensure this.

Openness Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing.

Honesty Holders of public office should be truthful.

Leadership Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support

Procurement requirements As a public body, the CCG will need to adhere to legislation that governs the award of contracts by public bodies, including the Public Contracts Regulations 2006, and will need to satisfy the obligations of transparency, equal treatment and non-discrimination set out in those regulations. CCGs also need to comply with the regulations implemented under section 75 of the Health and Social Care Act, which place requirements on commissioners to ensure that they adhere to good practice in relation to procurement, do not engage in anti-competitive behaviour, and protect and promote the right of patients to make choices about their healthcare. .

NHS England has published procurement guidance for CCGs to support them in meeting the requirements of the section 75 regulations.

Subject to DH regulations on procurement choice and competition and subject to current procurement rules set out in the Public Contracts Regulations 2006, CCGs will need to decide where it is appropriate to commission community based services through competitive tender or an Any Qualified Provider (AQP) approach and where through single tender. In general, commissioning through competitive tender or AQP will introduce greater transparency and help reduce the scope for conflicts.

There may, however, be circumstances where the CCG could reasonably commission services from GP practices on a single tender basis, i.e. where they are the only capable providers and as such the CCG is required to set out in their Constitution their proposed arrangements for managing conflicts of interest.

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The CCG will therefore have safeguards in place to manage conflicts of interest, including:

Arrangements for declaring interests

Maintaining a register of interests

Excluding individuals from decision-making where a conflict arises

Engagement with a range of potential providers on service design

Those persons involved in tendering activities are required to declare any conflicting interest they may have in connection to the procurement exercise at the outset of the tendering process. This will be kept by the procurement department and an example of this form is provided at Appendix B.

As best practice continues to evolve, the NHS England will reflect it in the guidance it gives to CCGs and therefore this policy should be reviewed annually.

2. Definitions Sponsorship

Funding from any external source including funding all or part of costs of a member of staff, equipment, research, staff training, pharmaceuticals, meeting rooms, costs associated with meetings, hotel and transport costs including travel abroad, and provision of free services e.g. speakers. If the external source is the pharmaceutical industry, the CCG has a separate policy on sponsorship relating to the pharmaceutical industry and a register to declare such sponsorship.

Fees

The money paid to an employee for a service provided to a private or commercial sector organisation.

Hospitality & Gifts

The acceptance of meals, refreshments and gifts or invitations to non-work related functions from the commercial sector.

Inclusion in the Register Declarations made will be included in the register through the completion of a form declaring gifts, hospitality, sponsorship (non-pharmaceutical), rewards or inducement. (Appendix A). Sponsorship and Joint Working with the Pharmaceutical Industry is covered under a separate policy that will have its own form for completion attached (being developed for the next Governing Body meeting).

3. Legal Framework and Principles

The Bribery Act 2010 has introduced the offences of offering and or receiving a bribe. It also places specific responsibility on organisations to have in place sufficient and adequate procedures to prevent bribery and corruption taking place. Under the Act, Bribery is defined as “Inducement for an action which is illegal, unethical or a breach of trust. Inducements can take the form of gifts, loans, fees, rewards or other privileges". Corruption is broadly defined as the offering or the acceptance of inducements, gifts, favours, payments or benefit in kind which may influence the improper action of any person; corruption does not always result in a loss. The corrupt person may not benefit directly from their deeds; however, they may be unreasonably using their position to give some advantage to another. To demonstrate the organisation has sufficient and adequate procedures in place and to demonstrate openness and transparency, employees are required to comply with the requirements of the Gifts, Hospitality, Sponsorship Rewards and Inducement Policy.

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There is a separate CCG Anti Fraud and Bribery Policy which makes reference to the paying and receiving of bribes, bribery through intermediaries, facilitation payments, documents and records, joint ventures and consortia, agents and other intermediaries, contractors and suppliers, recruitment processes and employment contracts, gifts and hospitality and political, charitable and cultural donations and contributions.

For a more detailed explanation see the Anti Fraud and Bribery Policy (on the staff Intranet). Should an employee wish to report any concerns or allegations they should contact their Local Counter Fraud Specialist.

Additionally, NHS Standing Orders and European Commission Directives on Public Purchasing for Works and Supplies require fair and open competition between prospective contractors or suppliers.

The CCG should comply with the regulations implemented under Section 75 of the Health and Social Care Act, which will place requirements on commissioners to ensure that they adhere to good practice in relation to procurement.

4. Policy

Gifts The CCG has established a Gifts, Hospitality, Sponsorship (non-pharmaceutical) Rewards or Inducements Register which is held by the Corporate Services department .

As a general rule employees should not accept (or in some circumstances give)

Gifts from or to suppliers or outside organisations contracted through working duties as outlined

in the CCGs Prime Financial Policies and the NHS Constitution

Preferential rates, or benefits in kind, for private transactions carried out with companies to whom they have or may have official dealings as part of their work with the CCG.

Accept any gift which exceeds the value of £30

Any offers of cash

Employees are required to record the receipt of gifts, hospitality, sponsorship, rewards or inducements over the value of £30 and the offer of such, regardless of whether or not they are accepted.

Casual gifts by contractors or others e.g. at Christmas time, may not be in any way connected with the performance of duties so as to constitute an offence under the Bribery Act and therefore items of low intrinsic value such as diaries, calendars and other items of work related stationery and equipment may be accepted and need not be recorded in the register. It must be clear that no condition should be attached to the receipt of gifts or other forms of aid from a commercial organisation.

Employees are not to accept gifts which are over £30 in value. Several small gifts worth a total value of £100 or more from the same or closely related source in a rolling 12 month period should be declared in the register in line with the procedures set out in this policy.

It is also acceptable to receive other small value items, for example from a patient or relative in appreciation of the treatment and care received, or seasonal items, if it is made clear to the offered that it is accepted on behalf of the CCG and is either shared with colleagues or donated to an event raising charitable funds.

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Under no circumstances must employees accept personal gifts of cash, even below the £30 threshold. It is permissible for employees to accept cash donations to forward to any associated CCG charitable fund-raising events but their line manager should be made aware.

Hospitality Employees may accept modest hospitality, provided it is secondary to the purpose of the meeting and this it is similar to the scale of hospitality which the CCG would be likely to offer. Such acceptance does not need to be declared. Repeated minor hospitality from the same organisation must be considered carefully by the employee and in turn the employee’s line manager.

Employees are required to record the receipt of hospitality over the value of £30 and the offer of such, regardless of whether or not they are accepted in the CCG’s Register, kept by the Company Secretary in the Corporate Services department..

Sponsorship

Commercial Sponsorship

This policy must be read together with the CCG’s Policy on Sponsorship and Joint Working with the Pharmaceutical Industry.

Acceptance by an employee of commercial sponsorship for attendance at relevant conferences and courses is acceptable but only where permission has been granted in advance from senior management. The CCG must be satisfied that acceptance will not compromise purchasing decision in any way.

A record of acceptance or receipt or offers (even if not accepted) must be made in the register via the declaration form.

Clinical employees/professionals may submit a copy of their approved application for professional and study leave for inclusion in the register and thereby meet this requirement.

Occasionally commercial sponsorship might be provided for a whole department encompassing a number of staff. In these circumstances it is the responsibility of the relevant director as applicable to complete a declaration for inclusion in the Register.

On occasions when the CCG considers it necessary, an employee advising on the purchase of equipment, or a service to inspect such equipment, or the service operation in other parts of the country (or exceptionally, overseas) the CCG may wish to consider meeting the cost so as to avoid putting in jeopardy the integrity of future purchasing decisions. Sponsorship falling into this category must be referred to the relevant Director for advice.

Commercial sponsorship of posts

This may be offered but must not be entered into without a contract being formed and signed by the CCG’s Purchasing Manager (or equivalent role) and authorised in line with the Scheme of Delegation.

Meetings funded by the medical supplies/pharmaceutical industry

Where a meeting funded by the medical supplies/pharmaceutical industry or an allied commercial sector is hosted or organised by the CCG, that fact must be disclosed in the papers relating to the meeting and in any published proceedings e.g. minutes, action notes. The division hosting or organising the meeting must ensure that the receipt of funding is recorded in the Register. Again, this is covered by a separate policy and register relating to sponsorship and joint working with the pharmaceutical industry.

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Sponsorship of Research & Development

Where there is industry collaboration in Research & Development, companies may make a contribution towards the study's costs or supply a product. Any funding for research purposes should be transparent. There should be no incentive to use more of any particular treatment or product other than in accordance with the peer reviewed and mutually agreed protocol for the specific research intended. When considering a research proposal, whether funded in whole or part by industry, NHS bodies will wish to consider how the continuing costs of any pharmaceutical or other treatment initiated during the research will be managed once the study has ended. Patients and their carers should be informed that the CCG may not be able to continue to supply trial drugs when a study ends and any consent process that they sign should reflect this.

Fees Fees, if offered, for a broadcast, lecture or other work, can be accepted for work undertaken in the employee’s own time. If preparation is done in time when one is contracted to work for the CCG or if CCG resources (e.g. secretarial and photocopying) are used, staff should refer to the Chief Officer for further advice. All external consultancies should be declared to the Chief Officer.

If an employee has been paid by a pharmaceutical company or other private sector company to provide lectures in their own time to other health and social care workers in the geographic area to which the CCG provides services then the employee should make clear to the audience if the opinion they give in such a lecture is different from the CCG’s own policy.

Preferential Treatment in Private Transactions Employees must not seek or accept preferential rates or benefit in kind for private transactions carried out with companies with which they have had, or may have, official dealings on behalf of their employer.

5. Procedure

Gifts

Low value promotional items of value less than £30 or other forms of aid from a commercial organisation, where no condition is attached, may be accepted.

Employees are not to accept gifts over £30 in value and under no circumstances may they receive personal gifts of cash, even below the £30 threshold.

Employees may not accept any gifts of cash from any person outside of the organisation (it is acknowledged that on rare occasions a cash gift may be given to employees in respect of a retirement gift, or similar, and that donations may be made from persons not employed directly with the CCG – this is deemed acceptable if shown as proportionate and not as influencing the CCG employee or member in any form).

Several small gifts worth a total value of £100 or more from the same or closely related source in a rolling 12 month period should be declared in the register in line with the procedures set out in this policy.

Employees directly involved with contractors should complete a declaration of gifts, hospitality, sponsorship (non-pharmaceutical), rewards or inducements declaration form retrospectively on a monthly basis, (other than items of low value such as diaries or calendars), or to declare a nil return for a quarter. They should also disclose details of gifts, hospitality, etc., offered but declined.

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Employees involved in procurement are required to submit a return to the Company Secretary whenever hospitality or gifts of a value over £30 are offered irrespective of whether they are accepted. In any event the procurement staff and senior management should complete a return on an annual basis to include a nil return if appropriate. The completed and signed form should be returned to the Company Secretary who will be responsible for the maintenance and scrutiny of declarations register. This form is the same as used by all employees but should be used more frequently by those mentioned in this section.

Failure to make a declaration, or a false declaration could result in an investigation by the Local Counter Fraud Specialist which could result in a disciplinary, and/or criminal/civil action if corruption is discovered.

When the register is updated it will need to include;

Names of employees and organisations receiving or providing the gifts

The nature of the gift

Reason for the gift

Approximate value

Indication whether the gift was rejected or accepted.

Equipment is rarely free. If the equipment is not part of a formal commercial arrangement, cannot be linked to the purchase of consumables or other products or to ongoing maintenance contracts and is of benefit to the CCG it can be accepted. Medical and electrical equipment must be approved by Medical Electronics and entered on the asset register before use. The receipt must be declared in the Register.

Equipment that is offered and is linked to consumables or other products and ongoing maintenance contracts must be notified to the purchasing manager who will advise on whether the offer is acceptable and what processes need to be followed. If there is disagreement with that advice, the Chief Officer will confirm the appropriate decision.

If at all possible the purchase of major donated equipment especially that valued at over £500 should be carried out by the CCG’s purchasing manager after funds have been donated to the CCG. Lower value donated equipment should be declared in the Register. Medical and electrical equipment must not be put into use before approval by Medical Electronics and entered on the asset register.

Sponsorship This policy must be read together with the CCG’s Policy on Sponsorship and Joint Working with the Pharmaceutical Industry (to be provided to the next Governing Body for approval).

Employees should not actively seek commercial sponsorship from private sector organisations.

Commercial sponsorship offered for conferences and courses may be acceptable if they are relevant to the CCG and the development or training of the individual and if they have a genuinely educational, rather than solely promotional, purpose. Attendance at meetings should be free of commercial pressures (such as obligations to attend promotional events). Employees offered such sponsorship must gain prior written approval from their Director and provide the approximate value of the sponsorship. The detail of the sponsorship must be declared in the Register.

Where such sponsorship requires foreign travel the written approval of Chief Officer is required.

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When tendering for new equipment evaluation may be required overseas. In these cases the advice from the Department of Health is that the CCG should pay the costs of such travel to maintain the integrity of the purchasing decision. Once a contract award has been made site visits abroad may be required for the purposes of inspection. Foreign visits require the approval of Chief Officer and should be recorded in the Register.

Commercial sponsorship of posts is acceptable under the following circumstances. The sponsorship must support the CCG in the delivery of healthcare. All such commercial contracts will be negotiated by the CCG’s Purchasing Manager only under the relevant NHS Conditions of Contract. The CCG must not link the contract to the promotion of any particular product or service or limit staff and patient’s clinical choice of product. Competition should be sought if it is available.

Commercial sponsorship through advertising is acceptable under the following circumstances. The CCG is obtaining a fair percentage of income from such agreements especially when multiple choice products or services are offered. All such commercial contracts will be negotiated and signed by the CCG’s Purchasing Manager, only under the relevant NHS Conditions of Contract. The contract must include a clause that ensures that all products and services advertised are not being promoted by or necessarily used by the CCG.

Where there is industry collaboration in R&D, companies may make a contribution towards the study's costs or supply a product providing it meets the criteria described in the policy.

Hospitality

Modest hospitality, provided it is normal and reasonable in the circumstance, for example lunch on the course of working visits may be acceptable. However, it should be similar to the scale of hospitality offered by the CCG.

All employees are required to record the receipt of hospitality over the value of £30 and the offer of such, regardless of whether or not they are accepted in the CCG’s Register, kept by the Company Secretary.

When the register is updated it will need to include;

Names of officers and organisations receiving or providing hospitality

The date the event took place

The nature of the hospitality

Reason for the hospitality

Approximate value

Indication whether the hospitality was rejected or accepted.

Fees Honoraria or fees for speakers or delegates at commercial company organised meetings should be declared in the Register.

Employees speaking at commercial company-organised meetings should make clear the extent to which their presentation is based on their own original work, their own review of the evidence or on information supplied by the commercial organisation.

Anyone perceived as a representative of the CCG should make it clear when they are expressing a personal view that differs from the CCG’s official position e.g. if they are advocating use of a drug that is not included on the CCG’s formulary.

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Sponsorship for accompanying persons is not acceptable unless they have a role that makes it appropriate for them to attend the meeting.

Reporting concerns Employees who are unsure of their responsibilities under this Policy or whether to make a declaration are encouraged to ask their line manager for guidance.

Those that have genuine concerns regarding the offer of gifts, hospitality or sponsorship are encouraged to report this as soon as possible, without fear of penalty. The CCG’s Whistleblowing Policy provides information about how to report concerns.

6. Freedom of Information Act 2000

Employees should note that under the Freedom of Information Act 2000, the information contained within the CCG Register will be subject to disclosure to members of the public on request.

7. Consequence of Breach The CCG detailed financial policies have been adopted by the Governing body and are mandatory for all employees. The policy for gifts, hospitality, sponsorship (non-pharmaceutical), rewards and inducements, forms an integral part of the CCGs Prime Financial Policies and the wider NHS Constitution and is therefore also mandatory.

Failure to comply is a disciplinary offence and if appropriate, may be referred to the Local Counter Fraud Specialist.

8. Related Policies Prime Financial Policies

Standing Orders

Code of Conduct for NHS Managers

Standards of Business Conduct for NHS Staff

Corporate Governance Framework for NHS CCGs

Anti Fraud Policy and Bribery Policy

Whistle-blowing Policy

CCG’s Policy on Sponsorship and Joint Working with the Pharmaceutical Industry.

Standards of Business Conduct and Managing Conflicts of Interest Policy

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APPENDIX A-DECLARATION OF GIFTS, HOSPITALITY, SPONSORSHIP (non-Pharmaceutical), REWARDS OR INDUCEMENTS.

Name: Position:

Period / Month:

A. NIL RETURN

B. I confirm that for the above period, I have not received nor been offered any hospitality, gift, sponsorship, reward or inducement over the value of £30 per item.

Signature: Date:

B. For the above period I wish to declare the following gift, hospitality , sponsorship (non-pharmaceutical), reward or inducement offered:

Date of offer:

Name, Address & Business Source/Provider

of gift, hospitality, sponsorship (non pharmaceutical) reward or inducement

Nature and Value

of gift, hospitality, sponsorship (non pharmaceutical) reward or inducement

Notes (for clarification purposes or to state where offers have been declined.)

I confirm that I have complied with the relevant CCG Policies; Standing Financial Instructions, Standing Orders and the Standard of Business Conduct Policy.

Signature: Date:

Note: Directors and other members of CCG staff directly involved with contractors should complete this form retrospectively on a monthly basis, to declare Gifts, Hospitality, Sponsorship (non Pharmaceutical) Rewards or Inducements received (other than items of low value such as diaries or calendars), or to declare a nil return for a quarter. They should also disclose details of gifts, hospitality, etc., offered but declined. Employees involved in procurement, senior management and other member of CCG staff are required to submit a return to the Company Secretary whenever hospitality or gifts of a value over £30 are offered irrespective of whether they are accepted. In any event, procurement staff, senior management and Associate Directors should complete a return on an annual basis to include a nil return if appropriate. The completed and signed form should be returned to the Corporate Services department. Failure to make a declaration, or a false declaration could result in an investigation by the Local Counter Fraud Specialist which could result in a disciplinary, and/or criminal/civil action if corruption is discovered.

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Appendix B-TENDER DECLARTION FORM

To ensure the CCG treats all tenders with impartiality, fairness and openness, any personal interest that may affect, or be seen to affect the decision making and eventual outcome of a tender must be recorded.

