NHS City and Hackney Clinical Commissioning Group (CCG) Board Friday … Us/Board... · Chair: Dr...

Chair: Dr Clare Highton Chief Officer: Paul Haigh

NHS City and Hackney Clinical Commissioning Group (CCG) Board

Friday 25 October 2013, 14:15 – 16:00

Bloom 1, Tomlinson Centre, Queensbridge Road, London, E8 3ND

AGENDA Chair: Dr Clare Highton Agenda Items

Led by & Appendix number

Timing

1. Welcome, introductions and declarations of Interests

Clare Highton Verbal

1415-1420 (5 mins)

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

Clare Highton Papers 2a & 2b Pages 3-17

1420-1425 (5 mins)

3. Questions from the public Clare Highton Verbal

1425-1435 (10 mins)

CLINICAL STRATEGY (FOR DECISION) 4. Commissioning for Values Clare Highton

Paper 4 Pages 18-41

1435-1445 (10 mins)

5. Winter Pressures update • To note confirmation of funding.

Karl Thompson Paper 5 Pages 42-48

1445-1455 (10 mins)

6. Out of Hours mobilisation update Haren Patel Paper 6 Pages 49-56

1455-1505 (10 mins)

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7. PPI Committee update: • CCG response to the Call to Action; • November 2013 event.

Jaime Bishop Papers 7a, 7b & 7c Pages 57-88

1505-1525 (20 mins)

PERFORMANCE 8. CCG Finance update:

• Month 6 Finance and Activity report; • 2013/14 Homerton University

Hospital NHS Foundation Trust contract;

• 2013/14 WELC Risk Share; • 2014/15 planning update.

Philippa Lowe Paper 8 Pages 89-99

1525-1545 (20 mins)

FOR INFORMATION 9. Reports from Subcommittees of the Board:

a. Key issues from the Clinical Executive Committee;

b. Key issues from the Finance and Performance Committee.

Clare Highton Papers 9a & to follow Pages 100-101

1545-1550 (5 mins)

10. Friday 29 November 2013 draft CCG Board agenda

Clare Highton Paper 10 Pages 102-104

1550-1555 (5 mins)

11. Any Other Business Clare Highton Verbal

1555-1600 (5 mins)

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MINUTES OF THE NHS CITY AND HACKNEY COMMISSIONING GROUP BOARD

HELD ON FRIDAY 27 SEPTEMBER 2013

AT BLOOM 1, TOMLINSON CENTRE, QUEENSBRIDGE ROAD, LONDON, E8 3ND PRESENT: Dr Clare Highton (CCG Chair)

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

IN ATTENDANCE: Emma Craig (Hackney HealthWatch) Sam Mauger (City of London HealthWatch)

Sean Overett (CSU Director of Contracts) Sohail Bhatti (LBH interim Director of Public Health) Matthew Knell (CCG Business Co-ordinator) Karl Thompson (CCG Urgent Care Programme Director and Head of Corporate Affairs) Dr Victoria Holt (CHUHSE Clinical Director) for agenda item 4 Kate Adams (111 Clinical GP Lead) for agenda item 5 Dylan Jones (HUHFT Chief Operating Officer) for agenda item 6 Sallie Rumbold (HUHFT Divisional Operations Director) for agenda item 6 Louise Egan (HUHFT Divisional Head) for agenda item 6 Jenny Singleton (CSU Quality Assurance Manager) for agenda item 11 Dr May Cahill (CCG Urgent Care Clinical Lead GP) for agenda item 12 Frances Schmocker (CCG Maternity and Children’s Services Programme Director) for agenda item 14

Agenda Item 1 – Welcome, introductions and declarations of Interests The Chair, Dr Clare Highton (CH) welcomed members to the September 2013 meeting of the NHS City and Hackney Clinical Commissioning Group (CCG) Board. CH and Gary Marlowe declared interests in agenda item 4, as opted out GPs and members of the City and Hackney Urgent Healthcare Social Enterprise and confirmed that they had taken no part in the procurement process. Agenda Item 2 – CCG Committee business Minutes of the last meeting

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The minutes of the Friday 26 July 2013 CCG Board meeting were cleared without change. Register of Interests The Board noted the Register of Interests. Matters arising All matters arising were covered under the agenda of the meeting. Agenda Item 3 – Questions from the public Caroline Brooks had submitted a question in writing ahead of the Board meeting, Matthew Knell (MK) apologised for the question not being present at the meeting and advised that the CCG would make a written response. ACTION: MK to co-ordinate written response to Caroline Brooks question. Michael Vidal (MV), a member of the public, asked what the CCG is doing with regards to patient information sharing in practices following the national policy. CH asked MV to take his question to the Local Medical Committee (LMC) and NHS England (NHSE), as the data collection was not ordered by the CCG, neither did the CCG have any control or input to the NHSE driven process. Agenda Item 4 – Award of ‘Out of Hours’ contract Victoria Holt (VH), Clinical Director from City and Hackney Urgent Healthcare Social Enterprise (CHUHSE) joined the Board meeting, passing on apologies from Deborah Colvin and Mark Cockerton. The CCG tabled a paper outlining the process undertaken to reach the procurement decision to award the contract to CHUHSE. The CCG Board thanked VH for a comprehensive bid and VH stated that she and everyone involved in CHUHSE were overjoyed to be given the opportunity to transform local out of hours (OOH) care. VH explained that CHUHSE was underpinned by local knowledge from local GPs with excellent experience not just clinically, but of working and living in the area. Their service will be responsible and flexible, with bases of operation at Homerton University Hospital NHS Foundation Trust (HUHFT), Lawson Practice and the John Scott Medical Centre, giving the organisation accessible coverage of the borough and, in the Lawson Practice, a site that is located close to the City of London. CHUHSE want to demonstrate what a great out of hours service looks like and work with HUHFT to impact on Accident and Emergency (A&E) attendances and activity. CHUHSE knew that there was support and desire for their service, with 34 local GPs having applied for shifts before the organisation formally existed or had secured the contract. All

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GPs who have approached CHUHSE have also been involved in the bid process and have been invaluable in developing and refining its plans. Over 90% of all doctors applying to CHUHSE have local connections – they had either trained in the area, worked locally or lived nearby. CHUHSE do not anticipate staffing issues considering the interest and quantity of applications they have received, they already have capacity to provide a full service. Christine Blanshard (CB) recognised that the CHUHSE contract represents a £1.6m cost pressure for the CCG and asked for detail on how CHUHSE will deliver out of hours services to offset the pressure. VH replied that CHUHSE have several plans to put into practice, including the wider availability of peak hours out of hours access at its three sites, doubling the historical number of GPs on call to two and closely working with HUHFT. Honor Rhodes (HR) asked what difference City of London patients will see with in the service. VH responded that the key difference will be the availability of the Lawson Practice in peak hours, easily accessible to City residents will be important and that CHUHSE will be working with Barts Health in addition to HUHFT to ensure their services are aligned and communication is clear between all involved organisations. CHUHSE are also a member of a national health social enterprise network that they will be sharing best practice and knowledge with and learning from. Jaime Bishop (JB) praised CHUHSE’s patient engagement work undertaken to date and CH asked for more information on the HUHFT relationship, considering VH’s dual role in PUCC at the Trust. VH replied that CHUHSE and HUHFT are still working through specifics, but that CHUHSE hope to demonstrate an impact on activity at both A&E and in the PUCC. VH flagged that GPs and the OOH service will need to operate on different IT systems to those used at HUHFT, presenting some complications with regards to comparisons and access to data across organisations. A member of the public asked when the service would mobilise and Paul Haigh (PH) responded that Harmoni is still in place as the current service provider and the CCG hopes to mobilise the CHUHSE service towards the end of November or beginning of December 2013. The CCG wants to ensure that a safe transfer of the service takes place before the worst of the winter period commences in January 2014. CH supported this plan, adding that the CHUHSE service will also need to be advertised widely and used to support the CCGs winter plan. Agenda Item 5 – NHS 111 step in provider Dr Kate Adams (KA) joined the CCG Board meeting to present an update on the status of the local 111 service and the appointment of a step in provider. KA briefed the Board that NHS Direct (NHSD) had been appointed to deliver the local 111 service in the original procurement process had consequently delivered a solid service locally, with low ambulance conveyance rates. Unfortunately, it appeared as though NHSD had committed to providing too many 111 contracts around the country and encountered problems in delivery that have been widely discussed over the last few months.

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Since NHSD requested to exit the local contract (which covers Waltham Forest, East London and the City (WELC)), another procurement process took place, resulting in Partnership of East London Co-operatives (PELC) being appointed to deliver the core 111 service, while the out of hours call handling has been retained with the CCGs out of hours provider until a point where it is felt to be safe to flip that part of the service over. NHSD remains the provider until PELC are mobilised and the service switches over, this is expected to take place in early November 2013. The CCG will continue to encourage use of patients local GP and the new OOH service once live, while ensuring the 111 service is safe and reliable for those who wish to use it. KA noted that under the new provider, the call cost will increase, but that the rise has been contained in comparison to other areas in the same situation. The CCG Board discussed the current use of the service, noting that there are approximately 65 calls a day in the area currently, with the most common calls concerning toothache and access to emergency dentistry. HR asked that this issue be taken up with NHS England as the commissioners of primary care dental provision in the area. ACTION: 111 team to escalate volume of calls concerning dentistry to NHS England. Siobhan Clarke (SC) expressed some concern around the proliferation of out of hours services and how patients could be supported to navigate them. KA responded that they have audited the use of the various systems in place and will continue to do so to reach an informed view of usage and any future change. There is room for improvement and efficiency in assisting patients in reaching the right service in their first contact, for instance patients presenting to their GP the following day following a 111 call the previous evening. Philippa Lowe (PL) noted that there is provision in the existing contract with NHSD for them to be pursued for closure costs and that the CCG will retain the right to take this up. MV asked why the service isn’t commissioned by NHSE, considering it covers their services as much as the CCGs. CH responded that NHSE had delegated responsibility for the provision of a locally specific service to CCGs, but retained some responsibility for assuring the service. KA asked the Board to delegate the review of the independent third party assurance of the 111 service to the 111 Programme Board, which has membership from each of the three CCGs, in City & Hackney this is via Karl Thompson, Urgent Care Programme Director. The Board agreed to this request and asked the Urgent Care Programme Board to receive and review the assurance. DECISION: CCG Board agreed to delegate the review of the independent third party assurance of the 111 service to the 111 Programme Board. DECISION: CCG Board asked the Urgent Care Programme Board to receive and review the 111 service independent third party assurance.

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CH thanked KA for her work in this area and stated that the CCG needed to be clear and transparent when working with patients to assist them in reaching the most appropriate out of hours advice or treatment. Part of that conversation could include information about the cost of A&E attendance against OOH, 111 and GP services and where the most accessible, safe and effective clinical care for their needs lies. Agenda Item 6 – Homerton Hospital Community Health Services Dylan Jones (DJ), Sallie Rumbold (SR) and Louise Egan (LE) joined the CCG Board to speak to this agenda item. CH thanked them for attending and briefed the Board that Tracey Fletcher had presented to the last meeting on this subject and that the Board had asked for the Homerton University Hospital NHS Foundation Trust (HUHFT) to return to discuss the impact of their Community Health Services (CHS) on the local area and other services. This report would follow to a future meeting of the Board, but that HUHFT were present to discuss bids against the readmissions fund to support further integration of their services and better services for the area. DJ outlined the bids that HUHFT had put forward, advising the Board that they reflected the direction of the integration of care that the Trust was moving towards, and that they had been jointly developed by clinical and operational colleagues. The integration of some bids with local social care services was vital and the Trust would be working closely with the relevant colleagues across organisation to ensure the vital elements are in place. CH advised the Board that each of the bids has been considered by the CCGs Clinical Executive Committee (CEC) and the relevant CCG Programme Board was working directly with HUHFT and the Commissioning Support Unit (CSU) to work up further detail and service specifications. PL added that although the funding this year was non recurrent via the readmissions fund, the proposals must be sustainable and able to be continued on successful evaluation. CH supported DJ’s commitment to social care integration and asked that HUHFT also consider its communication and links with other organisations, for instance the London Chest Hospital where occasional issues with referral and transfers had been experienced. CB raised that last year’s Heart Failure audit had revealed patients experiencing better care until cardiologists care than another specialty, so why was the HUHFT bid working against those results. DJ replied that a cardiologist would be involved in the service, but working in partnership with a geriatrician. HR asked that any evaluation of the services includes measures of patient experience and staff views. HR added that the Trust could do better in communicating its high level of leadership, both clinical and operational and promotion of excellence across the area. SC asked whether the Trust had considered forming an admission avoidance integrated team, as had proven successful in several others of the country. DJ replied that it could be looked into.

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MD asked how the investments success will be measured, PH advised that there would be further information on this in the following agenda item and DJ added that HUHFT needed to ensure that the bids were clear and well documented and that the service improvement measures were transparent and agreed by all parties. DJ continued to explain that the previous 18 months has seen a noticeable decrease in social care package availability and ease of access and consequent pressure on HUHFT. The discharge management team bid is a short to medium term fix to the problems being experienced to deal with the winter of 2013/14 and that the service will be assessed and iterated on for potential future expansion. DJ responded to HR’s earlier question regarding Trust leadership, briefing the Board that a staff wide exercise on the strategic direction and behaviours is underway and that the Trust recognises this area has been an issue in the past. Louise Egan (LE) added that the Trust’s movement towards reducing agency workers and employing directly has been helping. Sohail Bhatti (SB) asked that the Trust look into the various tools available to it to measure and report on leadership and staff engagement. CH thanked HUHFT for their presentation and informed them that the Board would be taking a decision on the bids in the following agenda item. Agenda Item 7 – Reinvestment of readmissions and emergency tariff funds PH asked the Board to endorse the recommendations from the CCG’s CEC with regards to the reinvestment of readmissions and emergency tariff funds, as discussed in detail by the Board in the previous agenda item. PH also asked for delegated authority for PH and PL to sign off the final service specifications once key performance indicators (KPIs) are worked up. This authority was needed to ensure swift mobilisation of the services prior to the next Board meeting. DECISION: CCG Board endorsed the reinvestment of readmissions and emergency tariff funds recommendations from the CEC and agreed to invest in the bids outlined in the Board paper. DECISION: CCG Board agreed to delegate authority to PH and PL to agree the final reinvestment of readmissions and emergency tariff funds service specifications. PH added that the Finance and Performance Committee (FPC) and Clinical Quality Review Meeting (CQRM) will be monitoring the performance and quality of the services covered by the bids and that further monies are likely to be available, as not all of the funding available in the reinvestment pool has been used. Further bids have been invited to address admissions from nursing homes and the Board will be kept updated. Agenda Item 8 – 2014/15 Community Health Services contract