All persons involved in the tender exercise including those on a tender evaluation governing body will be required to complete and return a signed declaration of interests form declaring any pecuniary or other interest that is material and relevant to the CCG or tender. Should no interest exist a declaration stating such is required.

Relevant items include but are not limited to:

Directorships, including non-executive directorships held in private companies or PLCs.

Commercial activity as a sole trader

Ownership, partnership or majority or controlling shareholdings in organisations likely or possibly seeking to do business with the CCG.

A position of authority or any material connections with a voluntary or other body in the field of healthcare or social services or contracting for services with NHS organisations.

Note: Declaration may exclude you from taking part in the tender evaluation and / or any decision making process that could affect the award. Decision will be taken by the CCG’s Chief Finance Officer.

Tender: …………………………………….. Dated…………………………………….

I declare that the information I have given on this form is a true and accurate record to the best of my knowledge at the time of completion. I understand that if I knowingly provide false information this may result in disciplinary action and I may be liable for prosecution and civil recovery proceedings. I consent to the disclosure of information from this form to and by the NHS body and the NHS Protect for the purpose of verification of this claim and the investigation, prevention, detection and prosecution of fraud.

Name Position Please state the nature of the interest: (if no interest please insert “no interest”)

Signed Dated

-All signed forms to be returned to the Corporate Services department and stored for audit purposes.

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ITEM 7.2 To: Meeting of Barking and Dagenham Clinical Commissioning Group Governing Body From: Martin Sheldon, Chief Financial Officer Date: 28 January 2014 Subject: CSU contract 2014/15 and beyond Executive summary We have reviewed the service offering from the North East London CSU for 2014/15. The new service model has a smaller core offering with the option of purchasing additional services if required. This suits our approach, as there are elements of the services we wish to consider alternative models of delivery. The leads for each service offer have commenced the negotiation of the changes required to the services and the development of the KPIs. There are copies of the latest proposed service descriptions attached. We have insisted our model of operation i.e.three independent CCGs working separately but sharing key functions is written into the contract. The cost of the service has improved overall with greater clarity of individual service lines. The core service cost currently is £2.2m with additional services costing £0.5m. The total cost is £2.7m. This compares with a 2013/14 cost of £2.708m. We are still negotiating on price as the current cost is higher than we want to pay. Also certain additional services may either cease or be brought in house, which will reduce the overall cost. We are reviewing each service line to ensure that the offer is comparable between years and there is no reduction of service. We anticipate completion of the negotiation by the end of February 2014 and subject to adequate pricing and quality standards will continue with the CSU service for 2014/15. At this stage we will keep our options open for 2015/16 and beyond. We will propose a way forward once we have completed the negotiation for 2014/15. Recommendations The governing body are asked to: • Note the progress on the negotiation and intention to continue with the CSU core service offer for

2014/15 and elements of the additional services. • Agree the action for the CFO to continue to negotiate especially on price and composition. • Receive a final report in March 2014.

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1.0 Purpose of the Report 1.1 The purpose of the report is to provide an update on the progress of the current negotiations

with the CSU for corporate services in 2014/15.

2.0 Background 2.1 The CCG was required as part of its set up in 2013/14 to contract for corporate services from

NELCSU. We are now able to negotiate for services which more closely reflect our requirements and to negotiate on price.

2.2 We have taken this opportunity to require that services being delivered more closely reflect our needs, whilst also intending to improve the value for money of the contract. Our approach has been with the intention to contract from a further if the changes we require are forthcoming and the pricing is appropriate.

2.3 We will only form an opinion on our approach to 2015/16 and beyond once we have completed

the negotiation for the coming year.

3.0 Report Content 3.1 The negotiation has progressed during November and December 2013, even though it has

been challenging for service leads to review their individual service lines. This has progressed but is not yet complete. We are especially keen to ensure this is completed and the individual KPIs for each service line are identified.

3.2 The offer from the CSU has changed following feedback from the CCG in two key ways.

3.3 Not all services are now amalgamated in a core offer. The services have been split between core and additional services. This is particularly helpful as we may not require all additional services in future.

3.4 The offer is also divided into a number of individual service lines with individual prices. This will

allow us to consider the value of each service line and potentially consider procurement in future by service line.

3.5 The financial negotiation continues with the CSU. The population of Barking & Dagenham has

posed problems. The impact of individualising the service lines based on activity measured during the summer may have disproportionally impacted on the split between CCGs.

3.6 We are continuing to negotiate as we feel there are additional cost savings to be made.

3.7 We have insisted our operating model of three independent CCGs working together is

embedded into our contract with the CSU. The CSU have agreed to this and it will be incorporated as part of our signed contract.

4.0 Resources/investment 4.1 There will be a cost of £2.7m subject to further negotiation.

4.2 There may be resource implications of service changes where we decide to bring services in

house. We will include all details of these implications in the final report for the March Governing Body.

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6.0 Risk 6.1 There is a low immediate risk of not reaching a conclusion, as we intend to continue to negotiate

both on price and service; we are broadly happy with the progress made so far.

6.2 There is a potential risk if we bring services in house with regard to managing the transition from the CSU to the CCG. This will be managed by using appropriate project management and if appropriate will be subject to a separate Governing Body Report.

Attachments: 1. Latest Service Specification 2. Latest Pricing Schedule

Author: Martin Sheldon Date: 20 January 2014

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Revised pricing Appendix 2

Core bundleBarking & Dagenham

Total core £2,215,098Reporting and BI £752,496Contracts & Quality Management £859,713Corporate £23,447Finance £372,260Support for commissioning, QIPP planning and service redesign £207,181

Additional services

BundleBarking & Dagenham

1 CCG IT £02 Comms £114,8373 Continuing Healthcare Commissioning Support £270,8274 HR £36,9075 IFR Process Management £51,2656 Information Governance £07 Medicines Management (Primary and Secondary Care) £08 Supporting CCG Public Sector Equality Duties £09 Surge management and seasonal planning £19,109

10Total £492,945

Core + additional £2,708,043

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ITEM 7.3

To: Meeting of Barking and Dagenham Clinical Commissioning Group Governing Body From: Sue Assar, Interim director of corporate services Date: 28 January 2014 Subject: OD Plan progress report

Executive summary

As part of the authorisation process the CCGs were required to produce an outline Organisational development plan. In doing this BHR CCGs gave a commitment to review the plans in 2013/2014 with a view to producing a more comprehensive plan for each of the organisations. The purpose of this paper is to provide the governing bodies with a progress report and to set out the timescale for the production of the plans.

Recommendation

The governing body is asked to note the progress made and the timescale for the production of a comprehensive OD plan.

Progress since authorisation

1. Corporate and personal objective setting

There has been a clear focus on defining the framework for organisational development through the setting of corporate objectives and then aligning these with personal objectives for all governing body members. Personal objectives have also been cascaded down through the corporate and borough teams to ensure that individuals are clear about their contribution to achieving the organisations goals and that there is a structure for performance management. The process for setting objectives at director level took longer than originally anticipated, with final sign off taking place in December and in the light of this objective setting for 2014/15 will start in February as Operating Plans are agreed. The process and timeline for delivery has been drafted.

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2. Senior management and governing bodies away days

Two events have taken place. In September the management teams spent time with senior colleagues from the CSU reviewing objectives and what organisational development was required to meet those objectives and achieve future potential. The teams also looked at working relationships between the CCGs and the CSU and what could be done to make best use of skills and capacity to deliver objectives. A number of practical actions were agreed and are being taken forward by the JMT and the CSU.

One of the actions from the September away day was to arrange an event for governing bodies on 5 December. The theme for the day was ‘Becoming higher performing CCGs – better for patients’.

During the day participants explored

• How the CCGs can accelerate the development and improvement of primary care services and how to utilise the CCGs’ governance arrangements to support this

• How the CCGs need to be working as high performing commissioning bodies and to identify what development work needs to be put in place to get there

• What behaviours should be expected of all staff and clinical leaders to deliver high performance commissioning

Outcomes from the day included a commitment to developing a behaviours and values charter for the CCGs, agreement that further work would be undertaken to engage with and influence member practices and that new approaches to patient and public engagement would be developed locally to support more effective communication. It was also agreed that the CCGs would take forward innovation across primary care to make the best use of resources as a priority, putting in place a structure and process to do this taking account of best practice in terms of governance . Feedback from the day was positive and supportive of taking the outcomes forward

Further away days for the governing bodies have been built into the corporate calendar for 2014/15.

3. Communications

During 2013/2014 a weekly staff newsletter has been produced which goes out each Wednesday. From September this has included ‘Ask Conor’ a direct link which all staff can use to ask questions of the Accountable Officer and receive a response. There have also been regular staff briefing sessions led by Conor, although borough teams are now much more involved and have begun to use the sessions to share good practice and innovation across teams.

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The first staff online survey was undertaken in October. The survey was circulated to all employees across the CCGs and achieved a 50% response rate. A further survey is to be undertaken in February which will build on the questions used in October and will. include all governing body members. The Organisational Development Group will review the proposed questions at its next meeting prior to the survey being issued. The results of the February survey will be compared with the first survey (where applicable) and communicated to all staff.

4. Organisational Development Group.

An organisational development group, Chaired by Sue Assar, has been established and held its first meeting on 7 January. Membership of the group has been drawn from both the borough and corporate teams and there is representative mix of skills and experience. Initial terms of reference have been agreed and these are attached as Appendix A to this report

The priorities for the group are

• A skills audit across teams and training needs analysis to be matched against the organisations current and future requirements

• Developing the values and behaviours charter for wider discussion (the group wants to build on the work started at the December away day and will invite participant from the GBs away day to join their discussions on the charter)

• Utilisation of additional resources available for training • Agreeing and overseeing the non-mandatory training programme • Development of a formal personal development programme.

The work of the group will be fed back to the JMT on a regular basis for review and alignment of borough versus pan CCG resources and requirements.

5. Next steps

As detailed in the terms of reference for the OD group, the timescale for their work is as follows:

• Skills assessment completed end of February • Training programme drawn up - March • Values and behaviours charter development for wider discussion - March • OD plan for each CCG produced in draft - July for GB approval September 2014.

6. Recommendation

The governing body is asked to note the progress made and the timescale for the production of a comprehensive OD plan.

Sue Assar

Interim Director of Corporate Services

January 2014

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Organisational Development Terms of Reference

Meeting Organisational Development Group Purpose

To support the development of OD Plans together with a set of values and behaviours for the BHR CCGs which will enable them to deliver their stated objectives for 2013/14 and 14/15, taking account of the strategic direction of the organisations as stated in their CSPs and the outcome of the skills assessment exercise and identified training needs.

Role 1. To agree a framework for a skills assessment exercise across the

three CCGs. 2. To oversee the exercise and to feedback the results to JMT and

Executive Committees 3. To use the outcome of the skills assessment to indentify collective

and individual training priorities and to develop a programme to meet those needs

4. To ensure that opportunities exist for self improvement and development of all staff

5. Building on work already undertaken by the Governing Bodies develop a set of values and behaviours for each of the CCGs which will underpin the OD plans for each of the organisations and to ensure that these are tested widely before being presented to GBs for final sign off in March

6. To contribute to the design and development of the OD plan for each of the three CCGs

7. Link with the CSU to provide a review/advise re OD initiatives as necessary

8. To produce regular updates for JMT and other committees as required

Membership

Members:

• Interim Director of Corporate Services (chair) • Deputy Director of Corporate Services • Senior representative from each of the Borough teams • Finance representative • Medicines Management representative • Innovation team representative

External support will be provided by Sarah Harvey Loop2

Frequency of meetings

Meetings shall be held every 3 weeks during the initial phase of the group’s work

Timescales

• Skills assessment completed end of February • Training programme drawn up - March • Values and behaviours charter development for wider

discussion - March

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• OD plan for each CCG produced in draft - July for GB approval September 2014.

Updated following discussion at OD Group 7/01/2014

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ITEM 7.4 To: Meeting of Barking and Dagenham Clinical Commissioning Group Governing Body From: Sue Assar, Interim director of corporate services Date: 28 January 2014 Subject: Election of clinical directors

Executive summary As Governing Body members are aware the “urgent action” procedure was used on 7 January to agree the arrangements for the election of clinical directors and to agree the makeup of the assessment panel. The election process is now underway and the purpose of this paper is to formally note the timetable and process and to ratify the decision about the makeup of the assessment panel.

Recommendations The Governing Body is asked

• To ratify the decision of the urgent action group regarding the makeup of the assessment panel

• To note the timetable for the appointment process

• To resolve to call a members meeting on or soon after 7 March to formally appoint the clinical directors.

1.0 Introduction

1.1 As Governing Body members are aware the “urgent action” procedure was used on 7 January to agree the arrangements for the election of clinical directors and to agree the makeup of the assessment panel. The election process is now underway and the purpose of this paper is to formally note the timetable and process and to ratify the decision about the makeup of the assessment panel.

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2.0 The Urgent Action Group

2.1 The Urgent Action Group procedure was used as decisions needed to be taken before the Governing Body meeting on 28 January in order to progress the election and to ensure that there was sufficient time for a robust nomination and voting process. The meeting on 7th January was chaired by Kash Pandya, lay member governance and Martin Sheldon, Jacqui Himbury, Dr Burack and Dr Mohan were present. The minutes of the group will be presented to the next meeting of the Audit and Governance meeting on 11 February for a review of the reasonableness of the decision to take urgent action.

3.0 The appointment process

3.1 The Electoral Reform Service has been commissioned to undertake the administration of the ballot and the returning officer arrangements for the election. Letters have now been issued to all eligible GPs i.e. partners and employees of all members who have been working for or with a member for a minimum period of twelve months, seeking expressions of interest.

Appointments will be made on merit and to support this all candidates who submit an expression of interest supported by two nominations will be formally assessed by a panel against a list of essential and desirable skills, competencies and attributes drawn from the generic job description.

The assessment panel must not include any person who is employed by the CCG or a member of the Governing Body. The urgent action group considered the proposed make up of the panel and agreed that it should be made up as follows:

• A CCG Chair from another local CCG • A lay member from another local CCG • A director with board level responsibility for strategy/ business planning

from another CCG or Local Authority

A senior HR advisor will be available to support the panel.

The panel will assess each application and conduct a short interview. This will include existing clinical directors applying for re-election. Those candidates considered suitable will then go forward for election. There will be one vote per position for each GP who is eligible to vote. A GP is eligible to vote if he/she is on the NHS performers list and works for a minimum of four sessions a week for a member practice. If there is only one recommended nominee per position GPs will be asked to vote by simple majority to approve the recommendation. If there is more recommended nominees than positions the vote will be on the basis of those with the largest number of votes will be

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appointed. In the instance of a tie there will be a re-count. If there is still a tie after the re-count normal electoral practice will be followed and lots will be drawn.

Once the clinical directors are appointed nominations will be sought for the Chair, A secret ballot amongst the Clinical Directors will be conducted to appoint the Chair

4. Timetable

4.1 The time table for the election is as follows:

Nominations sought from 20 January to midnight 7 February

10 –14 February nominations assessed by the panel

Nominations considered suitable will then go forward for a vote. This will run from 19 February, closing midnight on 5 March

The results will be available from 7 March. A Members Committee will be required on or soon after that date to formally appoint the Clinical Directors. The Governing Body needs to resolve to do this, giving three weeks’ notice. This meeting will also be used to formally agree any amendments to the constitution

April New and re-appointed CDs and Chair take up post

5. Recommendation

5.1 The Governing Body is asked

• To ratify the decision of the urgent action group regarding the makeup of the assessment panel

• To note the timetable for the appointment process

• To resolve to call a members meeting on or soon after 7 March to formally appoint the clinical directors.

Sue Assar

Interim Director of Corporate Services

January 2014

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Title: Barking and Dagenham Executive Committee Date: 22 October 2013 Time: 1:30 – 4:00pm Venue: Barking Community Hospital, Rooms 1& 2

Present: Dr Waseem Mohi Chair Dr Raj Kumar Clinical Vice Chair Dr Arun Sharma Clinical Director Dr Gurkirit Kalkat Clinical Director Dr Rami Hara Clinical Director Dr Jagan John Clinical Director Dr Chandra Mohan Clinical Director Sharon Morrow Chief Operating Officer Martin Sheldon Chief Finance Officer, BHR CCG’s Conor Burke Accountable officer, BHR CCG’s Attendance: Mabel Sanni Executive Assistant Apologies: Dr Richard Burack Clinical Director Jacqui Himbury Nurse Director Item Action 1.0 Welcome and apologies Apologies had been received from Dr Burack and Jacqui Himbury. 1.1 Declarations of conflicts of interests WM reminded the Executive of the need to update the conflict of interest

forms and send to the Governing body committee officers. Action: MSa to resend the new forms to all CD’s for completion.

MSa

1.2 Minutes from - 27 August 2013 The minutes of the meeting on 27 August 2013, were agreed as an accurate

record.

1.3 Matters/Actions arising Weight management programme – SM advised that practices were yet to

receive information about the weight management programme. This action had been escalated to Matthew Cole to progress.

LETB development funding SM briefed the Executive on the workforce development projects that had

been approved by the LETB for both BD specific projects and collaboration with BHR CCGs. The Executive was asked to agree the management approach to the delivery of the training programmes as outlined in the paper. SM confirmed that the programmes would be for non-statutory training

Item 1.2

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programmes and that JH had committed to supporting the commissioning of nurse training across all 3 CCG’s. The Executive noted the need for a robust programme which should be mapped to the CCG’s overall training needs, and sought assurance that there was a robust system in place for forward planning, evaluating and monitoring progress against plan. It was agreed that the Primary Care Improvement Group would lead on the commissioning of non medical training and that there should be cohesion with current Education Steering Groups’ training programme. Action: MS/SM to review guidelines clarifying the rules on the use of the LETB monies. JJ noted need for further scrutiny of the EoL bid; as there were some caveats with regards to the use of the monies. SM noted that the proposal was for the EoL training to be overseen by the EoL steering group with the exception of BD’s which is planned to be delivered through the Integrated Care Steering Group. Action: Carla Morgan (CM) to be asked to provide a briefing to the Executive on the EoL bid. The Executive noted the report and requested an update on the implementation plan at the next meeting.