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CH informed the CCG Board that the existing Community Health Services (CHS) contract, currently held by HUHFT is due for tender in March 2014. The CCG has been monitoring the progress of similar processes undertaken by other CCGs around the country and after internal discussion is recommending that the Board offer a one year extension to the existing contract with HUHFT in order to learn from other area’s experiences. DECISION: CCG Board agreed to extend the CHS contract by 12 months, to end in March 2015. CH added that this extra time would allow the CCG to further work up the services as a comprehensive integrated care service, not just ex Primary Care Trust (PCT) community services. HR agreed, adding that a procurement exercise now could prove to be damaging to the long term future of the services involved. SB informed that Board that the London Borough of Hackney is currently evaluating its options with regards to the services it has inherited and that those options do include procurement. Agenda Item 9 – Establishment of a Prioritisation Sub Committee of the CCG Board CH outlined the role of the Prioritisation Sub Committee, as indicated in the accompanying Board paper, adding that historically the Department of Health had released funding to support winter pressures to all Trusts; however those funds had been reserved to Trusts experiencing issues this year. DECISION: CCG Board agreed to establish a Prioritisation Sub Committee as outlined in the Board paper. PH briefed the Board that the recent winter pressures changes meant that HUHFT would not be receiving any support this winter. The CCG is proposing to instead invest some of its available funding through a separate process to the main Prioritisation process. PH proposed to run this secondary process will be run through the Urgent Care Programme Board (UCPB) and asked for Board authority to sign off investment of funds by agreement between PH, CH and PL. Details of the agreed investment would return to the October 2013 CCG Board and be limited to a maximum of £1m. Again, time was of the essence in this area to enable HUHFT to mobilise the additional capacity in time for the winter pressures period. DECISION: CCG Board agreed to delegate examination of winter pressures bids to the UCPB and authority to agree a maximum of £1m funding to PH, CH and PL collectively. ACTION: Details of the agreed winter pressures investment to return to the October 2013 CCG Board. Stuart Maxwell, a member of the public asked that the Prioritisation Sub Committee be open to observation by the public. CH agreed, adding that the CCG wanted to be

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transparent about these decisions and asked for members of the public interested in attending the meeting to contact the CCG to obtain details of the meeting. Agenda Item 10 – CCG Finance update PL outlined the latest financial position of the CCG, including that the year to date position was breakeven and the CCG was reporting a £4,084k surplus and £679k favourable to full year plan. QIPP delivery reports an amber rating, with delivery of some schemes dependent on final contract agreements being signed. However, £0.5m actual and £0.6m prescribing savings were recognised and reported in M5 and help bridge the present under delivery in other areas. The CCG is experiencing a current acute overspend of approximately £3m, however does have a variety of challenges underway with Trusts regarding charges and with NHSE regarding allocations which are expected to reduce this position. PL apologised for the poor quality of the dashboard on page 48 of the report, which is due to errors in data supplied by the CSU and misattribution of activity across commissioners. The CCG is still experiencing significant challenges in seeking reliable data and resolution of this area is the finance team’s highest priority in order to reach a true picture of performance for month 6. Sean Overett (SO) recognised the challenges faced by the CCG and informed the Board that the CSU is working to address the issues. PL informed the Board that the 2013/14 contract with HUHFT has been agreed and is currently being finalised for signature. NHSE have published a draft 2014/15 funding formula which, if unchanged, could result in around a £17m reduction in the CCG commissioning allocation. Consultation on the formula is underway, but the final formula is expected to be age based, rather than the current deprivation formula. On the positive side, it is proposed to base the allocation on GP list size, rather than the current Office for Nation Statistics survey, which helps mitigate some of the impact. The CCG Board discussed the change, expressing hope that any move to a new formula will be staggered to allow areas to adjust to the significant changes in funding and consequent impact on services. PL added that the allocation change, coupled with the Integrated Transformation Fund (ITF) impact could result in up to a £27m reduction in funding for the City of London and Hackney. PL will be monitoring this area closely over the next few weeks and will keep the Board updated. PL briefed the Board that the CCG has written to all its providers informing them of the CCGs need for patient consent to share identifiable information with the CCG in order to guarantee payment of invoices. This step has been necessary due to the changes in information governance (IG) rules and the challenged the CCG has been facing in assuring that the invoices it pays against are correct and being charged to the responsible commissioner. Some providers have taken issue with the request, but the CCG Board supported the move, adding that the Board could not assure itself of its accounting procedures without access to this information.

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PL updated that the PCT legacy management team has now closed and that balances remaining in the NHS City and Hackney PCT accounts would be passed to the CCG in the upcoming weeks. This would allow the CCG to investigate some of the obligations organisations across the area had attempted to resolve with the legacy management team unsuccessfully. Agenda Item 11 – Quarterly Quality report Jenny Singleton (JS) joined the CCG Board to present the Quarterly Quality report. JS noted that the report includes a wealth of information arising from the 2012/13 acute and mental health staff surveys which had been released and analysed recently. JS acknowledged that the CCG has asked for future inclusion of clinical audit information and that this will be available in future reports. CB asked why the data for Barts Health appeared to be lacking. JS responded that the Trust was experiencing problems in disaggregating data across its sites. HR added that this can’t continue and what data is present didn’t inspire confidence in the Trust, also that HUHFT appears to be lacking in several key areas in the staff survey as well. Both Trusts could do with a strengthening of clinical leadership and higher ambitions. SC commented that many existing and established NHS tools for measuring quality could be significantly improved to make them useful for commissioning for health gain. SC added that data in the report is very useful, but needs to be taken with a balanced view of the whole system. CB added that HUHFT comes out of the report as a well-managed, efficient organisation. The majority of clinical outcomes are good, however the patient experience is lacking in areas. CB questioned how the CCG as the commissioner can address the values and culture of an acute Trust in order to improve those measures. CH added that the trend of lower patient surveys scores is well documented in inner city areas and is a challenging problem to address due to a multitude of factors. The strong staff survey results should be praised. The CCG needed to work with the Trust to support further development in this area. Sam Mauger (SM) emphasised the need to embed compassion across all services and encouragement of a deep patient understanding and empathy amongst staff is vital for the Trust. SM stated that HealthWatch has taken feedback from patients that although HUHFT is a trusted hospital, patients do witness problems in their experience there. Agenda Item 12 – PCT Review of GP Out of Hours Services at NHS City and Hackney, NHS Camden, NHS Islington and NHS Haringey May Cahill (MC) joined the Board to support the Board’s discussions of the PCT review of the Guardian newspaper’s allegations regarding Harmoni’s out of hours service from the start of the year. The Board accepted the final report from NHSE, who had inherited it from

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the PCT on its closure, noting that the CCG had had no input into the terms of reference of the investigation, content or final version of the document. MC acknowledged the delay in the release of the report, and that it appeared to have slipped in the NHS re-organisation. It was thought that the PCT Board had not seen the report prior to its closure. PH added that the CCG must ensure that it is more open and transparent than historical organisations in areas similar to this – material like this should be open to public scrutiny and questioning. MC outlined the measures put in place since the novation of the out of hours contract to the CCG from the PCT in April 2013, including a revised and strengthened quality and performance monitoring framework. The Board noted the improvements in Harmoni rota fill in the last few months. Nick Mann (NM), attending the Board meeting as a member of the public and a local GP asked the Board whether the inconsistencies and inadequacies of the PCT report had been noted, chiefly that the report contains contradictory information with regards to Harmoni’s ability to alter time stamping data and consequently it’s performance reporting. NM raised that the report makes specific mention of witnessing a GP working for Harmoni changing time stamp information in retrospect, after the report had stated this is not possible. CH responded that the CCG will look further at this matter and escalate it to the appropriate authorities formally. ACTION: MK to gather NM’s statement regarding data collection inconsistencies in the PCT report and escalate it to the appropriate organisation. CH moved on to discuss how the CCGs strengthened performance and quality framework will also apply to the new out of hours provider and will be widened to include clinical audit, patient experience measures and GP views of working with the service in the future. Agenda Item 13 – Maternity capacity update Frances Schmocker (FS) joined the Board meeting to present an update on capacity issues recently encountered at HUHFT, noting that performance had improved in recent weeks and that patient experience measures remained strong. Continuity of midwives in ante natal services had been specifically praised, but post natal care on wards was identified as needing some improvement in patient experience. The Board recognised that the ante natal experience was possibly not realistic to expect on the ward, but asked the Maternity Programme Board to work with HUHFT to deliver improvements where possible. Agenda Item 14 – Award of Social Prescribing contract FS updated the Board that the extraordinary CCG Board earlier in September 2013 had agreed to award the pilot social prescribing contract to Family Action following an invitation to tender process sent to five local voluntary community services. The Board thanked FS

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for the CCGs work in this area, expressing excitement at the prospects for the future of the service. FS updated that work was now beginning to commence the service, with a three month ‘soft’ launch and a formal ‘go live’ in January 2014. The service was for 12 months initially, but work was underway to investigate an extension to 18 months and the Board would be kept updated. HR asked that the evaluation of the project is shared widely, noting that she had recently come across a similar project that she would forward on details of to FS. Agenda Item 15 – Reports from Subcommittees of the Board The Board accepted the reports from its subcommittees and noted the contents. Agenda Item 16 – Draft September 2013 CCG Board agenda The Board noted the agenda of the following months meeting. Agenda Item 17 – Any Other Business No other business was discussed. AGREED BY: AGREED ON:

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

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

Foundation Trust that does not hold any contracts

with the CCG.

Clare Highton 18/04/2013 CCG Chair

Long Term Conditions Programme Board Clinical Lead GP /

Chair

Childrens Programme Board Lead GP

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

our practice now provides a CCG Commissioned

community ENT clinic run by my GP partner

Dominic Roberts with our local ENT consultant. The

practice also employs 3 Heart Failure nurses and

their HCA.

Lower Clapton is a research associate practice, so

does not hold grants but does participate in

research that is funded.

Clare Highton 18/04/2013 CCG Chair

Long Term Conditions Programme Board Clinical Lead GP /

Chair

Childrens Programme Board Lead GP

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

and Portman NHS Trust is my husband.

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

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

Hamlets

Dianne Barham 16/04/2013 London Borough of Hackney Healthwatch Representative ELFT

Tower Hamlets CCG

Hackney and the City PCT

Undertaken research for ELFT, Tower Hamlets CCG,

Hackney and the City PCT.

Emma Craig Not yet received London Borough of Hackney Healthwatch Representative Not yet received Not yet received

Gary Marlowe 16/04/2013 CCG Board GP

Planned Care Programme Board Clinical Lead GP / Chair

De Beauvoir Surgery (CCG Member Practice) Partner at De Beauvoir Surgery of GMS services and

a provider of Locally Enhanced Services.



London-wide Medical Committee City and Hackney Representative at the London-

wide Medical Committee, the representative body

for London’s GPs.



British Medical Association London Regional Council Representative for the

British Medical Association (the major trades union

for medical practitioners) - regional representative,

representing doctors professional and working

interests.

NHS City and Hackney Clinical Commissioning Group

Register of Interests

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Haren Patel 16/04/2013 CCG Clinical Vice Chair

Clinical Executive Committee Chair

Prescribing Programme Board Clinical Lead GP / Chair

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

and Intermediate/Secondary Mental Health Service

Provision. Interest in mental health services at the

Latimer PMS Plus Practice.




Latimer PMS Plus Practice (CCG Member Practice) Partner, Dr Geeta Patel clinician with special

interest.




North East London Medicine Management Committee Co-Chair of North East London Medicine

Management Committee




City and Hackney Local Medical Committee Member of the City and Hackney Local Medical

Committee (the representative body for GPs)




Acorn Lodge Nursing Home Lead Clinician providing NHS GMS and Enhanced

Services under Nursing Home LES to the Acorn

Lodge Nursing Home. Interest in intermediate care

and community services under PMS contract.

Honor Rhodes 16/04/2013 CCG Board Associate Lay Member

Individual Funding Request Panel member

Barton House Practice (CCG Member Practice) Patient at Barton House, Albion Rd Practice



Tavistock Centre for Couple Relationships Director of Strategy at the Tavistock Centre for

Couple Relationships.



Children and Family Courts Advisory and Support Service

(CAFCASS)

Non Executive Director at Children and Family

Courts Advisory and Support Service (CAFCASS).



Early Intervention Foundation Trustee at the Early Intervention Foundation.



The Institute of Wellbeing Mentor to CEO of The Institute of Wellbeing, a

voluntary agency who may seek to contract with

the NHS in future in South London.



Oxleas CAMHS Partner is a Consultant Family Therapist with Oxleas

CAMHS

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Jaime Bishop 23/09/2013 CCG Board Public and Patient Involvement Lay Member

Public and Patient Involvement Committee Chair

Fleet Architects LTD Director of Fleet Architects LTD, a company working

on socially valuable buildings. We do not currently

have any involvement in the City and Hackney area.

50% shareholder in Fleet Architects. Fleet have

been appointed in 2013 to advise on the

reconfiguring of property in Newham (The Centre

Manor Park) which involves liaising with tenants

including the CHS arm of the East Foundation Trust

(ELFT).



HealthPorts LTD Fleet Architects own 33% of HealthPorts LTD, a (as

yet not trading at all) company established to

design accessible sustainable modern health

centres. Fleet provide design services. There are

currently no projects although in the course of

researching new projects HealthPorts has contact

both with the NHS, GPs and other health providers

outside of the City and Hackney Area.



Architects for Health Executive Committee Member and Head of

Education at Architects for Health, I run annual

Student Design Competitions in conjunction with

other healthcare stakeholders including NHS Trusts.

2011 and 2012 were in conjunction with Guys and

St Thomas NHS FT.



Barretts Grove Practice Patient as a Hackney General Practice, Barretts

Grove.



ELIC (East London Integrated Care) LTD Member of the ELIC (East London Integrated Care)

LTD (a Practice Based Commissioning body) Audit

Committee that is overseeing the wind up of the

dormant social enterprise.

ELIC is now defunct save some final legal winding up

proceedings underway.

Karl Thompson Not yet received CCG Urgent Care Programme Director and Head of

Corporate Affairs

Not yet received Not yet received

Lynn Strother 18/04/2013 City of London HealthWatch representative Age UK London

The Greater London Forum for Older People

The charities I am employed by – Age UK London

and The Greater London Forum for Older People

are funded by grants and donations.

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

Audit Committee Chair

Remuneration Committee Chair

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

placement agency not operating in or with the NHS.




Aletheia Partners LLP Aletheia Partners LLP, a Private Equity advisory firm

not operating in or with the NHS.




Tower Hamlets CCG Lay Member for Governance for Tower Hamlets

CCG

Paul Haigh 16/04/2013 CCG Chief Officer ELIC (East London Integrated Care) Chief Executive of ELIC (East London Integrated

Care) (a Practice Based Commissioning body

registered as a social enterprise). The social

enterprise has now ceased trading and is being

wound up

Also member of ELIC’s Audit Committee that is

overseeing the wind up of the dormant social

enterprise.

Paul Haigh 16/04/2013 CCG Chief Officer NHS England Partner - Helen Bullers is Regional Director of HR

and Organisational Development (London), NHS

England.

Philippa Lowe 16/04/2013 CCG Chief Financial Officer GreenSquare Group Group Audit Committee Chair and Group

Development Committee member for GreenSquare

Group, a Group of Housing Associations. KPMG are

internal audit provider to the HA and external

auditors to the CCG. GSG hold many contracts with

public and private sector bodies.

Philippa Lowe 16/04/2013 CCG Chief Financial Officer PIQAS Ltd Director of PIQAS Ltd, a Consultancy firm. Dormant

company from 1/4/13.

Siobhan Clarke 22/02/2013 CCG Board Registered Nurse YOUR HEALTHCARE CIC MANAGING DIRECTOR OF YOUR HEALTHCARE CIC

WHICH HOLDS CONTRACTS FOR HEALTH AND

SOCIAL CARE IN KINGSTON AND RICHMOND. ALSO

SHAREHOLDER.

Siobhan Clarke 12/09/2013 CCG Board Registered Nurse Albion Care Alliance CiC Director and shareholder of Albion Care Alliance

CiC, an alliance of a number of mutual or co-owned

organisations that aim to grow businesses and

services that add value to member organisations,

their services, staff and society.

17

NHS City and Hackney CCG

Commissioning for Value insight pack

NHS England Gateway ref: 00525

Contents NHS City and Hackney CCG18

Why act – what benefits do the population get?

• Improvement opportunities

Your value opportunities in City & HackneyCCG development

• Phase 2 & 3• Where to look…using indicative data

The approachIntroduction: the call to action

Further support available to CCGs

• What's in this section?

• Savings opportunities

Now you may be thinking…

Possible next stepsAn invitation to a support event

• Headlines for your health economies• Summary

What to change; how to change

Contents

The call to action

NHS City and Hackney CCG19

The call to action

The approach - where to look...using indicative data

In his letter of 10 October, Sir David Nicholson set out ten key points to support planning for a sustainable NHS. The letter included information about these ‘Commissioning for Value ’ packs for CCGs which will help you identify the best opportunities to increase value and improve outcomes. The insights in these packs will support local discussion about prioritisation and utilisation of resources. The aim of this pack is to help local leaders to improve healthcare quality, outcomes and efficiency by providing the first phase in the NHS Right Care approach - “Where to Look”. That is, where to look to help CCGs to deliver value to their populations. They are also the first product CCGs will receive as part of the new planning round for commissioners - a vital part of NHS England’s ‘Call to Action’ where everyone is being encouraged to take an active part in ensuring a sustainable future for the NHS.


The approach - where to look...using indicative data

The Commissioning for Value approach begins with a review of indicative data to highlight the top priorities (opportunities) for transformation and improvement. This packs begins the process for you by offering a triangulation of nationally-held data that indicates where CCGs may gain the highest value healthcare improvement by focussing their reforms. To learn more about Phases 2 & 3 – What and How to Change, see the slides later in this pack.

The approach NHS City and Hackney CCG

21

The approach

This pack contains a range of improvement opportunities to help CCGs identify where local health economies can focus their efforts – ‘where to look’ – and describes how to approach local prioritisation. It does not seek to provide phases 2 and 3 of the overall approach. Information on these phases will be explained in detail at the national events.

National events will be held on the 12th (London) and 13th (Manchester) of November. These will help CCGs identify how they can incorporate the commissioning for value approach into their strategic and annual planning. They will allow them to find out more about CCGs that are already using the approach to drive real improvement: both on health outcomes and financial sustainability. To book your place go to www.rightcare.nhs.uk/commissioningforvalue

Pre-event support will be available to help CCGs understand more about the detail in the packs. Advice on how to interpret the data will be provided. This will include introducing CCGs to the whole range of health investment tools and guidance on how to use these.

Post-event support will be available to provide in depth pathway analysis. NHS Right Care will also be able to provide advice on how to deliver optimal health care.

Why Act – what benefits do the population get?


Why Act – what benefits do the population get?

• Achieved Turnaround (Warrington CCG - Winner of HSJ Commissioning Organisation of the Year 2012) • Financial sustainability (West Cheshire CCG - Winner of HSJ Commissioning Organisation of the Year 2010, see Annex 1) • Clinically led annual QIPP planning and delivery (Borough of Wigan) and Clinical Leaders driving change (Vale of York CCG) • Galvanising commissioners in a growing number of health economies (20+ CCGs and growing)

The NHS Right Care approach to value improvement

The NHS Right Care approach is to focus on clinical programmes and identify value opportunities, as opposed to focussing on organisational or management structures and boundaries.

Value opportunities exist where a health economy is an outlier and therefore will most likely yield the greatest improvement to clinical pathways and policies.

Triangulation of indicative data balances Quality, Spend and Outcome and ensures robust assessment.

CCG Development NHS City and Hackney CCG

23

CCG Development

The use of these packs and the approach described can help CCGs develop the strategic commissioning skills necessary for delivering quality care today and transforming services for tomorrow, as outlined in the following three of the six assurance domains:

• Constant clinical focus on improving quality and outcomes

• Significant engagement from constituent practices

• Involvement of the wider clinical community in commissioning

Domain 1

A strong clinical and multi-professional focus

• System-wide strategic planning

• Evidence based operational planning

• Effective delivery of the plan

Domain 3

Clear and credible planning and delivery

• CCG is clinically led and properly constituted with the right governance arrangements

• Delivers statutory functions efficiently, effectively and economically

• Procures high quality support as required to meet the business needs

Domain 4

Robust governance arrangements


What does your data tell you?

Your value opportunities in NHS City and Hackney CCG

What is in this section?


• NHS Islington CCG

• NHS Wandsworth CCG

• NHS Lewisham CCG

• NHS Southwark CCG

• NHS Waltham Forest CCG

• NHS Haringey CCG

• NHS Lambeth CCG

• NHS Greenwich CCG

• NHS Hammersmith and Fulham CCG

• NHS Brent CCG

What is in this section?

1. Charts: potential financial savings and potential lives saved (where mortality outcome is appropriate) for the 10 of the highest spending major programmes when compared with similar CCGs in England. Savings are shown compared with the average of the other 10 CCGs in the cluster group (blue bar) and compared with the average for the ‘best’ 5 of the cluster (blue and red bars combined). See ‘methodology’ annex for further details.

2. Tables: The tables show those indicators which are significantly worse than the average for the ‘best’ 5 CCGs in the cluster group and the scale of opportunity if the CCG improves to the average for those best 5.

This section brings together a range of nationally-held data on spend, drivers of spend (e.g. disease prevalence, secondary care use) and quality/outcomes to indicate where the CCG may gain high value healthcare improvements by focussing its reforms. It relates to Phase 1 of the process set out earlier in the pack and focusses on the question ‘Where to look?’ To learn more about Phase 2 and phase 3 – What and How to Change, see later slides. The analysis presented over the following pages shows the improvement opportunities for your CCG:

Most of the data contained in the tables relates to the financial year 2011/12.

Headlines for your health economy

The analysis is based on a comparison with your most similar CCGs which are:


Headlines for your health economy

Value Opportunities

NHS City and Hackney CCG

Circulation Problems (CVD) Cancer & Tumours Endocrine, Nutritional and Metabolic Problems Mental Health Problems

Quality & Outcomes Circulation Problems (CVD) Cancer & Tumours Respiratory System Problems

Acute and prescribing spend Circulation Problems (CVD) Endocrine, Nutritional and Metabolic Problems Cancer & Tumours Neurological System Problems

Spend and Quality/Outcomes


19

What are the potential lives saved per year?

26

9

8

2

0 5 10 15 20 25 30 35 40

Trauma and Injuries

Gastro Intestinal

Respiratory

Circulation

Neurological

Cancer

Potential Lives Saved

Potential Lives Saved Per Year If this CCG performed at the average of:

Similar 10 CCGs Best 5 of similar 10 CCGs

What are the potential savings on elective admissions?

A value is only shown where the opportunity is statistically significant

To note: Lives saved only includes programmes where mortality outcome have been considered appropriate


What are the potential savings on elective admissions?

83

177

726

68

195

191

554

0 100 200 300 400 500 600 700 800 900 1,000

Genito Urinary

Trauma and Injuries

Musculo Skeletal

Gastro Intestinal

Respiratory

Circulation

Neurological

Endocrine, nutritional & metabolic

Cancer

Potential Savings (£000s)

Potential Elective Savings If this CCG performed at the average of:



To note: Lives saved only includes programmes where mortality outcome have been considered appropriate


223

1,354

185

396

222

108

300

226

424

151

139

240

0 200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000

Genito Urinary

Trauma and Injuries

Musculo Skeletal

Gastro Intestinal

Respiratory

Circulation

Neurological


Cancer


Potential Non-Elective Savings If this CCG performed at average of:


What are the potential savings on non-elective admissions?

What are the potential savings on prescribing?



What are the potential savings on prescribing?

40

59

1116

63

40

77

75

33

182

308

83

0 200 400 600 800 1,000 1,200 1,400 1,600

Genito Urinary

Trauma and Injuries

Musculo Skeletal

Gastro Intestinal

Respiratory

Circulation

Neurological


Cancer


Potential prescribing savings If this CCG performed at the average of:




380

Disease Area Spend £000 Drivers of Spend and Quality

No. of patients,

admissions,

bed days, etc Quality

No. of patients,

life-years,

referrals, etc.

Cancer & Tumours

• Elective and day-case admissions

• Non-elective admissions

• FHS prescribing

554

425

146


• Emergency bed days

378

155

• Breast cancer screening in last 36 months

• Mortality from lung cancer under 75 years (Directly age-

standardised)

• Successful quitters at 4-weeks

1,326

8

844

Circulation Problems (CVD)



372

1,778

• Cardiovascular disease primary prevention prevalence

• Heart failure prevalence

• Heart failure due to LVD prevalence

• Obesity (ages 16+) prevalence



333

503

174

7,363

168

459

• Mortality from all circulatory diseases under 75 years

• Reported prevalence of CHD on GP registers as % of

estimated prevalence

• Reported prevalence of hypertension on GP registers as %

of estimated prevalence

• Transient ischaemic attack (TIA) cases with a higher risk

who are treated within 24 hours

• Patients admitted to hospital following a stroke who spend

90% of their time on a stroke unit

34

1,142

3,855

9

25

Endocrine, Nutritional and

Metabolic Problems


• FHS prescribing

139

1,424

• Diabetes mellitus (diabetes) (ages 17+) prevalence


• Observed vs expected emergency bed days for diabetes

patients

1,866

121

57

• Patients with diabetes in whom the last IFCC-HbA1c is 64

mmol/mol or less

216

Gastrointestinal


• FHS prescribing

523

75

• Non-elective admissions 364 • Mortality from gastrointestinal disease under 75 years 9

Genitourinary• Non-elective admissions 396

Maternity & Reproductive

Health


• FHS prescribing

635

111



1,286

3,092

Mental Health Problems

• FHS prescribing 416 • Total bed-days in hospital for patients >74 years with a

secondary diagnosis of dementia

571 • Mortality from suicide and injury undetermined all ages

• People with mental illness and or disability in settled

accommodation

• Improving access to psychological therapies - recovered

patients

• Reported numbers of dementia on GP registers as a % of


6

71

223

96

Musculoskeletal System

Problems (Excludes Trauma)


• FHS prescribing

108

77

• Non-elective admissions 45 • Knee replacement, average health gain expressed in QALYs 39

Improvement and saving opportunities


Disease Area Spend £000 Drivers of Spend and Quality

No. of patients,

admissions,

bed days, etc Quality

No. of patients,

life-years,

referrals, etc.

Improvement and saving opportunities

Neurological System

Problems



• FHS prescribing

917

151

241



419

232

• Mortality from epilepsy under 75 years

• Patients with epilepsy on drug treatment and convulsion

free, 18+ yrs

2

40

Respiratory System

Problems


• FHS prescribing

226

33

• Chronic obstructive pulmonary disease prevalence


205

278

• Reported prevalence of COPD on GP registers as % of


1,075

Trauma & Injuries



• FHS prescribing

151

222

80



36

149

Overall



• FHS Prescribing

1,438

6,616

2,529

• Non-elective admissions 5,687 • Potential years of life lost (PYLL) FEMALE amenable to

healthcare

• Potential years of life lost (PYLL) MALE amenable to

healthcare

162

728

This pack presents opportunities for quality improvement and financial savings for a range of programme areas. These are based on comparing NHS City and Hackney CCG to the best 5 amongst a peer group of 10.

For more information about the methodology and indicators used see Annexes 2 and 3.


Note:

• Only programme areas with the greatest opportunities are listed in this summary slide.

• The programme areas with significant opportunity for financial savings are: Circulation Problems (CVD), Endocrine,

Nutritional and Metabolic Problems, Cancer & Tumours and Neurological System Problems.

The CCG needs to balance the need to improve quality and reduce spend with the feasibility of making the

improvements. If you would like to discuss this summary with a member of the team, email [email protected].

• Improvement opportunities have been quantified to answer the question ‘is it worth focusing on this area?’ They may not be directly translatable

into improvement targets.

• The improvement slides may indicate other opportunities even where there is no triangulation. This is especially important for mental health

which has fewer measures and so is not so easily triangulated.

• There are significant opportunities in terms of both quality and spending in the following programme areas:

Circulation Problems (CVD), Cancer & Tumours, Endocrine, Nutritional and Metabolic Problems and Mental Health

Problems.

• The programme areas with a signficant opportunity for quality-related improvements are: Circulation Problems

(CVD), Cancer & Tumours and Respiratory System Problems.

Summary - Are there programmes which seem to offer more opportunities for improving value?

Now, you may be thinking… NHS City and Hackney CCG

34

Now, you may be thinking…

“The data are wrong”

The data are “indicative”, they do not need to be 100% robust to indicate that improvement is needed in an area, especially where more than one indicator (triangulation) suggests the same.

“The data are old”

The data are the most recent available. Have you done anything since to improve the pathway? If not, the opportunity remains.

“Some of the data are for PCTs”

“We’ve already fixed that area”

CCG data are used wherever they are available. If you think that your CCG population is different – determine where you should be on the comparator before concluding that you need not act.

Great news! Double-check that the reforms have worked and move on to the next priority area identified by the indicators.

What to change, How to change


What to change, How to change

The NHS Right Care model has three basic steps: Where to Look; What to Change; and How to Change. This pack supports Where to Look by indicating the areas of care your population can gain most benefit from your reform energies. What to Change helps you to define what the optimal value care looks like for your population. How to Change helps you to implement the changes to deliver that care.

Possible next steps


Possible next steps

Sense Checking

• Compare these findings with what you are already doing/planning to do in your improvement plans

• Compare with what you already know – do not try to fix something already fixed but also, do not assume something is fixed without checking

Deep Dive Review

• In depth analysis of a priority pathway (See What and How to Change)

• Working with local business intelligence teams, using local and national intelligence, to define the current and the optimal system for that service area

• Identify the changes needed to move from current to optimal

• Propose and approve the changes as your reform programme in this area

Share and Deliver

• Share this pack and your conclusions with your partners

• Identify available local support to move on to “What to Change”

• Work with local transformation teams to support and deliver service redesign

An invitation to a support event


An invitation to a support event

NHS Right Care, NHS England and Public Health England will bring together local CCGs, Health and Wellbeing Boards, Commissioning Support services and NHS England Area Teams for two national support events. These events will:

• showcase real life examples of the model delivering improvement and financial sustainability • give CCGs an opportunity to discuss their pack findings with the team, and • bring together CCGs and commissioning and transformation resources in your area

There are online booking forms for the above events on the NHS Right Care website If you are unable to attend, NHS Right Care will be hosting a series of Webex presentations. Check our website at: www.rightcare.nhs.uk/commissioningforvalue/




The NHS Right Care website offers resources to support CCGs in adopting this approach:

• online videos and ‘how to’ guides • casebooks with learning from previous pilots • tried and tested process templates to support taking the approach forward • advice on how to produce “deep dive” packs locally to support later phases, within the

CCG or working with local intelligence services • access to a practitioner network

The initial ‘where to look’ packs, the events and resources above and an email helpline for data analysis support to help with understanding your packs, are free. CCGs can also opt to buy bespoke support to take forward the ‘what to change’ and ‘how to change’ aspects of the approach. Initial requests should be submitted to the email address below. There is also an opportunity to apply to be a ‘Pioneer Health Economy’ and receive a whole support package to embed the process within the health economy including the relevant Commissioning Support units and Health and Wellbeing Boards. Email the support team direct on: [email protected] to request further help.