MS/SM CM

Urgent Care SM proposed that the urgent care strategy be brought to the November

Executive Committee; this would allow for further detailed work and broader clinical engagement on the Upney Lane specification at the next informal clinical directors meeting. The expectation is that the strategy would be taken to the January Governing Body meeting for sign off. The Executive noted the report.

Influenza programme SM reported that funds had been secured from Public health to give an

additional resource to support practices in winter planning over the next few months; the Primary Care Improvement (PCI) Group is developing a detailed action plan which would be shared with practices at the November PTI. SM advised that two training sessions had taken place on the 1st and 15th of October. The Executive noted the report and approved the recommendations as outlined in the paper.

2.0 Risk Assurance 2.1 Risk report SM presented the risk report and noted that there were two new risks

reported this month. The Executive noted the risks to the delivery of the outpatient demand management and integrated case management QIPP. However, it was noted that had been some improvement in the ICM QIPP, and it was beginning to reflect a reduction in emergency admissions related to ICM. SM advised that the biggest risk was with the outpatient demand management, where no savings were being projected to date.

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The Executive discussed mechanisms for capturing risks at practice level which should feed into the locality risk register and to the locality meetings. The Executive also considered the following in relation to the locality meetings:

Breadth of the agenda of the locality meetings; may not deliver the expected outcomes if agenda is too broad. It considered whether it would be necessary to break the agenda down into more manageable specific areas,

Use the informal clinical directors meetings as fora to prepare the agendas for the locality meetings.

Highlight the key headlines for each locality Whether the duration of the meetings were adequate Mechanisms for engaging with non attending practices Lack of understanding from the practices

JJ highlighted a quick win solution to data capture and risk reporting and highlighted the use of a web based intranet system used at Merton CCG. The Executive welcomed the idea and asked JJ to get further details to see if a similar system could be adopted. Action: JJ to seek further details and liaise with CB to progress further. RH made the observation that practices were likely to be encouraged and motivated further if successes are celebrated more, rather than focusing on what had not been achieved; would be useful to celebrate what has been achieved against plan. The Executive noted the report.

JJ/CB

3.0 Strategy and Planning 3.1 Commissioning Intentions 2014/15 SM presented the Executive with a progress report on the Commissioning

Intentions, highlighting that the high level CI’s had been taken to various groups for engagement. The next step is to hold a further meeting with Clinical Champions and Clinical Directors on the 31st of October 2013 to feedback on progress. SM advised that national planning guidance would be published in December; noting that CCG’s were expected to prepare a 5-year strategy; key headlines to be incorporated had been received. The Executive discussed the need for a 5-year strategy and 2-year operating plan that embodies B&D’s specific plans and ensure that implementation and delivery is owned locally. The Executive agreed that it in order to manage future challenges the strategy must be transformational; the plan must not just focus on cutting things away to achieve targets. The need for a step change in the way we operate in primary care was noted. The Executive considered the danger of losing engagement with member practices due to the slow pace of change and implementation/delivery.

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The Executive discussed clinical engagement in developing the strategy and suggested that a brainstorming session should be arranged, so that there is a collective agreement of the key priorities. It was agreed that a half day away day be convened and suggested that the time planned on the 31st of October could be extended to a half day workshop to gather ideas, all Clinical Directors and Champions should be mandated to attend this event. It is expected that the outcomes of the workshop would also inform the Market day event planned in November with providers. Action: CCG half away day. The Executive noted the report.

SM/MSa

3.2 Hate Crime Strategy SM presented the strategy and asked the Executive to approve the strategy

and action plan. SM sought the Executive’s view on how the CCG would engage with the community safety partnership and its subgroups. The Executive approved the Hate Crime Strategy and delivery plan and supported the requirement for all staff to have equality and diversity training. It was noted that the Chief Operating Officer was the CCG representative on the Community Safety Partnership and that the CCG had a role in supporting the development of partnership strategies. It was agreed that the CCG did not have the capacity to attend all strategy subgroup meetings but would input into strategy development where needed.

4.0 Service Transformation & Development 4.1 Provision of Minor Surgery SM presented the report recommending a process of managing minor

surgery in primacy care when the community minor surgery service ends in November 2013. The Executive supported the proposal to encourage practices to deliver primary care activity at locality level and queried the guidance on transporting liquid nitrogen. Action: SM to circulate guidance on the transportation of liquid nitrogen. The Executive agreed that local arrangements should consider: practitioner accreditation; facilitating practices to work together within a locality; premises and maintenance costs. Consideration would also need to be given as to whether there is a financial case for local provision of a minor surgery DES. The Executive asked to receive a locality implementation plan at its next meeting indicating a skills map; interest and premises; it suggested that the primary care improvement group consider a training session for practice nurses in cryotherapy and cautery from the LETB funds; and asked that the planned care steering group develop a locality proposal for a CCG commissioned community service for complex minor surgery. Action: SM to circulate service specification.

SM SM

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4.2 LES options paper

SM presented the LES options paper and sought the Executive’s view on the recommendations indicated in the report. The Executive agreed to Decommission anti-coagulation LES as practices should now be

undertaking the monitoring as part of the core service.

Deferred decision to decommission the Advanced diabetic care – insulin initiation until an alternative service was commissioned, as Diabetes is one the of the key priority areas for BD. The Executive agreed that the need for the new service and should be linked with the work undertaken through the planned care group. Members also agreed that:

o All practice nurses to be upskilled up to insulin initiation o BD needs to own its local plan with regards to diabetes due to the

prevalence in the borough. Following discussion, AS agreed to work with the GPwSIs and locality leads to shape the development of a new service. Action: AS to take forward with GPwSI and Locality Lead.

Post-operative wound care and suture removal – The Executive

discussed the reasons why BRHUT do not undertake suture removals within the community; if this it was part of the tariff. Action: MS to take forward with BHRUT and clarify what is included the tariff; and explore whether if included, could be clawed back. The Executive asked to receive a business case with procurement options at its November meeting.

Nursing home – The Executive asked to receive a business case at its November meeting with an outline plan and timescales for securing a service from 1st April 2014.

Phlebotomy – The Executive asked to receive a business case at its

November meeting. Hormonal implant – RH advised that a background paper, specification

and costing had been developed in conjunction with Havering CCG. The Executive asked to receive a business case at its November meeting. Action: RH agreed to forward background paper and specification to SM.

AS/SM MS

5.0 Quality and Performance 5.1.1 Finance and Contracting Report M6 MS presented the finance report, noting that BD was ahead of plan at month

6, with all risks built in. He advised that Barts presented the greatest risk and they had been formally asked to justify their figures. Forecast outturn has been changed with NHSE agreement to deliver a 2% surplus this year; and he was confident that the plan could be delivered.

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Medicine management – The forecast had shifted significantly between M4 and 5, which had initially been reported as an error. The medicines management team are investigating this further and MS will report back to the Executive. The Executive asked for further detailed reporting on the running costs spend and should include spend on CSU and in-house spend. Action: MS to bring a report to the next Executive Committee on running costs. The Executive noted the report.

MS

5.1.2 Contracting Report M6 The Executive noted the report. 5.2 QIPP report M5 SM presented the QIPP report at month 5, noting the areas of over

performance as well as improvement in performance against plan. It was noted that localities 4 and 5 were outliers in terms of delivery and proposed that this was discussed in more detail at the next meeting. JJ reported that there were two actions related to ultrasound pathways and cardiology that needed progression and he was unclear of their status of approval. Action: RH/SM to progress via the planned care group. ICM – at M5 a reduction in emergency admissions against the 10 ICDN codes was reported. Overall there has been a reduction in emergency admissions compared to the same period last year. Cardiology - The executive sought further clarity on what were hot clinics in the acute setting. The Executive noted the report.

RH/SM

5.3 Pharmacy cost rectification plant The Executive noted the report 6.0 Development and Governance 6.1 Area Prescribing Committee ToR MS presented the Area Prescribing Committee Terms of Reference. The

Executive noted that the Chair position was expected to be decided upon at the next APC The Committee noted the report and approved the Terms of Reference.

6.2 Clinical Directors Election SM presented a proposed timetable regarding the re-election of clinical

directors.

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The Executive endorsed the timetable and report. 7.0 Items for information Minutes of sub-committees:

The Executive Committee noted the minutes of the JET Integrated care group Urgent care working group

8.0 AOB SM advised that the procurement that direct access diagnostics – MRI,

ultrasound would be going out to tender; contract would be offered for 3 years. The committee confirmed that it did not wish to decommission activity currently being provided by BHRUT Action: SM to share draft specifications for the Executive to have the opportunity to comment.

SM

9.0 Date of next meeting 26 November 2013 Signed: …………………………………………………… Date: …………………………..

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Title: Barking and Dagenham Executive Committee Date: 26 November 2013 Time: 1:30 – 4:00pm Venue: Barking Community Hospital, Rooms 1& 2

Present: Dr Waseem Mohi Chair Dr Raj Kumar Clinical Vice Chair Dr Arun Sharma Clinical Director Dr Gurkirit Kalkat Clinical Director Dr Richard Burack Clinical Director Dr Rami Hara Clinical Director Dr Jagan John Clinical Director Dr Chandra Mohan Clinical Director Sharon Morrow Chief Operating Officer Martin Sheldon Chief Finance Officer, BHR CCG’s Conor Burke Accountable officer, BHR CCG’s Attendance: Mabel Sanni Executive Assistant Diane Jones Deputy Nurse Director, BHR CCG’s

(representing Jacqui Himbury) Apologies: Jacqui Himbury Nurse Director, BHR CCG’s Item Action 1.0 Welcome and apologies Apologies had been received from Jacqui Himbury. 1.1 Declarations of conflicts of interests Nil 1.2 Minutes from 22 October 2013 The minutes of the previous meeting were agreed as an accurate record. 1.3 Matters/Actions arising 1.3b Risk reporting – Data capture JJ reported was awaiting feedback, and agreed to progress and feed

back at the next meeting. Action: JJ JJ

1.3c Provision of minor surgery SM reported that a framework was being developed with cluster 2 to

support the locality provision of the DES minor surgery. Following discussions, the Executive agreed to have a dedicated session at the next informal CD meeting on the 10th of December to progress the development of minor surgery provision.

Item 1.1

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1.3d Direct access diagnostics procurement SM reported that the specifications had been circulated to the clinical

leads and would have been signed off. There had been 17 responses to the PQQ; the ITT is expected to be published by week ending 29th November. The Executive noted the report.

1.3a. EoL care briefing SM reported this would be implemented through the integrated care

teams and that discussions were underway with NELFT with regards to progressing the primary care training. Following confirmation that health analytics would continue to be developed for integrating of end of life registers; the Executive sought assurance that health analytics would integrate with all community systems and asked that Rob Meaker provide a briefing to the Executive, with assurance that RiO adequately interfaces with all systems in both community and primary care. Action: Rob Meaker The Executive discussed the robustness of the governance process regarding approval of training programmes; JJ confirmed that all training programmes would be ratified at the GP Education steering group chaired by TCM. SM reported that the governance arrangements for the EOLC project were through the integrated care steering group. The Executive noted the report.

RM

2.0 Risk Assurance 2.1 Risk report SM presented the risk report noting the new and key risks and asked the

Executive to agree the risks and confirm that the mitigating actions were sufficient to lessen impact to the organisation. Primary care commissioning – the Executive noted this was in relation to some of the transitional issues with NHSE. Members agreed this risk could be downgraded. The Executive discussed the issue of NHSE’s non-reimbursement of rent on LIFT buildings. Following discussion, MS agreed to take forward with NHSE via the assurance meetings. Action: MS. Planned care – the Executive discussed the need for a review of the plans regarding demand management; and agreed that it would be useful to receive a report from NHSE on whether there had been a rise in associated with a reduction in referrals. The Executive noted the need for a mechanism for measuring the quality impact for each QIPP project and agreed that each red rated risk ought to have a quality section, to assure the Executive that quality issues were being addressed. Action: SM The Executive noted that Margaret Hodge had requested a report on

MS SM SM?

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mortality rates by practice at a recent visit; and agreed that a mechanism to report this needed to be developed. The Executive noted the report.

2.2 CHC Assessment and Review Service Diane Jones (DJ) presented the CHC report noting that the paper related

to older people and children and did not include learning disability. CB highlighted that a change in the way that services were commissioned was required to support the implementation of a national requirement to offer all CHC clients a personal health budget from April 2014. This proposal also aligned to the Year of care project that B&D had been piloting. Giving notice on the assessment service was the first step in the process of creating a new and different model. From April, the CCG will be responsible for the assessment, review and budget of those clients and manage the commissioning of those services. The Executive asked for a plan to getting the recommendations in place at the December Executive and for the plans to be signed off at the January Governing Body meeting. Action: DJ/JH The Executive confirmed support for the recommendations and endorsed the report.

DJ/JH

3.0 Strategy and Planning 3.1 CSP Update (incl ITF) SM presented the report highlighting the recent requirement to develop a

5 year strategic plan across a strategic planning unit, which locally is being defined through the existing partnership arrangement of the Integrated Care Coalition. The Executive expressed some reservations that a collaborative plan may focus on wider strategic issues and not more local issues. The Executive noted that local health and wellbeing boards would also need to have some input into the plans; and acknowledged the differences between how each board within the health economy operates. SM assured the Executive that the 2-year operating plan, was a more detailed plan which the HWWB’s would also need to have oversight on and would reflect local priorities. SM confirmed that an ITF plan would be submitted for each CCG and LA within BHR economy; the Executive agreed to review the proposed arrangements for next year in further detail at the next informal CD meeting and to receive a report at the December Executive. Action: SM The Executive noted the report.

SM

3.2 Urgent care strategy RB presented the strategy highlighting that this was a three year plan

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with a focus on care closer to home; the need for a re-specification of the remaining WiC at Upney Lane was noted. The Executive were reminded of the urgent care working group meeting scheduled on the 4th of December was an open engagement for CCG members to engage in the development if the WiC specification. . SM reported that contact negotiations were commencing with NELFT; the Executive noted that the draft specification would be the basis for the Upney Lane contract negotiations for 14/15. SM reported that a recent Monitor report on WiC centres had expressed concerns about the impact of the planned closures of WIC across the country on patients. Following discussion, the Executive asked for a briefing on the Monitor report at the December Executive, so that the report could be formally considered. Action: SM The need to align the strategy and developments for 15/16 was noted. The Executive discussed the future of urgent care provision, noting the need for the strategy to also identify how outcomes would be measured and have a description of patient engagement; patient story. The Executive noted that the CCG would need to take a position on what was reasonable capacity for urgent care and the need for efficiencies within the system. CB reported that the BHR CCGs were considering the option of a prime provider contract for the provision of urgent care services and further consideration could be given to primary care urgent care services. The Executive also considered the need to connect the locality practice’s response into the wider system wide response, and the need for clarity around patient flows was also noted. The Executive approved the strategy and recommended that clear metrics were developed to measure improvement. The committee agreed commissioning intentions for the walk in centre service at Barking Hospital. Action: RB/SM to identify a day to develop the strategy further.

SM RB/SM

3.2c Primary care surge scheme update SM presented an update on month 1 position; overall there were 2231

appointments offered in October, with 83% utilisation. The Executive considered the options available for utilising the remainder of the commissioned capacity during the course of the pilot. The Executive endorsed the recommendation of a combination of options C and D, and to open up surge to practices that weren’t in Wave 1from January 2014. The Executive confirmed that provision needed to be in addition to baseline activity in order for surge payments to be made. Action: Implement option C now, detailed plan on D to be provided to the

SM

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December Executive.

4.0 Service Transformation & Development 4.1 ECG interpretation services proposal GK presented a proposal to commission an ECG interpretation service. It

was noted that the CCG was re-procuring a direct access diagnostics service for cardiology and activity levels would need to be reviewed to consider the impact of this service. The Executive supported the proposal and asked for an update on implementation at the next meeting.

SM

4.2 Ophthalmology business case SM presented a paper proposing the development of a glaucoma referral

refinement and triage service. It was noted that the community eye service provide elements of this service and it was agreed that as a first step, the CCG would undertake a service review led by cluster 1 and GK. SM to provide detailed list of ophthalmology contracts for review. Action: SM/GK

SM/GK

4.3 Locally commissioned out of hospital services SM sought approval for the paper to be deferred to the December

Executive, as it required some further work. . SM confirmed that a BHR diabetes working group had been set up as a sub-group of the planned care steering group, to take forward a diabetes improvement project. Action: SM to facilitate a meeting with AS and the GPwSIs.

SM

5.0 Quality and Performance 5.1a Finance Report MS presented the finance report, highlighting the aim to bring

performance back in line before the end of the year. MS confirmed that the CCG was forecasting to deliver a 2% surplus and it was agreed with NHSE that that this would be returned in 14/15, which would enhance the position for next year. It was noted that there was a need for continued focus on the Barts position. Maternity pathway – 60% of cases have been coded as complex, and a deep dive review of activity Is being conducted by the CSU. The CCG is negotiating with BHRUT on the Q1 and Q2 closedown position and has made a reasonable offer.

MS

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BHRUT had raised with CCGs a funding issue that had emerged for cardiac rehabilitation services as the service had been funded from revascularisation monies which were no longer available. This presents a cost pressure of around £57K for B&D. MS was asked to confirm whether this is part of the CCG budget. Action MS investigate and report back The Executive noted the report.

5.1.b Contracting Report The Executive noted the report. 5.2 B&D CCG running costs report The Executive noted the report, agreed that the nursing directorate was a

necessary cost and requested for a report on spend on a quarterly basis. Action: MS

MS

5.3 QIPP report SM presented the QIPP report and asked the Executive to agree the

recommendations as outlined in the report. The Executive discussed the QIPP workshops planned for the 4th and 6th of December, and agreed that the majority of CD’s would be available on the 4th. Members agreed that the 6th was not a convenient day and asked that the workshop planned for the 6th be rescheduled for another day to allow for maximum CD attendance. Action: MSa to advise the CSU. SM reported that a mapping exercise had been scheduled on the 27th of November with the Finance team to review month 7 position in more detail and to begin budget planning discussions for 14/15. The Executive were yet to receive the pathways and asked that this actioned. Action: RH

Cardiology Ultrasound – awaiting consultant endorsement: SM to progress.