The CCG planning process


Email the support team direct on: [email protected] to request further help.

Online annexes to these insights packs

In addition to the Commissioning for Value packs, NHS England will be publishing further material to help commissioners navigate their way through the planning process, including detailed planning guidance and financial allocations.

You will be able to find out more about this in the CCG bulletin and on the NHS England website www.england.nhs.uk

The CCG planning process


Online annexes to these insights packs

Acknowledgements

The Commissioning for Value benchmarking tool (containing all the data used to create the CCG packs), full details of all the data used, links to other useful tools and details of how to contact the team are all available online at: www.rightcare.nhs.uk/commissioningforvalue

The production of these packs and the supporting materials and events have been produced as a collaboration between NHS England, Public Health England and NHS Right Care. We are also grateful to those CCGs, too numerous to list, who helped provide challenge and feedback in the development of these packs.


Winter pressures funding

UPDATE TO CCG BOARD For information

25 October 2013

42

Decision required

The City and Hackney CCG Board is asked to note the following: • The process applied to assessing the winter pressures funding • The recommendation of the group (CCG Chair, Chief Officer and Chief Finance Officer) to award

the funding • The on-going assessment and utilisation of funds as well as the process for release of contingency

elements of funding

43

Background

The CCG Board at its meeting on 27 September 2013 AGREED to the following;

• To ask the Urgent Care Board to review winter pressures bids and to make a recommendation to the group with delegated authority to authorise non recurrent funding;

• To delegate responsibility to the following group, the CCG Chair, Chief Officer and Chief Finance Officer to review and authorise bids for winter pressures on a non recurrent basis.

• Winter pressures funding has previously been provided centrally to aid the additional pressures seen throughout the winter period which are felt to be above and beyond reasonable expectation agreed with a provider in their contract to maintain service and quality

• This year at total of £250M of funding was provided only to those trusts identified as being at greatest risk and so based given the Homertons green performance YTD against its 4 hour A&E target (96.02%) and the status of being fully assured as a result of the tripartite panel scrutiny, we did not receive central funding.

• The CCG allocated a pot of non recurrent funding up to the amount of £1M in order to alleviate winter pressures, asking providers to complete a template to highlight their requirements.

• Currently £960k has been requested within the three bids which have received provisional support by the group assessing the funding requests.

• In addition to funding being available, this year the increased focus on A&E performance and the requirement to deliver recovery plans, demand and capacity planning and a general winter resilience plan and checklist has significantly improved upon the preparation seen in previous years. 44

Bids progressing HOMERTON Costs Amount £ Description

Additional ED SpR (10 hours per day Mon-Thurs, 20 hours per day Fri-Sun)

£135,000 December to March

Additional Medical SpR (10 hours per day, 4 months) £95,000 December to March

Paediatric SHO (6 months) £40,000 October to March

Additional PUCC GP and/or ENP shifts at weekends and at night

£120,000 December to Mach

Provision to procure additional short-term capacity as required

£300,000 October to March

Additional ACN nursing assistants with 1 for each of the 4 localities

£60,000 December to March The assumption is that additional staff would need to be sourced from approved agencies

The aim of this bid is to obtain additional funding that will support the Trust in continuing to meet the 4 hour A&E waiting time target in Q3 and Q4 of this year. It has been well documented that winter pressures have a significant negative impact on the delivery of this target across London. In previous years, winter pressure funding has been made available to Trusts and the Homerton has used this funding to good effect in the past. In 2012/13, the trust received non-recurrent funding to support winter pressures. This investment enabled the Trust to maintain its 4 hour wait time target for 11 out of 13 weeks. 45

Bids progressing CHUHSE

The extensive publicity given to CHUHSE securing the tender may lead to inappropriate demand over the already challenging winter from patients who should be accessing daytime care. Once CHUHSE goes live in early December they expect that there will be a very high level of interest in the services that we provide and much greater awareness, over the first few months, of the alternative that CHUHSE offers to the Emergency Department. The launch of our new service will be covered extensively and positively by local media and wider. They will use the opportunity to raise awareness about appropriate use of our service. However, there is a risk that some confusion is generated by the initial enthusiasm that local people will have for the service and that some patients may seek to use the service as an alternative to their daytime Practice. Once they are fully mobilised and have been able to engage with the local Community they don’t see an on-going problem and will be able to educate patients about appropriate use and liaise with Practice colleagues but there is a risk of demand issues arising in the first few months of go-live. They are very aware that the OOHs service has been very high-profile and likely to remain so for some time in both local and national media. They would therefore like to have access to funding to enable additional GPs to meet that demand, in a flexible way. CHUHSE expect to be able to fill shifts quite readily should we identify actual or projected high levels of demand.

Costs Amount £ Description Engage an extra GP from 6 am to 8 am specifically for home visits aimed at admissions avoidance and to ensure that we can provide maximum support to GP Practices. This would be for the winter months only and paid at premium rates.

24000

December to March

Have a contingency fund to enable us to supplement clinical shifts where we see demand pressures.

60000

December to March

Facilitate a paid standby pool of home-working GPs with the facility to log-in to our patient pool at periods of high demand.

15000

December to March

Pulse Oximeters (40 x £50)

2000

46

Bids progressing ELFT

The demand on urgent and emergency care increases during the Winter months, previous years have demonstrated that this is also the case for psychiatric related presentations to the Homerton University Hospital Emergency Department, and an increase in referrals to the Home Treatment Team as a means of avoiding hospital admission. Until the new RAID service commences in January/Feb, Homerton Liaison continues to be staffed by the Crisis Service /Home Treatment Team with minimal resources. Last year the service was given additional funds to cope with increased demand, and this Winter, demand is also likely to rise. In fact, over the last 9 months there has a been a 50% increase in psychiatric referrals to the ED. Additional resourcing will ensure that patient waiting times remain as low as possible, that breaches will not increase and that care can be delivered swiftly and effectively. An additional dedicated senior nurse will also ensure that psychiatric assessments and care plans can be more focussed on the HUH wards, as the in-patient demand is also likely to increase. Currently there is no dedicated service offering mental health input to the HUH wards. The present situation is purely reactive, managed by a 0.5 wte Consultant and on-call junior psychiatry trainee doctors. It is expected that some temporary resource will maintain and improve this service in light of anticipated Winter pressures until the RAID service takes over. It is hoped the additional funding will commence as soon as possible, but at the latest by the end of November 2013 and run until February 2013 by which time RAID should be fully established.

Costs Amount £ Description

2 x Band 7 Senior Nurses £30K Mid November to Mid February

4 x Band 6 Nurse Practitioners £56K Mid November to Mid February

1 x Staff Grade Doctor £19K Mid November to Mid February

0.5 x Band 3 Administrator £4K Mid November to Mid February

47

Next steps • The CCG group reviewing these bids are ensuring that a robust mechanism is in place to monitor

utilisation of the funding and where elements of the requests relate to contingency funding that might not be drawn down, a process will be developed to assess and release these funds to providers in an appropriate and timely manner

• The Finance and Performance Committee will have oversight of the respective performance against target and the Urgent Care Board will also monitor utilisation of funds.

• The CCG is working with providers to ensure they utilise the funds as described and will advise them of the process for release of funds.

48

Out of Hours – Launch of new service provider and notice to existing provider

UPDATE TO CCG BOARD For information

25 October 2013

49

Decision required The City and Hackney CCG Board is asked to note the following: • The rigor and scrutiny applied to assessing the CHUHSE mobilisation plan • The recommendation of the mobilisation steering group to launch the new service on 02

December 2013 • The agreement to write to the existing provider, Harmoni, effectively serving notice to

end the contract on the morning of 02 December • The on-going process for assessing mobilisation risks and seeking assurances that the

transition to a new service is safe, seamless, well managed and monitored appropriately

50

Background

• The CCG Board at its meeting on 27 September 2013 AGREED to award the out of hours primary care service to City and Hackney Urgent Healthcare Social Enterprise (CHUHSE). The award of the contract followed a robust, open and transparent procurement process which commenced in March 2013 and concluded on 01 October 2010 following the expiration of the 10 day standstill period. It should be noted that no challenges or intentions to challenge the award decision during the standstill period were received. The CCG is therefore free to enter into a contract with CHUHSE.

• Following the decision to award the tender to CHUHSE the board commissioned the out-of-hours steering group to reconvene as a mobilisation steering group in order to track, monitor, and give clinical and operational challenge to the provider’s mobilisation plan. The group would also give assurances to the Urgent Care Board and CCG Board (when appropriate) around the robustness of the plan and the seamless transition of the service.

• The first task of the mobilisation group was to make a recommendation to the CCG Chief Officer setting out a launch date for the new service and to give assurance that the contract with the existing provider could be safely stood down. This briefing sets out that recommendation and the considerations made by the steering group.

51

Process for considering launch options

4

There were a number of key conversations, deliberations and considerations made in assessing the mobilisation plan and in subsequently making a recommendation for the CCG Chief Officer. The table below sets out the these conversations with the relevant stakeholders and the key outcomes from those discussions:

Date of meeting

Stakeholders and purpose Key outcome/agreement

19/09 CCG, CSU and Harmoni – discuss ways of working during transition and preferred options for exiting the contract

Agreed that an early exit was a preferred option for both parties and that 31 Jan was NOT a feasible option. A November start and exit date was mooted

24/09 CCG and CSU – discuss mobilisation plan as submitted in tender. Drilled down key areas of challenge

1 November start date as set out in plan assessed to be too ambitious. Agreed to seek assurances around financial risk and plan to manage service during Winter.

25/09 CCG, CSU and CHUHSE – kick-off meeting, discussion on ways of working, expectations and debate around launch date.

Initial launch date agreed 25 November. Lengthy discussion on finances with CHUHSE seeking two months payment in advance. This was not agreed but a start of the month payment scheme was agreed to assist cash-flow

04/10 Mobilisation steering group – in depth analysis and challenge of mobilisation plan

Launch date pushed back to 2 December. Agreed that Finance be a standing item at the meeting. Metrics to be provided for clinical rotas, GP assessment, screening and recruitment.

07/10 CHUHSE and Harmoni transition meeting – to agree transition timetable and launch date

2 December agreed as launch date for CHUHSE and exit date for Harmoni. Ways of working agreed, key dates for staff consultation, data transfer and IT/telecoms inventory agreed. 52

Overview of the mobilisation timetable The key date to note is recommended launch date of 02 December 2013. Other key dates to note are: • Clinical activities commence week beginning 07/10 complete on 18/11 • Staff engagement and consultation commences week beginning 14/10 • Conversations with Adastra and other IT/Telephony companies already started • Hardware installation commences 4/11 • 111 transition and handover already started with CHUHSE Clinical lead Holt attending meetings • Final Go/No Go decision made ensuring CHUHSE are on track for a 02 December delivery Key changes to mobilisation plan: • Launch date pushed back to 2 December 2013 to allow all activities to be completed prior to launch • Move site and BETA testing forward by 1 week to allow any issues to be resolved before launch • Delay marketing of service to January in order to enable provider to manage activity during winter period

53

Key risks – considerations and mitigations In assessing the mobilisation plan, the steering group identified risks under the following broad headings: Capacity, Staffing and TUPE, Financial, Communication, Testing, Hand-offs and Escalation. These risks are analysed further in the following paragraphs: Capacity • The CHUHSE CEO is managing the implementation plan on a full-time basis. • The CHUHSE Clinical Governance lead has committed to supporting the implementation on a full-time basis, with the

exception of doing three clinical sessions per week. Clinical capacity is enhanced via two additional GPs on an informal basis.

Staffing and TUPE • Conversations have commenced following an initial meeting with Harmoni on 7 October. CHUHSE have secured the

support of a full-time HR consultant and staff meetings are being scheduled. • Given the TUPE list it is assumed that CHUHSE will not need to recruit however they have built this activity in as a

contingency • The CEO has commenced discussions with THDOC to ensure that their call handling service is staffed to manage the

anticipated number of City and Hackney calls.

Technology and infrastructure • An inventory list for the Homerton equipment has been drawn up to allow CHUHSE to consider how they will progress • N3 is already in place at HQ and at Homerton base. Adastra system is already in place and linked to the hosted Adastra

system at Royal London. • CHUHSE will be expecting to take over the Harmoni City & Hackney patient database. Adastra is experienced at doing

that and will work with CHUHSE and Harmoni to agree the timing of this. • Special patient notes are also transferred and Harmoni have a good track record of keeping these updated. CHUHSE will

need to get the co-operation of Practices so that they are engaged in the process to ensure continuity of care. 54

Key risks – considerations and mitigations Communication • Clinical rota issued to GPs week beginning 4 October so shifts are now getting planned. • CHUHSE have been raising awareness that they are looking to recruit further GPs and interviewing additional applicants. • The steering group have advised against over marketing to patients for the first few weeks and to delay their marketing campaign until

January 2014 to enable them to manage the anticipated activity and not create any further increases in volume. • It has also been confirmed that the CCG is looking to undertake promotional activity regarding GP registration and use of primary care

services and so will ensure a coordinated approach is achieved with CHUHSE. Testing and contingency • The steering group have asked the CHUHSE to bring the planned testing dates forward to ensure that any issues that surface can be

resolved prior to launch date. • The CHUHSE have access to hosted infrastructure at Royal London and will benefit from their fall-back and contingency arrangements.

There are also systems that support home working and cloud-based telephony enables recorded calls to be made from any phone with call cost paid by CHUHSE.

• Hand-offs and escalation • Introductory meeting with 111 provider PELC taken place. • Regular meetings with THDOC arranged • LAS on list to consult • The steering group will see and sign off all policies in relation to escalation procedures, managing patient safety, dealing with complaints,

comments and feedback • The steering group will agree a policy for informing the on-call programme director about any incidents

Finance • The CCG have agreed to an early month payment in December • CHUHSE have applied for winter pressures funding allowing for additional cash flow to be available • CHUHSE are also seeking overdraft arrangements with Barclays Bank.

55

Next steps Key next steps to the mobilisation plan are as follows: • Mobilisation steering group to continue to meet on weekly basis to continue to monitor and track progress against

plan • Contract with CHUHSE needs to be signed. Schedules continue to be drafted in collaboration with the CHUHSE,

final sign-off scheduled for 25 October. • Contract monitoring process, format and content to be agreed. This has been set out in specification, however it is

worth reviewing in collaboration with CHUHSE, building on the good work developed with Harmoni in the last few months

• Report back on progress to the next Urgent Care Board • CCG to communicate agreed start date with key stakeholders, CCG to consider a press release and individual

stakeholder letters. CCG to work with CSU on communication plan for this activity

56

PATIENT AND PUBLIC

INVOLVEMENT COMMITTEE

BOARD REPORT 18.10.2013

57

Update on current work plan for 2013/14

• PPI Committee fully established with regular representation from PPGs, community groups and stakeholder organisations

• PPI representatives in place with all Programme Boards – working on Programme Board communications plans with CCG team – Maternity Liaison Committee and Mental Health working with wider networks though integrated with the CCG model

• Project Officer now in place - more capacity to support PPG and super PPG planning

58

Our focus over next 3-6 months? • PPI Team are meeting to review the work-plan in October and think

through next years priorities and plan. • Supporting our existing model through exploring effectiveness by working

with LA’s and Healthwatch as this becomes more developed • ‘Have Your Say’ function on website will be maximised. Options for

consultation and dialogue apps funded by NHSE. Potentially a public newsletter on work of CCG building on the ‘soft membership’ approach in year one

• How can we widen our model to include Peer support/EPP/shared decision making embedded in clinical pathways – building on Social Prescribing

59

Quality and Patient Experience Issues discussed with PPI Committee

• Beginning to develop the triangulation process by linking formal quality

reporting to patient experience and feedback • In Patient Survey - working with Homerton and Healthwatch on improving

Inpatient Survey Results. We want to understand what it means for patients to say they feel unsafe. Feedback from patient representatives may suggest that this may be about the quality of care as much as the idea that it’s about ‘incidents’ on the ward.

• CSU developing a patient experience ‘dashboard’ for all out commissioned services – gathering all the measures regarding patient experience into one place. Due by November.

• ELFT ‘sleeping out’ practice.

60

Commissioning Intentions Event

• Joint event with both Health and Wellbeing Boards • Focus on Patient Involvement in the commissioning of services as well as

individuals • Keynote speakers • Presentation on City and Hackney Health needs by Director of Public

Health • Individual workshops led by clinical leads for Programme Boards,

supported by Patient Representatives and Programme Directors: details of plans in an accessible format, thinking about a you say, we will do approach

• Plenary / Feedback • Please come along!

61

Commissioning Intentions Event

Key objective for the event will be to focus discussions on how patients can be active participants in their care – how the CCG commissions for this from services and how can this be measured? We would like to use the Commissioning Intentions Event to ask Patients and Public about measures for • Feeling involved in decisions about your care • Good information given i.e. what does success look like in these domains

We would like these measures to be included in the CCG plans going forward and where appropriate.

62

External perspectives • National Developments - PPI Guidance issued by NHS England: to be

used if helpful to CCGs. NHS ‘A Call to Action’ • National Consultation on the future of the NHS. NHSE have asked CCGs

to support engagement with the Public on this consultation. Key questions will be available for people to input and comment on at the Commissioning Intentions Event.

• We will also have a consultation on our website for people to comment on the National Call to Action. We will be linking the national questions to our commissioning intentions where this is appropriate.

• We are participating in an event with the Older People’s Reference Group where we will use local issues to support the Call to Action questions.

63

how can we maintain financial sustainability?

what must we do to build an excellent nhs now & for future generations?

how can we meet everyone’s healthcare needs?

how can we improve the quality of

nhs care?

64

02

Foreword 03

The NHS belongs to the people: a call to action 05

How is the NHS currently performing? 07

What challenges will the health and care service face in the future? 11

Seizing future opportunities 17

What’s next? 21

Conclusion 24

Index

65

03

The NHS is 65 this year: a time to celebrate, but also to reflect.

Every day the NHS helps people stay healthy, recover from illness

and live independent and fulfilling lives. It is far more than just

a public service; the NHS has come to embody values of fairness

compassion and equality. The NHS is fortunate in having a budget

that has been protected in recent times, but even protecting the

budget will not address the financial challenges that lie ahead.

If the NHS is to survive another 65 years, it must change. We know there is too much unwarranted

variation in the quality of care across the country. We know that at times the NHS fails to live up

to the high expectations we have of it. We must urgently address these failures, raise performance

across the board, and ensure we always deliver a safe, high quality, value-for-money service. We

must place far greater emphasis on keeping people healthy and well in order to lead longer, more

illness-free lives: preventing rather than treating illness. We also need to do far more to help those

with mental illness.

Foreword: NHS Call to Action

66

04

There are a number of future pressures that threaten to overwhelm the NHS. The population is

ageing and we are seeing a significant increase in the number of people with long-term

conditions - for example, heart disease, diabetes and hypertension. The resulting increase in

demand combined with rising costs threatens the financial stability and sustainability of the NHS.

Preserving the values that underpin a universal health service, free at the point of use, will mean

fundamental changes to how we deliver and use health and care services.

This is not about unnecessary structural change; it is about finding ways of doing things differently:

harnessing technology to fundamentally improve productivity; putting people in charge of their

own health and care; integrating more heath and care services; and much more besides. It’s about

changing the physiology of the NHS, not its anatomy.

For these reasons, this new approach cannot be developed by any organisation standing alone and

we are committed to working collectively to improve services. This is why Monitor, the NHS Trust

Development Authority, Public Health England, National Institute for Health and Care Excellence

(NICE), the Health and Social Care Information Centre, the Local Government Association, the NHS

Commissioning Assembly, Health Education England, the Care Quality Commission (CQC) and NHS

England want to work together alongside patients, the public and other stakeholders to improve

standards, outcomes and value.

We are all committed to preserving the values that underpin the NHS and we know this new future

cannot be developed from the top down. A national vision that will deliver change will be realised

locally by clinical commissioning groups, Health & Wellbeing Boards and other partners working

with patients and the public. That is why we are supporting a national ‘Call to Action’ that will

engage staff, stakeholders and most importantly patients and the public in the process of designing

a renewed, revitalised NHS. This is all about neighbourhoods and communities saying what they

need from their NHS; it is about individuals and families saying what they want from their NHS.

Above all, this is about ensuring the NHS serves current and future generations as well as it has

served those in the past.

David Nicholson,

Chief Executive

NHS England

David Flory,

Chief Executive

NHS Trust

Development

Authority

Andrew Dillon,

Chief Executive

National Institute

for Health and Care

Excellence

Duncan Selbie,

Chief Executive

Public Health

England

Alan Perkins,

Chief Executive

Health and Social

Care Information

Centre

Ian Cumming,

Chief Executive

Health Education

England

David Bennett,

Chief Executive

Monitor

Zoe Patrick,

Chair of the

LGA Community

Wellbeing Board

Local Government

Association

David Behan,

Chief Executive

Care Quality

Commission

Peter Melton,

Chief Clinical

Officer, North East

Lincolnshire CCG,

Co-chair of NHS

Commissioning

Assembly steering

group67

05

Every day the NHS saves lives and helps

people stay well. It is easy to forget that only

65 years ago many people faced choosing

between poverty if they fell seriously ill or

forgoing care altogether. Over the decades

since its inception the improvements in

diagnosis and treatment that have occurred

in the NHS have been nothing short of

remarkable. The NHS is more than a system;

it is an expression of British values of fairness,

solidarity and compassion.

However, the United Kingdom still lags behind

internationally in some important areas, such as cancer

survival rates.1 There is still too much unwarranted

variation in care across the country, exacerbating

health inequalities.2 As the Mid-Staffordshire and

Winterbourne View tragedies demonstrated, in some

places the NHS is badly letting patients down and this

must urgently be put right.

But improving the current system will not be enough.

Future trends threaten the sustainability of our health

and care system: an ageing population, an epidemic of

long-term conditions, lifestyle risk factors in the young

and greater public expectations. Combined with

rising costs and constrained financial resources, these

trends pose the greatest challenge in the NHS’s 65-year

history.

The NHS has already implemented changes to make

savings and improve productivity. The service is on

track to find £20 billion of efficiency savings by 2015.

But these alone are not enough to meet the challenges

ahead. Without bold and transformative change to

how services are delivered, a high quality yet free at

The NHS belongs to the people:

a call to action

Executive Summary

1 Christopher Murray et al. (March 2013), “UK health performance: findings of the Global Burden of Disease Study 2010”, The Lancet.2 For example, unwarranted variation in common procedures and in expenditure. See John Appleby et al. (2011), “Variations in health care: the good, the bad and the

inexplicable”, King’s Fund and Department of Health (2011), “NHS Atlas of Variation in Healthcare: Reducing unwarranted variation to increase value an improve quality”.68

06

the point of use health service will not be available

to future generations. Not only will the NHS become

financially unsustainable, the safety and quality of

patient care will decline.

In order to preserve the values that underpin it, the

NHS must change to survive. Change does not mean

top-down reorganisation. It means a reshaping of

services to put patients at the centre and to better

meet the health needs of the future. There are

opportunities to improve the quality of services for

patients whilst also improving efficiency, lowering

costs, and providing more care outside of hospitals.

These include refocusing on prevention, putting people

in charge of their own health and healthcare, and

matching services more closely to individuals’ risks

and specific characteristics. To do so, the NHS must

harness new, transformational technology and exploit

the potential of transparent data as other industries

have. We must be ready and able to share these data

and analyses with the public and to work together

with them to design and make the changes that meet

their ambitions for the NHS.

So this document is a ‘Call to Action’ – a call to those

who own the NHS, to all who use and depend on the

NHS, and to all who work for and with it. Building a

common understanding of the challenges

ahead will be vital in order to find

sustainable solutions for the future. NHS

England, working with its partners, will

shortly launch a sustained programme of

engagement with NHS users, staff and

the public to debate the big issues and

give a voice to all who care about the

future of our National Health Service. This

programme will be the broadest, deepest

and most meaningful public discussion

that we have ever undertaken.

Bold ideas are needed, but there are some

options we will not consider. First, doing

nothing is not an option – the NHS cannot meet future

challenges without change. Second, NHS funding is

unlikely to increase; it would be unrealistic to expect

anything more than flat funding (adjusted for inflation)

in the coming years. Third, we will not contemplate

cutting or charging for core NHS services – NHS

England is governed by the NHS Constitution which

rightly protects the principles of a comprehensive

service providing high quality healthcare, free at the

point of need for everyone.

The Call to Action will not stifle the work that clinical

commissioning groups and their partners have already

accomplished. It is intended to complement this work

and lead to five-year commissioning plans owned

by each CCG. The Call to Action will also shape

the national vision, identifying what NHS England

should do to drive service change. This programme

of engagement will provide a long-term approach to

achieve goals at both levels.

The NHS belongs to all of us. This Call to

Action is the opportunity for everyone who

uses or works in the NHS to have their say on

its future.

“doing nothing is not an option – the nhs cannot meet future challenges without change.”

69

07

Over recent years, the quality of NHS services has improved and, as a result, so has the nation’s

health. However, there is still too much unwarranted variation across the country. In England the

Government measures the quality of care in five areas, collected together in the NHS Outcomes

Framework. Each of these areas is discussed below.

How is the NHS currently

performing?

Quality at the core

Around 80% of deaths from the major diseases, such as cancer, are attributable to lifestyle

risk factors such as excess alcohol, smoking, lack of physical activity and poor diet.5

3 Office for National Statistics (2011) http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-2275874 World Health Organisation (2013) http://data.euro.who.int/hfadb/5 World Health Organisation (2011) “Global Status Report on Non-communicable Diseases”

As a nation we are living longer than ever before.

Between 1990 and 2010, life expectancy in England

increased by 4.2 years.3 The NHS has made significant

improvements in reducing premature deaths from

heart and circulatory diseases but the UK is still not

performing as well as other European countries for

other conditions.4

Preventing disease in the first place would significantly

reduce premature death rates. Early diagnosis and

appropriate treatment of disease can also reduce

premature deaths.

Preventing people from dying early

70

08

Long-term conditions (LTC) or chronic diseases cannot

currently be cured, but can be controlled or managed

by medication, treatment and/or lifestyle changes.

Examples of long-term conditions include high blood

pressure, depression, dementia and arthritis.

Over 15 million people in England have an LTC. They

make up a quarter of the population yet they use a

disproportionate amount of NHS resources: 50% of

all GP appointments, 70% of all hospital bed days and

70% of the total health and care spend in England.6

People living at higher levels of deprivation are more

likely to live with a debilitating condition, more likely

to live with more than one condition, and for more of

their lives.7

The NHS, working with local authorities and the new

health and wellbeing boards, needs to be much better

at providing a service that appropriately supports

these patients’ needs and helps them to manage their

own conditions. Better management of their own

conditions by patients themselves will mean fewer

hospital visits and lower costs to the NHS overall, and

more community-based care, including care delivered

in people’s homes

Demand on NHS hospital resources has increased

dramatically over the past 10 years: a 35% increase in

emergency hospital admissions and a 65% increase

in secondary care episodes for those over 75.8 A

combination of factors, such as an ageing population,

out-dated management of long term conditions,

and poorly joined-up care between adult social care,

community services and hospitals accounts for this

increase in demand.

Compounding the problem of rising emergency

admissions to hospital is the rise in urgent readmissions

within 30 days of discharge from hospital. There has

been a continuous increase in these readmissions since

2001/02 of 2.6% per year.9

New thinking about how to provide integrated services

in the future is needed in order to give individuals the

care and support they require in the most efficient

and appropriate care settings, across health and social

care, and in a safe timescale. For example, the limited

availability of some hospital services at weekends

has a negative impact on all five domains of the NHS

Outcomes Framework: preventing people from dying

prematurely; enhancing the quality of life for people

with long-term conditions; helping people to recover

from ill health and injury; ensuring people have a

positive experience of care; and caring for people in a

safe environment and protecting them from avoidable

harm.

Enhanced quality of life for people with long-term conditions

Helping people recover following episodes of ill health or following illness

6 Department of Health (2012), “Long Term Conditions Compendium” (3rd edition).7 The Marmot Review (2010), “Fair Society Healthy Lives”.8 Royal College of Physicians (2012), “Hospitals on the edge? The time for action”.9 Health and Social Care Information Centre

http://www.hscic.gov.uk/searchcatalogue?q=title%3A%22Hospital+Episode+Statistics%2C+Admitted+patient+care+-+England%22&area=&size=10&sort=Relevance]

“better management by patients will mean fewer hospital visits & lower costs to the nhs overall.”

71

09

The UK rates highly on patient experience compared

to other countries. A 2011 Commonwealth Fund

study10 of eleven leading health services reported

that 88% of patients in the UK described the quality

of care they had received in the last year as excellent

or very good, ranking the UK as the best performing

country. However, the data also show that the UK has

improvements to make in the coordination of care and

patient-centred care.

Everyone working in the NHS must strive to maintain

and improve on this high level of patient satisfaction

and extend it to everyone who uses the NHS. People

from disadvantaged groups including the frail

older population, some black and minority ethnic

groups, younger people and vulnerable children,

generally access poorer quality services and have a

poorer experience of care (some also have lower life

expectancies). This can be made worse by these groups

having lower expectations of the experience of care

and being less likely to seek redress. We must act to

improve access and the quality of services for these less

advantaged groups.

Patient experience

10 Commonwealth Fund (2011), “International Health Policy Survey”.

“Everyone working in the NHS must strive to maintain and improve on this high level of patient satisfaction and extend it to everyone who uses the NHS.”