The Executive agreed the need to have a dedicated PTI on diagnostics. Action: TCM/RH to progress. The Executive noted the report.

MSa RH TCM/RH

5.4 Quality of care and patient safety report Diane Jones presented this report, highlighting that there continues to be

a strong and dedicated focus on improving quality. She highlighted the improved collaboration with the council regarding nursing home visits. The Executive discussed the need for improved communication between practices and nursing homes.

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A practice nurse trainer had been appointed working 2 days per month; this resource is available to all 3 CCGs’. The Executive noted the need for regular training for practices nurses and discussed funding; DJ confirmed that funding for practice nurse training was included in the global sum. The Executive noted that practices were unable to advertise jobs on the NHS jobs website without CCG support or endorsement; SM agreed to look into this. Action: SM Looked after children – The Executive discussed the need for a designated nurse for LAC; DJ advised that there was a proposal for one of the designated safeguarding nurses to take on the additional LAC responsibilities and the deliver the function across the 3 CCG’s. The Executive agreed that this was a strategic role and confirmed that it would prefer to have a WTE designated nurse for LAC to cover BHR CCG’s as there was concern that the existing safeguarding nursing posts would not provide the sufficient capacity required to fulfil the statutory functions of the LAC role. Designated doctor for BD – The Executive noted the challenges of appointing substantively to this post. RB to be involved in the discussions with Steve Feast and Jacqui vanRossum. Action: DJ to take forward

SM DJ

6.0 Development and Governance 6.1 LETB implementation plan The Executive noted the report. 6.2 Business Continuity Plans SM presented the report and asked the Executive to approve the policy

and plans as outlined in the report. The Executive endorsed the business continuity plans.

6.3 Board development day The Executive noted the report. 7.0 Items for information The Executive Committee noted the minutes of the:

Primary care improvement group Integrated Care Group UCLP urgent care report Communication & Engagement plans for intermediate care Urgent Care Working Group JET

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8.0 AOB GpwSi – JJ directors funding. Action: SM to progress 9.0 Date of next meeting 17 December 2013 Signed: …………………………………………………… Date: …………………………..

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Title: Barking and Dagenham Executive Committee Date: 17th December 2013 Time: 1:30 – 4:00pm Venue: Barking Community Hospital, Rooms 1& 2

Present: Dr Arun Sharma Clinical Director (Chair) Dr Rami Hara Clinical Director Dr Chandra Mohan Clinical Director Sharon Morrow Chief Operating Officer Martin Sheldon Chief Finance Officer, BHR CCG’s Attendance: Mary Pirie Locality Admin Support Rob Meaker Director of Innovation, BHR CCGs Diane Jones Deputy Nurse Director, BHR CCGs (Representing Jacqui Himbury) Apologies: Dr Waseem Mohi; Dr Raj Kumar; Dr Gurkirit Kalkat; Dr Richard Burack; Dr Jagan John Conor Burke; Jacqui Himbury Item Action 1.0 Welcome and apologies The chair welcomed the group and apologies were noted.

Declarations of conflicts of interests Dr A Sharma declared a new conflict of interest, that he has been

nominated through the PELC Council elections.

1.1 Minutes from 26th November 2013 The group agreed the minutes from the previous meeting.

1.2 Matters/Actions arising Please see attached.

2.0 Risk Assurance 2.1 Risk Register SM informed the group that there were no new risks that had been added

to the risk register since the previous meeting. Clinical Directors were invited to feedback risks that had been raised at locality meetings. Dr Hara informed the group that an issue had been identified in Cluster six, where a GP practice was not engaging in the development of an improvement plan and he was not clear what the process was for managing this issue. The group agreed that there risk to the CCG in not having a clear mechanism for investigating and dealing with practice performance issues. Actions

Add this new risk to the risk register Look at examples of what other CCGs are doing to manage this

process

SM

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3.0 Strategy and Planning 3.1 Strategic Plan Update SM provided an update on the strategic and operational planning

requirements for 2014/15, and summarised the key areas of progress. SM informed that the final guidance is due for the Integrated Transformation Fund (ITF) on 18th December, and that the ITF plan for 2015/16 will be dependent on an agreement of a local two year plan by the Health and Wellbeing Board in February 2014. The plan will need to align with the national criteria which are yet to be announced. The group agreed that this should be an item for the next meeting. SM provided the group with the draft BHR Strategic Headline Plan on a Page and explained that NHS England has requested that BHR CCGs submit a draft strategic plan by the 18th December. The plan includes a locally agreed system objectives and key delivery mechanisms, which have been drafted from discussion through the BHR Integrated Care Steering Group/ Strategic Planning Group with input from NHS England. The plan will be presented to the Integrated Care Coalition on the 10th January and will be presented to the CCG Governing Body for approval before final submission which will be in June 2014. The Clinical Directors felt that the BHR Strategic plan on a page is not borough focused. The CCG already has plan on a page which should be used to extract the detail for the BHR plan on a page. Actions

The group agreed that views of the Clinical Directors in regards to the BHR Plan on a page would be fed back to NHS England.

MS

4.0 Service Transformation & Development 4.1 Nursing Home Business Case SM informed the group that following the decision at the last meeting to

continue to commission primary care enhanced support to nursing homes, the CCG team is in the process of developing the business case for investment in primary care. This will consist of GP practices providing weekly visits to nursing homes to avoid admissions into hospital and CTT & McMillan Nurses attending homes. MS updated that Havering are using a Red/Blue light system which is working well and this could be used for B&D. The group agreed that a report from Havering on the system to be reviewed at the next meeting. Actions

The group agreed that the business case should include nursing home calls and how the CCG are going to measure the impact on services going into nursing homes

The group agreed that a report from Havering on the Red/Blue light system to be reviewed at the next meeting

SM SM

4.2 Designated LAC Nurse DJ provided a paper and sought approval for a proposal to establish a

Designated Nurse for Looked after Children (LAC) Nurse, informing the

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committee that this role will span three CCG boroughs. The committee had previously raised questions of capacity by upgrading an existing post. DJ explained that some functions of the CCG designated nurse had been removed following the transition from PCT to CCG and that the CCG would be buying in additional support to support serious case reviews. The proposal would formalise an existing arrangement and provide some acknowledgement of the grading of the post, ensuring consistency with other boroughs. Having received these assurances, the committee approved the proposal. Dr Mohan expressed concerns that GPs have not received level three safeguarding training. DJ advised that CCGs are only responsible for level one & two training which is done online. Level three training is the responsibility and funded by NHS England, once NHS England have release the funding then the GP practices can buy into Level three training. AS asked for clarity on how the strategic lead for safeguarding had an impact on operational delivery and suggested that there needed to be some accountability for the wider agenda.

4.3 Section 75 Learning Disabilities SM updated the committee on the joint project with LBBD to develop a

joint commissioning strategy for people with LD and challenging behaviour and a section 75 for learning disability services. It is agreed that LBBD will be the lead commissioner for the section 75 services. SM reported that there is some work to be done to develop the governance arrangements and management of financial risk. A workshop his being arranged for January to work through some of these issues. Rob Adcock is the CCG finance lead. It is expected that the section 75 will be signed off at the March Governing Body meeting and Health and Wellbeing Board. The group acknowledged the report and will await an update.

4.4 WIC Review: Preliminary Report by Monitor Dr Sharma reported that the Urgent Care group had reviewed the

preliminary report published by Monitor on Walk in centres and had produced a briefing for the Executive Committee. The group had considered the implications for B&D CCG following their decision to close the Broad Street Walk in Centre. It was considered that the CCG has considered all the factors identified by Monitor in the preliminary review in the decision-making process for the walk in centre at Broad Street. A further review of the final Monitor report when available in January 2014 will be conducted by the Urgent Care Working Group and any additional findings will be reported to the Executive Committee. Committee noted the report and requested that the in-house solicitor

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provide a briefing for the informal CD meeting on the implications of the report.

SM

4.5 Proposal for locality provision of surge appointments SM provided an update on the primary care surge scheme pilot,

informing the group that the second wave application deadline was the 17th December 2013 at 5pm. SM reported that five of the nine outstanding practices have submitted their applications and they hope to start in mid January 2014 . The group agreed that a discussion needs to happen with the four remaining practices, to find out if they would support their patients being seen at different GP surgeries within their locality. Actions

The group agreed that the November performance data report can be shared at the informal meeting to discuss how practices can be supported to manage additional surge capacity.

SM

4.6 Information Sharing Pilot RM provided an update of the Data sharing report and sought approval

for option B from the group, informing them that Vision is a better long term option than MIG. The group agreed and gave approval but noted that there needs to be an agreement with the practices on what patient data can be shared. It was agreed that all practices should be upgraded to Vision 360 and that a pilot should be put in place for one of the localities, to see what issues would occur before rolling the project out to the other five localities. Following the upgrade, practices should be able to participate in borough/ locality pilots when they are ready to do so.

4.7 Primary Care development MS provided an update on the Primary Care Development proposal and

detailed the next steps and proposed the actions to be completed by the end of January:

Undertake workshop to develop Primary Care Commissioning Agree 2014/15 Primary Care Commissioning priorities Recruit Programme director Establish external development advisor panel Research best practice models and initiate provider discussions in

individual CCGs Develop a combined Primary Care Improvement Plan

MS reported that he will be meeting with NHS England later this week as NHS England may fund and take a lead on the project. MS will update the group by email once the meeting with NHS England has taken place.

MS

5.0 Quality & Performance 5.1 Finance and Contracting report MS tabled the finance report for month 8, informing that the CCG has

achieved a surplus of £3.18m, a £1.59m higher surplus compared to the

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planned year to date surplus of £1.59m. Also it is estimated at year end the CCG will achieve a 2% surplus, of £4.77m. However, activity in October had been higher than planned. MS reported that a meeting was taking place this week with NHSE to agree the reconciliation for specialist commissioning. The group noted that the report was not ready to circulate in advance as the meeting had been brought forward one week due to Christmas. The report was noted therefore with a more detailed review to take place at the next meeting.

5.2 Quality and Safety Report Members were referred to item 4.2. It was noted that there was not a

separate quality report for this meeting.

5.3 0844 numbers update SM updated the group that nine practices in B&D still operate 0844

numbers. This is of concern to patients and Healthwatch have asked how the CCG is addressing this issue. The committee noted that NHS England has the contractual levers to address these concerns and that practices are switching when contracts come to and end. The committee acknowledged patient concerns and agreed that it would be helpful for the CCG to issue a position statement on the use of premium rate numbers and encourage member practices to withdraw from them. It was agreed that Dr Mohi will respond to Healthwatch on behalf of the CCG.

SM

6.0 AOB Dr Hara updated the committee on an anticoagulation project meeting

that he had attended and raised some issues about decision making. The group agreed that there needs to be more clarification on the decision process for procurement. SM will review with James Gregory and Dr Hara outside of the meeting.

SM

6.1 Proposal to change the date of the February Executive to the 18th February 2014

The group was informed that it has been requested that the February Executive meeting be moved to the 18th February due to the Finance and Committee meeting taking place on the 25th February 2014. SM outlined the risk that the QIPP activity and finance reporting will not be available for circulation before the meeting. The group agreed that the meeting date can be changed to the 18th February 2014 and for Mary Pirie to update the calendar invite and update attendees.

MP

9.0 Date of next meeting 18th February 2014

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Signed: …………………………………………………… Date: …………………………..

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Messages from the Audit & Governance Committee

The key messages for the Governing Body from the Audit Committee meeting held on 12 November 2013 were;

• The Committee welcomed the achievement of Level 2 of the information governance toolkit and the likelihood that the CCGs would now be able to gain access to patient data to verify provider claims. The Committee requested that the information governance e-learning tool be extended to governing body members to ensure that they were also aware of these issues.

• Progress in resolving legacy balances, invoice backlogs and care home assessments issues was noted. The Committee remain concerned about these issues and asked to be kept apprised on progress in agreeing reliable opening balances for the CCGs. The audit chairs for the 12 CCGs in NE and NC London have written to the NHSE audit chair to record their concern about the NHSE's recent unauthorised access to our accounting ledgers. A reply is awaited.

• The Committee have asked for details of the final accounts closedown plans for 2013/14 to ensure that we are on track for meeting required statutory targets and deadlines.

• The external audit plans and fees for the CCGs for 2013/14 were approved. • Internal audit recommendations on the BAF were agreed and the Finance &

Delivery Committees and Quality & Safety Committee requested to implement them as the owners of the BAFs.

• The CSU met the Audit Committee in a private session to discuss the progress being made to deliver contractual commitments and the remedial action being taken to deal with emerging issues.

Kash Pandya

Chair, BHR CCGs Audit & Governance Committee

Item

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1 Draft BHR Audit Mins 3 Sept 2013 v2

Draft Minutes of the joint Barking & Dagenham, Havering and Redbridge CCG’s

Audit & Governance Committee held on 12 November 2013 at Becketts House

Present -Members Kash Pandya (KP) BHR Audit Chair, Lay Member for Audit & Governance Khalil Ali (KA) Lay Member PPI Redbridge CCG Charles Beaumont (CB) BHR Co-opted Member for Audit & Governance Richard Coleman (RC) Lay Member Havering CCG Tan Vandal (TV) Secondary Care Consultant Sahdia Warraich (SW) Lay Member PPI Barking & Dagenham Ah Fee Chan (AFC) Secondary Care Consultant In attendance-Officers Rob Adcock (RA) Deputy CFO Sue Assar (SA) Interim Director of Corporate Services Rob Meaker (RM) Rob Meaker, Director of Innovation Martin Sheldon (MS) Chief Financial Officer Angela Ward (AW) BHR Company Secretary In attendance-auditors Nick Atkinson (NA) Internal Auditor, BakerTilly Lei Wei (LW) External Auditor , PWC Kevin Lowe (KL) External Auditor, PWC Mark Trevallion (MT) LCFS, BakerTilly

Action

9.00-9.15

Committee Members held a private pre-meeting.

9.15-9.30

Committee Members held a private meeting with External Auditors

82/13 Apologies for absence 9.30 The Chair welcomed Members and other attendees and noted there were no

apologies for absence.

83/13 Declaration of Interests Subject to a minor adjustment, the revised Declaration of Interest Register for

Audit and Governance Members was noted.

84/13 Minutes of meeting held on 3 September 2013 The minutes of the previous meeting were subject to one amendment and

then agreed as a correct record to be signed by the Chair.

85/13 Matters Arising The actions taken since the last meeting and reports provided at this meeting

were noted. In noting the progress through committees of the Whistle-blowing and Anti Fraud policies, the Chair felt they were now complete enough to be operational and should be publicised to staff. Also training for the Chair was to be arranged as soon as possible.

SA

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There was a request for page numbering to improve Ipad access to reports and this would be arranged for the next meeting.

AW

86/13 Board Assurance Framework NA had held a useful meeting with the BHR BAF Co-ordinator and given

advice on improving robustness but felt the CCG’s had made good progress. The Co-ordinator was meeting regularly with Directorates to update the sections and gain assurances. There had been one issue with the Redbridge BAF but that had since been resolved and a cover page would be provided to aid Member assurance. SA added that the IA had been helpful as best practice was gained and the BAF reports to the January Governing Bodies would respond to changes suggested. KA questioned how the CCG could take lessons learnt forward following the identification and mitigation of risk. NA added that complaints and incidents and RCA would be picked up at other committees eg. Quality & Safety and Finance & Delivery and often identified BAF risks did not materialise. It was confirmed that Pam Dobson was the owner/manager of the risk process but individual Directors were responsible for identification and mitigating action. TV added that SIs/Never Events came through from the CQRMs and assurance was sought at Quality & Safety that systems and processes were in place and action being taken by the Providers to rectify. The Chair added the Audit & Governance Committee were tasked with seeking assurance that effective arrangements were in place. SA added that in the next report there would be a description of processes in place to ensure risk management was working. MS added that management of risk mainly occurred outside of meetings and progress on that was reported at Committees. KA suggested that Governing Body cover reports should identify links with the BAF and this would be considered further. The Chair requested that the Finance & Delivery Committees and the quality & Safety Committee should also consider the internal audit findings and recommendations, as they were the owners of the BAF. Progress to date on the BAFs and IA involvement was noted.

SA SA AW

87/13 IG- ONEL Cluster follow up and progress against action plan RM was pleased to provide feedback from a recent email confirming

Redbridge CCG had reached Level 2, gaining a satisfactory assessment of the interim Accredited Safe Haven from their Information Governance Toolkit Assessment. Similarly emails on Barking & Dagenham and Havering were expected to follow. The next step was for the Data Access and Information Sharing (DAIS) team to assess whether the CCGs could now progress to data sharing to complete the process. It was hoped this full status could be acquired by January. The Chair asked the Director to pass on the Committee’s thanks to all involved and appreciation of the task completed, noting the CCGs position earlier in the year. The Chair called for the momentum to be maintained and continuation of efforts to embed IG although acknowledged that there was now some evidence of reporting. Members discussed some near-miss events noting that real incidents would be reported to the Committee. National benchmarking of incidents was of interest to the Committee. It was agreed there would be a review at the next meeting of incidents this year to date and

RM

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benchmarking data. RM confirmed that the target of 95% staff trained had been reached. Noting the CQRMs of the main provider Trusts were maturing, RC questioned wider inclusion of care homes and voluntary sector. MS advised that it was planned that all contracts should be covered. RM provided an additional report on IG training for Audit & Governance Committee Members. Current focus was on the basic level of training and instructions provided to access the course. To raise the profile of IG at Governing Body level it was agreed that RM would send this to all Governing Body Members with an end of December deadline set. A technical issue had been raised around GP practice system crash and it was currently unclear if this was a network or software issue but it seems limited to one or two practices. An update would be provided next time due to concerns of patient impact. A risk management approach was being taken. The Committee noted the good progress being made on Information Governance.

RM RM

88/13 Business Continuity Plan progress SA outlined the national requirement to plan and the progress made to date.