This is why the first offer in Everyone Counts: Planning

for Patients, is to support the NHS in moving towards

more routine services being available seven days a

week. The National Medical Director has established

a forum to identify how to improve access to more

comprehensive services seven days a week which will

report in the autumn of 2013.

NHS England recently announced a review of urgent

and emergency services in England, which will also

recommend ways to meet the objective of a seven-

days-a-week service. Not only will this offer improved

convenience for patients, full-week services will also

improve quality and safety.

0972

10

Health inequalities is the term that describes the

unjust differences in health, illness and life expectancy

experienced by people from different groups of society.

In England, as elsewhere, there is a so-called ‘social

gradient’ in health: the more socially deprived people

are, the higher their chance of premature mortality,

even though this mortality is also more avoidable.

People living in the poorest areas of England and

Wales, will, on average, die seven years earlier than

people living in the richest areas.13 The average

difference in disability-free life expectancy is even

worse: fully 17 years between the richest and poorest

neighbourhoods.14 Health inequalities stem from more

than differences in just income - education, geography,

and gender can all play a role.

The NHS cannot address all the inequalities in health

alone. Factors such as housing, income, educational

attainment and access to green space are also

important (the “wider social determinants of health”).

In fact, it is estimated that only 15-20% of inequalities

in mortality rates can be directly influenced by health

interventions that prevent or reduce risk. If the NHS is

to help tackle these inequalities we must work closely

with Government departments, Public Health England,

local authorities and other local partners to ensure the

effective coordination of healthcare, social care and

public health services.

Health inequalities

11 Charles Vincent, Graham Neale and Maria Woloshynowych (2001) “Adverse events in British hospitals: preliminary retrospective record review”, British Medical Journal.12 National Patient Safety Agency (2012), “National Reporting and Learning System Quarterly Data Workbook”

http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-data-summaries/?entryid45=13515313 The Marmot Review (2010), “Fair Society Healthy Lives” 14 The Marmot Review (2010), “Fair Society Healthy Lives”

Although great improvements in patient safety have

been made, the findings from the Mid-Staffordshire

public inquiry set out starkly what can happen when

safety is not at the heart of everything the NHS

does. The NHS must work to ensure that all patients

experience the safe treatment they deserve. Global

healthcare expert Professor Don Berwick was recently

asked by the Prime Minister to look into improving

safety in the NHS and will report back with his findings

later this year.

In addition to reducing harmful events, we must

make it easier for staff to report incidents. In 2011,

1,325,360 patient safety incidents were reported to

the National Reporting and Learning System,12 of

which 10,916 or less than 1% were serious. Despite

this large number of reports we know we have not

captured everything, and are working to make it easier

for staff and patients to report incidents or near-

misses. Learning from even largely minor incidents is

important as it helps the NHS to avoid more serious

incidents in the future.

Patient safety

Over the past 15 years, international studies have suggested that around 9 in 10 patients

admitted to hospital experience safe treatment without any adverse events and our NHS is no

different. But even these relatively low levels of adverse events are far too high. Of those people

who do experience adverse events a third of them experienced greater disability or death.11

73

11

What challenges will the health and

care service face in the future?

As the NHS strives to improve the quality and performance of current NHS services and to live up to

the high expectations of patients and the public, we must anticipate the challenges of the future -

trends that threaten the sustainability of a high-quality health service, free at the point of use. It is

the potential impact of these trends that means that while a new approach is urgently needed, we

must take a longer-term view when developing it.

Future pressures on the health service

Ageing Society

Increasing expectations

Rise of long-termconditions

Increasing costs of providing care

Limited productivity gains

Constrained public resources

74

12

People are living longer and while this is good news an

ageing population also presents a number of serious

challenges for the health and social care system:

• Nearly two-thirds of people admitted to hospital

are over 65 years old.

• There are more than 2 million unplanned

admissions per year for people over 65, accounting

for nearly 70% of hospital emergency bed days.15

• When they are admitted to hospital, older people

stay longer and are more likely to be readmitted.16

• Both the proportion and absolute numbers of

older people are expected to grow markedly in the

coming decades. The greatest growth is expected

in the number of people aged 85 or older - the

most intensive users of health and social care.17

Studies suggest that older patients account for the

majority of health expenditure. One analysis found

that health and care expenditure on people over 75

was 13-times greater than on the rest of the adult

population.18

Ageing society

Extra care housing is sometimes referred to as very sheltered housing or housing with care. It

is social or private housing that has been modified to suit people with long-term conditions

or disabilities that make living in their own home difficult, but who don’t want to move into a

residential care home.

This ‘retirement village’ type of housing offers an alternative to traditional nursing homes,

providing a range of community and care services on site. Compared with residence in

institutional settings, extra care housing is associated with better quality of life and lower

levels of hospitalisation, suggesting the potential for overall cost savings.19

Extra care housing: supporting older people to stay independent

“studies suggest that older patients account for the majority of health expenditure.”

15 Candice Imison et al. (2011), “Older people and emergency bed use: exploring variation”, King’s Fund.16 Jocelyn Cornwell et al. (2012), “Continuity of care for older hospital patients: A call for action”, King’s Fund.17 Commission on Funding of Care and Support (2011), “Fairer Care Funding: The Report of the Commission on Funding of Care and Support”.18 McKinsey & Co. (2013), “Understanding patients’ needs and risk: a key to a better NHS”.19 A Netten et al. (2011), “Improving housing with care choices for older people: an evaluation of extra care housing”, Personal Social Services Research Unit.

75

13

People with one or more long-term conditions are

already the most important source of demand for NHS

services: the 30% who have one or more of these

conditions account for £7 out of every £10 spent on

health and care in England. Those with more than

one long-term condition have the greatest needs

and absorb more healthcare resources; for example,

patients with a single long-term condition cost about

£3,000 per year whilst those with three or more

conditions cost nearly £8,000 per year. These multi-

morbid, high-cost patients are projected to grow from

1.9 million in 2008 to 2.9 million in 2018.20

Patients with multiple long-term conditions must be

managed differently. A hospital-centred delivery system

made sense for the diseases of the 20th century, but

today patients could be providing much more of their

own care, facilitated by technology, and supported by

a range of professionals including clinicians, dieticians,

pharmacists and lifestyle coaches. They also need close

coordination amongst these different professionals.

Changing burden of disease

0m

2m

4m

6m

8m

10m

12m

14m

16m

18m

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Num

ber

of p

eopl

e

Projection

Source: Department of Health projections (2008 based) One LTC Two LTCs Three LTCs

Actual/projected numbers with one or more long-term conditions by year and number of conditions

“the 30% who have one or more long-term condition account for £7 out of every £10 spent on health and care in england”

20 Department of Health (2012), “Long Term Conditions Compendium” (3rd edition).76

14

There are now 800,000 people living with dementia in the UK. By 2021, the number of

sufferers is projected to exceed one million and dementia is estimated to cost the NHS,

local authorities and families £23 billion a year. As the Prime Minister’s 2012 Challenge on

Dementia noted, diagnosis comes too late for many dementia patients and they and their

families don’t always get the care and support they need. This is in part because too little is

known about the causes of this disease and how to prevent it, but some areas are leading

the way in offering better care. In Stockport, Greater Manchester, local GPs are working

with the Alzheimer’s Society to increase diagnosis rates and provide post-diagnosis support.

GPs have agreed a ‘fast-track’ referral process for suspected dementia patients that will also

trigger support from Alzheimer’s Society staff and volunteers. The scheme also sets out to

improve the skills of clinicians to better recognise the early signs of dementia and increase

early detection.21

Meeting the dementia challenge: rapid diagnosis and referral

We know that the risk of developing debilitating

diseases is greatly increased by personal circumstances

and unhealthy behaviours such as drinking, smoking,

poor diet and lack of exercise, all of which contribute

to premature mortality. If predictions are correct, and

46% of men and 40% of women are obese by 2035,

the result is likely to be 550,000 additional cases of

diabetes, and 400,000 additional cases of stroke and

heart disease.22 Although we understand the problem,

we do not yet have enough evidence to be sure

about what will facilitate sustainable weight loss and

other associated behaviours. Working together with

individuals, their families, employers and communities

to develop effective approaches will be an extremely

important task for the next generation NHS.

Lifestyle risk factors in the young

Patients and the public rightly have high expectations

for the standards of care they receive - increasingly

demanding access to the latest therapies, more

information and more involvement in decisions about

their care.23 If the convenience and quality of NHS

services is compared to those in other sectors, many

people will wonder why the NHS cannot offer more

services online or enable patients to receive more

information on their mobile telephones. Patients want

seven-day access to primary care provided near their

homes, places of work, or even their local shop or

pharmacy. They also want co-ordinated health and

social care services, tailored to their own needs. To

provide this level of convenience and access, we need

to rethink where and how services are provided.

Rising expectations

14

21 Alzheimer’s Society (2012), “Dementia 2012”.22 Y.C. Wang et al (August 2011), “Health and economic burden of the projected obesity trends in the USA and the UK,” The Lancet. 23 See for example Economist Intelligence Unit (2009), “Fixing Healthcare: The Professionals Perspective”.77

15

The cost of providing care is getting more expensive.

The NHS now provides a much more extensive and

sophisticated range of treatments and procedures

than could ever have been envisaged at its inception.

New drugs, technologies and therapies have made a

major contribution to curing disease and extending the

length and quality of people’s lives. The NHS can now

treat conditions that previously went undiagnosed or

were simply untreatable. It is of course a good thing

that the NHS has more therapies at its disposal and can

now diagnose and treat previously neglected illnesses.

However, many healthcare innovations are more

expensive than the old technologies they replace -

for example, the latest cancer therapies24 - which raises

affordability questions. We must ensure that we invest

in the technology and drugs that demonstrate the best

value and this rigour must be extended throughout the

system, evaluating not just therapies and technologies,

but also different models of delivering health and care

services.

Increasing costs

The NHS is facing these challenges at the same time

that the UK is experiencing the most challenging

economic crisis since the 1930s and adjusting to an era

of much tighter public finances. The broad consensus

is that for the next decade, the NHS can expect its

budget to remain flat in real terms, or to increase with

overall GDP growth at best. This represents a dramatic

slow-down in spending growth.

Since it began in 1948, the share of national income

that the NHS receives has more than doubled, an

average rise of about 4% a year in real terms. As part

of its deficit reduction programme the Government

has severely constrained funding growth.

In addition, recent spending settlements for local

government have not kept pace with demand for

social care services. Unlike healthcare funding, social

care funding is not ring-fenced; councils decide how

much of their budget to spend on services based on

local need. As a result, financially challenged local

authorities have, in some locations, reduced spend on

social care to shore up their finances. Reduced social

care funding can drive up demand for health services,

with cost implications for the NHS.26 We therefore

need to consider how health and care spending is best

allocated in the round rather than separately in order

to provide integrated services.

Limited financial resources

In England, continuing with the current model of care will result in the NHS facing a funding

gap between projected spending requirements and resources available of around £30bn

between 2013/14 and 2020/21 (approximately 22% of projected costs in 2020/21). This

estimate is before taking into account any productivity improvements and assumes that the

health budget will remain protected in real terms.25

15

24 Richard Sullivan et al (September 2011), “Delivering affordable cancer care in high-income countries”, The Lancet Oncology.25 NHS England analysis.26 Research has found that spending on social care could generate savings in both primary and secondary healthcare and that increased social care provision is related to

reductions in delayed hospital discharges and readmission rates. See Richard Humphries (2011), “Social Care Funding and the NHS: An Impending Crisis?,” King’s Fund

and J Forder and JL Fernández (2010), “The Impact of a Tightening Fiscal Situation on Social Care for Older People”, PSSRU Discussion Paper 2723, London, Kent and

Manchester, Personal Social Services Research Unit. 78

16

90.095.0

100.0105.0110.0115.0120.0125.0130.0135.0140.0

FY 13/14 FY 14/15 FY 15/16 FY 16/17 FY 17/18 FY 18/19 FY 19/20 FY 20/21

Total Projected Costs Projected Resource

Projected resource vs. Projected spending requirements

Measuring the productivity27 of the NHS is

methodologically difficult and hotly debated. The

Office of National Statistics suggests that between

1995 and 2010 average productivity in the NHS grew

at 0.4%, whilst in the economy as a whole it grew

at a much faster rate of 2% over the same period.28

Beneath this, NHS labour productivity levels have

increased faster than equivalent rates in the wider

economy by an average of 2.5% per year between

2007 and 2010.29 This suggests that the NHS may not

be using its capacity as efficiently as it could.

NHS productivity remains an unresolved debate.

However, traditional productivity improvements will

not be enough to plug the future funding gap. NHS

England’s analysis suggests that the overall efficiency

challenge could be as high as 5-6% in 2015/16

compared to the current 4% required efficiency in

2013/14.30 Improvements such as better performance

management, reducing length of stay, wage freezes or

better procurement practices all have a role to play in

keeping health spending at affordable levels. However,

these measures have been employed to deliver the

so-called “Nicholson Challenge” of 4% productivity

improvements each year, amounting to some £20bn

in savings, and there is a limit to how much more can

be achieved without damaging quality or safety. A

fundamentally more productive health service is now

needed, one capable of meeting modern health needs

with broadly the same resources.

Limited productivity improvements

“the overall efficiency challenge could be as high as 5-6% in 2015/16 compared to the current 4% required efficiency in 2013/14.”

27 At its most basic productivity is the rate at which inputs (like labour, capital and supplies), are converted into outputs (like consultations or operations) and outcomes

(such as good health) in order to improve quality of life.28 Office for National Statistics (2010), “Public Service Productivity Estimates: Healthcare, 2010”. 29 Office for National Statistics (2010), “Public Service Productivity Estimates: Healthcare, 2010”. 30 This is the challenge for the NHS after national action to constrain wages and other input costs. In recent years these have typically delivered c.1% per annum in

savings which over the period modelled would equate to c.£8bn.

Source: NHS England

£bns

79

17

Seizing future opportunities

The future doesn’t just pose challenges, it also presents opportunities. Technological, social and other

innovations – many of which are already at work in other industries or sectors – can and should be

harnessed to transform the NHS. These exciting opportunities have the potential to deliver better patient

care more efficiently to achieve the transformation that is required, some of which are discussed below.

These are not exhaustive and it is crucial that as a service we become better able to spot other trends

and innovations with the potential to reshape health services.

We must get better at preventing disease. In the future

this means working increasingly closely with partners

such as Public Health England, health and wellbeing

boards and local authorities to identify effective ways

of influencing people’s behaviours and encouraging

healthier lifestyles. The NHS has helped many people

quit smoking (although there are still about 8m

smokers in England), but has yet to develop similarly

sophisticated methods for assisting people to improve

their diet, take more exercise or drink less alcohol.

About 4% of the total health budget in England is

spent on prevention and public health, which is above

the Organisation for Economic Co-operation and

Development (OECD) average,31 but this will strike

many as too little. We need to look at our health

spending and how investment in prevention may be

scaled up over time. It is not just about investment;

partnering with Public Health England, working with

health and wellbeing boards and local authorities and

refocusing the NHS workforce on prevention will shape

a service that is better prepared to support individuals

in primary and community care settings.

A health service, not just an illness service

31 Department of Health (2009), “Public Health and Prevention Expenditure in England”.80

18

Developing effective preventative approaches means

helping people take more control of their own health,

particularly the 15 million people with long-term

conditions. The evidence shows that support for

self-management, personalised care planning and

shared decision making are highly effective ways

that the health system can give patients greater

control of their health. When patients are involved

in managing and deciding about their own care

and treatment, they have better outcomes, are less

likely to be hospitalised,32 follow appropriate drug

treatments33 and avoid over-treatment.34 Personalised

care planning is also highly effective.35 A major trial of

Personal Health Budgets, a tool for personalised care

planning, has shown improved quality of life and cost-

effectiveness, particularly for higher needs patients and

mental health service users.36

Giving patients greater control over their health

Manchester Royal Infirmary has developed an innovative dialysis provision pathway, which

allows patients to perform extended haemodialysis at home, rather than in hospital. This has

delivered improved health and longevity, empowering patients through greater involvement,

freedom and flexibility, and offers wider benefits of fewer medications and hospital visits

resulting in substantial reductions in healthcare costs.37

Manchester Royal Infirmary: home dialysis

The digital revolution can give patients control over

their own care. Patients should have the same level of

access, information and control over their healthcare

matters as they do in the rest of their lives. The NHS

must learn from the way online services help people to

take control over other important parts of their lives,

whether financial or social, such as online banking

or travel services. First introduced to the UK in 1998,

now more than 55% of internet users use online

banking services.38 A comparable model in health

would offer online access to individual medical records,

online test results and appointment booking, and

email consultations with individual clinicians. Some

of the best international providers already do this.39

This approach could extend to keeping people healthy

and independent through at-home monitoring, for

example. These innovations would not only give

patients more control, they would also make the NHS

more efficient and effective in the way that it serves

the public.

Harnessing transformational technologies

18

32 JH Hibbard and J Green (February 2013), “What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs,”

Health Affairs.33 Expert Patients Programme (2010), “Self-care reduces costs and improves health: the evidence”.34 D Stacey et al. (May 2011), “Decision aids to help people who are facing health treatment or screening decisions”, Cochrane Summaries and Department of Health

(2011), “NHS Atlas of Variation in Healthcare: Reducing unwarranted variation to increase value an improve quality”.35 “RCGP Clinical Innovation and Research Centre (2011), “Care Planning: improving the lives of people with long term conditions”.36 https://www.phbe.org.uk/37 NHS England (2013), “Catalogue of Potential Innovation”.38 Office for National Statistics (2009), “e-society” (Social Trends 41).39 For example Kaiser Permanente and the Veterans Administration, both in the USA

81

19

Guy’s and St Thomas’ NHS Foundation Trust, in London, has recently deployed a new

e-Intensive Care Unit (ICU) to keep a ‘second pair of eyes’ on critically ill patients. Used in

about 300 hospitals in the US, where studies have shown the system has reduced mortality

rates and hospital stays, the eICU allows critical care specialists to remotely monitor patients

using high-definition cameras, two-way audio and other instruments that keep track of vital

signs. Not only does the system facilitate provision of 24/7 care, it also enables the most

experienced specialists to spread their skills more widely and to help more patients with the

greatest need.40

e-Intensive Care: a second pair of eyes

Digital inclusion will have a direct impact on the

health of the nation, and so innovation must be

accessible to all, not just the fortunate. From April

2013, 50 existing UK online centres in local settings,

such as libraries, community centres, cafes and pubs,

are receiving additional funding to develop as digital

health hubs where people will be able to find support

to go online for the first time and use technology and

information services such as NHS Choices to improve

their health and wellbeing.

To support active patients the best quality data

must be collected and made available. Dramatic

improvements need to be made in the supply of timely

and accurate information to citizens, clinicians and

commissioners. Commissioners can use improved data

to better understand how effectively money is being

invested. For patients, more and better data will enable

them to make informed decisions about their health

and healthcare.

The new Friends and Family Test asks patients whether

they would recommend their hospital wards or A&E

department to their friends and family should they

need similar care or treatment. Beginning in July 2013,

the results will be published on the NHS Choices

website. This is just one example of transparency

which will for the first time allow citizens to compare

NHS performance based on the opinions of the

patients.

Exploiting the potential of transparent data

“the new friends and family test asks patients whether they would recommend their hospital to their friends & family and the first results will be published on nhs choices in july 2013”

1940 Guy’s and St. Thomas’ NHS Foundation Trust, www.guysandstthomas.nhs.uk/news-and-events/2013-news/20130703-eICU.aspx

82

20

A relatively small minority of patients accounts for

a high proportion of health service utilisation and

expenditure. This suggests an opportunity to manage

patients, and help them manage themselves, more

intelligently, based on an understanding of individual

risk.

Healthcare is becoming more personal in other ways

too. Recent biomedical advances suggest a revolution

in medicine itself may be afoot that could enable

clinicians to tailor treatment to individuals’ specific

characteristics. For instance, it has been proven that

mutations in two genes called BRCA1 and BRCA2

significantly increase a person’s risk of developing

breast cancer. Individuals can now be tested for these

mutations, allowing early detection and targeted use

of therapeutic interventions. Similar progress is being

made in understanding the biological basis of other

common diseases. The health service needs to consider

how to invest in this work and how it can most

effectively be translated into everyday practice.

Moving away from a ‘one-size fits all’ model of care

All too often we think of health expenditure as solely

a cost, but investment in individuals’ wellbeing and

productivity delivers vast benefits to society and the

economy. Conversely, illness costs the UK economy

dearly: in 2011, 131 million work days were lost due

to sickness.42 This translates into an annual economic

cost estimated to be over £100bn whilst the cost to

the taxpayer, including benefits, additional health costs

and forgone taxes, is estimated to be over £60bn.43

In addition to preventing and relieving illness, the

NHS has a central role in contributing to economic

growth. The NHS is the largest single customer for

the UK health and life sciences industries including

pharmaceutical, biotechnology, medical devices and

other sectors,44 and Britain is recognised as a leader in

biomedical research. We must consider how the NHS

can work with industry partners to make sure that the

health and life sciences continue to be a growing part

of the UK economy.

Unlocking healthcare as a key source of future economic growth

As part of the Inner North West London Integrated Care Pilot, patient information was combined

across primary, secondary and social care providers to understand the impact of high-risk patients

on services and expenditure. The data showed that the 20% of the population most at risk

of an emergency admission to hospital accounted for 86% of hospital and 87% of social care

expenditure. Yet despite this high concentration in expensive downstream services, only 36% of

primary care resources were expended on these same patients.41 This suggests that through better

management of these patients in primary care many hospital admissions could be prevented and

intensive social care support reduced, resulting in improved care with reduced costs.

Risk-stratification in North West London

41 McKinsey & Co. (2013), “Understanding patients’ needs and risk: a key to a better NHS”.42 Office of National Statistics (2012), “Sickness absence in the labour market”.43 Department of Health (2011), “Innovation, Health and Wealth”.44 Department of Health (2011), “Innovation, Health and Wealth”

83

21

What’s next?

This document discusses the key problems

and opportunities that a renewed vision

for the health service must address. In the

next phase of work, we will analyse, with

our key partners, the causes of these trends

and challenges and share these more widely

in order to begin to generate potential

solutions. Some of these solutions may come

from reviews that are already underway such

as the Urgent and Emergency Care Review

and the Berwick Review on improving safety

in the NHS. Some solutions may be adapted

from small-scale pilots or international models

that can demonstrate success, but there is no

doubt that new ideas are needed.

We cannot generate these new ideas alone. NHS

England is committed to working collectively to

improve services. This is why Monitor, the NHS Trust

Development Authority, Public Health England, NICE,

the Health and Social Care Information Centre, the

Local Government Association,the steering group of

the NHS Commissioning Assembly, Health Education

England and the Care Quality Commission want to

work in partnership with NHS England to understand

the pressures that the NHS faces and to work together

alongside patients, the public and other stakeholders to

identify new and better ways to deliver health and care.

The NHS constitution stipulates that the NHS belongs

to the people and so does its future. In keeping

with this principle we will be working together with

staff, patients and the public to develop new local

approaches for the NHS. We need your help to ensure

that the ideas identified are sustainable and respect the

values that underpin the health service. To enlist your

help, we are launching a nationwide campaign called

‘The NHS belongs to the people: a Call to Action’.

84

22

A call to action is a programme of engagement that

will allow everyone to contribute to the debate about

the future of health and care provision in England. This

programme will be the broadest, deepest and most

meaningful public discussion that the service has ever

undertaken. The engagement will be patient - and

public-centred through hundreds of local, regional and

national events, as well as through online and digital

resources. It will produce meaningful views, data and

information that CCGs can use to develop 3-5 year

commissioning plans setting out their commitments to

patients and how services will improve.

The call to action aims to:

• Build a common understanding about the need

to renew our vision of the health and care service,

particularly to meet the challenges of the future.

• Give people an opportunity to tell us how the

values that underpin the health service can be

maintained in the face of future pressures.

• Gather ideas and potential solutions that inform

and enable CCGs to develop 3-5 year

commissioning plans.

• Gather ideas and potential solutions to inform

and develop national plans, including levers and

incentives, for the next 5 – 10 years.

A call to action

What will happen with the data and views that are collected?

All data, views and information will be collected by CCGs and NHS England. This information will then be used

by CCGs to develop 3-5 year commissioning plans, setting out commitments to patients about how services

will be improved.

This information will also be used by NHS England to shape its direct commissioning responsibilities in primary

care and specialised commissioning.

Information gathered in this way will drive real future decision making. This will be evident in the business

plans submitted for both 2014/15 and 2015/16. These plans will signal service transformation intentions at

both local and national level.

85

23

The call to action will offer a number of ways for

everyone to engage with the development of a

renewed vision for the health service including:

A digital call to actionStaff, patients and the public will be able contribute

via an online platform hosted by NHS Choices. This

platform will enable people to submit their ideas, hold

their own local conversations about the future of the

NHS and search for engagement events and other

interactive forums.

‘Future of the NHS’ surgeries with NHS staff, patients and the publicLocal engagement events will be led by clinical

commissioning groups, health and wellbeing boards,

local authorities and other local partners such as

charities and patient groups. These workshop-style

meetings will be designed to gather views from

patients and carers, local partner groups and the

public. We will also be holding events designed to

capture the views of NHS staff, for instance, through

clinical senates.

Town hall meetingsHeld in major cities across the NHS, these events

will engage local government, regional partners,

business and the public. These regional events will give

people who have not contributed locally a chance to

participate in regional discussions.

National engagement events A number of national events focusing on national

level partner organisations to the NHS will be held.

These will include Royal Colleges, patient groups and

charities, the private sector and other stakeholders.

How will the call to action engage people?

There is no set of predetermined solutions or options

about which we are consulting. Bold, new thinking is

needed and we will consider a wide range of potential

options. However, there are three options that we will

not be considering:

1. Do nothing. The evidence is clear that doing nothing

is not a realistic option nor one that is consistent

with our duties. We cannot meet future challenges,

seize potential opportunities and keep the NHS on a

sustainable path without change.

2. Assume increased NHS funding. In the 2010

spending review, the Government reduced spending

on almost all most public services, although health

spending was maintained. We do not believe it would

be realistic or responsible to expect anything more

than flat funding (adjusting for inflation) in the coming

years.

3. Cut or charge for fundamental services, or ‘privatise’ the NHS. We firmly believe that fundamentally

reducing the scope of services the NHS offers would be

unconstitutional, contravene the values that underpin

the NHS and - most importantly - harm the interests

of patients. Similarly, we do not think more charges

for users or co-payments are consistent with NHS

principles.

86

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The NHS is one of our most precious institutions. We need to cherish it, but

we also need to transform it. Future trends threaten its sustainability, and that

means taking some tough decisions now to ensure that its future is guaranteed.

We believe that by working together as a nation, we have a unique opportunity

to transform the NHS into a health service that is both safe and fit for the future.

The NHS needs your help. Have your say.

Conclusion

2487

Your Partner For Success

NHS City and Hackney Clinical Commissioning Group

Engagement Event

Wednesday 27th of November 2013, 6.30pm-8.30pm The Trampery (formerly known as City Edge)

125-127 Mare Street, London E8 3RH

Have your say! Help shape local services and join us in discussing the CCG’s

commissioning intentions for 2014-15.

Focus groups led by the CCG Clinical Leads - Maternity Services, Children’s Services,

Mental Health Services, Urgent Care, Planned Care, Primary Care Quality, Prescriptions and Medicines Speakers Your chance to comment on the NHS Call to Action Programme and the CCG Equality Objectives Opportunity to ask questions and meet your local CCG Team Refreshments

Places are limited - please contact us to book your chosen workshop!

Tel. 020 7683 4659 Email: [email protected] www.cityandhackneyccg.nhs.uk 88

NHS CITY & HACKNEY CCG BOARD MEETING 25 October 2013

FINANCE & ACTIVITY REPORT Month 6 - 2013/14

NHS City & Hackney CCG 1 89

Contents

NHS City & Hackney CCG 2

Executive summary Finance and activity dashboard & trend Key risks narrative Key risks, opportunities and assumptions underpinning year

end forecast Running costs performance Financial Statements

90


Executive Summary A review of Month 6 financial position and month 5 activity, was undertaken by Finance & Performance Sub-Committee.

The year to date position was a surplus of £1.2m and a forecast outturn (FOT) surplus of £27.8m resulting in a favourable variance of £24.5m. This position is as a result of:

C&H have reached agreement with Homerton and are able to reassess the FOT and risk reserves held on the acute and CHS contracts

CCG has discussed with Homerton‘ their ability and willingness to recognise the NR income which backs a number of C&H’s planned developments in 13/14 and agreed the CCG expenditure profile on these schemes

C&H have been holding the PCT carry forward for NR investment, but froze it pending the risk of non-return of the 13/14 specialised top slice

The specialised top slice has been returned to the CCG and an expected further specialised sum has also been returned. The CCG has matched the return of funding with the budgets which were based on actual or anticipated contract values and it is broadly in line with expectation

Favourable legacy balances were not recognised whilst the CCG undertakes a full assessment of what it is inheriting.

For M6 an in-depth risk review was undertaken on known issues assessing the probability of those risks materialising to ensure the CCG can adequately cover these over the remaining 6 months

Dashboard (page 4) highlights a GREEN RAG rating against the CCG I&E position. Work continues to address issues with Barts Health and other Providers along with activity data received to date is subject to review and validation.

QIPP delivery reports an AMBER RAG rating which is reflected in the forecast outturn.

The CCG has been unable to verify the accuracy and validity of reported activity from many Acute Trusts and is working with the CSU to rectify this situation as a matter of urgency, see page 9.

Risks and opportunities which make up the forecast are highlighted on page 6.