The Audit Chair had separately reviewed and commented on the draft and following this Committee’s review and comment, the Executive Committee would sign off the plans with delegated responsibility given by the Governing Bodies. It was noted that BHR were not yet in receipt of the NELFT Plan but this would not prevent completion of the BHR plans. MS added the NELFT were currently providing core IT services that was a risk area for the CCGs. A table-top exercise was planned for the New Year. KA referred to the PCT’s role in gold, silver and bronze command but it was confirmed that the CCGs were not Category 1 responders (as the Provider Trusts/LAS were) and this would be emphasised in the report. The adequacy of the £10k Contingency Fund was questioned and MS confirmed that this was established for ease of access during an incident and further funds would be made available by the Governing Bodies as necessary. This would be clarified in the Plan. The Chair added that it was necessary to be clear of the roles and responsibilities of other organisations for liaison purposes e.g. NELFT and NA added an assurance that the CSU had plans that IA had seen. The Committee noted work to date to develop the Business Continuity Policy and Plan and that they would receive an update at the next meeting on the outcome of the testing exercise carried out.

SA SA SA

89/13 Finance update including Legacy Balance Transfers and Invoice Management

Legacy Balance Transfers

MS described the PCT end of life balances and difficulties to date in deciding ownership. It had recently been decided that these would be managed by CCGs but MS emphasised this was management and not ownership

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delegated from the NHSE. As the CFO, MS had delegated authority to sign off up to £250k and RA had authority to sign off up to £50k. With higher sums requiring NHSE authorisation. Each CCG will have benefits and deficits arising from the legacy balance. The deadline for agreement of balances to be transferred is now 29 November. The CCGs would now manage non clinical payable and accruals including Continuing Health Care. A new SBS Ledger, X25, has been developed to house these balances and relevant CCG and CSU staff will have ledger access. This new ledger will not be part of CCG accounts and MS added that payment to providers for partially completed spells backdated to April would be made. MS added that Finance would focus on maximising opportunity whilst mitigating risk and BHR was well organised for the task ahead. MS would report back regularly to the Committee as arrangements progress.

Concerns about the robustness of the opening balances inherited by the CCGs were discussed. KL said that he would be working with MS to gain the required assurances on opening balances and would report on progress made.

The new arrangements were noted.

Invoice Management

An update on unpaid invoice position at the CSU was provided. There were currently 4000 unpaid invoices with high numbers for Continuing Health Care and also for non-contracted activity. BHR had noted improved listening and responsiveness and the CSU had provided a rectification plan and was committed to clearing the backlog by mid December. MS assured Members that the CCGs had not been subject to late payment interest but would approach the CSU if this did occur. From a patient engagement forum, SW had heard concerns for small providers and voluntary sector who could be impacted by cash flow problems from late payments and questioned special arrangements or advance payments. MS would deal with specific issues raised by exception rather than altering set processes. RC questioned when we would be on target and position for year end. NA added that the public payment target would not be met and KP stressed the reputational issue for BHR CCGs. MS was asked to provide an email update to the Committee Members at the December deadline.

The Committee noted the new commitment to improve performance and would receive an update at the next meeting.

MS MS/KL MS

90/13 External Audit Plans

KL presented the three CCG Plans and outlined the external auditor appointment arrangements, key responsibilities to be discharged, independence and how PWC had sought to provide continuity of staff from PCT to CCG. The Plans included a strategic approach and there would be much focus on legacy issues of transfer of assets and liabilities. Key risks had been assessed and the audit and reporting timetables for 2013/14 provided.

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Risks included management override of controls by manipulation, fraud in revenue and expenditure and material mis-statements in opening balances. KL added that materiality, based on a national formula, had been set at 2% of expenditure and questioned Committee’s acceptance of a suggested level of ‘clearly trivial’ as £183k and this was supported. It was noted that this audit was on transactions not the control framework.

The report provided assurance questions from the Committee on Fraud Risk and the Committee felt assured robust arrangements were in place but requested attention to duplicate payments due to this year’s legacy issues. Reporting lines of Fraud were confirmed. MS had raised questions of NHSE on the control framework and was awaiting further clarity. However there appeared to be resolution of the protracted discussion on the adjustments for specialist commissioning and the risk had now reduced from £18m to £2m.

MS also was robustly challenging Propco assumptions, particularly on void space costs and costs that Propco had not recovered eg unpaid rentals. Members noted that the CCGs were not accepting this responsibility and negotiation continued. The vacant St Georges site was discussed and BHR’s view was that although this was PCT led it was not a transferable matter for the CCGs. BHR had requested disposal of two local sites surplus to requirements.

The Chair had received a response from NHSE that they had been justified in removing funds that had impacted B& D accounts. Although it was suggested that this was an isolated issue, it was known that other CCGs had been affected. The Chair explained that the response received was unsatisfactory and a further letter was being sent to the NHSE. He agreed to report on progress made at the next meeting.

External Audit fees for each CCG were set by the Audit Commission and based on CCG size but a 10% decrease was expected next year. KL would provide Members with details of the formula applied. Risk was raised around the timing of assurance documents due in April from SBS and McKesson who were working for CSU and MS would discuss this with David Slegg. NA added that IA would also check on this through CSU liaison and referred to the usefulness of the Assurance Committee. KL confirmed that high, medium and low risk aligned to the audit terms of significant, elevated and normal. KL would provide an update on whether PBR was being abandoned and whether this work would be done centrally. The Chair requested a timetable for the closedown of accounts noting a day had been set aside on 4 June for formal sign off.

The Committee supported the PWC External Audit Plans.

MS KP/AW KL MS KL MS

91/13 LCFS progress against plan and risk assessment results

MT referred to the risk assessment report and advised that Bakerilly had

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access to benchmarking from 28 CCGs. The BHR good performance was commended and the clear zero tolerance approach taken. The recommendations and the management response with timetable would be provided to the next meeting. A slight amendment was made to wording of Recommendation 10 around Conflicts of Interest.

Staff training was raised and MT confirmed some training was done and it was now clear who was to receive further training. Noting the E-Learning tool SA would ensure Board Members were involved in training. It was noted that some training was being provided at the 5 December Board Away Day.

Members noted the progress report.

MT SA

92/13 Internal Audit report

NA’s report referred to the 4 final reports on IG Toolkit and individual BAFs issued since the last meeting and Members noted today’s update on IG compliance and the BAFs. Attention was drawn to a change to the timescale for Continuing Heath Care (CHC) audit whereby a joint review with CSU and NELFT was required.

The report covered the IA follow up of ten legacy recommendations and six remained under review, 1 high, 3 medium and 2 low, the high one relating to Payroll Feeder systems. A further update on these recommendations would be provided at the next meeting.

The report also provided an update on the CSU and attention was drawn to the Assurance Committee minutes that followed. The report provided client briefings/sector update and Members were now receiving personal copies.

The inherited CHC backlog and business as usual work was discussed and the audit review would seek to clarify who was doing what in the process for assessment, brokerage and care provision and recommend streamlining. KA raised patient/family perspective of assessment outcome and it was noted an appeal process would be available.

The progress report was noted.

93/13 Draft Gifts and Hospitality policy

Further detail had been added to the draft policy to include financial limits and if supported by the Audit & Governance Committee this would accompany the Whistle-blowing and Anti-Fraud policies going to the January Governing Bodies. These policies would be referred to at the Board Away-Day. It was noted the policy referred to sponsorship by pharmaceutical companies and a separate draft policy was currently being considered by Medicine Management and would come to the next Audit Committee. Members questioned sponsorship of membership meetings and discussed pharmaceutical representative attendance at public Governing Body meetings. Further discussion would occur when the Committee received the

SA AW

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Signed…………………………………………….………

Dated………………………………………

draft policy.

94/13 Annual Committee Work-plan

The work scheduled for the next meetings was noted. MS added that he was arranging an early trial run of the annual accounting process/close down arrangements in the New Year and would report on that at the next meeting.

AW

95/13 Proposed meeting dates 2014/15

The meeting dates for 2014/15 were noted and agreed.

96/13 Any Other Business

There was no other business.

97/13 Messages for Governing Bodies

The Chair would list the key messages arising from the meeting to feedback to the January Governing Bodies.

KP/AW

98/13 Quality & Safety Committee Minutes

The minutes of the meeting held on 8 October 2013 were noted.

99/13 Information Governance Minutes The minutes of the meetings held on 26 July 2013, 4 September, 18

September, 17 October and 4 November were noted.

100/13 Assurance Committee Minutes (CSU) The minutes of the meeting held on 7 October 2013 were noted.

101/13 CCG Finance & Delivery Committee Minutes Minutes of the Barking & Dagenham meeting held on 1 October 2013 were

noted. Minutes of the Havering meeting of 25 September were noted. Minutes of the Redbridge meeting on 3 September were noted.

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Joint BHR CCGs Quality and Safety committee, 8 October 2013 v2 Page 1 of 5

Joint BHR CCGs Quality and safety committee Date: 8 October 2013

Time: 13.30-15.30 Venue: Boardroom A, Becketts house

Present: Tan Vandal (TV) Chair Secondary care consultant – B&D/Havering CCG Ah-Fee Chan (AFC) Vice Chair Secondary care consultant – Redbridge CCG Jacqui Himbury (JH) Nurse director – BHR CCGs Dr Sarah Heyes (SH) Clinical director – Redbridge CCG Louise Mitchell (LM) Chief operating officer – Redbridge CCG Dr Samia Azeem (SA) Clinical director – Redbridge CCG Dr Raj Kumar (RK) Clinical director – Barking and Dagenham CCG Sharon Morrow (SM) Chief operating officer – Barking and Dagenham CCG Clare Burns (CB) Deputy Chief operating officer – Havering CCG

In attendance: Diane Jones (DJ) Deputy nurse director – BHR CCGs Rod Leung (RL) Business manager – BHR CCGs

Apologies: Dr Ashok Deshpande (AD) Clinical director – Havering CCG Dr Muhammad Rahman (MR) Clinical director – Havering CCG Alan Steward (AS) Chief operating officer – Havering CCG Rachael Brady (RB) Quality assurance clinical governance manager – NEL CSU Dr Chandra Mohan (CM) Clinical director – Barking and Dagenham CCG

Item Action 1 Welcome and apologies The Chair welcomed those present and apologies were noted.

2 Declarations of conflicts of interest There were no additional declarations of interest to those recorded on the CCG’s

Register of Interests.

3 Minutes from 6 August 2013 The minutes of the previous meeting were agreed.

4 Matters/Actions arising 5.0 serious incident (SI) sign off and panel ToR

• JH clarified for the committee that the Barts Health (BH) incident sign off process virtually mirrors our own, although it was not as robust, but they now have more formal meetings with set dates.

• SH had a meeting with the chair of Tower Hamlets which had gone well. JH had decided not to write to the Chair of the Whipps Cross Clinical Quality Review Meetings (CQRM) as they appeared to be making an effort to improve and progress is being made to form a single overarching Barts Health CQRM.

• AFC and SH would attend the next Barts Health CQRM when the date was received.

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• JH confirmed that the CCGs were not sighted on the internal BH SI process as we are not the lead commissioner, but would request it. JH expected that the CQC would review the process on the 4 November.

6.0 Provider performance quality assurance indicators: Barking, Havering, and Redbridge NHS university trust (BHRUT) and North East London Foundation Trust (NELFT) serious incidents JH informed the Committee that we were still being omitted from circulars and emails and LM added that as partners we need to continue with challenges. JH agreed to update the Committee when the SI Committee had been established. SH suggested that GPs should be informed of any SI’s as soon as they are identified. RK enquired whether this should be done at a closed Protected Time Initiative (PTI)/ Protected learning engagement (PLE) meeting or by secure email. The Chair noted many changes occurring at BH and the need to maintain a focussed interest in the new BH CQRMs. JH would ask Nisha Patel to be put on all the mailing/distribution lists and the Chair would ask Tower Hamlets CCG for SH, LM and DJ to be put on their mailing lists. 10.0 Impact of poor coding practice on patient care. The Chair reported that he had updated the recent meeting of the Audit and Governance Committee on coding issues.

JH TV

5 Clinical Quality Review Meetings (CQRMs) JH presented the report to the Committee that provided assurance that the

BHRUT and NELFT CQRM’s were fit for purpose. There was an issue with clinical director’s (CD) attendance at NELFT CQRMs and JH was currently having a discussion with NELFT to change the time/date of the meetings. SM voiced her concern over the fact that we had not agreed times with CDs to attend those meetings. A risk was highlighted that the quality monitoring framework was not in place as needed for our medium contracts such as PELC, ISTC and hospices. However, there was a plan in place to mitigate this risk. SH raised ongoing monitoring by NELFT of discharged patients and provided an example of a patient directly requesting intervention and the NELFT response. The Chair questioned contractual obligations around responding effectively to patients requiring further support following discharge. SM agreed that this should be reviewed to clarify the pathway to follow to ensure there were no gaps in care. RK added that there are many changes occurring and clarity was needed. JH expressed her concerns and CB requested this be made a priority. SH commented that it would be useful to get this type of information at PLE/PTI meetings, so all GPs receive it at the same time and are able to raise questions. RK added that we needed to simplify the pathways for GPs but recognising that consultants also required improved continuity and better planned follow-up care post discharge. The Chair summarised the action as:

• To confirm NELFT’s contractual obligation • Note that consultants were aware and also had concerns

SM

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• To identify gaps and rectification • The full care pathway needed to go into CCG Commissioning Intentions • Above all, risks need to be mitigated to ensure patient safety

JH added that the CCG needed to be clear of what it was commissioning; we needed to assess against the contract and if there was a gap in the commissioned pathway, it would be included in the Commissioning Intentions. It was agreed that identified gaps would be added to the risk register. Also RK and CB would report to the joint mental health project steering group, then feedback to the Committee.

RK/SM

6 Provider quality assurance framework JH presented the report highlighting the approach taken for quality assurance of

the CCG three main contracts BHRUT, NELFT and BH. In summary BHRUT, with Havering as the lead commissioner, have a very robust framework reflecting the level of risk the CCG was currently managing. NELFT, with B&D as lead commissioners, also have a strong framework although not as robust as BHRUT, with one of the main concerns being the lack of CD attendance at the CQRMs. Redbridge CCG, as the BHR lead commissioners for BH, is finding it a challenge working with the lead commissioner for the provider, Tower Hamlets CCG. As such, the framework is not robust and remains a significant risk. The Chair commented that this was a very useful paper noting BHRUT assurance framework was sound and NELFT assurance framework needed further work for the Committee to be assured. He noted and expressed concern at NELFT objecting to the performance reviews and would like to see some flow charts on the reporting structure. SH expressed concern over lack of engagement with TH CCG and agreed to email the TH CCG Chair requesting to be added to the BH CQRM distribution list. JH informed the Committee that from an assurance point of view we have to continue what we are doing and keep the pressure on and it will be interesting to see the CQC report following the 4 November 2013 inspection. The attached quality report gives the Committee an idea of the level of detail/quality indicators that are required for the report. SM enquired as to whether exception reports can be made available for the areas that are under-performing. JH responded that locality reports already go to the Executive Committee and a broader report to the Joint Executive Committee. The Chair, LM and SM were keen that a brief version of the report still comes to the QSC for information and assurance.

SH JH

7 Summary Hospital-level mortality indicator (SHMI) report JH presented this comprehensive and well written report noting BHRUT were an

outlier across the London benchmark, and will continue to reduce their SHMI. CB required that this was included on the risk register. AFC enquired whether they need to inform the Committee of the sections highlighted in yellow (the areas which may warrant further discussion and consideration). JH explained that the report would go to the CQRMs although they may need to go into fuller detail. The Chair pointed out that SHMI data needs careful interpretation with regard to volume of cases. SH highlighted that for BHRUT pneumonia is a concern but the severity had not been described. Noting that deaths had increased from Qtr 1 data, the Chair commented that this could be a reflection of coding practice and further clarification was required. AFC stated that each hospital is supposed to have a mortality and safety committee involving clinicians. LM added that asking

JH

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the right questions is the core of what the QSC is here to do. JH agreed to share the content of this report with the relevant Trusts and ask them to respond to concerns raised by the Committee. The Chair added that we will await their responses and JH can then raise take at the CQRMs.

JH

8 Continuing Health Care (CHC) JH presented the report to the Committee indicating that the report focuses on the

three most recent risks: 1. Unaccounted patients 2. Additional review backlog since 1 April 2013 3. Overdue initial assessments.

JH advised that both the CSU and NELFT have committed to the external review. The review is being done by Baker Tilly auditors and started on 7 October and will take two weeks. They will be looking into the reason we have 171 overdue initial assessments across the 3 boroughs. Jacqui Van Rossum at NELFT has investigated and assures JH that they are not as serious as initially thought. JH has asked for a detailed list of the 171 broken down into category and she will then pass this on to her brokerage nurses to investigate. The Committee wanted to know the reason behind the audit. JH advised that the review should bring to light all the things we are not yet sighted on as we need to know the risks requiring mitigation. Current issues with the CSU include:

• The patient tracker report was not being properly presented and there were 982 people currently on the patient tracker.

• The Broadcare system information was not being managed properly.

The CSU and NELFT brokerage team had not agreed on whether there were problems and CSU operational management was questioned. Adding a manager that directly reported to JH was discussed. The Chair added that the position seemed unsafe with regards to the CSU and NELFT and flagged this as a risk within the system as the Committee did not yet feel assured that the CSU was meeting its contractual obligations. The outcome of the internal audit and CCG actions would be reported to the next Committee meeting.SM questioned if the review covered adults and children and JH clarified that she had been advised that children were being properly managed, so the review will be mostly focussed on adults The committee noted the report and agreed to assess the results of the external review when it becomes available.

9 Any other business LM expressed concern that we needed to find a mechanism for medium and

smaller value contracts and there needed to be somewhere to bring the issues to. LM suggested these are picked up under the contract negotiation review model. The Chair enquired about Quality & Safety reports on other contracts like Care UK, PELC and other contracts in the community. It was emphasised Quality needs to become part of Commissioning Intentions AFC felt transition was the problem and questioned why a deadline could not be set to close down contracts. JH confirmed that finance was not the issue but capacity and manpower, including quality of nurses. The Chair noted the focus on major providers and requested a list of smaller providers and what we are commissioning from them. JH confirmed that there was a contract database

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available with many completed contracts but also some gaps. She added that we need to seek further assurance on the risks that have been identified so we can justify and seek further assurance. SM indicated that the CSU holds all that information for the CCGs. The Chair expressed concern over inability of some Committee members to attend because of other commitments and asked for an attendance log so that he can raise the issue with Members concerned and look for alternatives such as deputies.