91


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

TREND4795

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

TREND

QIPP

PRESCRIBING

NON-ACUTE

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

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

THIS IS THE DELIVERY OF QIPP AGAINST THE PROFILED ANNUAL PLAN. THE TREND REPRESENTS THE YEAR TO DATE DELIVERY AGAINST TARGET WHICH IS 23% (£679k) BEHIND

PLAN

THIS IS THE SPEND ON PRESCRIBING IN LINE WITH THE PPA (PRESCRIPTION PRICING AUTHORITY) FORECAST VS ANNUAL

PLAN. PRIOR MONTH FAVOURABLE POSTION ERODED DUE TO DH ERROR

THIS IS THE SPEND ON MENTAL HEALTH, COMMUNITY HEALTH & CONTINUING CARE VS ANNUAL PLAN. M6 WAS

OVERSPENT BY 1.4% (£686K)

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

£15m

£25m

£35m

£45m

£55m

£65m

1 2 3 4 5 6 7 8 9 10 11 12£328m

£333m

£338m

£343m

£348m

£353m

£358m

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

-30%

-20%

-10%

0%

10%

20%

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

-30%

-20%

-10%

0%

10%

20%

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

FINANCEDASHBOARD

QIPP PERFORMANCE vs PLAN

SepSep

PRESCRIBING PERFORMANCE vs PLAN NON-ACUTE PERFORMANCE vs PLAN

-15%

-10%

-5%

0%

5%

10%

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

92


Key Risks - Finance Key risks are quantified on Page 6 and are based on the main drivers behind the performance shown in the dashboard on Page 4. Barts Health was reported on full year plan. Work continues to investigate and review activity which has been reported. Work also continues on

Homerton to review and validate multiple areas which has resulted in a £2.4m overspend to full year plan. However, the exceptional charge for maternity has been resolved and reversed. The contract position has been agreed, with minor considerations to conclude relating to CQUIN and non recurrent investment. Data quality issues continue to exist with Providers and clarification is pending post M6 close.

Actions: Residual contract matters to be concluded with Homerton by C&H CCG and the CSU. CSU to complete data validation, linked to final contract agreements on all remaining contracts.

The forecast outturn is based on a projection of month 5 activity data. Performance at HUHT is reported as over plan, however, there are a number of issues to resolve such as growth in Elective Admissions, Tests and Outpatient Procedures with spend higher than M6.

Barts activity also requires further detailed review and continues to include activity commissioned by NHSE and the LA and remains to be resolved via the claims process. Variances are evident across the contract, most significantly in Emergency Inpatient Care with almost a quarter of the over performance relating to un-coded activity.

Actions: CSU to complete validation of activity and to address issues relating to activity commissioned by NHSE and the LA. Non-acute over performance on CHC has been subject to detailed review with the situation worsening. Serious concerns remain over the

integrity and administration of the Broadcare system. The CSU are working to address this issue for M7 close, however, internal audit have been commissioned to carryout a review covering NEL CCGs, but with a bias towards C&H CCG. The FOT at M6 was £988k adverse to full year plan equating to a 20% over-spend.

A national adjustment made by DoH to correct the Prescribing forecasting process resulted in an adverse FOT movement of £680k and eliminated an upside on QIPP previously reported under this category.

Programme Costs were also overspent by £156k on a full year basis due to a restatement from Running Costs in line with an ongoing CCG wide project to correctly identify and attribute running cost expenditure. This refinement is ongoing. The overspend is offset by an underspend of the same amount reported within Running Costs.

Action: CSU to deliver on CHC improvements as presented to the Finance & Performance Committee and to address the output of the audit review QIPP is forecasting a £792 full year gap with the Prescribing reversal being part mitigated by newly recognised savings within Planned Care.

The situation will be monitored and managed accordingly on a year to go basis.

93


CITY & HACKNEY CCG

Ref: Description Risk Opp £'000

Prob.% Adj. risk/opp

Recurring £'000

Adj. risk/opp

Non Recurring

£'000

(16,567) (11,311) MEMO Risk/Opp £'000

0% 0 0 C&H PCT legacy ledger position delivering a possible £3m surplus which as yet the CCG is not able to consolidate into its position.

18 Risk Overseas visitors and CHC 3,400 0% 0

19 Risk Contracting risk and other 1,520 0% 0 0 Contracting risk and other

(7,390)17 Opp

0

NR investment reserve, part utilised to cover winter pressures, the newly appointed OOH provider and ELFT

Opp 2014/15 0Forecast Outturn Variance (27,878)

Risk 2014/15 0

PCT Carry Forward (8,390) 88% 0

Overseas visitors and other demand not recoverable through allocation adjustments

20 Opp PCT Legacy position (3,000)

(3,921) Balance of 2% NR reserve

16 Opp Miscellaneous Reserves (12,395) 61% (7,600) 0 Contracting risk, over performance and overseas visitors

14 Opp Uncommitted NR 2% Strategic Reserve (3,921) 100% 0

Uncommitted NR 2% Strategic Reserve15 0 0Opp (2,826) 0% Approved schemes funded by NR reserve

0 Recognised in M6 reported position

13 Opp Committed NR 2% Strategic Reserve (2,825) 0% 0 0 Barts transitional funding, RAID, Primary Care business case, advocacy and A&E

12 Opp Spec Com Allocation (12,300) 100% (12,300)

9 Risk Non Acute 186 100% 186 0 Mental Health, CHS, et al FOT overspends

11 Risk NHS Direct, 111, OOHs 474 0% 0 0 Costs of re-tendering /re-provision

10 Opp Running Costs (265) 100% (265) 0 Planned FOT underspend

0 Uncertainty of costs realised between now and the end of the year.

8 Risk Continuing Healthcare 1,748 57% 988 0 Additional demand risk

7 Risk NCA 556 0% 0

0 Allocations pending

6 Risk Barts contract performance 876 0% 0 0 Contract settlement pending and risk from poor data quality

5 Opp UCLH allocations pending and minor settlements

(4,493) 0% 0

25% (876) 0

0Over performance on out of area acute contacts; GST, NMUH, RHOH, Moorfields, Whittington, UCLH et al which are subject to continued review.

4 Opp Claims and Challenges Acute contracts (351) 28% (98) 0 Claims raised against acute activity

3 Risk Outer sector - Acute contracts - Overspends 1,275 76% 975

2 Opp Contingency (3,476)

Summary and Progress Report on Financial Risksto 30 September 2013

Narrative

1 Risk HUH Acute contract with overspend 5,145 47% 2,423 0 Over performance and contract overspend

94


Running Costs Performance on CCG Running Costs are shown below. The CCG is not permitted to exceed its allocated Running Cost Allowance, but is permitted to allow any unspent balances to be used for Commissioning. The total allocation is £6.54m and the forecast spend is £6.28m The underspend on CCG spend year to date is due to vacancies, restatement to Programme Costs and an uncommitted

contingency. Actions: CCG to continue to review requirements for management and administration in support of delivering its

objectives

Total Planned Spend

CSU Planned Spend

CCG Planned Spend

Monthly Running Costs vs. Plan

95


Key Risks - Activity The key risks behind the dashboard variances are reported here and reflect the recommendations of the review carried out at the Finance and Performance Committee The graphs on the next slide represent data submitted by providers but includes activity for which the CCG is not responsible, so gives a

distorted position. The CSU are working with providers to address serious unacceptable data quality concerns, and the CCG is pressing the CSU to resolve these issues for the next report. The situation has been further exacerbated by the constraints imposed by the new application of IG rules which has prevented the CCG doing its own detailed validation and is wholly reliant on a small number of accredited CSU staff who can access patient level data. Urgent Care

Actions: To continue to review and monitor comparative conversion rates and decide on applicable action to be undertaken. A&E

Actions: To develop and build upon the existing portfolio of analysis by undertaking a series of real time audits and qualitative interviews with both patient and A&E staff. Planned Care

Action: Review of the drivers of Musculoskeletal spend and C&H CCG and CSU to agree a new pathway price with HUH

Maternity

Actions: Audit of case mix activity to be carried out, subject to specification being completed by C&H CCG Maternity Lead Non-acute

Actions: Ensure CHC Broadcare database is properly administered and the financial year to date and FOT position is correctly demonstrated and reported M7 close. This area is subject to a deep dive review.

96


ACUTE ACTIVITY

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

TREND

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

TREND

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

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

ACTIVITYDASHBOARD

-10%

0%

10%

20%

30%

40%

50%

60%1 2 3 4 5 6 7 8 9 10 11 12

-10%

0%

10%

20%

30%

40%

50%

60%

70%1 2 3 4 5 6 7 8 9 10 11 12

-10%

0%

10%

20%

30%

40%

50%1 2 3 4 5 6 7 8 9 10 11 12

-10%

0%

10%

20%

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50%1 2 3 4 5 6 7 8 9 10 11 12

-10%

0%

10%

20%

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40%

50%1 2 3 4 5 6 7 8 9 10 11 12

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Financial Statements - 1


INCOME & EXPENDITURE ACCOUNT City & Hackney

Annual Budget £’000

YTD Budget £’000

YTD Actual £’000

YTD (Under)/Overs

pend £’000

Forecast Actual £’000

Forecast (Under)/Overs

pend £’000

Improvement/Deterioration

vs Month 5 £'000

In Sector Acute Trusts 123,545 61,734 62,983 1,249 125,968 2,423 (577)Out of Sector Acute Trusts 36,710 18,355 19,129 774 37,358 648 609Other Acute 7,814 5,718 2,094 (3,624) 4,208 (3,605) (688)Subtotal Acute 168,069 85,806 84,206 (1,600) 167,534 (535) (656)

Mental Health 46,183 23,091 23,008 (83) 46,017 (166) (166)Community Health 37,235 18,618 18,627 9 37,254 19 1Other Non Acute 18,057 8,242 9,005 763 19,400 1,344 550Subtotal Non Acute 101,475 49,951 50,640 689 102,671 1,197 385

Prescribing 29,596 14,798 14,849 51 29,698 102 680Other Primary Care Services 6,995 3,198 3,204 7 7,008 13 25Subtotal Primary Care 36,591 17,996 18,053 57 36,706 115 705

NHS Property Services 878 439 536 97 878 0 0

Reserves 40,068 220 0 (220) 15,083 (24,985) (25,028)

QIPP 0 0 0 0 0 0 0

TOTAL CSU 347,080 154,412 153,435 (976) 322,872 (24,209) (24,594)

Corporate 6,540 2,962 2,716 (246) 6,275 (265) 0TOTAL CORPORATE 6,540 2,962 2,716 (246) 6,275 (265) 0

GRAND TOTAL 353,620 157,374 156,151 (1,223) 329,147 (24,474) (24,594)TOTAL RESOURCE LIMIT (357,025) (157,374) (157,374) 0 (357,025) 0 800(SURPLUS)/DEFICIT (3,405) 0 (1,223) (1,223) (27,878) (24,474) (23,794)

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KEY BALANCE SHEET INDICATORS

Compliance with Public Sector Payment Performance Target 85.8%

Financial Statements - 2

The projected cash position is expected to reduce in M7. At present, contracts are still pending finalisation and payments are being made only ‘on account’ reflecting contract offers.

0 0.2 0.4 0.6 0.8 1 1.2

0-30

31-60

61-90

Over 90

Aged Debtors

£k

Days

02,0004,0006,0008,000

10,00012,00014,00016,00018,000

Max

Actual

Actual Month End Cash vs Maximum Cash Holding

£k

99


NHS City and Hackney Clinical Commissioning Group Clinical Executive Committee (CEC)

Wednesday 9 October 2013 key issues Feedback from the members The Clinical Executive Committee (CEC) discussed where budgets for practice consumables lie and the issues with regards to finding ownership. The Clinical Commissioning Group (CCG) has committed to taking responsibility for blood bottles used under its Local Enhanced Services (LES) and has asked practices to take up further issues with other organisations via the Local Medical Committee (LMC). Practices reported ongoing issues with obtaining data to support the clinical audits required under the CCGs LES schemes, with most resorting to practice list data. Feedback from the CCG Programme Boards Planned Care advised that a Magnetic Resonance Imaging (MRI) Any Qualified Provider (AQP) will be advertised shortly, with some issues around access to IT systems left to resolve. The Public and Patient Involvement (PPI) Committee briefed the CEC that a public event will be held in November 2013 and that all CCG Clinical Leads will be approached to gauge their involvement. Commissioning Intentions for 2014/15 London Borough of Hackney (LBH) and City of London (CoL) Public Health (PH) and Health and Wellbeing (HWB) and NHS England (NHSE) Specialised Commissioning and Public Health joined the CEC for a discussion on 2014/15 Commissioning Intentions and interdependencies across commissioners. The meeting was the first time this amount of ‘new’ commissioners had all been in the same room together and shared plans for the following year. Investment proposals LBH presented initial proposals for use of the section 256 funds, which constituted £5m held with NHSE but requiring CCG approval for use to support social care initiatives. The proposals, once further developed and discussed in detail at CCG Programme Boards will proceed to the CCG Board for final approval. Long Term Conditions Programme Board update The CEC was updated on the work of the Long Term Conditions Programme Board (LTCPB), focusing on it’s work in spirometry, COPD, diabetes and integrated care. Geographical Clustering is another major piece of work currently underway and the CCG will be fully briefed on the proposals at a future meeting. IG issues were a serious concern

100


for the Board with regards to its integration of care and quality monitoring through clinical audits. CCG Finance update The CEC received the September 2013 CCG Board finance report and were updated on progress since initial production and expected changes to the national NHS allocations formula.

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NHS City and Hackney Clinical Commissioning Group (CCG) Board

Friday 29 November 2013, 1415 – 1655

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

AGENDA Chair: Dr Clare Highton NOTE – the Friday 29 November 2013 CCG Board public meeting will be preceded by a 1300-1400 closed organisational development session for CCG Board members only. The meeting will open to the public and regular CCG Board attendees at 1415. Agenda Items

Led by & Appendix number

Timing

1. Welcome, introductions and declarations of Interests

Clare Highton Verbal

1415-1420 (5 mins)

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

Clare Highton Papers TBC (MK) Pages

1420-1425 (5 mins)

3. Questions from the public Clare Highton Verbal

1425-1435 (10 mins)

CLINICAL STRATEGY (FOR DECISION) 4. 2013/14 Non Recurrent Investment Clare Highton

Papers TBC (PH) Pages

1435-1455 (20 mins)

5. Section 256 funding approval London Borough of Hackney Papers TBC (LBH) Pages

1455-1505 (10 mins)

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6. IVF policy Maggie Harding Papers TBC (CSU) Pages

1505-1515 (10 mins)

7. 2014/14 Commissioning Intentions Clare Highton Papers TBC (PH) Pages

1515-1545 (30 mins)

PERFORMANCE 8. Quarterly Quality report Jenny Singleton

Papers TBC (CSU) Pages

1545-1605 (20 mins)

9. CCG Finance update: Month 7 Finance and Activity report; 2014/15 planning update.

Philippa Lowe Papers TBC (PL) Pages

1605-1620 (15 mins)

10. Board Assurance Framework Karl Thompson Papers TBC (KT) Pages

1620-1630 (10 mins)

11. Counter Fraud Plan Philippa Lowe Papers TBC (KT/PL) Pages

1630-1640 (10 mins)

FOR INFORMATION

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12. Reports from Subcommittees of the Board: a. Key issues from the Safeguarding

Group; b. Key issues from the Clinical

Executive Committee; c. Key issues from the Audit

Committee; d. Key issues from the Finance and

Performance Committee.

Clare Highton Papers TBC (MK) Pages

1640-1645 (5 mins)

13. Friday 20 December 2013 draft CCG Board agenda

Clare Highton Paper TBC (MK) Pages

1645-1650 (5 mins)

14. Any Other Business Clare Highton Verbal

1650-1655 (5 mins)

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