JH RL

10 Date of next meeting 10 December 2013, 13.30-15.30, Bentley meeting room, HCCG Offices, 3rd

Floor, Imperial Offices, 2-4 Eastern Rd, Romford RM1 3PJ. (This meeting was subsequently re-arranged for 9 January 2014)

Signed………………………………………………..Date………………………….

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1 Draft Quality & Safety Minutes 9 Jan 2014 meeting v2

Draft Joint BHR CCGs Quality & Safety Committee Date: 9 January 2014

Venue: Boardroom B, Becketts House Time: 3.30-5.20pm.

Present-Members Mr Tan Vandal (TV) Chair Secondary Care Consultant –B&D and Havering CCGs Dr Ashok Deshpande (AD) until 4.45pm

Clinical Director Havering CCG

Dr Raj Kumar (RK) Clinical Director Barking & Dagenham CCG Dr Chandra Mohan (CM) Clinical Director Barking & Dagenham CCG Dr Sarah Heyes (SH) until 4.45pm.

Clinical Director Redbridge CCG

Jacqui Himbury (JH) BHR Nurse Director Sharon Morrow (SM) Chief Operating Officer Barking and Dagenham CCG Alan Steward (AS) Chief Operating Officer Havering CCG In attendance-Officers Diane Jones (DJ) BHR Deputy Nurse Director Michelle Anstiss (MA) part NELCSU Assistant Director for Safety Rachel Brady (RB) NELCSU Quality Assurance & Clinical Governance manager Kerry Naylor (KN) part NELCSU Patient experience and effectiveness team Angela Ward (AW) BHR Company Secretary Apologies Dr Samia Azeem Clinical Director Redbridge Dr Ah Fee Chan Secondary Care Consultant Redbridge Louise Mitchell Chief Operating Officer Redbridge

Action

01/14 Apologies for absence The Chair welcomed those present and the apologies were noted. It was also

noted that Dr Muhammad Rahman had resigned from his Havering Clinical Directorship at the end of December and a replacement member for the Committee was being considered.

Chair

02/14 Declaration of Interests There were no interests declared other than those on the CCG’s Registers of

Interest.

03/14 Minutes of meeting held on 8 October and Matters Arising The minutes of the previous meeting were agreed.

The following updates on Matters Arising were discussed; 5.0 Clinical quality review meetings Mental health – Noting previous concerns on access/pathways and content of contract, SM reported that the contracting intentions group had met twice and BHR issues were raised. JH requested a formal approach to any gaps. SH was still experiencing access issues and called for an urgent NELFT response. RK added that a patient’s family were also impacted by delayed admission. CM in

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questioning the contract, suggested time periods post discharge for continuation of the provider’s care. Patients needed a contact number to avoid attending A & E. JH agreed to urgently pick up the difficulties on access that SH had raised. The Chair summarised that;

• Quality of care provided to patients appeared suboptimal

• Contractual arrangements with NELFT needed to be checked

• There was also an impact on hospital clinicians as they were noted to be dissatisfied with patient access as confirmed by RK

• More clarity was required on discharge arrangements SM added that contract negotiations for 2014/15 were underway and post discharge access would be raised. JH would take issues raised forward with urgency and liaise with SH and provide an update at the next meeting. 6.0 Provider quality assurance frameworks From the report, SH was pleased to note some positives in the WX position and other issues being addressed. Some areas were quality rich but fabric poor but the report was generally favourable. There appeared some low staff morale perhaps due to grade re-bandings. JH added that the draft CQC report was being shared the next day at the summit meeting and Trust responses were required on compliance issues. JH/LM/SH were currently engaged in commissioning arrangements and attending CQRMs. Staff issues would need to be raised at the CQRM. A further update would be provided at the given next meeting 9.0 Any Other Business Responding to a request for listing of small contracts JH confirmed that this would be provided to the next Committee meeting. Noting the Committee Membership included two CDs from each CCG, The Chair asked those present to ensure there was at least one clinician present from each CCG to maintain the quorum.

JH JH JH

04/14 BHRUT CQC findings/summit outcome and action plan on recommendations

Attached to the papers for more detailed reading were;

• CQC report on KGH quality report • CQC report on Queens • CQC report on BHRUT • CQC report on BHRUT data

The findings were from a national inspection in October, a published report in December and a well attended quality summit was held on 17 December to discuss these further. Members discussed the nationally announced ‘special measures’ of support that had recently been implemented and noted a new

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Director of Improvement would shortly be announced. A review was also beginning on leadership led by Sir Ian Carruthers and the CCG, with other partners, would be involved. The CQC would re-report on whether they found systematic, sustainable quality improvements. The new measures included ‘buddying-up’ for peer support with a high performing Trust and further details were awaited. Members noted that the CCGs, as partners, would need to respond to scrutiny and discussed Trust pressure of CQC compliance Notices together with TDA scrutiny and the need for robust action plans. CQC timelines were clear and fixed and limited responses not accepted but TDA arrangements were less clear. JH, in noting the CCG was not performance monitoring but seeking quality assurances from the Trust, would be discussing with the NHSE expectations of the CCGs. The CCGs would assist and support wherever possible and ensure that they were not asking for new work but maintaining challenge where necessary through a balanced approach. JH flagged up a quality issue requiring attention but not discussed at CQRM i.e. a hospital transfer policy for Queens to KGH site. Also the CCGs needed an annual plan of unannounced visits to BHRUT and this would be discussed with NHSE/TDA. The role of the Committee was discussed and the Chair noted the risks raised in the report but was aware of some areas of very good service e.g. critical care and stroke and looked to the action plans to demonstrate progress. Noting this was the first Trust under the new framework where special measures had been applied and roles of NHSE/TDA were not yet clear. Assurance on ‘business as usual’ work was important to the CCGs. On the positive side the LA and NELFT were being asked to support the leadership interviews and overall the measures were a good opportunity to aid improvement. AD referred to impact of special measures on areas such as the London cancer services. The Chair confirmed focus was on quality of care and outcomes and maintaining the key CWT targets e.g. In seeing the 2 week wait cancer referrals. SH emphasised that the CCGs acknowledged that there had been dramatic good improvements in some services over the past year. Continuity of senior management was important to see through change and the Committee awaited further news of the senior governance structure with appointment of the Director of Improvement as a consequence of ‘Special Measures’. The reports and actions planned were noted and further updates would follow.

JH

05/14 National Maternity Survey Outcomes

KN from the NELCSU attended to report on the findings of the 2013 national survey where the response level had been 38% in the Sector compared with a 48% response overall. Responses rates were 37% at BHRUT and 29% at Barts Health. The findings were split into three areas of labour and birth, staff and care in hospital after birth. Direct comparison with the 2010 survey was not possible due to survey changes. On the positive side the key findings for England were noted which included increased satisfaction with communication and understanding, treatment with kindness and confidence in staff. Those seeing the same midwife throughout their care responded more favourably. On the negative side were lack of consistency e.g. medical history taken, variable choices for patients, cleanliness and the response to concerns they raised during labour.

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Data on Acute Trust performance for London and the NEL sector was provided. Within the NEL data, scorings were given for the local maternity units and improvements flagged. BHRUT had the most improvements and the Homerton was the worst with the Whittington being the highest overall performer. Further detail was provided on BHRUT. Improvements and no deterioration, was evident. Such measurement was not possible at Barts Health as there were no comparators (as a new merged Trust). Also provided were Basildon & Thurrock results which showed improvement but no deterioration. As Chair of the maternity CQRM, CM proposed that improvements made needed to be built upon, lessons learnt and a sharing of good practice perhaps even buddying with better performers. Noting this survey was in February 2013, SH commended BHRUT improvements and emphasised real time data was important. DJ added that the CQC findings were important and the real time picture was discussed at CQRM. The Chair added that the report could not be seen in isolation and emphasis should be on continual and maintained improvements. Kerry Naylor believed continuity of midwives throughout care would improve local negative responses. JH confirmed that the CQC utilised the survey for monitoring purposes. The report was noted and it was agreed that at the next CQRMs the local Trusts would be asked to comment on the 2013 maternity survey findings and an update provided (matters arising).

DJ/CM

06/14 Continuing Health Care- External Review

The review was commissioned from Baker Tilly auditors by BHR CCGs and NELCSU when 171 assessments were waiting. NELFT had treated this as an SI. Attention was drawn to the findings, risks and 14 recommendations of the review and in particular red highlighted areas in the report. SM advised that a CHC Executive Committee had been established to take recommendations forward. The Committee noted the report and its recommendations and agreed that a further report would be available in two months with actions and timelines.

JH

07/14 Serious Incident (SI) trend Report Qtr.2

MA from NELCSU, responsible for the SI management function, attended and provided key highlights of her second report. Qtr.2 reported incidents across the NELCSU included in the 509 total were 294 by acute hospitals, 207 mental health and 8 by specialist/independent/private providers. The incidents were categorised by the national STEIS reporting system with the highest incidence being of pressure ulcers. Barts Health was a good reporter which lead them to be the highest acute reporter in the Sector. NELFT were the highest mental health reporter. Also provided was reporting by local Co-operatives, OOH service, Air Liquide and Inhealth Netcare. Attention was drawn to the 6 ‘Never Events’ reported in the Sector. NELCSU were working closely with contracting colleagues to ensure remedial action was taken. Such events were often retained post-operative foreign objects e.g. swabs. However new guidance should address where certain materials were deliberately placed and these planned ones would not feature as NEs in the future.

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Maternity incident reporting was discussed and ‘suspension of service’ seemed high. It was noted there could be some de-escalation when mothers transferred to other units. One maternal death was reported by BHRUT although the patient had died elsewhere. Members noted the recommendations and actions required and that BHRUT SIs were lower and there were no Never Events. The KPIs required reporting in 2 days of the incident to the DOH. A CQUIN target for improvement had been applied and reporting days had fallen from 41 to meet the national average. The target for completing SI investigation reports is 45 - 60 days. Members noted BHRUT’s performance and 7 overdue reports. The report referred to the national Central Alerting System (CAS) Alerts where providers had to respond and take action. BHRUT had met the targets. (Dr. Heyes and Dr. Deshpande left the meeting) NELFT had reported 156 SIs in Qtr.2 and reporting trends were provided. High reporting was a sign of a good safety culture and adherence to guidance with many related to pressure ulcers. Data showed pressure ulcers detected on admission to DN caseload and those that developed into an SI (grade 3 or 4) whilst under DN care. No Never Events had been reported by NELFT. Overdue investigation reports were noted and a task and finish group had been formed to address policies and practice on threshold criteria and de-escalation. NELFT had 6 overdue alerts in Qtr.2 and the Trust was being asked to report on completion. DJ raised delay in reporting by community services and SB added that the Trust acknowledged there was wide variance across teams of reporting into a central team. This community services issue would be raised at the CQRM. RK questioned if there was any impact from closure of NELFT’s Naseberry unit and that data would need to be studied pre and post closure and discussed further at the next meeting. Barts Health data showed 157 SIs across 3 sites with a high number of grade 3 and 4 pressure ulcer reports with high numbers being seen as good safety practice. The CSU team were assisting in a report template to deal with cases being reported where mothers have transferred to another Barts Health site. Barts Health reported 2 Never Events involving retained swabs. Preventative action being taken was noted. The CCG had written to the Trust with concerns of delays in reporting SIs (average 12 against 2 day target) and a response with assurances was received. It was expected that delay in completing SI investigation would decrease as the backlog was diminishing. A meeting with Barts Health was planned for 27 January aimed at closing down open legacy cases through evidence review. The Trust had 4 overdue CAS alerts and checks would be suggested on whether there were any other CAS related matters still open on the Risk Registers. The InHealth data (relates to DH contract let until March) showed 2 SIs, one a Never Event and both subject to ongoing investigation. AS added that the report demonstrated attainment of national averages but outcomes were key. The Committee focus was on risk mitigation and the data was useful tool for contract negotiations but further analysis by the Trust would assist. The Chair emphasised that a further action was to assess patient impact.

JH JH JH

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Signed…………………………………………….……… Dated………………………………………

The Qtr.2 updates were noted and there would be updates through Matters Arising actions.

08/14 Any Other Business

The Chair had been asked to raise with the Committee extending the Membership to include Lay Members. JH believed there were no objections to this but was concerned for Lay Member’s time and over-commitment and for them to understand that the detailed investigations were done at the CQRMs and the Q & S Committee was focussed on seeking assurances. JH would take governance advice from Sue Assar and the Chair would ascertain from the Lay Members, (PPIs), how best they could represent patients/public interests.

JH TV

09/14 Date of Next Meeting

The next meeting would be held at Becketts House Board room on 4 February 2014. Members received a tabled copy of the meeting dates 2014/5. Bring Forward items were currently CCG complaints and the Winterbourne review.

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Barking & Dagenham CCG PEF 19th September 2013 – final draft minutes Page 1 of 6

DRAFT

Barking & Dagenham CCG Patient Engagement Forum

Boardroom, Barking Community Hospital

19th September 2013

17.00 – 19.00 Present: Miriam Greenwood (MG) Chairperson, Barking & Dagenham

CCG Patient Engagement Forum Nicholas Hurst (NH) Vice-Chair, Barking & Dagenham CCG

Patient Engagement Forum Elaine Clark (EC) Forum Member Cllr George Barratt (GB) Forum Member Wendy Garton (WG) Forum Member Thomas Musau (TM) Forum Member Thomas Heavey (TH) Forum Member Rodney Mallison (RM) Observer Sharon Morrow (SM) Chief Operating Officer, Barking &

Dagenham CCG Sahdia Warraich (SW) PPI Lay person, Barking & Dagenham

CCG Dr Waseem Mohi (MH) Chair, Barking &Dagenham CCG Dr J John (JJ) Clinical Director, Barking & Dagenham

CCG Amy Burgess (AB) (minute taker) Patient & Public Engagement Advisor,

BHR CCGs Apologies: David Elliott Forum Member Pam Hamilton Forum Member Leonades Hadgi-Petrou Forum member

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Item Description Action 1.0 Welcome, introductions and apologies MG welcomed everyone present the meeting, in particular new

member Thomas Heavey.

2.0 Minutes and matters arising from the last meeting held on 9th July 2013

The minutes were signed off by members as an accurate record.

• AB to circulate the PPG toolkit to new member TH • JJ confirmed that a formal report outlining key findings

on A&E highest attendees will be brought to the next Forum meeting

• It was agreed that Healthwatch should have a regular slot on Forum agendas

• It was agreed that the governance section in the Terms of Reference be removed as it is not relevant

• JJ explained that he leads on the ICM delivery group and would like a patient to sit on the group. Please let AB know if you want to be involved

• It was suggested that the clinical lead and project lead for each of the key delivery groups attend the Forum to explain what it is they focus on. Then a forward plan can be developed

• JJ fed back about his suggestion to request funding from NHS England to hold a PPG meeting. They have said as soon as they are ready to offer that kind of support they will let JJ know. He in turn will feed back to the Forum.

AB JJ AB AB ALL AB JJ

3.0 Integrated care project As Gemma Hughes was unable to attend this meeting, AB

updated the Forum, explaining that GH is undertaking a research project into integrated care across Barking & Dagenham, Havering and Redbridge in her role as a research student (part-time) at Queen Mary, University of London. The research project will include in-depth qualitative research of patients' experience of integrated care with the aim of trying to better understand the practice of integrated care and therefore inform its development - both locally and to come up with some more general lessons for the NHS. The aim is to enable a rich and detailed understanding of the people, tasks and activities that are involved in ‘doing integrated care’, and from this, identify what good integrated care is and to work with local

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practitioners to help to achieve it in practice. An action research steering group is planned to help guide the research, and public/patient representatives will sit on this steering group. The steering group will meet bi-annually for a 3 hour/half day meeting and will play a key role in helping to refine the research plan; to understand the data that is being collected and to work out how to use the evidence from patient experiences to develop recommendations to improve services. The Chair and Vice-Chair of the Barking and Dagenham PEF have agreed to become members of the steering group. Other members of the PEF who are interested in this study are invited to contribute either to the steering group, to provide their comments through the PEF or directly to GH. Please let AB know if you are interested. JJ informed the Forum that that he is absolutely in support of this project, and that the feedback will help the CCG is showing where the gaps are. GH will present in more depth to the Forum in November.

AB

4.0 Introduction to the commissioning cycle SM presented to the Forum.

SM explained that the CCG is responsible for commissioning a range of health services for the local population. These include: For all residents in the borough

• Urgent and emergency care For patients that are registered with a B&D GP

• Planned hospital care • Community health services • Maternity and newborn • Some children’s services • Learning disabilities services • Mental health services • Continuing healthcare • Infertility services

Other commissioners of healthcare in the borough are the local authority (who provide services such as those relating to sexual health, physical activity and alcohol, drug and tobacco services) and NHS England (who provide services such as primary care GP, pharmacy and dental services, immunisation programmes

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and screening programmes). The Forum raised some concerns regarding how services will be monitored, given that there are multiple commissioners working together, so that people do not fall through the gaps. SM explained that this is certainly a concern but that all commissioners are working together to look at planning to ensure that there is no gap. JJ further assured members by explaining that great effort is being put into forging relationships. SM went onto explain that the CCG management of the commissioning process is through the development and implementation of its commissioning strategy plan. SM informed members that the CCG is now starting the annual refresh of its current commissioning plan, called “Plan on a Page”. The CCG are aiming to finalise the refresh by January 2014. The CCG must additionally deliver services within the budget allocation and develop Quality, Improvement, Productivity and Prevention (QIPP) plans. NHS England is launching “A call to action” stakeholder events in the autumn to start the debate with patients and the public on how the NHS can change to manage increasing demand. The Forum queried whether funding increases with population increases and SM confirmed that yes, this is the case. However there are problems with this as it is often based on census data which can be out of date. SM explained that it would be really helpful for the PEF to look at the overall commissioning strategy building on work to date. Additionally there will be opportunities for the PEF to be involved in reviewing the emerging QIPP work programme and inform CCG strategy decisions, as well as advise on engagement mechanisms with PPGs and monitoring and evaluation of patient feedback. The Chair thanked SM for the update.

5.0 Reviewing the governing body papers The Forum discussed a selection of the papers going to the

Governing Body meeting, to be held on the 24th of September. Paper 3.2: Francis report – update on implementation SM explained that the Francis Report outlined 290 recommendations which all NHS organisations have been considering. Barking and Dagenham CCG held a workshop in

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July and a task and finish group will be established in September comprised of commissioners, providers and user representatives from across BHR. This group will meet to develop a more detailed implementation plan that balances the views of the partnership and enable delivery of actions. TH commented that a national whistleblower number could be considered and SM agreed to mention this at the meeting. Paper 3.3: BHRUT A&E services clinical review SM explained that the three CCGs in Havering, Barking and Dagenham and Redbridge commissioned the London Clinical Senate to lead an external review into A&E services at BHRUT last month. The review followed long-standing concerns about the performance of emergency care at BHRUT and more recent concerns about potential patient safety risks due to permanent medical staffing issues. The initial findings indicate that while safe 24 hour A&E services can be maintained on both sites in the short term, a number of steps should be taken to improve the emergency departments at the Trust. SW requested information about the patient flows between King George Hospital and Queens. SM informed SW that this information will be available and will endeavour to find it. Paper 5.1: Development of intermediate care community services The CCG has commissioned a number of community treatment teams and there are plans in place to develop a robust community infrastructure. There are currently a number of community beds at Grays Court and these beds will reduce and replaced by enhanced rehabilitation support. Paper 6.1: Quality in commissioning report This report updated on a number of quality concerns at Barts Health and BHRUT. Particular focus was given to both the local acute trusts as a number of quality concerns had arisen over the past month. Paper 6.2: Patient experience report This report provided a summary of the range of feedback, updating on complaints; the friends and family test; the CCG Patient Engagement Forum and the Patient Participation Group audit.

6.0 AOB

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NH informed members that North East London Foundation Trust (NELFT) is piloting a new phone-in system called Care Connect which is funded by NHS England. This will provide a transparent means of feeding back patients experiences and concerns and will be going live shortly. SW informed SM that currently phlebotomy is not listed online as a service available at Barking Community Hospital. EC agreed, explaining that on many blood test forms it only signposts patients to Queens and King George Hospital. SM agreed to escalate this. AB informed members that she will be leaving BHR CCGs at the beginning of November to start a new role at Hammersmith and Fulham CCG. AB thanked the Forum, saying how much she had enjoyed working with them, and in turn the Chair and Forum members thanked AB and wished her luck.

SM

Date and time of next meeting 28th November 2013

Barking Community Hospital 17.00 – 19.00

Signed………………………………………………..Date………………………….

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Barking & Dagenham CCG Patient Engagement Forum

Boardroom, Barking Community Hospital

28th November 2013

17.00 – 19.00

Present: George Barratt Forum Member Julian Buckton ( JB -Minute Taker) Commissioning Support, North East

London CSU Elaine Clark (EC) Forum Member David Elliott (DE) Forum Member Miriam Greenwood (MG) (Chair) Forum Member Pam Hamilton (PH) Forum Member Tom Heavey (TH) Forum Member Wendy Garton (WG) Forum Member Gemma Hughes (GH) Senior Locality Lead, Barking & Dagenham

CCG Dr J John (JJ) Clinical Director, Barking & Dagenham

CCG Niall Smith (NS) Communications Lead NEL CSU Sahdia Warraich (SW) PPI Lay Member Governing Body, Barking

& Dagenham CCG Carol White (CW) Operations Director for Adult Care-NELFT Apologies: Sharon Morrow Chief Operating Officer, Barking &

Dagenham CCG Dr Waseem Mohi (WM) Chair, Barking and Dagenham CCG Colin Ward Forum Member Sarah D’Souza (SDS) Senior Locality Lead, Barking & Dagenham

CCG Michael Inns (MI) Forum Member Leonades Hadgi-Petrou (LHP) Forum Member Olivia Mukasa Forum Member Sue Levi Barking and Dagenham Public Health Dorothy Stokes (DS) Forum Member Nicholas Hurst (NH) Forum Member Andrew Strickland Communications Lead Item Description Action

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1.0 Welcome, introductions and apologies There was a round of introductions and apologies were given as

listed above..

2.0 Minutes and matters arising from the last meeting held on 19th September 2013

The group agreed the minutes from the last meeting, and an update was given for matters arising.

• AB to circulate the PPG toolkit to new member TH. GH to pick this up.

• JJ to circulate the report outlining the key findings on A&E highest attendees.

• It was agreed that Healthwatch to be chased to nominate a representative for the PEF.

• The previous decision that PEF meetings would be scheduled to allow a review of the Governing Body papers prior to each GB meeting was endorsed. Governing Body papers would therefore be included on forum agendas as appropriate.

• Corrected information about phlebotomy at Barking Hospital to be provided to patients

GH JJ GH GH GH

3.0 CCG Commissioning Strategy Overview

GH gave the group an overview of the 2014/15 planning cycle indicating the requirement to produce a 5yr strategic plan and 2 yr. Operating Plan. Barking and Dagenham, Redbridge and Havering CCGs have come together as a Planning Unit and will need to liaise with other Health economies as required. GH also outlined that Outcomes Benchmarking was used to determine the Commissioning priorities. The CCG funding allocations are expected to be released w/c 16 December 2013 which will determine the funding for B&D CCG. GH agreed to circulate documents around:

• The Operating Framework • Integration Transformation Fund (ITF) • A “Call to Action” • Joint Strategic Needs Assessment (JSNA) summary • B&D Health and Wellbeing Strategy

DE requested that a progress report on Commissioning Plans be brought to the Forum 6-12 months into the new financial year. SW noted that additional funding is available to CCGs for extended hours. To discuss with GH.

GH GH SW/GH

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4.0 Integrated Care

Intermediate Care Service proposed changes CW gave an update on Intermediate Care Services (please see attached presentation). The following points were raised by the group in Q&A/discussion: How will the services of the Community Treatment Team (CTT) be marketed to patients? Services will be marketed through a number of ways which include NHS 111, 999 and other community services. GP practices should also be aware of the CTT service. Is the cost cheaper than hospital Care? It is not necessarily cheaper to provide care and support in people’s homes but is better for patients in many cases and preferred by them. Also it can reduce pressure on hospital admissions and beds. Have there been complaints about CTT? There have been no patient complaints to date. There has however been feedback from other health professionals which is to be expected for a new service. Joint Assessment and Discharge Team – Update GH provided the forum with an update on work underway to simplify the discharge processes for complex cases. GH confirmed this work is led by the London Borough of Barking and Dagenham (LBBD). Social Care has also introduced 7 day working to support the discharge process and ensuring patients are discharged across the week. This work will support the freeing up of beds in the Acute Trust and is being monitored weekly as part of winter acute performance. The group noted some common problems with discharge for all patients including medication availability and discharge letters.

5.0 BHRUT update

GH provided a brief overview of developments at KGH and Queens A&Es and the fact that the report from the recent CQC visit is not yet released. GH asked the forum whether it would be helpful for Jacqui Himbury (Quality and Safety Director) to attend the next meeting to provide a more comprehensive update on Barking, Havering and Redbridge Hospital (BHR) and this was agreed.

GH

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6.0 Urgent Care Draft Strategy

GH provided the forum with a brief overview of the Barking and Dagenham Urgent Care Strategy. The key points were:

• The focus is on urgent primary care needs and patient access.

• Manage more care at home rather than in the acute services. • Delivery will be through commissioned services and primary

care improvement. GH further highlighted the key changes the strategy aims to achieve as follows:

• Decommissioning of Broad Street Walk in Centre (WIC) • A review of Upney Lane WIC to include minor

injuries/suspected fractures. • The Surge Scheme • Review of contracts • Review of the NHS 111 and Out of Hours (OOH) services. • More effectively marketing services to patients. • Supporting Primary Care Improvements. • Review and development of A&E and UCC services both at

KGH and Queens. GH expanded on the Surge Scheme and how this will work for patients in B&D. GH confirmed that 31 Practices currently deliver additional appointments as part of the Surge Scheme. A formal evaluation will take place of the Surge Scheme and will include patient satisfaction surveys. (National Patient Survey as well as Local Surveys) The group was asked to provide any further thoughts on other methods that could be used to effectively evaluate patient satisfaction with the pilot scheme.

7.0 Forward Planner

There was a discussion around the dates presented in the forward planner and whether this was in line with Governing Body dates as requested at previous meetings. It was agreed that the dates for the PEF be cross checked with the Governing Body dates to ensure they are aligned.

GH

8.0 Any Other Business

EC informed the group of the large scale computer change at BHR from PAS to Medway and that she was supporting the

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implementation from a patient perspective. EC raised an issue around a patient who has been waiting for a Diabetes Insulin Pump through the IFR process. GH agreed to look into the issue and report back to EC. DE requested that the CCG e-mail address be sent to him to facilitate communication. MG said it would be preferable for communication to go via the CCG support function. MG reminded the CCG representatives of the previous decision to invite chairs of each of the CCG groups to the PEF in successive meetings to explain what they are doing and seek the opportunity for PEF members to contribute to them if interested. MG reported that together with NH and SW she had met with the chairs, vice chairs and lay members of Havering and Redbridge PEFs and requested that the notes from the meeting should be provided.

GH GH GH GH

9.0 Date and Time of Next Meeting 23rd January 2014

Barking Community Hospital 17.00 – 19.00pm

Signed………………………………………………..Date………………………….

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Joint Executive Team Meeting

3 October 2013 7-9pm

Becketts House

MINUTES

Attendees: Dr Waseem Mohi (WM) Chair – Barking and Dagenham CCG Dr Raj Kumar (RK) Clinical Director – Barking and Dagenham CCG Dr Richard Burack (RB) Clinical Director – Barking and Dagenham CCG Dr Jagan John (JJ) Clinical Director – Barking and Dagenham CCG Dr Rami Hara (RH) Clinical Director – Barking and Dagenham CCG Sharon Morrow (SM) Chief Operating Officer – Barking and Dagenham CCG Dr Atul Aggarwal (AA) Chair – Havering CCG Dr Jitendra Kakad (JK) Clinical Director – Havering CCG Dr Alex Tran (AT) Clinical Director – Havering CCG Dr Anil Mehta (AM) Chair – Redbridge CCG Dr Sarah Heyes (SH) Clinical Director – Redbridge CCG Dr Syed Raza (SR) Clinical Director – Redbridge CCG Dr Shabana Ali (SA) Clinical Director – Redbridge CCG Louise Mitchell (LM) Chief Operating Officer – Redbridge CCG Conor Burke (CB) Chief Officer – BHR CCGs Martin Sheldon (MS) Chief Financial Officer – BHR CCGs Sue Assar (SA) Interim Director of Corporate Services – BHR CCGs Jacqui Himbury (JH) Nurse Director – BHR CCGs Jane Gateley (JG) Director of Strategic Delivery – BHR CCGs Graham Simpson (GS) Commissioning Support Director, NEL CSU

1.0 1.1 1.2

Welcome, introductions and apologies As the CCG Chairs meeting with Anne Rainsberry was over running Conor agreed to chair the meeting in their absence. The 3 Chairs joined the meeting during item 5. Apologies received: For B&D - Dr Sharma For Havering - Dr Sanomi, Dr Saini, Dr Deshpande For Redbridge - Dr Sood, Dr Azeem, Dr Mathukia For NEL CSU – Roy Weston

Note

2. 0 Declaration of interests No declarations of interests, other than those already declared through the register were recorded.

3.0 Minutes from the previous meeting

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The minutes from the previous meeting were agreed as correct. Note

4. 0 4.1

Risk assurance Collaborative risk log Barts Health contract Dr Heyes confirmed that the contract with Barts Health is still not signed. With regards to payment for Quarter 1 Martin Sheldon advised that it has been proposed that we only pay a quarter of the block contract (to plan). Subject to assurances of the data system this could also be a possibility for Quarter 2. Dr Heyes confirmed that the first Service Performance Review (SPR) and Clinical Quality Review Meetings (CQRM) have been held with Barts and that there will also be a technical sub group held on a monthly basis going forwards. Specialised Commissioning Martin advised that updated figures had been received and that we are awaiting final confirmation but it looks more positive than previous calculations. Continuing Healthcare Jacqui Himbury advised that since the update given to the Governing Body at their Part 2 meetings the situation has deteriorated but that urgent actions have been identified by the CSU and NELFT to rectify the situation. An external review will be undertaken with weekly monitoring of the backlog and reports going to the Joint Management Team meetings and monthly updates to the Executive Committee. Jacqui confirmed if necessary the nurses in the CCGs brokerage team could be released to oversee the NELFT team. BHRUT Conor advised that the CQC inspection is due to be on 14 October and that the CCGs will be approached to be involved. All Clinical Directors to be on standby. Jacqui confirmed that the Barts Health inspection is on 4 November.

Note Note JH All

5.0 5.1 5.2

Contract Quality and Performance BHRUT Alan Steward gave an overview of the headline financial position which shows Havering CCG most affected and advised that the forecast variance is if the current trend continues. Dr Kakad raised the issue of having all the information available to be able to challenge the Trust at meetings and ensuring that there are appropriate preparation meetings beforehand to discuss how to handle particular issues at the meeting. Martin to pick up with CSU to ensure that this happens. With regards to the areas of over performance it has been reported that there has been an increase in complex pregnancies but Dr John advised that Public Health are not reporting on this so further information/ challenge should be requested against any charges. Martin agreed to take the Chairs through all processes taken with BHRUT at the next Chairs meeting so assurance is given that the management team are doing all they can to improve their performance. NELFT Dr Kumar gave an overview of recent activity advising that LETB have provided funding for dementia training to primary care staff. There was a query on how IAPT performance is measured. Dr Kumar to circulate for clarification. With regards to the CTT dashboard that is emailed Dr Kakad queried who is responsible for responding to any queries raised as he is still awaiting a response from an email sent. Clarification of the process for raising and responding to queries is required. Conor confirmed that this will be looked into and that a response is sent back to Dr Kakad.

Note MS Note MS Note RK JG/SM

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5.3 5.4

Dr John advised that as he is involved in the DH Year of Care pilot he has been able to review the costs received for a set cohort of patients from NELFT and that that some costs are not as expected. This could be an opportunity to look at the detail to find out exactly what we are paying for. Martin agreed that there are a lot of areas we can review in order to negotiate a better price but that we need to prioritise what to look at first. Barts Health This item was covered under item 4.1. 14/15 Commissioning Intentions All to review and come back with any comments as soon as possible. The Commissioning Intentions will be signed off at the October Executive Committee meetings. Agreed to hold a market place event to bring together existing and potential providers to make them aware of commissioning intentions.

All CB/MS

6.0 Urgent Care There was a lively and frank discussion around BHRUT Urgent Care performance and what more could be done to improve the situation and if a ‘Plan B’ was needed if the recovery plan submitted by BHRUT failed. It was agreed that we will need to re-procure urgent care services but that a robust strategy and plan is needed. It was agreed that the urgent care steering group would be reformed and the urgent care leads supported by the management team will start to develop a plan for the short, medium and long term. It will then be down to the leads to advise if and when notice should be served on BHRUT. A progress report to come back to JET next month. Dr Burack advised that the specification for the Queens urgent care model has been drafted so this could be used going forward.

Urgent Care leads/AS Note

7.0 Q&A with management team There were no questions raised.

8.0 Any other business Dr Heyes raised the issue of intranasal vaccination for children and that it seems that it has been assumed by NHSE that GPs will do this without any consultation. Dr John advise d that this was taken to the Londonwide LMC and that it should be raised with them but this did not go to the BDH LMC for discussion. It was agreed that there is also an issue around pharmacists providing flu vaccinations. Conor agreed to draft a letter to NHSE around both of these issues, acting on behalf of the CCGs GP members, flagging a quality and safety issue around the possibility of patients being vaccinated twice.

CB/JH

9.0 Date of next meeting Thursday 7 November 1.30-3.30pm, Becketts House.

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Joint Executive Team Meeting 7 November 2013

ACTION NOTES

Attendees: Dr Waseem Mohi Chair – Barking and Dagenham CCG Dr Arun Sharma Clinical Director – Barking and Dagenham CCG Dr Rami Hara Clinical Director – Barking and Dagenham CCG Sharon Morrow Chief Operating Officer – Barking and Dagenham CCG

Dr Atul Aggarwal (meeting Chair) Chair – Havering CCG Dr Maurice Sanomi Clinical Director – Havering CCG

Dr Anil Mehta Chair – Redbridge CCG Dr Sarah Heyes Clinical Director – Redbridge CCG Dr Jyoti Sood Clinical Director – Redbridge CCG Dr Heath Springer Clinical Director – Redbridge CCG Dr Mehul Mathukia Clinical Director – Redbridge CCG Dr Muhammad Tahir Clinical Director – Redbridge CCG Dr Syed Raza Clinical Director – Redbridge CCG Louise Mitchell Chief Operating Officer – Redbridge CCG

Conor Burke Chief Officer – BHR CCGs Martin Sheldon Chief Finance Officer – BHR CCGs Jacqui Himbury Nurse Director – BHR CCGs Sue Assar Interim Director of Corporate Services – BHR CCGs Jane Gateley Director of Strategic Delivery – BHR CCGs Graham Simpson NEL CSU Roy Weston NEL CSU

1.0 Dr Aggarwal welcomed Neil Kennett-Brown, Programme Director, Change Programmes, NELCSU

to JET to present the review of specialist cancer and cardiovascular services in North and East London and West Essex. Neil, for clarity, explained that he is employed by CSU but this review is being undertaken for NHS England. JET noted the tabled summary leaflet that sets out “why services need to change to improve services for today’s patients and future generations”. Neil talked through an update briefing which had also been tabled. He focussed discussion on the “cancer activity at BHRUT” slide and specifically on the suggested changes to the urology service; bladder and prostate and confirmed the likely recommendations for these. In answer to a query on how the position re prostate cancer had changed in the previous six months, Neil reported that the original consultation had been looking at a single site option but the feedback had been that an evaluation of a two site option should be done. Following a question about whether CCGs had engaged BHRUT re the review, Conor reminded JET that it is specialist services who commission cancer services and not CCGs. He did however remind the meeting of the Cancer Cardiac Programme Board next week (11.11.13.) and also the Programme Board on 16.12.13. As the latter would be key in terms of agreeing the preferred

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option, Conor suggested the CCGs’ CD cancer leads attend this. There was a query relating to availability of data to support efficiency savings and whether better patient experience could be demonstrated. Neil informed JET that NHS England was confident that overall the review would be value for money but that the Business Case was still being developed. To close, Neil advised that programme was keen to have CCG representation on the Programme Board. He also wanted to encourage CCGs to attend a drop-in engagement event being held on 13.11.13. 5.30-7.30pm at The Library, Romford. When JET was asked by NK-B if the review, especially changes to those services which would most affect BHRUT (upper GI and prostate), had CCGs’ support, the response was that more information would be required before CCGs could respond to this question. JET noted that this detail would not be finalised until mid-December 2013. Conor agreed to re-circulate details of the meetings referred to above. Post meeting: Dr Mohi has agreed to attend the Programme Board on 16.12.13.

2.0 Welcome, Introduction and apologies Apologies were noted from: B&D Dr Richard Burack, Dr Jagan John, Dr Gurkirit Kalkat, Dr Raj Kumar and Dr Chandra Mohan Havering: Dr Ashok Deshpande, Dr Jitendra Kakad, Dr Muhammad Rahman, Dr Gurdev Saini, Dr Alex Tran and Alan Steward Redbridge: Dr Shabana Ali, Dr Samia Azeem and Dr Chidi Okorie

3.0 Declaration of interest There were no (new) declarations of interest.

4.0 Minutes from previous meeting/Matters arising The minutes from the meeting held on 03.10.13 were agreed. Contract quality and performance BHRUT Martin Sheldon confirmed he had discussed with CSU the need for relevant information to be available for meetings to enable challenges to be made. NELFT Sharon Morrow confirmed she had arranged a meeting had been arranged with NELFT and Dr Kakad to discuss the CTT dashboard. Urgent Care JET noted a progress report on the above. Prompted by reference in this report to the 14/15 contracting round, Conor informed JET that a “Market Event” had been arranged on 21.11.13. 1.00-5.30pm @ CEME, Rainham. He encouraged CDs to attend this. AOB Conor confirmed that a letter had been sent to NHSE re both the intranasal vaccination for children and the provision of flu vaccinations by pharmacists.

5.0 5.1

Risk Assurance Collaborative Risk Log JET noted the presentation “Common high level risks against corporate collaborative objectives” introduced by Sue Assar. She explained that this forms part of the Board Assurance Framework (BAF) which is discussed at both Executive Committees and Governing Bodies and had been brought to JET for review the actions being taken. There were no questions or concerns raised. Martin was pleased to be able to report that the major risk relating to specialised commissioning funding had now been resolved due to the pressure exerted by the Technical Group.

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6.0 6.1 6.2 6.3 6.4

Contract Quality and Performance 2014-15 Contract Round JET noted the proposed governance arrangements and summary high level timetable for the above. BHRUT Dr Aggarwal presented the slides “Headline financial position and areas of variance” and “Contract issues and risks”. JET noted the Month 6 figure which showed a -£2,048,000 variance. Martin informed JET that there were ongoing negotiations re Q1 and Q2 activity and also that he had requested a year-end figure. He agreed to prepare a proposal for agreement by JET. Following a number of queries relating to the activity, Martin assured JET that the situation is being managed through the contractual procedures but agreed to provide an activity analysis for each CCG. NELFT JET noted the update included with the agenda. Sharon informed JET that Q2 closedown would be at the end of November but that she was not expecting NELFT to achieve performance against target for ICM caseload KPI. She was, however, pleased to report that crisis plans had improved, the ICM diagnostic tool had been updated and that on 01.11.13 the intensive therapy team and community treatment team went “live” and would be trialled over the coming months. Re contract negotiation, JET noted that there had been discussions with NELFT around setting up CCG teams to work on moving commissioning intentions into deliverables. In response to a query about the varied level of services to each CCG, Sharon confirmed that each CCG has a separate service specification but in future, the plan is to have one standardised service specification across the three CGGs. She agreed to breakdown the service lines and said this would assist with knowing the funded WTE posts and related vacancy rates. CCGs could then review the service being delivered to the contract. Martin informed JET that the aim is to move from a block contract (as now) to one based on activity. There was a general conversation about looking at the various components that comprise the NELFT contract and considering which of these could be put out to tender. Sharon confirmed that this was a possibility but it would be unlikely to happen until the 15/16 contracting round. It was noted that a letter had been sent to Jacqui Himbury to raise a risk around a new referral appointment system that NELFT had introduced which placed the onus on checking if the referral had been accepted with GPs. Martin agreed to raise this at the next contract meeting. Barts Health Dr Heyes presented the slides “Headline financial position and areas of variance” and “Contract status”. She confirmed that the contract remained unsigned. Martin updated JET on the current position re the contract, confirming that there had been a meeting to discuss the unsigned contract. He stated that CCGs had been consistent throughout the negotiations and had agreed a figure early on in the proceedings and had stayed with this amount. As outturn currently £24m above contract, Martin confirmed that an inappropriate contract would not be signed. JET noted that a notice had been submitted to Barts Health for activity above plan. Referring to bullet point 6 on the contract status slide related to 4,500 potential 52 week breaches, Dr Aggarwal was very concerned about who these patients are. Martin agreed to take action to identify these individuals. PELC The briefing included with the agenda was noted plus Dr Raza tabled an update to confirm to JET that, despite the current issues raised by “PELC doctors”, it was business as usual. Members were pleased that an investigation had commenced to

MS MS SM MS MS

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look at the key lines of enquiry that had been raised in the PELC doctors’ correspondence. There were concerns that CCGs would need to intervene before the situation worsened but RS was able to reassure JET that daily reports were being received from PELC which confirmed how the rota would be covered. To finalise the discussion, Dr Aggarwal asked that JET be confident of the daily reporting arrangements and to await the report on initial findings due w/c 25.11.13.

7.0 Acute Reconfiguration Jane Gateley talked through the slides highlighting that the Trust Clinical Strategy would be a working draft between now and Christmas with a view to approval at Governing Body meetings in January 2014. The Trust Emergency Care and Urgent Care Services Business Case would be going to their Board in December 2013 and to Governing Body meetings in January 2014. Jane would emphasise with the Trust that Governing Bodies would be the decision-makers and Martin added that the approval path for the business case would be crucial. Appendix 1 “Proposed readiness indicators” was considered a useful document as it highlights the risks related to achieving closure of A&E at KGH.

8.0 Q&A with management team Q: How is the relationship with NHSE? A: CCGs relationship with NHSE is variable but good locally; COOs are developing

relationships with the primary care team and MS doing same with finance. On a wider level, the relationship is developing and BHRCCGs had gained respect in challenging (successfully) some of the edicts from NHSE.

Q: Does working together as three CCGs have benefits when looking to review and change community services? A: Need to recognise the real change must come from individual boroughs/

localities both from provider and commissioner. This is an area where work is in progress.

9.0 9.1

Any other business Governing Body Development Day Sue Assar to circulate the programme for above w/c 11.11.13. CDs commented that attending in the morning of the development day would prove difficult. Conor acknowledged this and agreed to review the programme to take account of this.

SA/ CB

10.0 Date of next meeting Thursday 3 December 2013 6.30 – 8.30pm.

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Joint Executive Team Meeting

3 December 2013

ACTION NOTES Attendees:

Waseem Mohi (meeting Chair) Chair – Barking and Dagenham CCG Dr Jagan John Clinical Director – Barking and Dagenham CCG Sharon Morrow Chief Operating Officer – Barking and Dagenham CCG

Dr Atul Aggarwal Chair – Havering CCG Dr Ashok Deshpande Clinical Director – Havering CCG Dr Gurdev Saini Clinical Director – Havering CCG Alan Steward Chief Operating Officer – Havering CCG

Dr Anil Mehta Chair – Redbridge CCG Dr Shabana Ali, Clinical Director – Redbridge CCG Dr Mehul Mathukia Clinical Director – Redbridge CCG Dr Syed Raza Clinical Director – Redbridge CCG Dr Muhammad Tahir Clinical Director – Redbridge CCG Louise Mitchell Chief Operating Officer – Redbridge CCG

Conor Burke Chief Officer – BHR CCGs Martin Sheldon Chief Finance Officer – BHR CCGs Jacqui Himbury Nurse Director – BHR CCGs Jane Gateley Director of Strategic Delivery – BHR CCGs

Graham Simpson NEL CSU

1.0 Welcome, Introduction and apologies Apologies were noted from: B&D: Dr Richard Burack, Dr Rami Hara, Dr Gurkirit Kalkat, Dr Raj Kumar, Dr Chandra Mohan and Dr Arun Sharma Havering: Dr Jitendra Kakad, Dr Muhammad Rahman, Dr Maurice Sanomi and Dr Alex Tran Redbridge: Dr Samia Azeem, Dr Sarah Heyes, Dr Chidi Okoirie, Dr Jyoti Sood and Dr Heath Springer BHR CCGs: Sue Assar NELCSU: Roy Weston

2.0 Declaration of interest There were no (new) declarations of interest.

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3.0 Minutes from previous meeting/Matters arising

The minutes from the meeting held on 07.11.13. had not been included with the agenda as an action log had been included in place of the minutes as they had been circulated previously. The Chair requested that they be re-circulated. BHRUT Martin Sheldon confirmed that negotiations around Q1 and Q2 were still ongoing. He added that, for a number of reasons, BHRUT had not yet provided a year-end figure and that it appears there will be an £8.5m over-performance across the three CCGs. Barts Health A report on the potential 52 week breaches had been prepared and MS, JH and LM would meet to discuss. Martin Sheldon was pleased to be able to report that Q1 and Q2 and the contract information schedule had been agreed. The block element of this contract remains under discussion.

LS

4.0 4.1

Risk Assurance Collaborative Risk Log JET noted risks relating to Objectives 4 and 5 and updates from Directors as shown below: • Continuing healthcare assessments – ongoing backlogs and delays presents a

significant risk Jacqui Himbury confirmed that this remains a risk but that actions are being taken to mitigate this. She is meeting weekly with the responsible Directors from NELFT/CSU. In response to a question on the severity of the risk, Jacqui confirmed it is still “Red” rated but by April 2014 it should change to an “Amber” risk. A paper would be prepared for the three Executive Committees and following these discussions, a proposal would be prepared for discussion at the three Governing Bodies in January 2014.

• Retrospective claims inherited from the PCT presents a financial risk to our organisations Martin Sheldon confirmed that CCGs would receive funding to cover the above. He had expected to receive this by now but has not so has escalated to NHSE.

• Barts Health contract not resolved and the financial risk is not clear On agenda under “Contract quality and performance”.

• Specialised commissioning position

Discussion around the BHRCCGs’ risk increasing to £6m has brought figure down to £3m. However, aim is to agree a position of £2m as negotiated previously. Conor informed JET that the process currently remains informal but would be formalised if agreement cannot be reached. BHRCCGs are working with WELC and they too agree with this approach. Resolution i.e. cost neutral to CCGs, by the end of December 2014 would be the aim.

• Safe delivery of services by PELC – the lack of adequate and appropriate staff presents quality and patient safety risks On agenda under “Contract quality and performance”. BHRUT ongoing performance concerns On agenda under “Contract quality and performance”.

JH

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5.0 5.1 5.2 5.3 5.4

Contract Quality and Performance BHRUT JET noted “Headline financial position and areas of variance” and “Contract issues and risks”. Alan Steward added that contract mechanisms were being used to reduce the £8m over-performance and that the issues re the Q1 and Q2 close down process had been escalated. Following a two week period when the 95% target had been achieved, w/c 02.12.13. the target had been missed. JET noted that at the Urgent Care Board (UCB) held on 28.11.13. it was agreed that the 95% target must be achieved from January 2014 onwards. Conor Burke stressed it is imperative that the position improves as there is both a local and national “spotlight” on emergency services. For information and related to the 95% target, he confirmed that BHRCCGs would commence procurement for UCC and PELC at the beginning of 2015 and, in the meantime, is actively managing both providers of these services. Jacqui Himbury informed JET that there had been a MRSA case and that she would raise this at the next Clinical Quality Review Meeting and also that she was concerned that there may be a risk around mixed-sex breaches. As the Care Quality Commission report is not due to be published until 18.12.13., she planned to postpone the Quality & Safety Committee scheduled for 10.12.13. and re-schedule for two weeks’ later so the report could be discussed. A report on this would then be prepared for the three CCGs’ Governing Body meetings in January 2014. NELFT Sharon Morrow talked through the paper covering Q2 closedown position, Community Health Services performance – Q2 overview and Mental Health Services performance – Q2 overview and the contract risks were noted. She also added that CCGs were having individual discussion around physiotherapy, notice would be served on the CHC assessment service and that contract negotiation steering groups had been established. Following a point about looking for savings from NELFT, Jacqui Himbury highlighted that we do not have NELFT workforce numbers as, currently, they are not required to provide this information against service lines. However, the intention is to strengthen this in future through the contract negotiation process. It had come to the attention of a JET member that NELFT were intending moving Children’s Services to a new site in Romford. Conor confirmed that if this was the case, NELFT would need to go through a consultation process. However, he would raise at a scheduled meeting with John Brouder and Jacqui Van Rossum on 04.12.13. This particular concern prompted Conor to request that the proper mechanism ie raise with relevant COO so they can raise with the newly-appointed NELFT Borough Directors, be used for these sorts of operational issues. In response to a question about whether the additional investment had made a difference, Sharon confirmed that she was aware of improvements in B&D. She added that for 14/15 there will be a review process for CQUINS and KPIs. The Chair closed the discussion by re-confirming that there should be an attempt to resolve operational matters so they are not brought to JET meetings and that he got the impression that BHR CCGs were being more stringent around the NELFT contracting arrangements of late and this is the preferred approach. Barts Health JET noted the slides “Headline financial position and areas of variance” and “Contract risks and key actions”. Louise Mitchell added that the arrangements with WELC were being strengthened to ensure BHR individual CCGs were represented more than currently. She would feedback on this following a meeting on 04.12.13. PELC Dr Raza introduced the above item and reported that Phase 1 of the investigation was

JH CB LM

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complete and it had reported that there had been no breach of contractual matters nor any clinical risk or SUIs. Phase 2 of the investigation would include a clinical review of early stage pregnancy records, evidence from PELC doctors and reviews of PELC and external audits. This would be completed in February 2014. It was raised that PELC had recently had elections to their council and that it is in their constitution that CCGs can have a representative. It was agreed that BHR CCGs would look into this role and report back to the next JET meeting. Market Event held on 18.11.13. JET noted the bullet-point briefing on the above. It was confirmed there would be a further event in January/February 2014 and, as part of this next stage, there would be a discussion on whether practices could be AQP providers. Commissioning Intentions (CI) and QIPP The update included with the agenda on the above was noted.

CB

6.0 Strategic and Operational Planning Jane Gateley talked through the paper included with agenda and in particular, highlighted the key dates schedule. She confirmed that although the deadlines are quite tight, it would be possible to use much of the work already done and for the primary care and specialist commissioning aspects, BHRCGGs would work with NHS England to complete. The scheduled Integrated Care Joint Health and Social Care Steering Group on 11.12.13. would now be used as a workshop to prepare for the strategic plan submission. The CCGs “Plan on a page” would be submitted to Governing Bodies and the Integrated Care Coalition in January 2014 for approval. BHR CCGs would be clear to NHSE that each Borough has a plan but work is very much undertaken across the three; an approach which is supported by NHSE. The paper referred to delivery through the Integration Transformation Fund (ITF) which prompted a question about the ITF. Conor explained that it is a Department of Health initiative that is administered via NHSE and is a ring-fenced resource that would enable CCGs to track how it is used to deliver improvements. JET noted that in 15/16 £6m per CCG would need to be identified for ITF. Jane confirmed that her team is already working on this with the CCGs and also there is a workshop “Transforming Integration in London” on 10.12.13. A report detailing priorities would be discussed at each Health and Wellbeing Board.

7.0 Planned Care Dr Mohi presented the above paper which covered the vision, progress 12/13, priority work streams (ophthalmology/MSK/diabetes), plans for 14/15. There had been a well support workshop on diabetes where the aim is to have the same standard of care across the three CCGs. The overall aim of the planned care work is to review current practice and if it is not of a high standard, to look at what is and replicate. Conor advised there would be support for GPs to develop to be able to provide services in future. There was a request for BHRUT to have a generic “ask BHRUT” email address. There is a local provider who has this and it is very useful. Dr Mohi agreed to raise at the next Planned Care Steering Group.

WM

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8.0

Q&A with management team Q: Is the JET venue going to be rotated? A: Conor confirmed that is the plan. Q: At a recent event “Transforming Primary Care” held on 28.11.13. there was a

sub-text that there would be an amalgamation of areas. Did Conor know more about this?

A: Conor confirmed he was aware of this thinking but did not know any more than had been presented at this event.

Q: Could CTT be developed? A: Conor informed JET that a frailty project has recently started but agreed further

discussion would be useful and suggested it be discussed at JET in a couple of months’ time.

Q: Is there an update on winter monies? A: A report had gone to the Urgent Care Board. Conor would arrange for this to be

circulated to JET.

Note CB

9.0 9.1

Any other business Collaborative cancer commissioning group Sharon Morrow informed JET that a collaborative commissioning cancer group would be set up and this would be the locality group which would feed into commissioning intentions and confirm the various configuration changes taking place. The first meeting of this group would be in the New Year. Alan Steward agreed to circulate the recent letter that had been sent to NHSE re specialist cancer services. Referring to the two week cancer referral pathway, Jacqui Himbury requested that if GPs experience any cases that are not being included on this, to let her know as she had been informed that this has occurred. She would be taking forward via CQRMs and the Quality & Safety Committee. Governing Body Development Day on 05.12.13. Further to discussion at JET on 07.11.13., the programme had been reviewed and the “Accelerating the development and improvement of primary care” session moved to the afternoon to enable clinical directors to attend. This key session would discuss how CCGs could take a leadership role in this and how primary care providers could be supported. Conor confirmed that the plan is to progress this in the New Year with some dedicated resource in place. JET Forward Planner January – March 2014 The above was noted and it was confirmed that the main agenda for the next meeting in January 2014 would be primary care development.

AS JH Note

10.0 Date of next meeting Thursday 9 January 2014 1.30 – 3.30pm

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